Shoulder

Ultrasound of the shoulder is a powerful and accurate method for the examination of the rotator cuff, biceps mechanism and the synovium. This article describes the anatomy, standard examination technique, indications, pitfalls and potential errors. It lists suggested imaging algorithms for a range of shoulder pathology.

Instability of the glenohumeral joint can be associated with anteroinferior capsulolabral rupture. To understand its static stabilizing effect better, the collagen fiber orientation of the inferior glenohumeral ligament (IGHL), a component of the anteroinferior capsulolabrum, was studied with a small angle light scattering technique. Three rectangular samples (approximately 11 ϫ 6 mm) were excised from the axillary pouch, one from the anterior band (AB) of the IGHL and one control sample from the long head of the biceps tendon of 7 cadaveric shoulders. The small angle light scattering technique scans the tissue with a heliumneon laser beam and quantifies the fiber alignment based on the resultant scattering pattern. The fiber orientation was quantified by an orientation index, defined as the angle within which 50% of the fibers lie. The axillary pouch had a random orientation, whereas the AB-IGHL was random with some regions of localized alignment. The percentage of tissue with an orientation index range of 25°to 45°was 23.2% Ϯ 8.5% and 29.0% Ϯ 13.1% for the axillary pouch and the AB-IGHL, respectively, whereas that for the long head of the biceps tendon was 61.6% Ϯ 15.2%. This suggests that the collagen fibers in the IGHL are not highly aligned and the anteroinferior capsulolabrum can be modeled as a continuous sheet. Moreover, a biomechanical evaluation of the anteroinferior capsulolabrum that investigates the possibility that the mechanical properties may be directionally independent should be conducted. (J Shoulder Elbow Surg 2003; 12:247-52.) The glenohumeral joint is the most commonly dislocated diarthroidal joint in the body, and after the initial episode, 85% to 90% of young persons have subsequent dislocation. 12 Whereas surgical repair lowers recurrence, redislocation rates are as high as 12% and 23% after open and arthroscopic surgical procedures, respectively. 29 Acute dislocation in human beings was often found to result in a Bankart lesion, 3,4,21 which includes rupture of the anteroinferior capsulolabrum. This is now known to include a lesion of the glenoid insertion site of the inferior glenohumeral ligament (IGHL), 14,18,25 the primary static restraint to anterior translation of the humeral head on the glenoid. Given that surgical repairs have focused on restoration of the anteroinferior capsulolabrum, 1,24 its anatomy has been meticulously studied. The collagen cross-links, collagen fibril diameter and density, amino acid composition, and elastic fibers have also been examined. 23 When compared with the capsule from unstable shoulders, the normal capsule consists of a greater number of cross-links and smaller fibril diameters. Further research has demonstrated that the anterior capsule is composed of areolar (loose connective) tissue. The anterior band (AB), axillary pouch, and posterior band (PB) of the IGHL have been identified, 20 and the ability of each component to resist forces along its long axes in the medial-tolateral direction was studied. 5,6,30 The AB-IGHL exhibits an increased thickness and superior mechanical properties compared with the other components of the capsule. 5 Recent research also demonstrated the importance of the capsular tissue between the AB-IGHL and PB-IGHL, the axillary pouch. 8,17 Significant forces were transmitted in the direction perpendicular to the long axis of the AB-IGHL. In an effort to understand the role of the anteroinferior capsulolabrum in resisting dislocation better, the orientation of the collagen fibers within each of the three regions of the IGHL has been qualitatively examined with polarized light microscopy. 10,20 O'Brien et al 20 found the axillary pouch to be less organized than either the AB-IGHL or the PB-IGHL and demonstrated a great deal of intermingling of the fibers. This finding indicated that the axillary pouch could resist forces other than those in the medial-to-

Purpose: To report a new technique of arthroscopic biceps tenodesis using bioabsorbable interference screw fixation and the early results. Type of Study: Prospective, nonrandomized study. Methods: Technique: The principle of arthroscopic biceps tenodesis is simple: after biceps tenotomy, the tendon is exteriorized and doubled on a suture; the biceps tendon is then pulled into a humeral socket (7 or 8 mm ϫ 25 mm) drilled at the top of the bicipital groove, and fixed using a bioabsorbable interference screw (8 or 9 mm ϫ 25 mm) under arthroscopic control. Patients: 43 patients treated with this technique between 1997 and 1999 were followed-up for at least 1 year. The technique was indicated in 3 clinical situations: (1) with arthroscopic cuff repair (3 cases), (2) in case of isolated pathology of the biceps tendon with an intact cuff (6 cases), and (3) as an alternative to biceps tenotomy in patients with massive, degenerative and irreparable cuff tears (34 cases). The biceps pathology was tenosynovitis (4 cases), prerupture (15 cases), subluxation (11 cases), and luxation (13 cases). Results: The absolute Constant score improved from 43 points preoperatively to 79 points at review (P Ͻ .005). There was no loss of elbow movement and biceps strength was 90% of the strength of the other side. Two patients, operated on early in the series, presented with a rupture of the tenodesis. In both cases the bicipital tendon was very friable and the diameter of the screw proved to be insufficient (7 mm). No neurologic or vascular complications occurred. Conclusions: Arthroscopic biceps tenodesis using bioabsorbable screw fixation is technically possible and gives good clinical results. This technique can be used in cases of isolated pathologic biceps tendon or a cuff tear. A very thin, fragile, almost ruptured biceps tendon is the technical limit of this arthroscopic technique.

The application of tape to the skin overlying the lower fibres of trapezius is generally thought to facilitate this muscle. However, this facilitation has not been thoroughly investigated. In this study, the effect of tape upon trapezius motoneurone pool excitability was assessed using the trapezius H reflex. The amplitude of the H reflex was measured across four conditions: before tape application, with Endura Fix tape, with the addition of Endura Sports tape and finally with the tape removed. Instead of the expected facilitation of lower trapezius, this tape inhibited lower trapezius activity. On average, the application of Endura Fix tape inhibited trapezius by 4%. The application of Endura Sports tape overlaying the Endura Fix tape inhibited trapezius on average by 22%. This inhibition did not last once the tape was removed. This suggests that any change in shoulder girdle symptoms or movement, which occurs with the application of this particular tape is not explicable on the basis of the facilitation of the lower fibres of trapezius. r

Motor improvements in chronic stroke recovery accrue from coupled protocols of bilateral movements and active neuromuscular stimulation. This experiment investigated coupled protocols and within-limb transfer between distal and proximal joint combinations. The leading question focused on within-limb transfer of coupled protocols on distal joints to a bimanual aiming task that involved proximal joints. Twenty-six volunteers completed one of three motor

Paliperidone palmitate (PP) is a long-acting injectable (LAI) antipsychotic, developed for monthly intramuscular (i.m.) administration into deltoid/gluteal muscle, approved for the treatment of schizophrenia in many countries. To assess the options for i.m. injection sites, dose-proportionality of PP was investigated after injection of a single dose (25-150 mg eq.) of PP in either gluteal (n ¼ 106) or deltoid (n ¼ 95) muscle of schizophrenic patients. Overall, mean (geometric) area under plasma concentration-time curve from time zero to infinity (AUC 1 ) of paliperidone increased proportionally with increasing PP doses, regardless of injection site. Mean maximum plasma concentration (C max ) was slightly less than dose-proportional for both injection sites at PP doses >50 mg eq. Mean C max was higher after injection in the deltoid compared with the gluteal muscle, except for the 100 mg eq. dose, while AUC 1 for both injection sites was comparable at all doses. Median time to reach C max (t max ) ranged from 13-14 days after deltoid and 13-17 days after gluteal injection across all doses. Single PP injections in deltoid and gluteal muscles in the dose range of 25-150 mg eq. were generally tolerable both locally and systemically.

Surface electromyographic (EMG) amplitude and mean power frequency (MPF) were used to study the isometric muscular activity of the right versus the left upper trapezius muscles in 14 healthy right-handed women. The EMG activity was recorded simultaneously with force signals during a 10-15 s gradually increasing exertion of force, up to maximal force. Only one side at a time was tested. On both sides there was a significant increase in EMG amplitude (~tV) during the gradually increasing force from 0% to 100% maximal voluntary contraction (MVC). The right trapezius muscle showed significantly less steep slopes for regression of EMG amplitude versus force at low force levels (0%-40% MVC) compared intra-individually with l)igh force levels (60%-100% MVC). This was not found for the left trapezius muscle. At 40% MVC a significantly lower MPF value was found for the right trapezius muscle intra-individually compared with the left. An increase in MPF between 5% and 40% MVC was statistically significant when both sides were included in the test. The differences in EMG activity between the two sides at low force levels could be due to more slow-twitch (type I fibres) motor unit activity in the right trapezius muscles. It is suggested that this is related to right-handed activity.

A graphical description of the change in the role played by each of the scapulohumeral muscles with respect to spatial joint position is presented. Moment arms were collected from a biomechanical model using the tendon travel method. Data cover elevation and flexion in a space between the frontal plane and a plane of elevation 60 anterior to this. Segments of a given muscle were seen possibly to exhibit antagonistic moment components in relation to others, emphasizing the importance of muscle segmentation in biomechanical models. Graphical description of muscle function in conjunction with electromyographic studies enables a more complete assessment of active muscle function in relation to arm motion and position. In cases of attenuated muscular function, this also offers a means of detecting which muscle is involved and which other muscles possess compensating potential. Two examples illustrate the use of this data, particularly to clarify clinical issues.

The effects of breathing on body roll have been previously investigated for the roll of the whole trunk only. The purposes of this study were: to calculate separately the shoulder roll (SR) and hip roll (HR) of swimmers during front crawl for non-breathing and preferred-side breathing conditions; to assess the differences in the magnitude and temporal characteristics of these variables between non-breathing and preferred-side breathing conditions; and to examine their association with swimming performance (indicated by swimming speed). Twelve male swimmers who competed at national and international level performed two maximum 25 m front crawl trials: one non-breathing and one with breathing to their preferred side. Performance was recorded with four below and two above water synchronised cameras. SR and HR in both trials were calculated for the breathing and non-breathing sides. The timings of SR and HR peaks to each side and at the positions of neutral roll were also calculated. Swimming speed was significantly slower in the breathing trial (po 0.01). Swimmers rolled their shoulders and hips to the breathing side significantly more in the breathing than in the non-breathing trial (SR: p o 0.01; HR: p¼ 0.03). Nevertheless, there were no significant differences in the overall SR or HR between these trials. In the breathing trial, SR was higher in the breathing than in the non-breathing side (p o0.01) but HR was not significantly different (p¼ 0.07). There was no evidence to suggest that temporal characteristics of SR or HR were associated with swimming performance.

Today advances in techniques and materials for rotator cuff surgery allow the repair of a large variety of types or extensions of cuff lesions in patients from a wide range of age groups who have different kinds of jobs and participate in different kinds of sports, and who have widely different expectations in terms of recovery of functions and pain relief. A large number of factors must be taken into account before implementing a rehabilita- tion protocol after rotator cuff surgery. These mainly include the technique (materials and procedure) used by the surgeon. Moreover, tissue quality, retraction, fatty infiltration and time from rupture are important biologi- cal factors while the patient’s work or sport or daily activities after surgery and expectations of recovery must also be assessed. A rehabilitation protocol should also take into account the timing of biological healing of bone to tendon or tendon to tendon interface, depending on the type of rupture and repair. This timing should direct the therapist’s choice of correct passive or assisted exercise and mobilisation manoeuvres and the teaching of correct active mobilisation movements the patient has to do. Following accepted knowledge about the time of biolog- ical tissue healing, surgical technique and focused reha- bilitation exercise, a conceptual protocol in four phases could be applied, tailoring the protocol for each patient. It starts with sling rest with passive small self-assisted arm motion in phase one, to prevent post-op stiffness. In phase two passive mobilisation by the patient dry or in water, integrated with scapular mobilisation and stabilis- er reinforcement, are done. Phase three consists of pro- gressive active arm mobilisation dry or in water integrat- ed with proprioceptive exercise and “core” stabilisation. In phase four full strength recovery integrated with the recovery of work or sports movements will complete the protocol. Because of the multi-factorial aspects of the problem, the best results can be obtained through a full transfer of information from the surgeon to the therapist to optimise timing and sizing of the individual rehabilita- tion protocol for each patient.

Patients with gastric adenocarcinoma frequently develop hepatic metastases or peritoneal carcinosis but involvement of the skeletal muscle is extremely rare. We report the case of a 71-year-old man with a painful soft tissue mass in the right shoulder. Two years previously, the patient had been treated for a locally advanced gastric carcinoma (surgery plus chemoradiotherapy). Surgical exploration with biopsy showed skeletal muscle metastasis from the gastric adenocarcinoma in the deltoid muscle. Chemoradiotherapy resulted in complete regression of symptoms from the metastatic lesion. The patient is alive and free of recurrence in the deltoid muscle after a follow-up of 13 months. Based on this case study, the difficulty of diagnosing skeletal muscle metastases, the prognosis and treatment options are discussed.

The aim of the study was to confirm the hypothesis that the longer a contraction is sustained, the larger are the changes in the spatial distribution of muscle activity. For this purpose, surface electromyographic (EMG) signals were recorded with a 13 · 5 grid of electrodes from the upper trapezius muscle of 11 healthy male subjects during static contractions with shoulders 90°abducted until endurance. The entropy (degree of uniformity) and center of gravity of the EMG root mean square map were computed to assess spatial inhomogeneity in muscle activation and changes over time in EMG amplitude spatial distribution. At the endurance time, entropy decreased (mean ± SD, percent change 2.0 ± 1.6%; P < 0.0001) and the center of gravity moved in the cranial direction (shift 11.2 ± 6.1 mm; P < 0.0001) with respect to the beginning of the contraction. The shift in the center of gravity was positively correlated with endurance time (R 2 = 0.46, P < 0.05), thus subjects with larger shift in the activity map showed longer endurance time. The percent variation in average (over the grid) root mean square was positively correlated with the shift in the center of gravity (R 2 = 0.51, P < 0.05). Moreover, the shift in the center of gravity was negatively correlated to both initial and final (at the endurance) entropy (R 2 = 0.54 and R 2 = 0.56, respectively; P < 0.01 in both cases), indicating that subjects with less uniform root mean square maps had larger shift of the center of gravity over time. The spatial changes in root mean square EMG were likely due to spatially-dependent changes in motor unit activation during the sustained contraction. It was concluded that the changes in spatial muscle activity distribution play a role in the ability to maintain a static contraction.

The importance of proximal-to-distal sequencing in human performance throwing has been reported previously. However, a comprehensive comparison of the proximal-to-distal sequence in team-handball throwing in athletes with different training experience and competition is lacking. Therefore, the aim of the study was to compare the ball velocity and proximal-todistal sequence in the team-handball standing throw with run-up of players of different skill (less experienced, experienced, and elite). Twenty-four male team-handball players (n ¼ 8 for each group) performed five standing throws with run-up with maximal ball velocity and accuracy. Kinematics and ball trajectories were recorded with a Vicon motion capture system and joint movements were calculated. A specific proximal-to-distal sequence, where elbow flexion occurred before shoulder internal rotation, was found in all three groups. These results are in line with previous studies in team-handball. Furthermore, the results of the present study suggest that in the team-handball standing throw with run-up, increased playing experience is associated with an increase in ball velocity as well as a delayed start to trunk flexion.

Introduction: Shoulder stiffness is a frequent complication of surgical repair of rotator cuff tears. Post-operative stiffness negatively affects surgical outcomes leading to a substantial comorbidity and to the failure of surgical treatment. Also, a stiff shoulder could commonly be concomitant with an rotator cuff tear (RCT).

Survivors of spinal cord injury need to reorganize their residual body movements for interacting with assistive devices and performing activities that used to be easy and natural. To investigate movement reorganization, we asked subjects with high-level spinal cord injury (SCI) and unimpaired subjects to control a cursor on a screen by performing upper-body motions. While this task would be normally accomplished by operating a computer mouse, here shoulder motions were mapped into the cursor position. Both the control and the SCI subjects were rapidly able to reorganize their movements and to successfully control the cursor. The majority of the subjects in both groups were successful in reducing the movements that were not effective at producing cursor motions. This is inconsistent with the hypothesis that the control system is merely concerned with the accurate acquisition of the targets and is unconcerned with motions that are not relevant to this goal. In contrast, our findings suggest that subjects can learn to reorganize coordination so as to increase the correspondence between the subspace of their upper-body motions with the plane in which the controlled cursor moves. This is effectively equivalent to constructing an inverse internal model of the map from body motions to cursor motions, established by the experiment. These results are relevant to the development of interfaces for assistive devices that optimize the use of residual voluntary control and enhance the learning process in disabled users, searching for an easily learnable map between their body motor space and control space of the device.

We aimed to determine the effect of manipulation under anesthesia in frozen shoulder patients. A blinded randomized trial with a 1-year follow-up was performed at 3 referral hospitals in Southern Finland. We randomly assigned 125 patients with clinically verified frozen shoulder to the manipulation group (n ϭ 65) or control group (n ϭ 60). Both the intervention group and the control group were instructed in specific therapeutic exercises by physiotherapists. Clinical data were gathered at baseline and at 6 weeks and 3, 6, and 12 months after randomization. The 2 groups did not differ at any time of the follow-up in terms of shoulder pain or working ability. Small differences in the range of movement were detected in favor of the manipulation group. Perceived shoulder pain decreased during follow-up equally in the 2 groups, and at 1 year after randomization, only slight pain remained. Manipulation under anesthesia does not add effectiveness to an exercise program carried out by the patient after instruction. (J Shoulder Elbow Surg 2007;16:722-726.)

Static superior shoulder instability is associated with long-standing rotator cuff tears. Factors or mechanisms which can prevent superior migration of the humeral head, and therefore allow preservation or restoration of shoulder function despite nonanatomical cuff repair, are poorly understood. The question has therefore arisen, whether centering of the humeral head was the result of active shoulder muscle function. It was the goal of this experimental investigation to (1) determine the pattern of glenohumeral translations during active shoulder abduction measured by openmagnetic resonance imaging (MRI) techniques, and to (2) determine the influence of experimental paralysis of the infra-and supraspinatus muscles on these translations. In contrast to prior experimental investigations, the humeral head remained always centered in the glenoid fossa during active abduction. No superior migration of the humeral head could be provoked with experimental paralysis of the supra-and/or infraspinatus muscles. The hypothesis that static or dynamic superior humeral head displacement is prevented by active-supra-and/or infraspinatus muscle function must therefore be rejected, for the shoulder with a structurally intact muscle-tendon-bone unit.

• ▶ sports injury prevention • ▶ rotator cuff strength • ▶ isokinetic • ▶ overhead sports • ▶ strength imbalance Shoulder Strength Imbalances as Injury Risk in Handball handball related injuries, as the fourth most prominent overall [ 20 , 24 ]. Furthermore, chronic shoulder pain appeared to be the most frequent symptom among the players (19 %) [ 24 ] , and acute shoulder injuries were not uncommon (1-9 %) [ 17 ]. Handball shoulder pathologies seem to be due to overuse and to micro-traumatic pathologies. Considering that handball players perform up to 48 000 throws per year, that the shoulder plays a major role in throwing performance [ 1 , 3 , 28 ] , and that the risk and rate of shoulder injury are high [ 17 , 24 , 28 ] , the prevention of shoulder injuries, by a structured step-by-step approach [ 2 , 27 ] , becomes a relevant and important focus. This is an especially important focus in the adolescent or youth female population, due to the high injury incidence, in order to prevent long-term or even permanent damage of the developing tissues and aff ected structures [ 5 , 26 ]. Among the intrinsic risk factors associated with the prevention of shoulder injury in handball players (such as modifi ed range of motion, scapulo thoracic dyskinesis, microinstability and muscle failure [ 29 , 31 ]), we chose to focus our Affi liations Affi liation addresses are listed at the end of the article Affi liations

Hypothesis: Posterolateral rotatory instability (PLRI) of the elbow results from injury to the lateral collateral ligament complex from trauma or iatrogenic injury. The lateral pivot-shift test (PST) is standard for diagnosing PLRI, but its subjectivity affects diagnosis and makes it difficult to train young surgeons. Awell-controlled investigation has not been done to quantify interclinician and intraclinician variability in PST mechanics in the intact and unstable elbow. The authors predict that there exist differences in PST mechanics between clinicians. Materials and methods: Five unpaired elbow specimens underwent PST intact and after sequential sectioning of lateral stabilizing ligaments. Multiple PST trials were performed on each specimen by 3 clinicians (1 expert, 2 in-training) while 3-dimensional motion and loads were recorded. Intraclinician and interclinician variability were analyzed. Results: Mean supination torque, valgus torque, and axial force were 3.6 AE 1.9 Nm, 5.6 AE 3.1 Nm, and e8.3 AE 15.7 N, respectively. Mean radial head displacement was 13.7 AE 4.6 mm. There were no significant differences in these measures after sequential ligament sectioning. One surgeon (in-training 2) applied significantly greater axial compressive forces across the elbow joint (5-9 N difference). Variability of axial force (380% AE 473%) was greater than that of supination torque (20% AE 11%), valgus torque (14% AE 4%), and radial head displacement (8% AE 6%; P < .05 for analysis of variance). Discussion: The clinicians performed the PST consistently and with comparable loads, with the exception of axial compressive force across the radiohumeral joint, which varied across clinicians by 1 to 2 pounds (5-9 N). Conclusion: This study suggests that the PST is a mechanically reproducible clinical examination, despite differing levels of training in performing the maneuver. With the exception of axial force, PST mechanics are highly repeatable for a given surgeon applying the test on a single specimen.

Background and Objective. Frozen shoulder syndrome (FSS) causes pain and restriction of movement in the shoulder. The aim was to assess changes in shoulder muscle isometric maximal voluntary contraction (MVC) force and active range of motion (AROM) in patients with frozen shoulder syndrome (FSS) after manipulation under general anesthesia (MUA).

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To delineate factors that differentiate shoulder dystocia with and without brachial plexus injury (BPI). A case-control study culled from an established shoulder dystocia database. Cases of shoulder dystocia-related BPI were identified and matched (1:1) with a control group of shoulder dystocia in which BPI did not result. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. From 1980 to 2002, there were 89 978 deliveries with 46 cases of dystocia and BPI. The rate of dystocia with BPI was 0.5 per 1000 births and of permanent BPI, 0.9/10 000 deliveries. The two groups were similar for maternal demographics, diabetes, gestational age, induction, use of epidural, the duration of labor, operative vaginal delivery, rate of macrosomia, and maneuvers used to relieve the dystocia. Fracture of the clavicle occurred significantly less often among those without (2%) vs. with BPI (17%; OR 0.10, 95% CI 0.01, 0.88). Neither antepartum nor intrapartum factors can differentiate the ...

In recent years the popularity of disabled sports and competition among disabled athletes has grown considerably. With this rise in exposure of, and participation in wheelchair sports comes an increase in related stressors, including musculoskeletal load. External mechanical loading may increase the risk of shoulder complaints. The objective of this literature review was to 1) identify and describe the prevalence and/or incidence of shoulder complaints in wheelchair athletes in the literature, to 2) examine the factors and underlying mechanisms that could be potentially involved, and 3) provide some insights into the development of preventative measures. A literature search was conducted using PubMed, Scopus and Embase databases, to identify relevant published articles. All articles in the English language that contained any type of shoulder complaint in relation with a wheelchair sports player, at any level of status (recreational to elite), of any sport, were included. Articles we...

To verify the precise anatomy of fhe radial tunnel, 60 cadaver elbows were dissected with special reference to 7 parameters: [I 1 the distance between the lateral intermuscular septum and he site of division of radial nerve into ik superficial and posterior interosseous branches was 92 mm (85 to 7 20 mm], (2) the length of the posterior interosseous nerve from its division to the arcade of frohse IAF) was 46 mm (35 to 65 mm), (31 fhe average disfance between the radial head and AF was 2 I mm / I7 to 30 mm], (41 the average length of its branch to the extensor carpi radialis brevis muscle from its division to AF was 28 mm (20 to 45 mm], (51 the average distance of the supinator branch from ik division to AF was 2 I mm (15 to 28 mm), (6) fhe relationship between the posterior interosseous nerve and the recurrent radial artery showed several variations, and (71 the texture of AF was fibrous in 80% and was membranous in 20%. We recommend that anatomic variations should be kept in mind to avoid complications during radial tunnel surgery 0 Shoulder

Purpose: Radiation therapy for head-and-neck cancer requires a reliable immobilization for an accurate and consistent treatment setup. This prospective, randomized study was done to compare two types of Posicast thermoplastic face masks, in terms of reproducibility, patient comfort, tolerability, and skin damage. Methods and Materials: The patients were randomly assigned to use a head mask (HM) or a head-and-shoulder mask (HSM). Three-dimensional treatment planning was followed by fractionated external-beam radiation therapy. Reproducibility was assessed by comparing port films with simulator films twice during treatment and by comparing actual treatment table positions weekly. Patient tolerability and comfort were studied weekly. The radiation-induced skin damage was assessed every week according to the World Health Organization toxicity scale. Results: A total of 260 patients were included, and 241 (93%) were evaluated. There were no statistically significant differences between the groups (HM or HSM) in terms of reproducibility. Patients using HSM experienced significantly more claustrophobia (p ‫؍‬ 0.023). Patients allocated to HSM receiving >60 Gy were found to have more skin reactions. Conclusions: The smaller HM reduced feelings of claustrophobia, as well as skin reactions, for patients receiving >60 Gy. The smaller mask did not compromise the reproducibility of the setup. © 2005 Elsevier Inc.

Hammersmith Infant Neurological Examination (HINE) is a set of tests used for grading neurological development of infants on a scale of 0 to 3. These tests help in assessing neurophysiological development of babies, especially preterm infants who are born before (the fetus reaches) the gestational age of 36 weeks. Such tests are often conducted in the follow-up clinics of hospitals for grading infants with suspected disabilities. Assessment based on HINE depends on the expertise of the physicians involved in conducting the examinations. It has been noted that some of these tests, especially pulled-to-sit and lateral tilting, are difficult to assess solely based on visual observation. For example, during the pulled-to-sit examination, the examiner needs to observe the relative movement of the head with respect to torso while pulling the infant by holding wrists. The examiner may find it difficult to follow the head movement from the coronal view. Video object tracking based automatic or semi-automatic analysis can be helpful in this case. In this paper, we present a video based method to automate the analysis of pulled-to-sit examination. In this context, a dynamic programming and node pruning based efficient video object tracking algorithm has been proposed. Pulled-to-sit event detection is handled by the proposed tracking algorithm that uses a 2-D geometric model of the scene. The algorithm has been tested with normal as well as marker based videos of the examination recorded at the neuro-development clinic of the SSKM Hospital, Kolkata, India. It is found that the proposed algorithm is capable of estimating the pulled-to-sit score with sensitivity (80%-92%) and specificity (89%-96%).

S houlder dysfunction is the second most common musculoskeletal problem seen in physical therapy 42 and affects approximately 16% to 21% of the population. 22,43 It is a leading cause of sick days among young adults, 21 and its prevalence in persons 65 years and older is 34%. 24 The direct cost for the treatment of shoulder dysfunction in the United States exceeds $7 billion annually. 30 There are numerous underlying musculoskeletal causes of shoulder dysfunction. These include tendinopathy, bursitis, rotator cuff tear, adhesive capsulitis, avascular necrosis, shoulder impingement syndrome, glenohumeral osteoarthritis, and trauma from injury. Shoulder dysfunction results in a variety of impairments such as pain, stiffness, weakness, postural deviations, and altered glenohumeral rhythm. These impairments, in turn, lead to limitation of activities of daily living such as reaching, lifting, overhead movements, carrying, pushing, pulling, grooming, and sleep. Common approaches to treating individuals with shoulder dysfunction are corticosteroid injections, nonsteroidal anti-inflammatory drugs, manipulation under general anesthesia, arthroscopic surgery, and physical therapy intervention, including therapeutic exercises, manual therapy, and various modalities. Prior studies have shown that medical and surgical interventions are not superior to physical therapy interventions for patients with shoulder dysfunction. 11,15,42 Therapeutic exercise is defined as "the systematic performance or execution of T T LEVEL OF EVIDENCE: Therapy, level 1a- .

Background: Shoulder osteoarthritis (OA) is a painful condition in which movement of
the shoulder becomes restricted. Treatment is aimed at pain reduction and maintain
or improve functions. Intra-articular steroid injections have proven to be an effective
and cost-effective treatment option. However, long-term use can weaken the shoulder
tendons and cause histological changes. Recently, botulinum toxin has been evaluated
for the treatment of the chronic joint pain. Its injection into the painful shoulder joints
may inhibit the inflammatory mediators and the neuropeptide release which act on
articular nociceptors and produce pain.
Objective: The present study compared the efficacy of ultrasound-guided intra-articular
Botox and corticosteroid injections in glenohumeral joint in terms of reduction of pain
scores and enhancing range of movement in patients with shoulder OA.
Methodology: Fifty eligible patients with shoulder OA were randomly assigned to two
groups of Botox and corticosteroid (each with 25 patients). Ultrasound-guided intraarticular injections were randomly performed in all participants. Patients were evaluated in terms of effect on pre-procedure pain scores, range of abduction, internal rotation and external rotation, at 2 weeks and 12 weeks after injection. Two-way ANOVA and t-tests were utilized to analyze the data.
Results: The study results indicated that the injection of Botox and corticosteroid in
the shoulder joint cause reduction in pain and increased range of movements of the
patients with glenohumeral OA. Botox injection exerts more long-lasting effects in
comparison to the corticosteroid group. Mean pain scores were lower in Botox group in comparison to the steroid group (2.75 vs. 4.24); patients in the Botox group experienced more pain reduction at week-12 and more increase in range of abduction, internal rotation and external rotation.
Conclusion: It is concluded that intra-articular Botox injection can be more useful than
intra-articular steroid injection in terms of pain reduction and function improvement.
Key words: Osteoarthritis; Botulinum toxin; Pain management; Acetylcholine; Receptors, Cholinergic
Citation: Hashemi SM, Khamene SMH, Nabi BN, Ghasemi M. Effects of ultrasound guided intraarticular botox vs. corticosteroids for shoulder osteoarthritis. Anaesth
Pain & Intensive Care 2018;22(3):355-360

Shoulder stabilization is of utmost importance in upper extremity reanimation following paralysis from devastating injuries. Although secondary procedures such as tendon and muscle transfers have been used, they never achieve a functional recovery comparable to that following successful reinnervation of the supraspinatus, deltoid, teres minor, and infraspinatus muscles. Early restoration of suprascapular and axillary nerve function through timely brachial plexus reconstruction offers a good opportunity to restore shoulder-joint stability, adequate shoulder abduction, and external rotation function. Overall, in our series, 79% of patients achieved good and excellent shoulder abduction (muscle grade, þ3 or more), and 55% of patients achieved good or excellent shoulder external rotation after reinnervation of the suprascapular nerve. The best results were seen when direct neurotization of the suprascapular nerve from the distal spinal accessory nerve or neurotization by the C5 root was carried out. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction and external rotation function.

Objective: To ascertain whether brachial plexus palsy (BPP) that occurs without shoulder dystocia (SD) represents a traction injury during unrecognized SD or a natural phenomenon with a different mechanism of injury, we compared risk factors and outcomes between SD-associated and non-SD-associated BPP. Study design: Neonates with BPP after cephalic vaginal delivery were pooled from all deliveries at Johns Hopkins (June, 1993-December, 2004) and a dataset of litigated permanent BPP from multiple institutions (1986)(1987)(1988)(1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003), grouped by SD association based on clinician documentation and compared by using Fisher exact and t tests. Results: Thirty percent of 49 non-SD-BPP and 11% of 280 SD-BPP lacked all risk factors for SD (P = .002). Compared with SD-BPP infants, non-SD-BPP infants were average weight (P ! .001) and had cord pH less than 7.10 (P = .01) more commonly and exhibited a trend toward posterior shoulder involvement (P = .06). Nearly all non-SD-BPP were temporary, whereas more than 90% of permanent BPP were associated with SD (odds ratio 17, 7.3-39.6). Conclusion: Non-SD-BPP is uncommon and likely mechanistically distinct from SD-BPP. Risk factors, birth weight, fetal acidosis, posterior arm involvement, and injury severity distinguish between shoulder dystocia-related brachial plexus injuries and those not recorded as such.

Background: Effectiveness of any individualized therapeutic modality in reducing pain in frozen shoulder is questionable and the combination of therapies has contradictory results. Objectives: The purpose of this study was to check the effectiveness between the treatment modalities of Ultrasound therapy and End range mobilization over Cryotherapy and Stretching as a treatment program in alleviating pain of patients with frozen shoulder. Methods: Forty subjects diagnosed to have frozen shoulder were randomly assigned to two groups. Subjects in Group I received Ultrasound therapy and End range mobilization of shoulder while subjects in Group II got Cryotherapy and Stretching of shoulder. Both the groups were treated for 6 days a week for 4 weeks. Response to pain was considered as the outcome measure. Results: Statistical analysis was done considering p<0.05 as statistically significant and the"t" value were estimated. It was found that ultrasound therapy when combined with end range mobilization had"t" value of 1.8342 in comparison to that of cryotherapy combined with stretching group. Conclusion: Ultrasound therapy with end range mobilization produced a better result than cryotherapy with stretching in reducing pain and therefore can be recommended in the treatment of frozen shoulder.

Objective: Shoulder sports injuries are relatively common in athletes who perform highly repetitive motions. The purposes of this study were to determine the prevalence of and risk factors for shoulder injuries and to analyze how individual and other sport characteristics contribute to the risk of shoulder injuries among 6 overhead sports, those being swimming, rowing, wrestling, basketball, volleyball, and handball. Methods: A cross-sectional study was carried out on 613 Iranian overhead sports athletes in different collegiate sport fields. Data were collected using different questionnaires. A structured questionnaire including demographics, sport characteristics, and also prevalence and risk factors of shoulder pain was used. Visual analogue scale and Disability of the Arm, Shoulder, and Hand questionnaires were used to determine the pain intensity and functional disability, respectively. Results: Point, last 6-month, last year, and lifetime prevalences of shoulder pain were 21.4%, 29%, 38.8%, and 41.6%, respectively. The highest point prevalence was related to the rowing athletes with 31.9% and the lowest for swimming athletes (12.3%). Sex, body mass index, sport level, days of practice per week, and satisfaction with income were found to be significantly correlated with the prevalence of shoulder pain (P b .05 in all instances). For those with shoulder pain, the mean pain intensity and functional disability were 53.8 mm and 15.46%, respectively. Conclusions: The prevalence of shoulder pain in athletes with highly repetitive overhead motions seems to be high. (J Manipulative Physiol Ther 2012;35:541-548)

Background: Augmentation of rotator cuff tears aims to strengthen the repair and reduce rerupture, yet studies still report high failure rates. This study determines key mechanical properties of rotator cuff repair patches, including establishing values for toughness and measuring the shear properties of repair patches and human rotator cuff tendons. We hypothesized that different repair grafts would (1) have varying material parameters, and (2) not all have mechanical properties similar to human rotator cuff tendons. Materials and methods: Eight specimens each from the Restore, GraftJacket, Zimmer Collagen Repair, and SportsMesh repair patches were tested to failure in tension and for suture pullout. We assessed ultimate tensile strength, tensile (Young's) modulus, and failure strain. This study also established toughness values and shear data. Storage modulus was calculated using dynamic shear analysis for the patches and 18 samples of normal rotator cuff tendon. Results: We report significant variability in important mechanical properties of repair patches, with the mechanical parameters of the patches diverting variouslydand often significantlydfrom values for human rotator cuff tendon.

We performed a retrospective review to evaluate acute medial collateral ligament injuries of the elbow in professional football players from 1991 to 1996 (5 seasons). There were 5 acute medial collateral ligament injuries in 4 players (1 player with bilateral involvement). All injuries occurred with the hand planted on the playing surface while a valgus or hyperextension force was applied to the elbow. There were 2 centers, both involved with long-snapping situations, 1 running back, and I quarterback. All elbows had valgus instability on physical examination. Despite this instability, all players were able to function without operative reconstruction of the medial collateral ligament. No evidence of valgus instability was seen at the time of follow-up (average, 3.4 years). Next, we reviewed all acute elbow injuries in the National Football League from the same 5-season period. Ninetyone acute elbow injuries were reviewed. Overall, there were 70 (76.9%) elbow sprains, 16 (17. 6 %) dislocation/ subluxation patterns, 4 (4.4%) fractures, and 1 (1.1%) miscellaneous injury. Review of the acute elbow sprains revealed 39 (55.7%) hyperextension injuries, 14 (20%) medial collateral ligament injuries, 2 (2.9%) lateral collateral ligament sprains, and 15 (21.4%) nonspecific sprains. The epidemiology of the 14 medial collateral ligament injuries was studied in more detail. The 2 most common mechanisms of injury were blocking at the line of scrimmage (50%) and the application of a valgus force with the hand planted on the playing surface

We report the case of a 79-year-old female who underwent a cemented shoulder hemiarthroplasty for a comminuted proximal humerus fracture. She recovered well postoperatively until 35 hours post-surgery when she suddenly developed dyspnea and went into cardiopulmonary arrest. Although she was initially resuscitated and transferred to the intensive care unit, she never regained consciousness and eventually expired on the 5 th postoperative day. At autopsy, microscopic examination of a wedge-shaped pulmonary infarct using Oil Red O staining disclosed bright, red-orange deposits in the capillaries and alveolar spaces compatible with fat globules. After a thorough search on Medline, it appears that this is the first documented case of fat embolism syndrome occurring after a shoulder replacement surgery.

OBJECTIVE: A mathematic model was developed to estimate the compressive pressure on the fetal neck overlying the roots of the brechial plexus by the symphysis pubis during a shoulder dystocia event. The induced pressure was calculated for both exogenous (clinician applied) and endogenous (maternal and uterine) forces during the second stage of labor. STUDY DESIGN: Intrauterine pressure and clinician-applied force data were taken from the existing literature. A free-body diagram was generated and equilibrium equations were used to calculate the contact pressure between the bass of the fetal neck and the symphysis pubis during a shoulder dystocia event. RESULTS: Clinician-applied traction to the fetal head (exogenous force) led to an estimated contact pressure of 22.9 kPa between the fetal neck and the symphysis pubis. In contrast, uterine and maternal expulsive efforts (endogenous forces) resulted in contact pressures that ranged from 91.1 to 202.5 kPa. The estimated pressures resulting from endogenous forces are 4 to 9 times greater than the value calculated for clinicianapplied forces. CONCLUSION: Neonatal brachial plexus injury is not a priori explained by iatrogenically induced excessive traction. Spontaneous endogenous forces may contribute substantially to this type of neonatal trauma. (Am J Obstet Gyneco12000;182:689-91 .)

The purpose of this study was to determine the biomechanical and anthropometric factors contributing to elbow valgus torque during pitching. Video data of 14 youth pitchers throwing fastballs were used to calculate shoulder and elbow kinematics and kinetics. Peak elbow valgus torque averaged 18 Nm and occurred just before maximal shoulder external rotation. The magnitude of valgus torque was most closely correlated with the thrower&#39;s weight. When subject weight and height were controlled for, maximum shoulder abduction torque and maximum shoulder internal rotation torque were most strongly associated with elbow valgus torque, accounting for 85% of its variance (P &lt;.001). When only kinematic variables were considered, maximum shoulder external rotation accounted for 33% of the variance in valgus torque. Given that the biomechanical variables correlated with peak valgus torque are not easily modifiable, limiting the number of innings pitched is likely the best way to reduce elb...