Introduction

The conservative management of Sub-Acromial Impingement Syndrome (SAIS) of the shoulder includes both physiotherapy treatment and subacromial injection with local anaesthetic and steroids. The outcome from injection treatment has rarely been evaluated scientifically.

Objective

Shoulder instability is a common cause of morbidity amongst Professional Rugby Union players. This study explores whether the risk of shoulder dislocation is associated with innate shoulder laxity.

Shoulder instability is a common cause of morbidity amongst Professional Rugby Union players. This study explores whether the risk of shoulder dislocation is associated with innate shoulder laxity. A prospective, randomised controlled study was completed in which all the Premiership Rugby Clubs in England were visited. 169 professional rugby players with no history of instability in either shoulder and 46 players with one shoulder with clinical instability symptoms were assessed. Shoulder laxity was measured by clinical evaluation, questionnaires and ultrasound. Anterior, posterior and inferior translation was measured in both shoulders for healthy players and the uninjured shoulder only for injured players. The results showed there was no significant difference between the left (anterior: mean 2.92 +/− 1.15 mm; posterior: mean 5.10 +/− 1.75 mm; inferior: mean 3.08 +/− 1.00 mm) and right (anterior: mean 3.07 +/− 1.14 mm; posterior: mean 4.87 +/− 1.61 mm; inferior: mean 2.91 +/− 0.99 mm) shoulders in healthy players (P > 0.05). The comparison between healthy shoulders (anterior: mean 3.00 +/− 1.15 mm; posterior: mean 4.99 +/− 1.68 mm; inferior: mean 3.00 +/− 1.00 mm) from healthy players and the uninjured shoulder (anterior: mean 4.16 +/− 1.70 mm; posterior: mean 6.16 +/− 3.04 mm; inferior: mean 3.42 +/− 1.18 mm) from injured players identified that players with unstable shoulders have a significantly higher shoulder translation in their normal shoulder than healthy players (P < 0.05). This is the first study looking at laxity and the risk of shoulder dislocations in sportsmen involved in a high contact sport. These results support the hypothesis that rugby players with “lax” shoulders are more likely to sustain a dislocation or subluxation injury to one of these lax shoulders in their sport.

Sub-Acromial Decompression (SAD) for impingement has a failure rate of 5–20%. We used MRI to see whether SAD failure is associated with muscle wasting or fatty degeneration in the rotator cuff. Fifty one patients with impingement were assessed using MRI pre- and post-op. Following arthroscopic SAD, seven patients with cuff tears were excluded. This study reviews the pre-op and 6 month post-op MRIs of the remaining 44 patients (25 males; 19 females) and also 17 additional MRIs obtained at three years post-op. MRI assessment was performed by an experienced radiologist using Zanetti’s muscle bulk assessment with values expressed as standard deviations from an age matched mean and Goutallier’s fatty degeneration assessment graded 0 to 4. There was a wide range of pre-op muscle bulk values (SupraSpinatus minus;2.4 to +3.4; SubScapularis minus;2.1 to +4.8; and InfraSpinatus/ Teres Minor minus;1.1 to +5.7). Comparing post-op with pre-op there was a gradual trend towards a reduced muscle bulk for each muscle after surgery but to a limited extent only (< 0.5SD). Pre-op fatty degeneration of SS and IS was grade 2 in about a half with a mild increase with time post-op (SS pre=50%, 6/12 and 3 years=59%; IS pre=45%, 6/12=43% and 3 years=59%). There was a similar age distribution for grades 1 and 2. Only three of the patients were a clinical failure at 6 months but this increased to five of the 17 patients scanned at 3 years. Predicting these failures was not possible based on the pre-op MRI data. The high initial success of SAD was not accompanied by an overall increase in muscle bulk or quality of the muscle at 6 months. The progressive loss of muscle bulk and quality over 3 years was accompanied by an increased clinical failure rate.

Introduction: The Constant Score Functional Assessment (CS) is now the standard method of assessing shoulder disability in Europe. Previous studies have indicated that the CS values associated with a full-thickness rotator cuff tear (RCT) are lower than for normal shoulders. This study was designed to investigate which parameters of the CS were most influenced by the presence of a RCT. As ultrasonograpy has now been shown to have a high accuracy for diagnosing full-thickness RCTs it was used to establish the diagnosis.

Methods: 28 patients attending the Shoulder Clinic were invited to take part in this study for which Local Ethics Committee approval had been obtained. The majority of patients had a painful shoulder on at least one side. All patients had a CS carried out with the “Strength” measurement made in 3 ways – 1) maximum force using a fixed spring balance – FSB(max); 2) maximum force using a commercial myometer – M(max); 3) mean force from 2 to 4 seconds using a commcercial Myometer – M(mean). The CS was measured with no knowledge of the patient’s history or diagnosis and blinded to the state of the rotator cuff. The patients were then assessed using ultrasonograpy of the shoulder (Diasus with an 8–16MHz head) to establish the presence of a full-thickness RCT.

Results: The CS Values for the left and right shoulders have been analysed separately.

The results have also been analysed for each part of the Constant Score – Pain, Activities of Daily Living, Range of Movement and Strength and these will be presented.

Discussion: It was anticipated that subjects with a RCT would be found to be weaker and have a reduced CS in an affected shoulder. This was found to be the case for the left shoulder but not for the right. The reasons for this will be discussed. The abnormally low CS for the normal right shoulders (Group 1) will also be explored.

Conclusion: The CS may be a valuable method of identifying those patients with a RCT. This study indicates that a more careful evaluation of “Strength” measurements still needs to be undertaken.

Introduction: This study was designed to investigate which parameters of the Constant Score are most influenced by the presence of a Rotator Cuff Tear (RCT).

Methods: 28 patients attending the Shoulder Clinic took part in this study for which Ethics approval had been obtained. Strength measurements were assessed in three ways: 1) maximum force using a fixed spring balance (FSB) 2) maximum force using the Nottingham Mecmesin Myometer 3) mean force during 2nd to 4th seconds using Nottingham Myometer. The CS assessor was blind to the volunteer’s history and state of their rotator cuff. Ultrasonography was used to establish the presence of a full-thickness RCT.

Results: The CS values for the left and right shoulders were analysed separately. No statistically significant difference (p> 0.05) was found between shoulders with a RCT and without a RCT in the pain, ADL and ROM parameters. Left shoulders with a RCT scored significantly different strength scores to those without (p< 0.05) but this significance was not seen in the right shoulders (p> 0.05). Shoulder strength measurements were highest with the FSB and lowest when measured using the mean force.

Discussion: The results obtained so far suggest that a shoulder with a full-thickness tear of the RC may obtain a significantly lower strength score than a normal shoulder. It does not suggest that any of the other three parameters of the CS can indicate the presence of a tear.

Conclusion: A reduction of shoulder strength alone might be a good indicator of a full-thickness RCT. However, this study indicates the importance of standardising the method of shoulder strength assessment for the Constant Score.