Examination of the Shoulder: The Past, the Present, and the Future

Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224-2780, USA.
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 11/2009; 91 Suppl 6:10-8. DOI: 10.2106/JBJS.I.00534
Source: PubMed
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    • " function between conservatively and surgically treated patients with subacromial impingement syndrome . ' ' After their systematic review of the literature , Beaudreuil et al . 25 concluded , ' ' the most extensively studied tests for subacromial impingement—Neer and Hawkins—are sensitive but lack specificity , ' ' a conclusion similar to that of Jia et al . 26 . In their 2009 Cochrane review , Coghlan et al . 27 concluded , ' ' There is ' Silver ' . . . level evidence from three trials that there are no significant differences in outcome between open or arthroscopic subacromial decompression and active non - operative treatment for impingement . ' ' Kuhn 28 stated , ' ' Unlike many diagnoses that are based o"
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    ABSTRACT: Acromioplasty for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. The rate with which this procedure is performed has increased dramatically. This investigation sought high levels of evidence in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment. We conducted a systematic review of articles relevant to the following hypotheses: (1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions, (2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch, (3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders, (4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and (5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch. Three of the authors independently reviewed each article and determined the type of study, the level of evidence, and whether it supported the concept of the impingement syndrome. Articles with level-III or IV evidence were excluded from the final analysis. These hypotheses were not supported by high levels of evidence. The concept of impingement syndrome was originally introduced to cover the full range of rotator cuff disorders, as it was recognized that rotator cuff tendinosis, partial tears, and complete tears could not be reliably differentiated by clinical signs alone. The current availability of sonography, magnetic resonance imaging, and arthroscopy now enable these conditions to be accurately differentiated. Nonoperative and operative treatments are currently being used for the different rotator cuff abnormalities. Future clinical investigations can now focus on the indications for and the outcome of treatments for the specific rotator cuff diagnoses. It may be time to replace the nonspecific diagnosis of so-called impingement syndrome by using modern methods to differentiate tendinosis, partial tears, and complete tears of the rotator cuff.
    The Journal of Bone and Joint Surgery 10/2011; 93(19):1827-32. DOI:10.2106/JBJS.J.01748 · 5.28 Impact Factor
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    ABSTRACT: Different orthopedic tests are used to evaluate internal derangements of joints. Radiologic examinations like magnetic resonance (MR) imaging are ordered on the basis of results of these tests to narrow the clinical diagnosis and formulate a treatment plan. Although these tests are clinically useful, the test terminology can be confusing and the significance of the tests not clearly understood. This article helps explain the clinical jargon of tests performed for the major joints of the upper extremity and their proper use and diagnostic value in conjunction with MR imaging. The article presents a structured algorithmic approach to explain the tests. For each joint, a hierarchy of clinical tests is performed, starting with general observation and range of motion, followed by more specific tests tailored to evaluate individual or grouped anatomic structures. MR imaging findings and clinical tests complement each other in making a final diagnosis. However, because of the varied sensitivity and specificity of the clinical tests and MR imaging, it is important to be familiar with their diagnostic value before making clinical decisions. Knowledge of clinical jargon and the proper use and diagnostic value of orthopedic tests can aid in interpretation of radiologic images by focusing search patterns, thus allowing comprehensive evaluation and optimized reporting. It also enhances communication with the orthopedist, thereby helping maintain continuity of care. Online supplemental material is available for this article. ©RSNA, 2014.
    Radiographics 03/2014; 34(2):e24-40. DOI:10.1148/rg.342125061 · 2.60 Impact Factor
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    ABSTRACT: One possible cause of shoulder pain is rotator cuff contact with the superior glenoid (cuff-glenoid contact) with the arm in flexion, as occurs during a Neer impingement sign. It has been assumed that the pain with a Neer impingement sign on physical examination of the shoulder was secondary to the rotator cuff making contact with the anterior and lateral acromion. We determined if the arm position where pain occurs with a Neer impingement sign would correlate with the position where the rotator cuff made contact with the superior glenoid, as determined by arthroscopic evaluation. We prospectively studied 398 consecutive patients with a positive Neer impingement sign during office examination and used a handheld goniometer to measure (in degrees of flexion) the arm position in which impingement pain occurred. During subsequent arthroscopy, the arm was moved into a similar position, and we measured the arm's position in flexion at the point the rotator cuff made contact with the superior glenoid using a handheld goniometer. We compared the degrees of flexion at which pain occurred preoperatively and at which there was cuff-glenoid contact. Among the 398 patients, 302 (76%) had arthroscopically documented cuff-glenoid contact, whereas 96 did not. For the 302 patients with a positive Neer sign preoperatively and with arthroscopically documented cuff-glenoid contact, the average preoperative impingement pain position was 120.1°±26.7°, similar to that of the average intraoperative cuff-glenoid contact position of 120.6°±14.7°. Our data suggest pain associated with a positive Neer sign more often relates to contact of the rotator cuff with the superior glenoid than to contact between the rotator cuff and acromion. Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 09/2010; 469(3):813-8. DOI:10.1007/s11999-010-1590-3 · 2.77 Impact Factor
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