The purpose of this study was to investigate the relation of the rotation angle, sports activity and instability of the shoulder. Three hundred and fifty eight shoulders (one hundred and seven males and eighty-one females; average twenty-two years old) were examined with rotation angle and instability. The rotation measurements were made with patients supine and the shoulder at 150 degrees flexion. The range of rotation (ROR) was defined as the sum of the external rotation angle (ER) and internal one (IR) in this position. The ROR, ER and IR angles (92.9, 51.0, 41.9 degrees) of the atraumatic shoulder instability were significantly larger than those (69.6, 46.3, 23.4) of the stable ones (p<0.01). In stable shoulders, the ROR was larger as their ages became younger (10s; 73.7,20s; 70.0,30s; 60.6 degrees). Additionally, the ER angle of the stable dominant shoulder with overhead sports (53.7) was larger than one with no sports (48.6) (p<0.03). Furthermore the ROR of a stable not-dominant shoulder with overhead sports (76.3) was larger than one with no sports (67.1) (p<0.03). In conclusion, the ROR of shoulder was large in the young and increased by instability and / or overhead sports.
The aim of this study was to assess the role of the subacromial bursa on the repair of a rotator cuff tear by the histopathological examination of the torn tendon. One hundred stumps of torn rotator cuff tendons were obtained from a hundred shoulders during surgery. A 10-mm length of torn tendon was prepared from along the torn edge of each stump. All specimens were sectioned at 3μm and stained histochemically and immunohistochemically. We divided the cases into four groups as follows: Group O: No bursal tissues in torn tendons (forty-five cases); G 1: Adhesion of bursal tissues on torn tendons (twenty-three cases); G 2: Bursal tissues invading or replacing the tendons within a half depth of the tendons (twenty-two cases); G 3: Bursal tissues invading or replacing the tendons diffusely (ten cases). The clinicopathological features were investigated and compared between the four groups. The duration of symptoms was longest in the G O and shortest in the G 2 with a high frequency of traumatic events. Most of the cases with massive tears were seen in G 2. Most cases with incomplete tears were seen in G 1or 2. Hyaline degeneration, chondroid metaplasia and calcification were frequently found in G O. Vascular proliferation and fatty infiltration were frequently observed in G 3. Subacromial bursal reaction against the tearing of the cuff was suspected to be a reparative process. Our findings suggested that bursal reaction after the tearing of the cuff might play an important role in the repair process. The bursa with underlying cuff should be preserved to repair the torn cuff tendons successfully.
We noted the bio-absorbable material for rotator cuff reconstruction, and devised a poly-L-lactic acid felt (PLLA felt). The infraspinatus tendons of beagle dogs were reconstructed with a PLLA felt. Tensile properties and histocompatibillity of the reconstructed tendons were examined at eight, sixteen, and postoperative thirty-two weeks. All specimens except one rupture case had healed. The ultimate strength of the specimens increased triple compared to that of the PLLA felt material at sixteen postoperative weeks. Stiffness increased five times at sixteen postoperative weeks. These increases were statistically significant (p<0.01). Rupture of all specimens occurred at the junction between the bone and the PLLA felt. Histological examination demonstrated infiltration of fibrous tissue between the PLLA felt fibers. Connection between the infraspinatus tendon and PLLA felt with a scar tissue was tight, however, connective tissue between bone and PTFE felt fibers was sparse even at sixteen or thirty-two postoperative weeks. There were a few deteriorated PLLA felt fibers at thirty-two postoperative week. Postoperative tensile properties of the PLLA felt graft recovered similar to those of PTFE felt graft, however, PLLA felt did not demonstrate the characteristic features of a bioabsorbable material up to thirty-two postoperative weeks.
The aim of this study was to investigate the potential to regenerate of rotator cuff tendon and insertion using a biodegradable scaffold as an acellular matrix. The bilateral infraspinatus tendons and its insertions of Japanese white rabbits were removed to create the defects (10x1Omm). The defects of the right shoulders were closed with a non-woven chitin fabric (NWCF), which was inserted into the bony trough. The contra lateral defects were not treated as a control. The shoulders were removed at two, four, eight, twelve weeks after surgery. Specimens were evaluated histologically and immunohistochemically. At two weeks, fibroblasts had been inducted into NWCF from the insertion side and deltoid muscle side. At four weeks, collagen fibers were observed. NWCF had expanded near the bony attachment At twelve weeks, the number of fibroblasts had decreased and the collagen tissue had matured. The degradation of NWCF was observed. The regeneration tissues were negative immunostaining in collagen type I and positive in collagen type III. In the control group, a thin membrane, a smaller number of cell and irregular collagen tissue were observed at twelve weeks. Chitin might have a good biocompatibility and contribute to good induction of fibroblast as a biodegradable scaffold material. On the other hand, NWCF had insufficient mechanical properties as a scaffold for regeneration of the rotator cuff tendon and insertion. These findings showed that the biodegradable scaffold had the potential to regenerate the rotator cuff tendon and its insertion. The limitation of this study was to be unable to regenerate normal collagen type in regenerated tissues.
It is well known that good functional results are obtained when acute rotator cuff tears are repaired in the early post-injury period. This study evaluated the tensile properties of the rotator cuffs that were repaired immediately after laceration, one week, three weeks, and five weeks after laceration. Bilateral infraspinatus tendons of thirteen adult beagle dogs were repaired with 4-strand suture technique. The average ultimate strength of the tendon repair site was 165.7 N for immediate repair,134.8 N for one-week delayed repair,141.7 N for three-week delayed repair,170.7 N for five-week delayed repair. The average stiffness of tendon repair was 14.5 kN/m for immediate repair,11.6 kN/m for one-week delayed repair,13.1 kN/m for a three-week delayed repair,13.7 kN/m for a fiveweek delayed repair. There was no statistically significant difference in the ultimate strength and stiffness between any of the repair groups. These results suggest that delayed tendon repairs within five weeks have almost the same quality to withstand passive physiotherapy as an immediate tendon repair. Thus this information is considered to be clinically significant for the repair of an acute rotator cuff tear in young active patients.
This study evaluated the intraobserver and interobserver reliability of cross sectional areas of the supraspinatus (SSP) and the infraspinatus (ISP) by ultra sound images. We examined fourteen shoulders of seven men (average age: twenty-seven years old). The same ultra sound system (Toshiba Echo Camera SSA340-A Toshiba, Co, Japan) was used for all measurements. According to the method of Katayose, the cross sectional area of the SSP was measured at midpoint of the spina scapula at an angle of 40°. That of the ISP was measured at the point of the glenohumeral joint of the spina scapula at an angle of 80°. Three observers measured three times each muscle. The mean of each area were recorded. After one week, measurements were repeated. Data were analyzed using a one-factor ANOVA and paired t-test. The areas of the SSP were 7.6±0.7, 7.5±0.9, and,7.6±0.9cm2on the right and 7.4±0.6, 7.4±0.9, and 7.5±0.9 cm2on the lef. Those of the ISP were 5.4±O.5, 5.2±0.5, and 4.6±0.9 cm2on the right and 5.1±O.5, 4.8±0.6, and 4.4±0.9 cm2on the left. The reliability of the interobserver of the ISP was low (P<0.05). It was difficult to measure the area of the ISP by ultra sound images because the border between the ISP and the teres minor was not clear. More acurate visualization of the border would increase the reliability.
Morphological changes of the supraspinatus muscle were evaluated by magnetic resonance imaging (MRI) to assess recovery after a rotator cuff repair. Ninety-eight shoulders in ninety-seven patients who underwent surgery for rotator cuff tears were included in this study. The shoulders were divided into three groups according to the size of the cuff tear: group A consisted of thirty-three shoulders with small to moderate sized tears, group B consisted of thirty-five shoulders with large tears, and group C consisted of thirty shoulders with massive tears. The width of the supraspinatus muscle on the MRI oblique sagittal view was assumed to reflect a rotator cuff atrophy and was measured preoperatively and at six months, one, one point five and two years postoperatively. In group A and group B, no significant changes were found over time. In group C, significant recovery of the supraspinatus muscle atrophy was seen between six months and two years postoperatively (p<0.05). In group C the ratio of the width of the supraspinatus muscle against the depth of the supraspinatus fossa was less than that in group A or B preoperatively and at six months postoperatively (p<0.01). The ratio in group C was less than that in group A at one, one point five and two years postoperatively (p<0.05). The width of the supraspinatus muscles at six months postoperatively appeared to serve as the standard to evaluate time-course changes of supraspinatus muscle atrophy. The width of the supraspinatus muscles would change six months postoperatively as a result of stretch of the muscle during a rotator cuff repair. Recovery in the supraspinatus muscle atrophy was seen two years postoperatively in the group with massive tears. Measuring a supraspinatus muscle atrophy by MRI appears to be useful to evaluate the postoperative recovery of the rotator cuff in patients with massive tears.
The purpose of this study was to reveal clinical outcome of arthroscopic rotator cuff repair using single-layer fixation method and evaluate postoperative MRI findings. We analyzed 46 shoulders, including 33 males and 13 females, with an average age of 56.2 (range,34-72) years. The average follow-up period was 19.1 (range,12-39)months and the clinical outcome was analyzed through the JOA score. We also evaluated the postoperative MRIs, which were performed 13.5 (range 9-24) months postoperatively on average, and classified its findings of T2weighted images into five categories: type I: thick with a low intensity, type II: thick with a partial high intensity, type III: thin without a discontinuity, type IV: suggesting a partial or small tear, type V: suggesting a medium or large tear. The average postoperative JOA score was 96.3 (pain: 27.7, function: 19.4, ROM: 292), improved from 70.9(pain: 12.6, function: 14.3, ROM: 24.4). Postoperative MRI showed fifteen type I, twelve type II, nine type III, five type IV, and type V, respectively. Preoperative tear size had quite a significant relationship to the postoperative MRI findings while no significant relationship had been observed to the postoperative JOA score. Furthermore, shoulders with better postoperative MRI findings had a higher postoperative JOA score with a statistical significance. In conclusion, clinical outcome analyzed through the JOA score was quite satisfactory compared to the postoperative MRI findings. Arthroscopic rotator cuff repair using single-layer fixation methods yields results compatible to open procedures at an average of 19 months follow-up.
The purpose of this study was to investigate the postoperative conditions of the rotator cuff MRI and sonography of the patients who underwent surgery for a cuff tear. Since 1998, we surgically treated seventy-six shoulders in seventy-five patients with a rotator cuff tear using “a less invasive surgery”. Six and twelve months after surgery, the shoulders were examined by MRI and sonography. MRI scanning was performed using a 1.5-Tesla MRI unit, and T2-weighted images of the SSP were obtained in the oblique. The condition of the repaired cuff was classified in 3 types according to MRI findings; Type 1: intratendinous low signal, Type 2: partial intratendinous high signal, Type 3: high signal. The condition of the cuff was also assessed using a 7.5MHz linear scanner for ultrasonografic examinations. The sonografic findings were classified into 3 types; Type 1: definite superficial layer, Type 2: definite-indefinite mixed superficial layer and Type 3: unclear superficial layer. In MR images, eight shoulders showed a Type 1 signal at six months and thirty-eight shoulders showed a Type 1 in twelve months. In sonography, twenty-five shoulders showed a Type 1 in six months and sixty shoulders showed Type 1 in twelve months. Thus a repaired cuff starts to demonstrate normal type 1 signal after surgery in both MRI and sonography.
Nonoperative treatment was popularly performed for subcutaneous ruptures of the long head tendons of biceps brachii because of slight functional deficit after conservative treatment However,10 or 20 percent loss of elbow flexion and supination remained after conservative treatment So, operative repair of proximal biceps tendon rupture is necessary for young, active patients who are not willing to accept the deformity or weakness of elbow flexion and supination. We operated on those patients who had intolerable pain and disturbance of working and sports with the subcutaneous ruptures of the long head tendons of biceps muscles by key hole method by Froimson. We wish to present the operative method and the outcome here. There were 12 patients (mean age: 52.5 years old,11 men and 1 woman) who underwent surgery for subcutaneous rupture of the long head tendon of biceps brachii. All the patients were operated on by key hole method by Froimson. We investigated the recurrence of the tendon rupture, pain, disturbance of working and sports, muscle strength, and shoulder function using the Japanese Orthopaedic Association (JOA) score. The mean follow-up period was 35 months. Recurrence of a tendon rupture was not seen in all the patients. All the patients had pain preoperatively, but did not have pain after surgery. All the patients had disturbance of working and sports preoperatively, but did not have them after surgery. Muscle strength was 4 preoperatively and significantly improved to 5postoperatively in all patients (P<0.05: paired-t test). The JOA score improved significantly from 63 preoperatively to 96postoperatively (P<0.01: paired-t test). All the patients obtained excellent results after surgery. We performed operated repair by keyhole method for subcutaneous ruptures of the long head tendons of biceps brachii for the patients who had intolerable pain and disturbance of working and sports and obtained an excellent outcome
Clinical features of rotator cuff tears were studied in relation to associated injuries of the long head biceps (LHB)tendon. Forty-two shoulders in 38 patients with a complete cuff tear received surgical treatment. They were divided into 3 groups according to the degree of LHB tendon injury (none, injured, ruptured). The injured group was further randomly divided into 2 sub-groups according to treatment (ignored. tenodesis). Clinical features and surgical results of all patients were evaluated. The average total JOA scores prior to the operation in the none, injured, and ruptured LHB tendon groups were 63.1,57.1, and 63.5 points, respectively, while post- operational JOA scores were 95.4,88.6,71.3 points, respectively. Further, improved points of pain score in the tenodesis of LHB group was significantly higher than in the ignored group. Preoperative assessment of LHB tendon disturbance in patients with a cuff tear was very helpful, as knowledge of the existence of injury and its treatment had an influence on the surgical results.
We performed McLaughlin's method to repair a massive rotator cuff tear. If suturing in McLaughlin's method provides insufficient strength, Palmaris longus graft in addition to McLaughlin's method has been performed. This study evaluated the clinical result of the technique above described. Thirteen shoulders of thirteen patients were examined. They consisted of eight males and five females with an average age of 65.7 years-old (range 59 to 80 years-old). The palmaris longus was looped through the edge of the rotator cuff and passed through the drill hole in the tuberosity. The edge of the rotator cuff was firmly fixed into the bone groove, then the Palmaris longus was tied at the lower part of the lateral aspect of the tuberosity. The residual portion of the Palmaris longus was spread to cover the undersurface of the rotator cuff. These cases were evaluated using the JOA score twelve months after surgery. The mean JOA score increased from 68.0points preoperatively to 92.4 points postoperatively: the preoperative pain score was an average of 8.1 points and postoperatively an average of 26.5 points. Palmaris longus Graft in addition to McLaughlin's method for massive rotator cuff tears showed satisfactory results.
We reported on the variance in cases which deviate from the critical path. Twenty-seven cases of cuff repair were treated with a critical path. Twenty were male and seven were female and their average age was 57.6 years old. We used the critical path in which patients had an abduction brace in sixteen cases and the critical path in which the patients had arm-sling in eleven. We examined two variance elements which were if outcome was achieved and how many days the patients stayed in hospital. All patients achieved outcome (patient improved their own symptoms before the operation and patient undersood the exercises after discharge). But there were fifteen cases of positive variance (early discharge) and twelve cases of negative variance (late discharge). Nine of the 15 negative variance patients delayed ther discharge from the hospital five days later than originally planned. From the point of element of variance (patient, medical staff, institute and social problem etc. ), the discharge of seven cases was delayed because of patient's physical conditions. Three were massive tear and two were large tear. Five patients had pain at the time of discharge and two patients lost their power because of a massive tear. In the positive variance five patients went back home more than five days earlier than the day they were supposed to be discharged. These five patients had a relatively small tear (1.8cm × 1.3cm in average) and had an arm sling after surgery. As a result, we changed critical paths. In the new critical path we can change the hospital days according to the size of the tear. Critical path is very useful for proper improvement of postoperative therapy which we did aimlessly until now and useful for proper hospital stays.
Night pain in shoulders with rotator cuff tears is one of the important factors in the decision making of surgical treatment. However, the details of symptoms have not yet been reported. We obtained information through a questionnaire on shoulders with rotator cuff tears and investigated the relationship between night pain and the pressure in the subacromial bursa The questionnaire was distributed to sixty-two patients (thirty-nine male, twenty-three female)with rotator cuff tears who experienced night pain. The pressure of the subacromial bursa of eighteen shoulders (thirteen male, five female) with rotator cuff tears were measured in the standing position, the supine position and the lateral decubitus position on the affected shoulder. The size of the rotator cuff tear was small in four, medium in eight large in three, and massive in three shoulders, respectively. Nine shoulders (six male, three female) with rotator cuff tears who had not experienced night pain were measured for a comparison. Five normal shoulders were measured as a control. Night pain was observed in the lateral decubitus position in 42% of the shoulders, in the supine position in 35%. However, there was no relation between night pain and the position of the upper limb. In shoulders with night pain, there was a significant difference in the pressure of the subacromial bursa between the standing and supine positions. In shoulders with night pain, the pressure of the subacromial bursa significantly increased in the supine position. We believed that this increase in the pressure may be related to night pain
We wish to report on three cases, a sixty-seven-years-old man had the right shoulder dislocation in January 2001, which was manually. reduced by a local doctor. He visitsd us in A pril 2001 complaining of pain and weakness of the right shoulder. The active shoulder elevation was 30 degrees. At surgery in June 2001, the cuff was repaired with the Paavolainen procedure. Nine months postoperatively, the active elevation was 125 degrees without pain and he returned to work. A sixty-three-year-old man visited us in May 2001 complaining of right shoulder pain and weakness after a fall in Feburary 1999. The active elevcation was 90 degrees. At surgery in Jury 2000, the cuff was repaired with Paavolainen's procedure. The active shoulder elevation became 120 degrees and he returned to work ten months postoperatively. A fifty-nine-year-old man fell down in September 1999 and his right shoulder was operated on. He visited us because of persistent pain and weakness in his right shouder. The active elevation was 20 degrees. At surgery in May 2000, the cuff was repaired with Paavolainen's procedure. The pain disappeared, but the active elevation was 40 degrees eighteen months postoperatively. Paavolainen's procedure can be an option in patients whose teres minor remains intact.
The author reported on one case of snapping scapula caused by the first serratus anterior and omohyoid muscle, and report this case with two similar cases likely to be caused by the latissmus dorsi muscle. A twenty-six-year-old truck driver visited our clinic complaining of snapping of the scapula associated with pain in raising his left shoulder. He tilted his neck to the right. When he lowered his abducted horizontally extended left arm snapping occurred at the superior angle of his left scapula Snapping occurred when a funicular object, likely to be the serratus anterior muscle, moved over the first rib laterally. In a more antero-lateral area, a different mild snapping could be palpated. It was considered to be the omohyoid muscle. If the scapula was fixed with fingers, no snapping occurred. In his operation, two thirds of the inner side of the first and second serratus anterior muscle and the omohyoid muscle were cut. Three years after the operation there sometimes occurred a slight snapping, but he did not experience any disturbance in his daily activities. A forty-six-year-old housewife visited our clinic complaining of a right painful snapping scapula She noticed after exstirpation of a tumor in her back. Spindle form swelling likely to be muscle was found on her inferior angle of the right scapula At operation severe adhesion of the superior border of the latissmus dorsi was found. The adhesion was cut and the superior border of the muscle was sutured to the fascia of the cranial side. After the operation the snapping occurred no more. A sixty-year-old housewife visited our clinic complaining of a snapping sound when she moved her right arm. The physical findings were similar to the second case. The snapping occurred sometimes, but not painful She is currently under observation.
Although the development of painful glenoid arthrosis is the most common reason for a reoperation after replacement of the humeral head, there are few reports in Japan. We reported an such a case because of high activity. The patient was sixty-seven-year-old man. He suffered from a left humeral fracture and his operation was performed in 1971. Then his left shoulder pain had continued, and a hemiarthroplasty (Neer II) to his left humerus was performed in 1993 in our hospital. After that the shoulder pain disappeared, and he was able to elevate his shoulder 170 degrees. In 2001 he again suffered from left shoulder pain because of a left glenoid arthrosis. On November 27,2001 a revision total shoulder arthroplasty was performed. Though his humeral head was displaced posteroinferiorly, the exposure of his glenoid was difficult. After the operation his shoulder pain decreased, and the elevation of his shoulder was 170 degrees. Sperling has reported on eighteen cases of this disease. Long-term studies are necessary to evaluate the durability of total shoulder replacement in this group of patients as well as in our case.
We reported on the clinical results and important points of treatment of rotator cuff tears with axillary nerve palsy caused by high energy injury. We had four cases with injured rotator cuff tears with axillary nerve palsy after anterior dislocations. They were all men(age: forty-six∼fifty-two). The first case concurred a pulmonary injury and right femur fracture. His rotator cuff was repaired three months after injury confirmed improvement of nerve palsy by electromyography. In the remaining three cases their cuff were repaired six weeks after injury, and confirmed improvement of nerve palsy. In the waiting period, ROM exercises were done against shoulder contracture. The clinical results were evaluated according to the JOA scores. The average follow up period was twenty-seven point two months. The average JOA score improved from 37.5 to 81.2 points. Axillary nerve palsy improved conservatively in all cases. All cases had a remained mild shoulder contracture but there was no instability. The early accurate diagnosis and careful treatment planning were needed. Differential diagnosis from brachial plexus injury was important Cuff tear should be repaired after confirming improvement of nerve palsy.
Three patients with chronic calcifying tendinitis of the shoulder, who failed to respond to conservative treatment, were underwent arthroscopic surgery. One patient was male and two were females. Their ages were thirty-two, forty-nine, fifty-nine. The follow-up period averaged thirteen months. We operated the patients under general anesthesia, in the lateral decubitus position, tracting their arms at 45°of abduction and 15° forward flexion We had posterolateral scopic portal and anterolateral working portal. At first, we resected the inferior subacromial bursa carefully using the MitekTM VAPR system, and then found the calcium deposit site as a white area on the rotator cuffs. We removed the calcium deposits through small incision made on the cuff arthroscopically, but did not close the incision on the cuff in all cases. After that, we performed arthroscopic subacromial decompression. Preoperative JOA score of all patients was 69 points and improved to higher than 90 points postoperatively. DePalma classified calcium deposit tendinitis into 3 types as acute, subacute, and chronic type. In many patients affecting chronic type, conservative treatment was not effective. Then we used to resect the calcium deposit using this open procedure. But now we can operate them arthroscopically. Arthroscopic surgery was very useful for the treatment of chronic calcifying tendinitis of the shoulder. All the patients did not have any symptom about the small tear on the cuff postoperatively.
Synovial chondromatosis is rare in the shoulder joint. The purpose of this paper was to report the case of synovial chondromatosis in the shoulder joint, treated by arthroscopic surgery. The patient was a thirty-six-year-old woman, complaining of right shoulder pain. She had swelling and tenderness in her anterior shoulder joint and limitation of range of motion. Plain X-rays showed a mild spur formation at the humerus head and enlargement of joint space. MRI revealed existence of loose bodies in the joint. Arthrogram also demonstrated numerous loose bodies in the articular space. Conclusively, the case was suspected of being chondromatosis and arthroscopic surgery was performed. Removal of loose bodies, seen especially in subscapular bursa,145 pieces in all, was done during arthroscopy. Histologic findings confirmed the diagnosis of synovial chondromatosis and revealed that every piece was superficially covered with a thin layer of synovial cells, while in the center hyaline cartilage was increasing in lobular formation. After surgery, the patient became free of shoulder pain. We conclude that arthroscopic surgery was useful in this case.
We reported on a young adult case of isolated subscapularis tendon rupture ass ociated with anterior shoulder dislocation. A twenty-two year-old male got his left shoulder dislocated, while riding a motor bicycle, one and half year ago. The dislocaion of the shoulder was reduced by another doctor. But his shoulder pain in motion continued. Three months ago, he fell down while snowboarding, his shoulder pain increased, and that led him to our hospital. On exsamination, ROM of the shoulder was not limited except in external rotation. He complained of left shoulder pain on abduction of 70 degrees and severe tenderness on the greater and lesser tuberosity. Lift-off test was positive. X-ray findings were normal except for a coracoid tip fracture. Subscapularis tendon rupture was revealed on MRIs and CTAs, An operation was performed. Subcapularis was ruptured totally from the lesser tuberosity, but theLHB was not dislocated. We repaired the subscapularis tendon to the lesser tuberosity using a suturing anchor and performed an anterior acromioplasty. The left shoulder pain disappeared completely, and lift-off test became negative within three months. When patients had residual pain after reduction of traumatic shoulder dislocation the rupture of subscapu laris tendon should be considered.
The purpose of this communication was to discuss a new mechanism of osteoc hondral injury of the glenoid fossa observed in a baseball player. A nineteen-year-old man was admitted to our hospital complaining of pain in his right shoulder when throwing since seventeen years of age. The ROM was not limited. While the Crank test and resistance test for rotator cuff muscles were positive, no instability was demonstrated. Radiographic examinations showed sclerosis in the osteochondral bone of the glenoid fossa. Computed tomography and magnetic resonance arthrography (MRA) revealed an osteochondral defect in the postero-inferior glenoid fossa. Oblique axial MRimages with the arm in abduction and external rotation (ABER) position showed a thick and tight AIGHL(anterior inferior glenohumeral ligament ) and a posterior shift of the humeral head relative to the glenoid fossa. Arthroscopic examination revealed a step in the glenoid fossa and loosening of the posterior joint capsule. The labrum, rotator cuff, and glenoid cartilage were intact. Based on these observations we carried out thermal shrinkage of the posterior capsule in arthroscopically. We considered that the thick and tight AIGHL caused posterior subluxation of the humeral head when the shoulder joint was in ABER position. This mechanism yielded a sharing and compression force to the glenoid fossa and resulted in a stress fracture in the postero-inferior osteochondral bone of the glenoid fossa.
We experienced a case of chondral injury of a shoulder joint by arm wrestling. The case is a thirty-three year-old male, a fireman. On 24th June,2001, while arm wrestling, he felt a strange sound from his shoulder joint when he rotated internally strongly at 30° abduction and the next second a forced external rotation forced his shoulder to be immobile with severe pain. The next day he consulted our clinic and complained of innability of elevation and severe pain. There was a swelling but no tenderness in his shoulder, but ROM was limited in all directions with severe pain. An apprehension sign existed at the position of external rotation. There were no Bankart lesions or Hill Sachs lesions on a plain X-ray film. A MRI showed an irregural joint surface of the glenoid, hematoma and a free body. An arthroscopy was done on 4th July 2001, a broad chondral defect was found both at the center of the humeral head and antero-inferior portion of the glenoid. IGHL showed an avulsion at 6 to 10 o'clock from the glenoid. A free body was removed and IGHL was re-attached to the glenoid over the chondral defect. Post operation, after three weeks immobilization ROM exercises were started. Now eighteen months have passed, he feels no pain, no apprehension, but some crepitation while moving to internal rotation from external rotation position. This case is different from ordinary shoulder dislocations both its mechanism and chondral lesion. We discussed these points and the treatment.
We present a case of Charcot joint of the shoulder which was treated by bipolar hemiarthroplasty of the shoulder. A fifty-four years old woman who complained of right shoulder pain and swelling of the shoulder visited to our clinic two years ago. Range of motion of the shoulder was severely restricted at 50°in flexion,10° in extension, the buttock level in internal rotation and -30°in external rotation. Radiographs of the shoulder revealed severe collapse of the humeral head. Her shoulder was diagnosed as Charcot joint due to syringomyelia. She had surgery for syringomyelia in the department of neurosurgery. However, her symptoms were not improved. Five months later she visited our clinic, we operated on her shoulder. Synovectomy, bipolar hemiarthoplasty and repair of the supraspinatus and subscapularis tendon were performed. At two years after surgery, the swelling and ROM of the shoulder improved without any loosening or dislocation of the humeral prosthesis.
There are many cases which merge a traumatic rotator cuff injury to the acromioclavicular dislocation. We examined it and the influence it exerts on its presence and also the postoperative results of this complication. We studied the fifty-nine shoulders of fifty-nine patients, who were diagnosed as Rockwood type III and operated on between 1993 and 2001. There were fifty-seven males and two females, whose age at the time of surgery ranged from thirteen —sixty-eight years old, average thirty-one point three years old. The Rockwood modified operative procedure was performed. The presence of complications of the rotator cuff injury were judged by physical examination at the time of the first medical examination. There were nine shoulders (15.3%), with complicated rotator cuff injuries whose age was twenty —fifty-five years old, average twenty-nine point six years old. Some patients among these had delayed rehabilitation because of the pain of the rotator cuff, but all had returned to their daily living and social work at the time of their final medical examination. It became clear with a survey the rotator cuff disorder had a comparatively of in complications an acromioclavicular dislocation that a direct blow to the shoulder becomes the primary cause.
After reconstruction of the coracoclavicular ligament on patients with complete separation of the acromioclavicular joint (Rockwood's classification III or V ), a residual subluxation is often found. We performed the modified Cadenat procedure on these patients, and investigated the distance between the clavicle and the coracoid process (C-C distance). The thirty-five patients; thirty-one males and four females, average age thirty-five years old, had reconstruction of coracoclavicular ligament. As a temporary fixation, Kirschner's wire (K) was used in twentythree patients and Wolter-clavicular plate (W) in twelve patients. We evaluated the therapeutic results more than nine months postoperatively. Using anteroposterior roentgenographic views, the C-C distances were measured, and we classified them into two groups based on the preoperative C-C distance, Group A (125 to 200% more than non-affected side) and Group B (over 200%). The postoperative C-C distance of each group more than nine months was respectively investigated. The therapeutic results were evaluated based on the criteria of JSS A-C joint dislocation score (total 90 points). The average of postoperative C-C distance was Group A,105.5% (K: 110.9%, W: 97.5%); and Group B,138.5% (K: 144.2%, W: 117.8%) respectively. The residual subluxation was found in Group A, two patients (K: 2, W: 0); and Group B, six patients (K: 5, W: 1). The average of JSS A-C joint dislocation score was Group A,85.7 points; and Group B,85.3 points. We should consider the temporary fixation to keep the anatomical position based on the C-C distance. Of these cases following a strong separation and soft tissue injury, we considered a certain temporary fixation using a plate to be significant.
The purpose of this study was to report our results of arthroscopic resection of the distal clavicle (arthroscopic Mumford procedure) for the acromioclavicular joint pain after a subluxation or the osteoarthritis. We evaluated 6shoulders of 6 patients. All patients were male and the average age at the surgery was 39.2 years (24-66 years), the average duration of the preoperative symptom was 8.3 months (3-17 months), and the average follow-up period was 38.5 months (25-57 months).5 cases were doing sport before a symptom appeared (baseball in 2 cases, ice hockey, judo and golf in 1 case respectively). The preoperative diagnoses were internal derangement after a type I or type II acromioclavicular joint injury in 4 cases, and were osteoarthritis in 2 cases. All cases had a positive lidocaine test for the acromioclavicular joint. At the time of the operation, about 1 cm of the distal clavic le was removed bursoscopically with the superior acromioclavicular ligament left intact. There were significant improvement of the JOA score, the JSS sports score, and the JSS AC joint score postoperatively. All 5 cases doing sport returned to the same level as before surgery. The arthroscopic Mumford procedure has the advantage of a low morbidity. To keep the stability of the acromioclavicular joint, the acromioclavicular ligament must be left intact. The amount of bone removal will be limited within about 1 cm, and it is necessary and sufficient.
The purpose of this study was to investigate the clinical outcome of patients with acute dislocations of the acromio - clavicular (AC) joint operated on according to our procedure, which consisted in a modified Phemister procedure and resection of the distal end of the clavicle. Seventeen patients(one woman) underwent surgery for acute dislocation of the AC joint; the in age ranged from sixteen to fifty-one years (average: twenty-nine point eight years). The right side was affected in twelve patients and the left in five. Resection of the distal end of the clavicle by 1 to 2 cm was carried out in addition to a modified Phemister procedure. All patients were followed up from thirty-six to one hundred eighty months (average: one hundred thirty months) postoperatively. We evaluated the patients using the JSS acromion-clavicular score and the JOA score. There were no cases of recurrences of dislocation and no patient complained of pain in the shoulder at the final follow-up examination. All patients regained full ROM and normal muscle power after surgery. The average time required to return to original work was two months. There was few complaint with regard to ADL or occupational activities. The patients regained good shoulder function and cosmetics appearance and returned to their original job or daily life activities in a short time after surgery. These results suggest that our procedure is useful to treat acute AC joint dislocations.
We treated eighteen cases of acromioclavicular joint dislocation in sumo wrestlers from 1982 to 2000. Their profile, methods of treatment, the number of absent season and the change of the ranking were examined. There were eighteen cases (Tossy's classification grade 2: eight cases, grade 3: ten cases). All eighteen cases were male. On average, their age was 19.5 years old, their experienced period was 3.0 years, their height was 180 cm and their weight was 120 kg. Their ranking were as follows: four cases were third division, two cases were fourth division, seven cases were fifth division and five cases were sixth division. Acromioclavicular joint dislocation accounted for 0.5 % in all sumo wrestlers injuries (18/3648). Operations were performed in five cases. Three cases were operated with modified Neviaser procedure. One case was operated with Dewar procedure. Another one case was operated with unknown method. Four of these five cases had escaped from the ring for one tournament after their operation and one case had escaped for two tournaments. Four cases continued sumo wrestling for 10.4 years on average(9.112.2 years). One case retired eight months after the operation. In thirteen conservative treatment cases, three cases had escaped from the ring for one tournament and the other ten cases did not escape. In the following tournament after the injury, four cases (grade 3: two cases, grade 2: two cases) promoted in their ranking and six cases (grade 3: two cases, grade 2: four cases) demoted in their ranking. Six cases returned to the same ranking or a better one than before the injury for four tournaments on average (two-six tournaments). Three cases ( grade 3: two cases, grade 2: one case) retired between two and five tournaments after injury. The operative treatment is recommended for grade 3 for sumo wrestlers and conservative treatment is recommended for a grade 2acromioclavicular joint dislocation.
Our purpose was to evaluate postoperative results of mo dified Phemister and Neviaser methods for acute (within three weeks from onset, Group A) and chronic (more than three weeks from onset Group C) Tossy's grade 3 acromioclavicular (AC) dislocations, respectively. Twenty-two shoulders with acute grade 3 AC dislocations (average thirty one point four yrs; twenty males and two females) and ten shoulders (average thirty six point one yrs; eight males and two females) were studied. Acute cases were reconstructed by a modified Phemister's method, and chronic cases by a modified Neviaser's method. The postoperative results were evaluated by the Japanese Shoulder Society score (JSS score), the X-P findings and patient's satisfaction score (classified into 5grades from very satisfactory to unsatisfactory). These factors were examined statistically by using nonparametric tests (Mann-Whitney's U-test and Spearman's test). The postoperative JSS scores (Group A/Group C) were 90.4/95.3. Scores in each item were as follows; pain 23.6/26.6, fatigability 17.3/19.2, ADL 19.6/20.0, ROM 29.4/29.5 I. n X-P findings, the superior migration of the distal clavicle was observed in six out of fifteen cases (40%)in Group A and three out of six cases (50%) in Group C. The superior migration rate (AC offset divided by the vertical length of the distal clavicle) was 39% and 45% respectively. In Group A, the relationships between the superior migration and pain, fatigability and satisfaction were observed statistically significant. Postoperative recovery of the migration rate of Group C was better than that of Group A. Considering the intraoperative findings, a secure repair of the coracoclaviclar ligament seems essential to avoid postoperative superior migration. Residual of the dislocations may cause pain or fatigue, so that an anatomical reconstruction of a dislocated AC joint is necessary, especially for those who do heavy work. Results of modified Phemister and Neviaser's methods were satisfactory for the acute and chronic grade 3 AC dislocations.
The surgical results of the acromioclavicular (AC) joint separation by sports were evaluated by using the AC score and the sports score. Additionally, the utility of both evaluation methods was examined. The results were excellent in both fresh cases and chronic cases after the surgery of the AC separation caused in sports, using the AC score and the sports score. The object, the treatment time point and surgical procedures influenced to the current AC score system. Especially, because an X-ray evaluation might be improper, improvement was required according to the surgical procedure. It was necessary to consider the importance of AC joint in each sport, when we used the sports score. We suggest that it was necessary to consider the patient's subjective evaluation and objective rating of the evaluation.
The purpose of this study was to investigate the long term results of the modified Cadenat's procedure (coracoacromial ligament transfer with anterior acromion) for acromio- clavicular dislocations. Fourteen patients with acromio-clavicular dislocations after a modified Cadenat's procedure were followed up. Their averaged age at the surgery was thirty eight point six (range: twenty two to sixty-one years old). The average follow-up period was ten point six years (range: seven-seventeen point two years). The cause of injury was sports injury in seven, a traffic accident in four and a fall down in three cases. The results were evaluated based on the Japan Shoulder's Society acromio-clavicular joint dislocation (JSS-ACD) score for acromio-clavicular dislocation. The average postoperative JSS-ACD score (excluding X-ray points) was 85.5points (range: 64 to 90points). There were two cases which had shoulder pain. In two cases which were the Japanese ice hockey league players, all cases returned to their competition level as before injury without any problems. These results suggest that a modified Cadenat's procedure for an acromio-clavicular dislocation leads to good results for a long time after the surgery
The purpose of this study was to determine if bony structures have relationship to individual joint laxity in recurrent anterior glenohumeral instabilities. We analyzed a consecutive series of 132 shoulders without any evidence of traumatic instabilities in contralateral shoulders. Subjects consisted of 95 males and 37 females with an average age of 24 (range,13-55) years old. Glenoid morphologies, evaluated through the use of 3DCT, were classified into 3 groups: Bony Bankart cases (BB), abnormal morphology without bony fragment (AS), and normal morphology (NS) compared with normal contralateral shoulders. Hill-Sachs lesions were also classified into 3groups: small and shallow (SS), wide and shallow (WS), and deeper (MD) types. Joint laxity was determined by the amount of humeral head translation during examination under anesthesia (EUA) prior to surgery into 3 grades: A: minimum translation, B: moderate translation, C: severe translation beyond the glenoid rim. We compared these bony structures with joint laxity. The number of stable grade A was significantly greater in group BB while that of grade C was greater in groups AS and NS (p=0.0004): The number of grade A was also greater in group MD while that of grade C was greater in group SS. In conclusion, bony structure in recurrent anterior glenohumeral instabilities was well preserved in lax shoulders. Contrastingly, in less lax shoulders, bony Bankart lesions were frequently observed and Hill-Sachs lesions tended to be deep and wide.
Recurrent shoulder dislocations rarely occur following traumatic shoulder dislocation in ages over fifty years old. Lesions of shoulder dislocation in older patients are not only Bankart lesion but also cuff tear. This time, we reported on the surgical results of recurrent shoulder dislocation in patients older than fifty years of age. In past nine years, one hundred-sixty one patients who had recurrent shoulder dislocation had surgery in our hospital. There were eight patients aged over fifty years who had an initial dislocation of the shoulder. All of those patients had a rotator cuff tear. These were four men and four women. Their ages were between fifty-two and seventy-seven years old (average 62.9). All the patients had their torn cuffs sutured. Two patients had Bristow procedure, one patient had a Boythcev procedure and one patient had a Bankart procedure. The average follow-up period was 35.3 months. The average JOA score was 56.6 at preoperatively, and was 87.4 at post-operatively. No patients revealed a recurrence of the dislocation of the shoulder, but restricted ranges of motion remained. When surgeons treat recurrent shoulder dislocation in patients aged over fifty, they should take a rotator cuff tear into account.
We investigated the usefulness of abduction and external rotation MR imaging (ABER-MRI) for detection of a capsular tear in patients with recurrent anterior shoulder dislocation. Fourteen shoulders of fourteen patients (mean age twentytwo point four years old) with recurrent anterior shoulder dislocation who had a capsular tear were examined. The tear site was the glenoid side in seven, the mid-portion in five, and the humeral side in two. MR imaging of the shoulder was performed with a 0.3-T imager (AIRIS, Hitachi). Oblique axial T1-weighted gradient-echo (GE) images were obtained. The assessments were compared with the arthroscopic findings. A thinning of the capsule was detected on the affected side of twelve cases. Normal capsule showed a low signal intensity without discontinuity. Seven cases with a glenoid side tear showed a signal change near the glenoid. Five cases with a mid-portion tear had severe thinning or disappearance of the capsule. In two cases the humeral side tear had a normal capsular appearance. The ABER-MRI appeared to be useful for detection capsular tears at the glenoid side and the mid-portion.
The purpose of this study was to present the results of an arthroscopic Bankart repair using suture anchors in selected patients and to discuss its indication. Thirty-two patients (eight women, twenty-four men, mean age twenty years-old) with a discrete Bankart lesion, no bilateral multidirectional instability, no large Hill-Sachs or bony anterior glenoid defect were repaired arthroscopically using suture anchors. Twenty-eight patients had excellent results, four good by Rowe grading system after a mean period of thirty-six (twenty-four- forty-eight)months follow-up. The mean loss of elevation, external rotation with arm at side and that in abduction was 1degree,4 degrees and 2 degrees, respectively. One (3 %) had recurrence. There were no complications. An arthroscopic Bankart repair for our selected patients restored stability of the shoulder and led to a favorable outcome in the overhead and contact athletes.
We used open Bankart procedure using suture anchor device for the recurrent anterior dislocation of the shoulder since 1996. We evaluated the middle term results. From 1996 to 2000, open Bankart procedure was performed on n inety shoulders of eighty-seven patients. We studied retrospectively forty-seven patients and forty-eight shoulders that were observed for more than two years postoperatively. The average age at the operation was twenty-seven point five years old (range fifteen-sixty years old). The mean follow up period was three point eleven years (range two-five point nine years). We used Japan Shoulder Society (JSS) Shoulder Instability Score in this study. There were forty patients who did some kind of sports. After the operation we followed up their return to sports activities. The mean JSS score was 85.8(range 58-97). The recurrence was noted in five shoulders. Three of them were caused by major trauma. Thirty-two patients had limitation of external rotation, and mean loss of range of motion compared with the opposite side was 16.3°. There were no complaints about the limitation. Thirty-eight of forty patients who did sports could return to their activities totally or partially. The mean recovery period was seven point two months (range three-thirteen months). Forty patients were satisfied with the results. Bankart procedure gives good results for the recurrent anterior dislocation of the shoulder with a high rate of return to the sports activity. However the inferior factors found in recurrent cases and the cases with a restriction of external rotation were examined.
1984 we have used a combined Bankart-Bristow procedure for recurrent anterior dislocation of the shoulder. Based on this follow-up study, we attempted to investigate the clinical efficacy for returning athletes to their previous levels. We evaluated ninety-three patients, ninety-five shoulders who were directly followed-up for more than two years post operatively. The average age at the time of procedure was twenty-three point five years old, and average follow-up period was eight point seven years. The following parameters were evaluated using the JSS Shoulder Instability score and the JSS Shoulder Sports score. There were two recurrent dislocation and subluxation (one dislocation another subluxation). The recurrence rate was 2.1 %(two out of ninety-three). The average loss of external rotation was 15.8° with the arm at side and 7.8° with the arm in 90° abduction. The average JSS Shoulder Instability score was 95.4 points. The average JSS Shoulder Sports score was 86 points. Return to previous sports was accomplished by eighty-six patients.. The rate of return to previous sports was 93 %. The rate of return to contact sports was 88.9%(forty out of forty-five). The rate of return to throwing sports was 87.5%(fourteen out of sixteen). There were forty-five high-level athletes (rugby 15, judo 14, American football 7, baseball 5, other sports 4) All of the five baseball players had surgery on the throwing side. For the group of highlevel athletes thirty-eight of the forty-five athletes could return to their previous sports. The rate of return to their previous sports was 84.4%(thirty-eight out of forty-five). The rate of return to their previous sports in judo players was 93 %(thirteen out of fourteen), in rugby players was 80%(twelve out of fifteen), in American football players was 86% (six out of seven), and in baseball players it was 60% (three out of five). We concluded that combined Bankart-Bristow procedure gave good results for recurrent anterior dislocation of the shoulders with a high rate of returning to sports activity.
We reported on 9 cases of double fractures of the clavicle and discussed the mechanism and the treatment of this unusual lesion. Four cases were due to direct force to the clavicle, two cases were struck the lateral side of their shoulders, one case was struck the supero-lateral side of his shoulder, two cases were unknown. The additional injuries of two cases were cerebral contusion, Four cases were lung and wall of the chest injuries. The associated injuries of the shoulder girdle in two cases were coracoid process fractures, one case was a tear of the coracoclavicular ligament, and one case was a fracture of the glenoid fossa. All cases of associated injuries of the shoulder girdle were caused by direct force to the clavicle. Five cases in which bone fragments were displaced widely were treated operatively. The clavicle end was treated by tension band wiring, and diaphysis was treated by intramedullary nailing of Kirschner's wire. All of the patients treated operatively acquired bone union. But one case fell into osteomyelitis. Two cases treated conservatively fell into a nonunion. The mechainsm of double fractures of the clavicle had two patterns, except for direct force to the clavicle. In all cases, the distal end fracture was the initial fracture by the external force directly impacting the distal clavicle. The cases of the mid-and distal fracture were struck on supero-lateral side of the shoulder, and then, the clavicle approached the first rib. The cases of proximal and distal fracture were struck on the lateral side of their shoulder, the shoulder rolled backwards, and then, produced a fracture of the proximal third of the clavicle secondly.
Three cases which have had iatrogenic fracture of the surgical neck of the humerus during closed reduction for an anterior shoulder dislocation with fracture of the greater tuberosity in elderly people were reported. They were all females and their age was more than sixty-five years old. We tried to reduce the dislocation without any anesthesia in all cases. The reduction procedures were simple traction methods reported by Stimson and Hippocrates. We recommended Milch's and Kocher's method under general anesthesia at the reduction of the shoulder joint in patients with two part fracture dislocations of the proximal humerus in elderly people.
Four-part fractures of the proximal humerus usually are treated with prosthetic replacement to avoid nonunion, malunion, nor avascular necrosis of the humeral head. We performed open reduction and internal fixation for this fracture by intramedullary pin and wire. The purpose of this study was to introduce our method and to evaluate the postoperative results. They consisted of three males and eight females whose averaged age was sixty-four years. The operative technique: the delto-pectoral approach allowed adequate exposure of the fracture site. The humeral head and shaft were fixed by two intramedullary Ender or Rush pins through the rotator cuff. The rotator cuff and humeral shaft were fixed by a wire extramedullary. Nine of the eleven fractures healed without postoperative displacement nor avascular necrosis. Necrosis of the humeral head occured in one case. In those ten fractures, postoperative follow-up periods was from one year to six years and two months, averaged two years and eight months, and the JOA score went from 73 points to 100 points, averag 82.4 points. In only one case of senile dementia, was the prosthetic replacement performed for a re-fracture of the humeral head. Our method by minimal fixation was minimally invasive for the soft tissue and blood supply of the humeral head fragment, and advantageous to revasculization of the humeral head fragment, and very useful for four-part fractures of the proximal humerus.
This report showed that the analysis of the isokinetic strength test for throwing shoulder injuries could be used to determine the appropriate time for the patient to return to pitching. During the last six years, among two hundred sixtyfive players studied, one hundred fifty high school baseball players were found to be uninjured while one hundred fifteen players were found to be suffering from throwing shoulder injuries. The tests were carried out using a CybexR II Multi-Joint Dynamometer. The patients were seated with their shoulders abducted at 90 degrees and their elbows flexed at 90degrees. The shoulders were tested for their rotational strength. We observed an imbalance of isokinetic strength of the shoulder by noticing a difference between the internal and external rotational strengths. In addition, we examined the data of concentric isokinetic endurance strength that had not been reported previously. Returning to pitching was found to be highly possible when the patients corrected the imbalance of internal and external rotational strengths and their concentric isokinetic endurance strength was above 70% measured by the concentric endurance strength test. Correction of the imbalance of internal and external rotational strengths and the improvement of endurance strength were considered to be necessary to judge the appropriate time for returning to pitching.
Dynamic examination of the superior labrum was performed by Ultrasonography (US). The superior labrum of twentyseven baseball players ranging from seventeen to thirty six years were investigated with a superior approach in which the probe was fixed at the interval between the acromion and the clavicula. We observed the movement of the superior labrum when the arm was stressed inferiorlly at the neutral position and the arm was rotated externally at the cocking position. The labrum of type 2 SLAP lesion moved more backward than in the normal cases at the cocking position. The labrum of the type 3,4 SLAP lesion detached from the glenoid with the inferior stress. US findings were correlated w ith the arthoroscopic inspections. This revealed that in the detection of SLAP lesion, ultrasonography had a sensitivity of 73.3%, a specificity of 75.0%, an accuracy of 74.1%. These results demonstrated that US was useful in the diagnosis of a SLAP lesion.
We reported on the clinical outcomes of the epiphyseal separation in the proximal humerus due to sports activities. Forty-seven patients including forty-five males and two females, whose average age was twelve years old (nine-sixteen years old), were enrolled as subjects. Sports activities were baseball in forty-one patients, softball in three, tennis in two and volleyball in one. The X-ray images revealed partial separation of the lateral epiphysis in thirty-six patients, full separation of the epiphysis in seven and slipping in four. All the patients took a rest from their sports and were subjected to conservative treatments. Medical checks such as examination of joint instability and ROM or muscle balance of the whole body were performed on all the patients. Complete improvement of the separated epiphysis was observed in all the patients. Forty-six patients could return to their previous sports. One patient who could not return to his previous sports activity had complications of SLAP lesion and little league elbow. In twenty-five patients, other sports injuries included those of the elbow, lower back, knee and so on. All the forty-seven patients had posterior capsular tightness of the shoulder joint. Some patients also experienced muscle tightness as tight hamstrings or motion restriction of the other joints. Therefore, the epiphyseal separation of the proximal humerus may not be only due to the problem of the shoulder joint but also due to muscle imbalance or tightness of the body. Proper training programs and early diagnosis are important to prevent and treat an epiphyseal separation. Moreover, detailed medical checks of the whole body should be regularly performed on adolescent athletes.
The purpose of this study was to clarify the mid-term clinical results after arthroscopic removal of painful Bennett's ossification in throwing athletes. A painful Bennett's ossification was diagnosed as follows: 1) Detection of a bony spur at the posterior glenoid rim on X-ray films.2) Posterior shoulder pain during throwing.3) Tenderness at the postero-inferior aspect of the gleno-humeral joint.4) Improvement of throwing pain by local anesthesia of the Bennett's ossification. Thirteen baseball players, who fulfilled all of our criteria and were followed up for minimally two years (twenty-four - fiftyone months), were retrospectively studied. Postoperatively, tenderness, throwing pain, recovery of throwing ability, return to playing baseball, and patient's satisfaction were investigated, and sports ability was evaluated using JSS shoulder sports score. There was no tenderness at the postero-inferior aspect of the gleno-humeral joint in any of the patients. Throwing pain disappeared in eight shoulders and was improved in five shoulders. Nine patients returned to baseball at their previous level of competition, while three patients returned partially but one patient could not return. The average JSS shoulder sports score had postoperatively improved to 84.8 points from the preoperative 44.8 points. No recurrence of throwing pain was seen including one case of re-ossification. The mid-term clinical results after arthroscopic removal of painful Bennett's ossification were almost all favorable, and persisted to remain unchanged for a long time.
The purpose of this study was to clarify the surgical outcome of the painful throwing shoulders followed up more than two years. We retrospectively studied fourteen cases (eleven male cases and three femal cases) ranging from eighteen to thirty-seven years of age (average, twenty-three point seven years). Ten baseball players, one volleyball player and three softball players were included. SLAP lesions were recognized in eleven csases, posterosuperior labral injury in three cases, partial-thickness rotator cuff tear and a labral injury were combined in four cases. Arthroscopic resection of the torn and detached labrum was performed in fourteen cases, arthroscopic debridement for the articular side partial rotator cuff tear was performed in two cases, open cuff repair was performed in one case and thermal capsular shrinkage in one case. We evaluated the throwing pain and the function with the Shoulder Sports Score of Japan Shoulder Society (sports score). All of the cases returned to their preoperative sports level from five to fourteen months (average nine months). The average pain score was 22.3 points and the function score was 29.1 points postoperatively at the time of return to their preoperative playing level. At the time of the last investigation, the pain score was 25.5 points and the function score was 35.5 points and 79% of the cases continued their preoperative sports activity. The surgical outcome for painful throwing shoulders were satisfactory.
The purpose of this study was to investigate the clinical results of arthroscopic treatment for throwing injury of the shoulder joint. Since April 1998, twenty-four overhead athletes with throwing pain in the shoulder who underwent arthroscopic treatment including debridement or repair of the labral injury, debridement of the rotator cuff injury and subacromial decompression were evaluated from twelve months to forty-three months as follow-up. Twenty-three cases returned to their preinjury performance level. J S S Shoulder Sports Score improved from 31.6 points to 72.9 points. The isokinetic strength of internal rotation had decreased by three months after operation, however it has recovered to the preoperative level at one year after the operation. The isokinetic strength of external rotation was higher than that of preoperative level at one year after the operation. The ratio of external rotation to internal rotation had changed from 58.8% to 68.2%. Arthroscopic treatment was thought to be beneficial for cases of throwing injury of the shoulder joint.
We performed medical check-ups on elite volleyball players to determine the effect of subacromial impingement on the range of motion (ROM) of the shoulder. We examined thity six athletes ranging from junior high school to college age. They were divided into two groups: 1) the positive impingement group (I Group) of athletes with a positive impingement sign, and 2) the negative impingement group (N-I group). We measured the flexion and rotation at both 90° abduction (2nd position), when athletes were in a supine position with their scapula fixed. Statistical analysis was performed not only between throwing and nonthrowing hand, but also between I and N-I groups. Fourteen showed a positive impingement sign, including one junior high school player, four high school players, and nine college players, which meant that the the longer their experince, the more volleyball players had the subacromial impingement (P< 0.05). In the I group, flexion and internal rotation at the 2nd position of the throwing hand were smaller than those of the nonthrowing hand (P< 0.05), and ROM of the throwing hand except for the internal rotation at the 2nd position was smaller than that in the N-I group (P<0.05). Smaller range of flexion and internal rotation at the 2nd position of the throwing arm is caused by a tightness of either the posterior capsule or surrounding rotator cuff, which may lead to subacromial impingement.
We measured the range of internal and external rotation of the shoulders and evaluated the effect of shoulder stretching in little league baseball players. Physical examinations were performed on fifty-two little league baseball players (range of age, nine to twelve years old), and measurements of the range of shoulder rotation were made with the patients supine and the shoulder at 90° abduction. Twenty-nine players, themselves and their partners were shown how to shoulder stretch and the effect of the stretching was evaluated. They demonstrated a significantly increased external rotation and a significantly decreased internal rotation range of motion compared with the opposite shoulders. The significant differences were found in all ages. Self stretching showed the least effect, while significant increased internal rotation was obtained by partner stretching. We found a significant loss of internal rotation of the throwing shoulders even in little league baseball players. Partner stretching was useful for recovery of the motion loss.