Paralysis of the long thoracic nerve is rare and the symptom of this lesion shows evident winging of the scapula. Sometimes it occurs by trauma and sports. We experienced two cases for which the causes of this palsy were unknown. One case was a 31-year-old woman and the other a 22-year-old man. The symptoms occured suddenly and the cause was not clear in either case. They showed evident winging of the scapula when elevating their affected shoulders in the flexed position. Blood analyses, shoulder and neck rentogenograms and MRI were normal. Electromyographic examinations showed a neurogenic pattern of the serratus anterior muscle and a delay in the long thoracic nerve's conduction velocity. These cases are thought to be an example of neuralgic amyotrophy and should be treated by conservative method.
Deep breathing causes a transient decrease of blood flow in the arms by neuro reflex and systematic circulation. Deep breathing is contained in Adson's maneuvers, and so we evaluated it in 42 TOS subjects and 30 healthy subjects. The reaction time during which the blood decreases and the cardiac waves were examined by Laser Doppler Flowmetry on the condition that 1)They were breathing deeply while sitting position 2)Adson's test 3)Reverse Adson's test.10 operative subjects with anomalies of the thoracic outlet portion were examined retrospectively by the same method. The reaction time and cardiac waves during Adson's test agreed with those of breathing deeply while sitting. No cases had any signs of a continuous decreasing blood flow or obliteration of the cardiac waves. These findings indicate that Adson's test is greatly effected by the neuro reflex of deep breating, and this test does not reflect the vessel compression. Accordingly Adson's test is not too useful as a vessel compression test.
Purpose The purpose of this study was to collect information about osteopenia in the upper end of the humerus from a series of individuals suffering from periarthritis of the shoulder. The BMD of the greater tubercle of the humerus in cases of periarthritis of the shoulder and in the reference cases was measured by using DEXA (Dual energy X-ray absorptiometry). Materials and methods In 18 cases of periarthritis of the shoulder,10 men and 8 women, the bone mineral density of the greater tubercle of the humerus was evaluated. The average age of the patients was 56.5 years for the men and 57.6 years for the women. The reference cases,9 men and 9 women, randomly selected from people (range,24-62) without any history of injury or disease in the upper extremities, had their bone mineral density measured. Results In the reference cases, the humerus of the handedness contained more mineral than did the contralateral one. All the women with periarthritis of the shoulder were right-handed and in all but one it affected the right side. Except in one case, there was a significant decrease of bone mass in the affected side as compared to that of the unaffected one. In the cases of men with periarthritis of the shoulder, the humerus of the handedness had a tendency to contain more mineral than did the contralateral one. Age, range of motion and duration of the disease did not seem to influence the degree of osteopenia. Condusion (1) The BMD of the greater tubercle of the humerus was measured by using DEXA. (2) The degree of osteopenia associated with periarthritis of the shoulder was significant in females. (3) In the reference cases, the mineral density was found to be higher in males and in the handed side.
The purpose of this study was to clarify the degree and related factor of bone mineral loss in the proximal humerus in patients with frozen shoulders. The subjects consisted of 10 cases of unilateral shoulder contracture without proceding trauma. The average age of the patients was 56 years. The mean duration of disability was 5.8 months (2-12 months). The bone mineral content (BMC) was mesured through dual energy X-ray absoptiometry using a Norland XR 26. The BMC of frozen shoulders was 83% in the proximal humerus,92% in the humeral shaft and 99% in the distal end of the radius compared to that of the unaffected side. The BMC was markedly reduced in the proximal humerus of a frozen shoulder. The age of the patients, the duration of disability, and the range of flexion was not correlated with osteopenia in the proximal humerus of the frozen shoulder. Two shoulders with 2 months' history showed significant osteopenia. The impairment of external rotation and external rotation ratio compaired to the unaffected side was slightly correlated with a loss of BMC in the proximal humerus. In conclusion, frozen shoulder was associated with significant osteopenia in the proximal humerus. This seemed to appear in the early phase of the disease. The impairment of external rotation was slightly correlated with the bone mineral content in the proximal humerus of frozen shoulder.
We will report on a study of real time ultrasonographic examinations to specify the pathognomonic factor of frozen shoulder. Ultrasonography was performed on 30 patients who suffered from unilateral frozen shoulder with the other side intact. The examination consisted of two series. Firstly, observation of each component of the rotator cuff was performed and it's thickness was measured. Secondarily, observations of the coraco-humeral ligament were performed dynamically and statically. The dynamic observation of the coraco-humeral ligaments was performed during the maximum internal and external rotation of the shoulder with special emphasis on elastisty of the ligaments. The static one consisted of measuring the length and thickness of the coraco-humeral ligament. Ultrasonographic findings were summarized as follows: There was no significant difference in the thickness of each rotator cuff component between the affected side and the normal one. No abnormal signs were found on the deltoid or the humeral head in any case. As concerns the dynamic observation of the coraco-humeral ligaments, the ligament of the affected side was revealed as being too stiff to expand fully during external rotation, while the ligament of the normal side had much elasticity. In conclusion, contracture of the coraco-humeral ligament was highly suggested as a pathognomonic factor of frozen shoulder.
Thirty-one shoulder arthrographies performed on frozen shoulder were studied before and after closed manipulative treatment. Patients were 15 males and 16 females aged 40 to 69, average 53years with 20 left and 11 right shoulders. Average duration was 6.5 months (1 to 60 months). All cases showed the typical syndrome of frozen shoulder with pain and stiffness. There were 20 Severe Degrees and 11 Moderate Degrees. Closed manipulative treatment was performed under brachial plexus anesthesia. Meglucamine Diatrizoate and air were injected into the shoulder joint before manipulation. The affected shoulders were studied radiologically. Before Manipulation, decreased volume with increased pressure and insufficient filling or rough edge of the shoulder capsule were found showing the adhesive changes of the shoulder. After manipulation the contrast medium was spreaded to the pertoralis major or the upper part of the humerus. There was no sign of fullthickness rotator caff tear to be found before and after manipulation. After the recovery of the shoulder motion, arthrography of the shoulder was reviewed again and found that the joint capsule was enlarged with intact feature showing the adhesive capsule can be returned to the normal condition basically and no dislocation of the biceps was shown.
[Purpose] The purpose of this paper is to think about the pitching form which causes chronic shoulder pain. [Method and materials] We questioned 145 male students and 117 college and semi-professional baseball players. How they used their bodies during a delivery, where their thumbs went just after its release and where they directed their palms in the cocking phase. [Results] “My thumb goes out of my palm,” was the answer given by 49.6% of the students and 10.3% of the pitchers and 21.3% of the other players. “My forearm is in a neutral position in the cocking phase, ” was the anwser of 43.4% of the students and 13.8% of the pitchers and 30.9% of the other players. These answers are very popular among young athletes with shoulder pain. This form necessitates a large rotation of the humerus during a delivery. This cumulative rotational force of the humerus causes an overuse injury of the shoulder. [Conclusions] We should recognize which techniques can be used rationally, so that the body will deliver without provoking shoulder pain. One of these is the rotation of the trunk and not the humerus. Looking for a rational form is a new aproach in the diagnosis and therapy of the overuse syndrome.
(Purpose) Many kinds of epiphyseal disorders have been reported on young athletes. Little league shoulder is one of the most important and famous epiphyseal disorders of the shoulder. In this report, we studied the management and the results of cases of epiphyseal disorders in the shoulder. (Patients and Methods) From January 1988 to June 1992, there were 18 cases of epiphyseal disorders in the shoulder in our clinic and sport clinic at Kumamoto Kaiseikai Hospital. There were 17 males and one female (aged 10-14). They consisted of 15 cases of little league shoulder and 3 cases of acrominal epiphysiitis. All of the cases were treated conservatively (iced massage, muscular strengthening exercises, stretching exercises etc. ). The cases with little league shoulder were prohibited from throwing during a certain time period. (Results) All of the cases recovered conservatively, but the recovery time of the cases of little league shoulder was usually longer than the others. Only one case recurred the same symptoms 2 years after. (Conclusion) Epiphyseal disprders in the shoulder are not rare in young athletes. We should diagnose them as soon as possible, for in the early stage of these disorders most of the cases recover easily by conservative treatments.
<Purpose> Since 1985, when Andrews et al. first described injury of the biceps tendon/labrum complex(BLC), many authors have reported on this injury with the advancement of the arthroscopic procedure. However no detailed anatomical investigation of the BLC has been reported. The purpose of this study was to determine the anatomical relationship between the biceps tendon and the labrum. <Materials and methods> Thirty one shoulder joints from 20 cadavera were observed macroscopically and microscopically. The age at death ranged from 48 to 92 years(mean 76 years). The distance from the top of the glenoid to its connection with the labrum was measured, and the labrum including its connection to the long head of the biceps was resected, and stained with hematoxylin and eosin. <Results> The fiber of the biceps long head and the labrum were observed to blend together at the anterior portion of the superior labrum. The continuity of the tendon and the labrum was so smooth that the location of their connection could not be identified macroscopically. On the other hand microscopically, the collagen fibers of each structure could easily be distinguished from the others, and no tight connection between them was observed. <Conclusion> Our anatomical investigation of the BLC revealed that, macroscopically, the long head of the biceps appeared to blend smoothly into the anterior portion of the superior labrum, but that microscopically, the collage fibers of the biceps tendon could be distinguished from those of the labrum and that the connection between them was loose at the top of the glenoid. These findings suggest that this portion is one of the vulnerable site to injury.
After detachment from the glenoid rim, the biceps tendon and labral complex (BLC) tend to transpose inferiorly, and become trapped between the humeral head and the glenoid fossa, often causing shoulder pain. This condition is called detached and floating BLC (D&F BLC). Few useful imaging tests for this injury have been reported, and it is usually only diagnosed by arthroscopy. In this study, we investigated the specific features of D&F BLC on CT arthrography (CTA) and MRI. Pre-operative CTAs were performed on 25 patients with D&F BLC and MRI was also carried on 13 of these patients. As controls, we studied 40 patients who had no abnormalities of the BLC at arthroscopy. The specific CTA finding indicating D&F BLC was the presence of air between the superior labrum and the glenoid fossa, and this finding was recognized in 12 patients who had D&F BLC (48%). In the control group, this finding was only noted in 2 cases. The specific MRI finding indicating D&F BLC was a linear high intensity area at the base of the superior labrum on T-2weighted oblique coronal views. This finding was recognized in 6 patients who had D&F BLC, (46%), while it was noted in only 1 of the control group. Therefore, the specificity of CTA for D&F BLC was 95% and its sensitivity was 48%, while the specificity of MRI was 96% and its sensitivity was 46%.
Cases with shoulder pain during movement caused by a lobral injury are reported here. The cases with recurrent shoulder dislocation were excluded. Ten cases with a range in age of from 16to 46 years old (28 on an average) were operated on. Six out of the 10 cases had episodes of shoulder trauma and 8 cases had been active in sports for a long time. Double contrast CT arthrography of the shoulder was performed in all of the cases before the operation and also in 6 cases after the operation. Partial resection of the labrum detached from the glenoid rim and slipped into the joint space was performed under arthroscopy in 7 cases, direct repair of the labrum and then the capsule in one case and tenodesis of the long tendon of the biceps was added in 2 cases. The post-operative follow-up period was 3 to 15 months (9 months on an average). A superior labral lesion was found arthroscopically in 9 cases consisting of 4 cases of superior labral lesion alone and 5 of a lesion associated with other intraarticular lesions. The associated lesions were degeneration of the long tendon of the biceps (2 cases), detachment of the anterior joint capsule (1), rupture of the anteroinferior labrum (2), degeneration of the middle one third of the anterior labrum (1), a loose body (1) and a bony Bankart's lesion (1). A common arthroscopic finding in these cases which had complained of apprehension due to a shoulder dislocation was the detachment of the anterior labrum in the middle one third or in the inferior one. The results of the ten patients were analyzed by the JOA scoring system for the shoulder joint. Significant improvement (p <0.001) was found statistically in the total score and on the subject of pain, as well. However, apprehension of the shoulder dislocation remained in two cases out of three.
Arthroscopic subacromial decompression has been performed for shoulder impingement syndrome since Ellman reported an overall success rate of 88%. The purpose of this paper is to assess the results of arthroscopic subacromial decompression (ASD) for shoulder impingement syndrome in our hospital. ASD was performed on 16 patients (18 shoulders). The age of the 12 men and 4 women ranged from 19 to 60 years (mean: 39 years).13 shoulders were classified as stage II and 5 shoulders as stage III (1 full thickness rotator cuff tear and 4 partial rotator cuff tears). The follow-up period ranged from 6 to 36 months (mean: 21 months). The results were evaluated on the JOA shoulder rating score. The average JOA score improved from 77.1 to 96.3 points. There was a significant improvement in pain, and 15 shoulders (83.3%) had satisfactory pain relief. With respect to complications, there were no infections or nerve palsy, but a fracture of the acromion occured 2 weeks after the operation in one patient. Furthermore, one patient with a full-thickness rotator cuff tear was reoperated on a cuff repair. Three athletes in this series returned to their previous sports' level ability without any pain. ASD allows for a less scarring procedure with fewer complications and a thorough diagnostic evaluation of the glenohumeral joint and rotator cuff. Since the deltoid muscle is not detached, patients can resume their daily routines immediately. In reviewing our results, ASD is recommended as an alternative to open anterior acromioplasty in advanced impingement syndrome cases.
The purpose of this study is to review the neurohistology of the subacromial bursae associated with imcomplete rotator cuff tears. Biopsy specimens of subacromial bursae were obtained from 8 shoulders (8 patients) who underwent surgery for imcomplete rotator cuff tears. Five of these incomplete tears involved the bursal side. The articular surface was torn in 2, and an intratendinous tear was found in one of the shoulders. There were seven men and one woman with an average age of 48.3 years (from 38 to 58years). The pre-operative duration of symptoms ranged from one to 14 months (average,6 months). After staining by using a modified gold chloride method, the serial sections were studied under a light microscope. The population of nerve elements within the subacromial bursae opposite a torn cuff was thin as was the blood supply. While at the site of the subacromial bursae, distant from the torn cuff, there were a number of neural elements. Overall, the bursae were densely supplied with blood vessels and nerves, and nerve fascicles and blood vessels lay in close association within the subacromial bursae. We consider the association of poor innervation and blood circulation to be important in the development of a rotator cuff tear.
In order to define the pathomechanism of the shoulder impingement syndrome, we investigated the pathological changes around the undersurface of the acromion and the coracoacromial ligament (CAL) in those patients showing a positive impingement sign. (MATERIALS and METHODS) Neer's anterior acromioplasty was performed on 50 shoulders of 49 patients with impingement syndrome. These 50 shoulders were divided into the following three groups: -1)impingement syndrome without a rotator cuff tear (13 shoulders),2)nontraumatic rotator cuff tear (16 shoulders), and 3)traumatic rotator cuff tear (21 shoulders). Fifty acromions and CALs were obtained en block when Neer's anterior acromioplasty was performed. The specimens were fixed in 10% formalin and sliced along the line of the CAL's fibers. (RESULTS) Hypertrophic changes of the fibrocartilage layer of the acromion and the CAL were observed. The pathological changes of the specimens were varied moderately from slight to severe. However, the site of the main pathological changes were observed at the undersurface of the acromion and the attachment of the CAL. The pathological changes were classified into three types according mainly to the sites involved. These were Type A: attachment of the CAL, Type B: undersurface of the acromion, and Type C: a combination of Types A and Types B. The pathological findings in those patients with impingement syndrome without a rotator cuff tear were similar to those with a nontraumatic rotator cuff tear, in which the pathological changes were mainly investigated at the attachment of the CAL, and slight changes were investigated at the undersurface of the acromion. These pathological results suggest that impingement is one of major causes of a nontraumatic rotator cuff tear.
In 1990, we reported on our preliminary study of bony spur of the acromion and the morphological changes of the rotator cuff. In 1991, we reported on our 2nd study of the spur with an asymptomatic shoulder. The results indicated that some factors which make a small bony spur are subclinical impingement and/or physiological impingement. In this paper we would like to clarify the factor which increases the size of a spur. Our subjects consisted of 123 cadavers with 241 shoulders. The severity of the injury to the rotater cuff and bony spur was evaluated radiologically. A normal or softening and fibrillation were found in 80% of 186 shoulders which had no spur or a small one. A partial or complete tear was found in more than 60% of 55 shoulders which had a medium or large spur. We believe that the factor which increases the size of bony spurs is the clinical impingement which is represented in rotator cuff tears.
We experienced a rare case of habitual posterior subluxation of the shoulder joint. A seventeen-year-old young man suffered from his first posterior subluxation of his right shoulder joint at the age of 14 without any, trauma. When he elevated his shoulder 90-degrees in the neutral position, and then rotated it internally, his shoulder subluxated posteriorly, and when he rotated his shoulder externally, it was reducted. In the plain roentogenogram (axial view), the humeral head subluxated posteriorly. Moreover, the humeral head subluxated inferiorly and laterally in the A-P -view (Zero position). In the CT arthrogram, hypoplasia of the postero-inferior margin of the glenoid and laxity of the posterior caplule were seen. We performed a posterior glenoplasty (Scott) and an inferior capsular shift (posterior approach, Neer) on this case. One year and 3 months after the operation, no posterior subluxation of the shoulder was observed. He could resume plaing rugby. The post-operative evaluation using the J. O. A. score was 100 points and excellent. Hypoplasia of the postero-inferior margin of the glenoid and laxity of the posterior capsule are thought to cause habitual posterior subluxation of the shoulder joint. We consider that both a posterior glenoplasty (Scott) and a posterior inferior capsular shift (Neer) should be performed for this disease. We believe that the repetitive throwing motion may occassion on habitual posterior subluxation.
We wish to report on three cases that had an old unreduced fracture of the greater tuberosity. They demonstrated pathological conditions of both a posterior displacement of the fragment and a rotator interval tear. The former produced impingement between the humeral head and the acromion, which made external rotation of the shoulder impossible in a 90-degree-abduction position. The latter showed an insufficiency of the rotator cuff, which weakened shoulder elevation. The cases were a 63-year-old man, a 54-year-old man and a 20-year-old man. They were all treated by ostersynthesis and a rotator cuff repair. The results of which were acceptable.
We report a rare case of acute repture of the tendon of the subscapularis muscle. On April 19,1992, a healthy 60-year-old man slipped and fell while his right hand kept a good grasp of a fixture. His right shoulder was forced into abduction and external rotation, and he noted immediate pain along the anterior aspect of his shoulder. On physical examination, tenderness and swelling were recognized along the anterior aspect of the shoulder. Active shoulder movement was severely limited. An arthrogram showed an extravasion of dye into the subacromial bursae and subcoracoid bursae. CTA and MRI showed a retraction of the tip of the subscapularis tendon. An operetion was performed on April 24,1992, the subscapularis tendon was found to be ruptured from the lesser tuberosity and retracted medially. The long head of the biceps was intact. The tip of subscapularis tendon was repaired to the anterior portion of the lesser tuberosity by a method simillar to McLaughlin's. The rotator interval was repaired. The post-operative course was satisfactory. The subscapularis tendon is a part of the anterior capsular mechanism and its defect causes an increase in the instability of the joint. As was neglected rupture of the subscapularis tendon, it resulted in shoulder pain, loss of strength of internal rotation and an increased range of external rotation. So a rupture of the subscapularis tendon should warrant operative treatment.
Various causative factors in a rotator cuff tear have been suggested by many investigators, and acrominal spur may be one such factor. In this report,2 cases of rotator cuff tear with subacromial spur are described. Both patients reported here, had spurs which were ossified ligaments extending anteriorly and downward from the insertion of the coracoacromial ligament. The rotator cuff was completely torn in both cases. The spur was considered to be the direct cause of the tear in Case 1, because the superficial layer of the cuff was markedly abraded in a crater-like shape. In Case 2, on the other hand, the tear was already so extensive that its cause was difficult to determine.
Three cases of subacromial bursitis with free bodies in rheumatoid arthritis are discussed here. Case 1: A 62-year-old woman, who was diagnosed as RA in 1970. In 1985 she had a marked swelling and pain on exertion in her left shoulder. Her range of motion was not so limited. Radiographs revealed no gleno-humeral joint deformity. Subacromial bursographs showed an enlargement and a honeycomb shadow of the bursa. Because of persistent swelling and pain, the thickened and enlarged bursa with 155 free bodies ranging in size from 5-10 mm were surgically removed in 1986. Case 2: A 52-year-old woman, who was diagnosed as RA in 1974. In 1986 she had pain and swelling in her left shoulder. The bursa with 90 free bodies ranging in size from 3-10 mm were surgically removed in 1987. Case 3: A 64-year-old woman, who was diagnosed as RA in 1981. In 1984 she had swelling and pain in her left shoulder. The bursa with 120 free bodies ranging in size from 5-25 mm were surgically removed in 1987. Surgical explorations revealed normal appearances of the rotator cuffs, and pathological findings of the free bodies were similar to the so-called rice bodies observed in chronic bursitis. After surgery, pain was relieved, and the swelling disappeared and has not recurred in any of the cases. The major symptoms were pain on exertion but the rotator cuffs were intact, so the impingement between the bursal walls and the free bodies seemed to cause the pain and promote the formation of free bodies.
The way the shoulder joint works in the shoulder complex is completely different system when compared with other joints. Therefore, the estimations using an isokinetic dynomometer are not always parallel to the correct shoulder function. We wish to report the check points and the clinical values of these estimation. (Method) 10 normal volunteers were examined. Each person was measured using a Kin-Corn 500H under various conditions at 60 El / sec and concentric contraction. (Results) 1) It was difficult to measure the peak torque and peak force correctly, especially for external rotation and internal rotation. 2) Each person was examined for abduction under various conditions. The force scattered in each under various conditions, for example, whether the body was fixed or not, and the supination or pronation of the forearm. It was difficult to measure under same and correct conditions. (Conclusion) When we measured the muscle strength of the shoulder joint using an isokinetic dynamometer, the most important point was to establish the measuring position and conditions.
[PURPOSE] Aseptic necrosis of the femoral head caused by decompression sickness has been frequently reported, however, there have been few reports on that of the humeral head caused by decompression sickness. In this paper, we wish to present clinical and radiological evaluations of aseptic necrosis of the humeral head. [MATERIALS & METHODS] Eight shoulders of five patients with aseptic necrosis of the humeral head caused by decompression sickness were reviewed. The average age of the patients was 48years, with a range of 27 to 60 years. All were male. The roentgenograms (A-P view) of all the shoulders were observed and classified. The range of motion of the shoulder, degree of pain and disturbance in daily living were evaluated with the J. O. A. score. [RESULTS] 1) On the roentgenograms, spherical segmental opacity of the humeral head without changes of the joint surface was found in four shoulders. Sequestration of the cortex was found in one. Osteoarthritic change was found in three.2) The J. O. A. score ranged from 48 to 98 points with an average of 78. Most of the patients had moderate pain. The disturbance in daily living and that of range of motion were not severe.
Cuff lesions such as tendinitis and tear exit frequently as the pathology of a painful shoulder. We considered that a cuff lesion could occur secondary to a dysfunction of the shoulder girdle. We will report on our investigations on the characteristics of a painful shoulder from the standpoint of the X-ray technique named “Scapula 45”. We examined 133 cases diagnosed as cuff lesion clinically. From the roentgenograms, the cuff function and scapula function were evaluated. We could diagnose cases with a cuff dysfunction, a scapula dysfunction and both dysfunctions. Many cases which had been clinically diagnosed as a cuff lesion showed cuff dysfunction or scapula dysfunction. Our results, suggest that a treatment should be selected aimed at improving the obstructed function.
The purpose of this study was to investigate the postoperative conditions of the rotator cuff of those patients with a cuff tear by ultrasonography. Aloka SSD-620 (7.5MHz) was used for this study. Bilateral shoulders of thirty-one patients were examined, while the patients sat upright with their shoulders in the neutral position. The measurements were made in two planes, the transducer having been placed in the fiber direction of the supraspinatus muscle and also perpendicular to that. The average age of the patients was 61 years (45 to 74 years). The follow-up period ranged from 1 to 10 years (average; 4 years 8 months). There was no correlation between the thickness of the cuff on the operated side with the age of the patients. Seven shoulders (23%) showed normal sonograms, and twenty-four shoulders (77%)had abnormal sonograms which showed irregular echogenesity, echogenic foci, an irregular superficial layer and thinning of the cuff, etc. The average thickness of the cuff on the operated shoulder was 5.8±1.9 mm and that of the normal shoulder was 7.2±1.3 mm. There was a statistically significant difference between the thickness of the cuffs of both shoulders. The thickness of the cuff depended on the size of the tear, that is to say, the larger the tear, the thinner the cuff. The patients with a less thick cuff had poorer scores according to the evaluation sheet of the Japanese Orthopaedic Association.
We wish to report on our study to determine the usefulness of MR imaging for the diagnosis of rotator cuff tears. Fourteen patients with rotator cuff tears' confirmed at surgery were reviewed. Images were obtained on a 0.2 T permanent magnet system using spin-echo pulse sequences with 5mm slices oriented in oblique coronal planes. In 12 of the 14 cases, the MR imaging showed a discontinuity and a high signal in the rotator cuff, but in 2 cases with small tears these direct signs of rotator cuff tear were not identified. Retraction of the supraspinatus tendon was observed in 2 of the 4 moderate tears and all of the 4 massive tears, and the extent of the retraction could be accurately assessed. MR imaging also depicted several soft tissues and bony abnormalities. These results suggest that MR imaging has good potential for diagnosing rotator cuff tears, even with a low-field-strength MR unit.
Arthrography of the shoulder and subacromial bursography exhibit superficial changes but can not detect substantial changes of the rotator cuff. We examined shoulder joints with a rotator cuff injury with MR imaging, and then compared them with operative findings. (Materials and Methods) 22 patients 22 joints (16 males,6 females, mean age 55.2 years), who suffered from a rotator cuff injury, were examined with MR imaging. MR examinations were performed on Gyroscan 0.5-T (Philips Medical System) and SMT100 1.0-T (Shimazu) with a circular surface coil. Imagings were performed in the anterior oblique coronal plane which is parallel to the scapular spine. (Results and Discussion) 6 full-thickness cuff tears 14 partial tears and 2 normal cuffs were exhibited in the MR images. We observed 9 full-thickness cuff tears and 13 partial cuff tears but no normal cuffs at surgery. A comparison of the MR images and the operative findings in a full-thickness tear showed a sensitivity of 55.6%, a specificity of 92.3% and an accuracy of 77.3%. PPV (positive predictive value) was 92.3% and NPV (negative predictive value) was 75.0%. On the other hand, a comparison of a partial tear showed a sensitivity of 87.5%, a specificity of 57.1% and an accuracy of 68.2%. PPV was 53.8% and NPV was 88.9%. MR imaging can noninvasively detect the location and the size of a tear and the degeneration of the rotator cuff. This is very useful in evaluating a rotator cuff injury.
If the degeneration of a rotator cuff is advanced, the cellularity of the tendon is diminished. We compared the signal intensity of the torn cuff on MR imaging with the cellularity of the tendon. We also studied the degeneration of the torn cuff by MRI. Forty-one shoulders with rotator cuff tears requiring repair were scanned pre-operatively with a 20cm surface coil in a 0.5T MRI system. A T1-weighted sequence, T2-weighted sequence, T2*-weighted sequence and proton-density-weighted sequence were performed. The specimens of the torn cuff edges were examined microscopically at a magnification of X400 in three parts, and the number of tendon cells in each part was calculated and averaged. There was no clear difference between the signal intensity of a torn cuff and that of a cuff defect portion on a Ti-weighted image. But there was a distinct difference between the signal intensity of a torn cuff and that of a cuff defect portion on T2, T2* and proton-density-weighted images. In the shoulder in which the ratio of the signal intensity of the torn cuff to the signal intensity of the deltoid muscle on Ti, T2, T2* and proton-density-weighted images was increased, the cellularity of the torn cuff was diminished. An increase in signal intensity of a torn cuff on Ti, T2, T2* and proton-density-weighted images was associated with the advance of degeneration of the torn cuff. The signal intensities of torn cuffs on T2, T2* and proton-density-weighted images should be used for the evaluation of the degeneration of a torn cuff rather than a T1-weighted image on which it is difficult to identify a torn cuff edge.
Fifty-one cases were diagnosed as having incomplete tears of the rotator cuff with MR imaging. In eleven cases out of the 51, incomplete tears were surgically confirmed (four bursal-side tears, two joint-side tears, and five intratendinous tears). The other 40 cases did not undergo surgery. Ti- and T2-weighted images were obtained along the oblique coronal plane in a 1.5-T MR system. High signal lesions in the rotator cuff on T2-weighted images were observed in all the eleven cases. In one of the eleven, the high signal lesion had almost the full thickness of a rotator cuff, while in ten of the eleven, the high signal lesions had partial thicknesses. T2-weighted images mainly showed the intratendinous part of the tears regardless of the perforation. Slightly increased signal lesions on Ti-weighted images had the full thickness of the rotator cuff in all the eleven cases. Noninvasive MR imaging enabled us to diagnose incomplete tears of the rotator cuff.
(PURPOSE) The diagnosis of sports injuries of the shoulder is difficult. What is useful for diagnosing them and how can we approach them? (MATERIALS and METHODS) The subjects comprised of 18 patients with a shoulder pain when they participated in a sporting activity. They were treated by arthroscopic surgery as joint side rotator cuff tears (J. S. T). There were 17 males and 1 female, ranging in age from 16 to 26 years with a mean of 19.9 years. We performed a plain X-ray, a local anesthetic test, a sonogram, an MRI and arthrography before the arthroscopic examination. (RESULTS) All of the patients returned to their previous sporting activities after arthroscopic surgery and rehabilitation. (CONCLUSION) The local anesthetic test was useful in deciding the location of the pain. We considered sonography as the most useful for a joint side rotator cuff tear. But we cannot diagnose a joint side rotator cuff tear without performing an arthroscopic examination.
To decide the appropriate treatment for articular-side partial rotator cuff tears (APRCT),31patients with arthroscopically documented APRCT were surgically treated and reviewed retrospectively. The mean age at time of operation was 31 years old (13-62) and the mean post-operative follow-up period was 22.5 months (12-66). APRCT was classified into three groups according to the depth of the cuff tear, the superficial tear (S-tear), the intermediate tear (I-tear), and the deep tear (D-tear).8 patients with a S-tear were treated by arthroscopic debridement of the lesion (S-tear &debridement group).23 patients had an I-tear.16 of them had an arthroscopic debridement of the lesion (I-tear & debridement group) performed of time, and 7 of them were treated by open repair procedure (I-tear & repair group).3 patients with a D-tear were treated by open repair procedure (D-tear & repair group). Arthroscopic or open subacromial decompression were simulteneously performed in all of the cases. The functional results were graded by Constant's shoulder rating scale (1987) which consisted of the evaluation of pain, function, range of motion, and strength of abduction. Clinical results were evaluated by the ratio of the rating scale; the involved side / the healthy side (%). Statistic significances were calculated by Student's t-test. According to the ratio of total clinical evaluation, the S-tear & debridement group was 99.3 +2.9%, the I-tear & debridement group was 97.4 + 4.4%, the I-tear & repair group was 87.3 + 7.7%, and the D-tear & repair group was 87.5 + 14.0%. There were no significant differences between the S-tear & debridement group to 2 and the I-tear & repair group to 4, but there was a significant difference between the I-tear & debridement group to the I-tear & repair group (p <0.01). The results of the strength of abduction were the S-tear & debridement group was 93.6 + 11.4%, the I-tear & debridement group was 98.4 + 18.7%, the I-tear & repair group was 78.6 + 11.2%, and the D-tear & repair group was 97.6 + 4.1%. A significant difference was also seen between the I-tear &debridement group to the I-tear & repair group (p <0.01). In this follow-up study, two things were clarified. Firstly, the clinical outcome of an arthroscopic debridement for APRCT was not influenced by the depth of a lesion with less than half of a rotator cuff thickness. Secondly, the arthroscopic debridement for an intermediate type APRCT with subacromial decompression provided a more favorable clinical outcome than did the open repair technique.
The purpose of this study was to evaluate the results of 29 arthroscopic subacromial decompressions (ASD) for rotator cuff tears. ASD was carried out on tears of the rotator cuff of 29 patients. There were 15 males and 14females, with an average age of 52 years (range 15 to 86 years). Eighteen had a partial thickness tear (PTT),5 had a full thickness tear (FTT) and 6 had a massive tear (MT). Patients with PTT were classified at the time of arthroscopy using Synder's classification. Two patients had Al,2 had A2,2 had A3,5 had B1 and 7 had B2. Patients were evaluated pre and postoperatively on the JOA shoulder rating scale (JOAS). In the PTT of 18 patients, sixteen had a major improvement on the JOAS 75.9 ± 10.4 preoperatively to 90.7 ± 6.4 postoperatively. In the PTT, Snyder's grade (severity and location) did not affect the results. In the FTT of 5 patients, four had a major improvement on the JOAS 66.8 ± 14.3 to 83.8 ± 10.8. In the MT of 6 patients, three had a relative improvement in the rating of pain but 3 had unsatisfactory results on the JOAS 58.7 ± 7.4 to 62.3 ± 7.8. We concluded that ASD is effective in the treatment of PTT and FTT (a small tear), but cannot support it as the treatment for a massive tear of the rotator cuff.
Departmenotf OrthopaediSc urgeryH, amamatsuR edC rossH ospital Fifty two cases of joint side tears diagnosed by arthrography were studied. There were 25males and 27 females with a mean age of 60 years. Forty three cases were treated conservatively and 9 cases were treated operatively. The initial score evaluated by the Japan Orthopaedic Association's shoulder score (hereafter JOA score) was 67 points and the follow-up JOA score was 83 points in the conservative group. The initial JOA score was 59 points and the follow-up JOA score was 93 points in the operated group. Therefore, the prognosis was better in the operated group than in the conservative group. Follow-up arthrographies demonstrated the disappearance of the tear portion (4 cases), reduction of the tear portion (4 cases), enlargement of the tear portion (20 cases), development of a complete tear (5 cases). The prognosis appeared to be satisfactory, when the joint side tear was small, and occurred in a young tendon with trauma in the conservative group.
This paper describes the pathogenesis and surgery of incomplete superficial surface tears of the rotator cuff (ISRCTs)based on our surgical experiences. Fifty-two shoulders of 51 patients who had ISRCTs were operated on between 1979 and 1990. Thirty-six patients were men and 15 women, with an average age of 50.8 years. This lesion could be divided into two groups; the one caused by overuse and the other caused by direct trauma. At operation, the severity of ISRCTs could be classified between grade 1 and 4 (erosion, crater, stump, peeling-off) according to the torn shape and the depth. Forty-six shoulders of 45 patients could be followed-up (ay.5 years) for this study. Forty-one shoulders were graded excellent but the remaining 5 shoulders, in which the torn cuff had been repaired, had considerable tension. Our operative procedure, combining acromioplasty, subacromial bursectomy, enough mobilization of the cuff and reattachment of the cuff to the greater tuberosity after resection of the avascularized cuff tissues, was effective.
(Purpose) The purpose of this paper is to evaluate the results of the operative procedures for an incomplete tear of the rotator cuff comparing them with the results for a complete tear. (Materials and Methods) In the last four years, we operated on 15 shoulders with an incomplete tear (group A) and 37 shoulders with a complete tear (group B) of the supraspinatus tendon. In group A, eight bursal side tears and 7 rim rents were involved. Neer's anterior acromioplasties were performed in all of the cases. In 7 cases, trimming and full-thickness resection at the end of the partially torn cuff and then McLaughlin's suturing were performed. Side-to-side sutures for 3longitudinal incomplete tears, and simple sutures for two flap tears were used. In all cases of group B, anterior acromioplasty (Neer) and McLaughlin's suturing were performed. The avarage ages of group A and B were 48 and 53 years old, respectively. (Results) According to the JOA's evaluation system,13 shoulders of the 15 incomplete tears had excellent results and 2 were poor. One of the 2 poor results had a re-rupture of the flap tear. (Conclusion) The results suggest that the most important thing is to maintain the end of a partially torn cuff. Trimming and a special suturing technique seem necessary.
We will discuss the unresolved issues conserning the diagnosis and appropriate surgical procedures for an incomplete rotator cuff tear. From 1988 to 1992,178 shoulders of 174 patients with a cuff tear were subjected to surgery, including 20 shoulders of 20 patients with an incomplete tear. The pallients consisted of 15 males and 5 females and their ages ranged from 35 to 69 years with an average of 46.0 years. The post-operative periode was from 1 to 71 months with an average of 25.1 months. The incomplete tear was classified into the following types: the bursal side tear (13), the joint side tear (5) and the intratendinous tear (2). The effectiveness of the diagnostic procedures, such as MRI and arthroscopy will be discussed, too. An arthroscope allows for the direct inspection of a rotator cuff and the documentation of its location and the extent of the pathologic changes. When a sizable partial defect is identified at open surgery, the tendon is re-attached to the bone or repaired with side to side suturing. Arthroscopic treatment consists of debridement of the torn cuff margin, followed by ASD. We perfomed this arthroscopic treatment on 4 cases.
41 cases of partial thickness tear of the rotator cuff underwent surgical treatment during a 16year period from 1976. We made an evaluation of the 6-months-or-more post-operative results in 35cases using the J.O.A.score. The types of partial cuff tear were (1) joint side tear in 20 cases,(2) intratendinous tear in 4 cases,and (3) bursal side tear in 11 cases. The joint side tear was frequently positive in the arthrogram (90%) and color injection test.72% of the bursal side tears were positive in the bursogram. To the contrary, it is extremelydifficult to diagnose an intratendinous tear pre-operatively. Neer's anterior acromioplasty was performed on all of the cases. A partial thickness tear wasresected, and repaired mainly according to McLaughlin's procedure. The total score improved from the pre-operative mean of 58 points to a post-operative mean of91 points. Most of the cases, i.e. 23 cases (66%), had a total score ranging from 91 to 100 points,followed by 8 cases (23%) in the range of 81 to 90 points. There were 4 cases (11%) with a poor scoreof 80 points or less. In our procedure, anterior acromioplasty was performed to remove impingement, and at thesame time, any partial tear detected was resected, followed by a repair at the normal site. Weconsider it important to make the bursal floor as smooth as possible to prevent post-operativeimpingement.
We studied 49 shoulders of 48 patients who had undergone surgery for incomplete tear of the rotator cuff. Eighty-eight percent were male,52% had a history of single violence. In 93% of the shoulders, depressions or marked softening were palpated at the site of the tear. The mean duration from injury to surgery was 18.5 months and ranged from 1 to 192 months. In terms of torn tendon, S.S.P. accounted for 63%, I.S.P. for 8%, and S.S.P. + I.S.P. for 29%. As for the type of tear, bursal-side tears(B.S.T.) accounted for 49%, intratendinous tear(I.T.) for 16%, joint-side tears(J.S.T.)for 27%, and a combined type for 8%. Only anterior acromioplasty was performed on shoulders with B.S.T. or J.S.T. that did not exceed one-third of the whole thickness of the tendon. Anterior acromioplasty and tenoplasty were done on the remaining shoulders. Of the 40 shoulders that could be followed post-operatively for more than one year, the results were excellent in 80%, good in 18%, and fair in 3%. These results indicated that anterior acromioplasty yielded satisfactory results in shoulders with B.S.T. or J.S.T. that did not reach one-third of the whole thickness of the tendon, and that tenoplasty was required for incomplete tears that exceeded one-third.
This study was designed to investigate radiologically the pathogenesis of a loose shoulder from the point of osseous factors. The materials were 42 shoulders of 37 patients with loose shoulder who proved to show a 30% or more descent of the humeral head. The parameters determined were: the head descending rate, glenohumeral index (G/H ratio), glenotilting angle (GTA), %glenohumeral angle (%GHA). In males aged 15 years or over (Group A), there was a tendency toward a negative correlation between the head descending rate and the G/H ratio(P<0.05). This was interpreted to mean that the osseous factors may have more influence on inferior instability than the muscular factors. Among the osseous factors, we considered the short diameter of the glenoid to be a main cause of loose shoulder in Group A. In females aged 15 years or less (Group B), there was a tendency toward a negative correlation between the head descending rate and %GHA (P<0.05). In the same way the muscular factors may have more influence on inferior instability than the osseous factors, and in the muscular factors the decrease in abduction power of the scapula is one of the main causes of loose shoulder in Group B. But no statistically significant difference was found between Group A and B in either the average of G/H ratio and %GHA. Therefore, as a short diameter of the glenoid and the decrease in abduction power of the scapula can not clearly be differentiated, we suspect both influence the pathogenesis of a loose shoulder.