Aims

The objective of our study is to identify the causes for recurrence and to evaluate the results of our technique.

Introduction

The role of in-situ decompression in patients with severe ulnar nerve compression is still controversial. The authors present a prospective study on the results of in-situ decompression in this selected group of patients treated through a mini open incision (4cms) and complete decompression by appropriate patient positioning.

Prevalence of rotator cuff tears increases with advancing age (Ellman et al). In spite of proximal humeral fractures being common in the elderly, the influence of a coexistent rotator cuff tear on outcome has, to our knowledge, not been previously investigated. This study prospectively assessed whether the presence of a rotator cuff tear in association with a proximal humeral fracture influences functional prognosis.

85 patients treated conservatively for proximal humeral fractures were evaluated prospectively with Ultrasonography to determine the status of the rotator cuff. Every patient was managed by immobilisation of the arm in a sling for two weeks followed by a course of physiotherapy based on the Neer regime. Functional outcome was measured using the Constant shoulder score and the Oxford shoulder score, at 3-months and 12-months post injury.

Sixty-six of the 85 patients were female. The fractures were equally distributed for hand dominance. There were 27 patients with an undisplaced fracture, 34 patients with Neer's Type II fracture and 24 patients with Neer's Type III and IV fracture. There were 43 patients with full thickness cuff tears and 42 patients with no cuff tear or a partial thickness tear. Full thickness cuff tears were much more frequent in the over 60 year age group, which is consistent with the known increased incidence of cuff tears with increasing age.

The outcome scores at 3 and 12 months showed no statistically significant difference for either the Constant score or the Oxford score with regards to cuff integrity. Analysis of these scores showed no correlation between presence or absence of a full thickness cuff tear and shoulder function

The results of this study indicate that rotator cuff integrity is not a predictor of shoulder function at 12 months following proximal humeral fracture, as measured by outcome scores. This suggests that there is therefore no clinical indication for routine imaging of the rotator cuff in patients for whom conservative management is the preferred treatment option.

Introduction: To quantify the magnitude and incidence of haemodynamic changes that occurs during the fixation of extracapsular proximal femoral fractures when using either intra-medullary or extra-medullary fixation device.

Methods: A prospective group of 31 patients with extra-capsular proximal femoral fractures were randomised to either fixation using an extra-medullary compression hip screw or an intra-medullary hip screw. All patients received a general anaesthetic adhering to a standardised anaesthetic protocol including invasive blood pressure monitoring and arterial blood gas sampling. Trans-oesophageal Doppler probe and monitor was used to record pre-operative hypovolaemia and peri-operative changes in cardiac output, stroke volume and corrected flow time (FTc – a reflection of left ventricular end diastolic pressure) during placement of implants.

Results: 77% of patients were hypovolaemic preoperatively, which was corrected with an average of 439 mls of colloid replacement fluid. Application of the extra-medullary CHS produced no change in haemodynamic function. However on insertion of the IMHS we found a statistically significant reduction in stroke volume, cardiac output and FTc without changes in pulse rate or mean arterial pressure. The changes were transient with normal cardiac function returning by 5 mins post operatively.

Conclusion: The transient fall in cardiac function during insertion of the intramedullary hip screw may be caused by fat embolism entering the venous circulation. As these changes are not detected with standard non-invasive monitoring we would recommend that intramedullary devices be used with caution in elderly patients who tend to have poor physiological reserve.

Introduction: Arthrodesis of the knee nowadays is used as a salvage procedure, commonly for patients with a failed TKR or in infected trauma cases. We present 4 patients with extensive bone defects following septic sequelae of trauma treated by Arthrodesis of the knee joint.

Materials and Methods: Four patients (avg. 46.5 years; range 37–57 years; three male and one female) with longstanding infected non-union fractures (3 months–2 years) at the knee joint (three Tibial plateau and one distal femur) were treated by initial debridement and removal of dead or infected bone. This led to substantial bone defects (6–12 cm) of the debrided bone at the knee joint. The patients then underwent bone transport with a circular frame to compensate for this bone defect before achieving an Arthrodesis of the knee joint. Three patients also had a free muscle flap for soft tissue coverage before bone transport was begun.

Results: Arthrodesis of the knee was achieved in all patients at an average time of 26 months (20–32 months). None of the patients have any active infection of the limb.

Discussion and Conclusions: Knutson et al (1984) said that massive bone loss may substantially reduce the success rate of Arthrodesis of the knee. Wilde and Stearns (1989) noted decreased fusion rates with greater degrees of bone loss. In our series the bone defects were a sequelae of infective non-union, this further complicates the healing process. However, using circular frame for Bone transport to overcome the defect and to achieve compression at the Arthrodesis site is a useful technique for such challenging cases.

Introduction: Arthrodesis of the knee nowadays is used as a salvage procedure, commonly for patients with a failed TKR or in infected trauma cases. We present 4 patients with extensive bone defects following septic sequelae of trauma treated by Arthrodesis of the knee joint.

Materials and Methods: Four patients (avg. 46.5 years; range 37–57 years; three male and one female) with longstanding infected non-union fractures (3 months–2 years) at the knee joint (three Tibial plateau and one distal femur) were treated by initial debridement and removal of dead or infected bone. This led to substantial bone defects (6–12 cm) of the debrided bone at the knee joint. The patients then underwent bone transport with a circular frame to compensate for this bone defect before achieving an Arthrodesis of the knee joint. Three patients also had a free muscle flap for soft tissue coverage before bone transport was begun.

Results: Arthrodesis of the knee was achieved in all patients at an average time of 26 months (20–32 months). None of the patients have any active infection of the limb.

Discussion and Conclusions: Knutson et al (1984) said that massive bone loss may substantially reduce the success rate of Arthrodesis of the knee. Wilde and Stearns (1989) noted decreased fusion rates with greater degrees of bone loss. In our series the bone defects were a sequelae of infective non–union, this further complicates the healing process. However, using circular frame for Bone transport to overcome the defect and to achieve compression at the Arthrodesis site is a useful technique for such challenging cases.

Following ankle sprain, there can be many causes of disability including ligament injuries, soft tissue or bony impingement, Peroneal tendon tears, osteochondral defects (OCD), synovitis and Osteoarthritis (OA)

Aim: To assess the use of Ankle MRI in clinical decision-making in patients with pain and/or chronic instability following ankle sprains.

Method: A retrospective case note review was undertaken for all ankle scopes performed and all Ankle MRI ordered by a single surgeon (AOA) over a three-year period (April 2004 – April 2007).

Results: During this period 54 Ankle arthroscopies were performed. 24 had pre op MRI scans (16 ordered by AOA and 8 by others who then referred the patient) and 30 had no MRI. 8 case notes were not available.

In 43 of the 46 available notes the patients presented with either chronic ankle pain or instability following ankle sprain. 32 had Anterolateral soft tissue impingement on arthroscopy. Of these 24 had MRI scans with only 3 reporting a soft tissue impingement.

13 patients had lateral ligament reconstruction. All 13 of these patients showed signs of instability on examination under anaesthesia (EUA). Of these 9 had MRI scans with 4 reporting a ligamentous injury. Five other patients had MRI scans that showed a lateral ligament injury but had a normal EUA and did not undergo a ligament reconstruction.

10 patients had moderate to severe OA on arthroscopy of the ankle. Of these 4 had MRI scans with 2 reporting OA changes but 2 reported as OCD.

Conclusion: Analysing the available data suggests that the indication to perform an arthroscopy is not dependent on the results of the MRI scan but is a clinical one.

The decision to reconstruct/repair the lateral ligament complex is a clinical one dependent on patient symptom and the EUA findings.

MRSA infections are a current concern in the elderly orthopaedic patient, with colonisation rates of between 417% reported in these patient groups. In our institution there has been concern regarding MRSA surgical site infection and cross contamination of elective and emergency patients. This prompted the unit to consider a screening programme to identify MRSA carriers. We undertook the following project to assess the feasibility and effectiveness of implementing such a screening programme.

The aim was to to ascertain the incidence of colonisation with MRSA, rate of wound infection and associated risk factors in patients admitted with a fractured proximal femur.

This was a prospective, blinded case series of 100 consecutive patients admitted to the trauma ward with a fractured proximal femur. Three swabs (axilla, nasal and perineum) were taken within 24 hours of admission. Data from each patient was collated and each patient was followed until discharge to assess for surgical site infection.

The age range was 60–97 years. 26% were admitted from institutional care. Four patients were colonised with MRSA on admission. An association was seen between patients colonised on admission and long term or recent residence in institutional care. One of these patients went on to develop colonisation of the surgical wound however this did not lead to surgical site infection and the patient was successfully treated with MRSA eradication therapy only. In these 4 patients all wounds healed satisfactorily with no evidence of infection.

While MRSA continues to be a growing concern in the press we found that rates of colonisation and subsequent infection were not high. There were no documented cases of MRSA wound infection in colonised individuals. Given the cost to detect these low levels of colonisation we do not feel that a screening regime would be cost effective or justified.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Background: In recent years an increased trend in MRSA infection has been seen in hospitals and the community, with colonisation rates of between 4 – 17% reported in these patient groups. There is also an association between carriage of Staph. Aureus and staphylococcal surgical wound infection.

In our institution there has been concern regarding MRSA surgical site infection and possible cross contamination of elective and emergency patients. There would be implications for implant related infections if this were to occur. This had prompted the unit to consider adopting a screening programme to identify and treat MRSA carriers. This would aim to minimise risk of post operative infection and cross infection. As little was actually known about the MRSA colonisation rates of admissions to our hospital we undertook the following project to assess the feasibility and effectiveness of implementing such a screening programme.

Aim: To ascertain the incidence of colonisation with MRSA, rate of wound infection and the associated risk factors in patients admitted to the trauma ward with a fractured neck of femur.

Method: A prospective, blinded case series of 100 consecutive patients admitted to the trauma ward with a fractured neck of femur. Three swabs (axilla, nasal and perineum) were taken within 24 hours of admission. Data from each patient was collected to ascertain the presence of risk factors linked to MRSA colonisation and each patient was followed until discharged to assess for surgical site infection.

Results: 304 swabs were taken from 100 patients. Age range 60–97. 26% admitted from institutionalised care and 74% admitted from their own home. Four patients were colonised with MRSA on admission (2 nasal, 2 perineal). An association was seen between patients colonised on admission and long term or recent residence in institutionalised care. One of these patients went on to develop colonisation of the surgical wound however this did not lead to surgical site infection and the patient was successfully treated with MRSA eradication therapy only. In these 4 patients all wounds healed satisfactorily with no evidence of infection.

There were three superficial surgical site infections postoperatively, all in individuals who were clear on their admission screening. Of these two were due to MRSA and one was due to MSSA. There were no cases of deep infection requiring further surgery.

Conclusion:While MRSA continues to be a growing concern we found that, in our hospital, rates of MRSA colonisation and subsequent infection were not high. There were no documented cases of MRSA wound infection in colonised individuals. Given the cost involved in swabbing all patients to detect these low levels of colonisation we do not feel that an expensive screening regimen would be cost effective or justified in our institution.

Introduction: Scoring systems for assessment of shoulder function are invaluable tools in determining changes in a patient’s condition. We utilised two commonly used assessment tools in patients with conservatively treated proximal humeral fractures to establish their behaviour in this patient group.

Methods: OSS and Constant Scores were collected prospectively at 3 and 12 months post injury, for 103 consecutive patients treated conservatively for proximal humeral fractures. Comparison of the scores was undertaken by creating scattergraphs, calculating Pearson’s correlation coefficient and producing Bland and Altman plots. Sensitivity to change was calculated using paired t-tests. Linear regression analysis was finally performed to predict Constant Score from the OSS.

Results: 177 sets of scores were collected. The scores correlated well with a correlation coefficient (r) of 0.84 (p< 0.001,n=177). This relationship was equally strong at 3 (r=0.77 (p< 0.001,n=94)) and 12 months (r=0.87 (p< 0.001,n=83)) and demonstrated a clear relationship between the scoring systems. Bland and Altman plots showed good agreement between the scores. Both scores were sensitive to change over time (OSS (t(81)=6.14,p< 0.001), Constant (t(80)=−10.27,p< 0.001)). Regression analysis produced a regression equation (R2=0.70) of: Constant Score=99.3-(1.67 times OSS). This level of model fit was statistically significant (F(1,175)=412.8,(p< 0.001))

Conclusion: This study provides information about the behaviour of two frequently used functional scoring systems in patients with proximal humeral fractures. Based on our finding we feel that these scores are appropriate assessment tools in these patients. The OSS may also be considered as an alternative for assessing longer term follow up as, being solely subjective, it is easier to administer and correlates well with the Constant Score.

To identify mechanisms of failure in plate and nail fixation in proximal humerus fractures. 5% of the proximal humerus fractures need surgical fixation, which is carried out, principally, by open reduction and internal fixation or closed reduction and intramedullary nailing. Fixation failure remains a problem. This study answers the mode of failure of these implants regardless of the fracture personality. In-vitro testing of proximal humerus fixation devices was undertaken in 30 simulated osteoporotic bone models. Fracture-line was created at the surgical neck of humerus in all samples and fixed with five fixation devices; three plating and two nailing devices. The samples were subjected to failure under compression and torque. Failure was achieved in all models. Three failure patterns were observed in torque testing:

The two conventional plates Cloverleaf and T-plate behaved similarly, failing due to screw pull-out from both the proximal and distal fragment with a deformed plate.

The failure mode is dependent on implant properties as well, independent of the fracture personality. It is important to recognise the potential points of failure (proximal or distal fragment) when making the choice of implant to avoid fixation failure.

Aim: To compare of strength of constructs using the newer and part specific nail systems: Polarus and European Humeral Nail with that using PHILOS and Conventional plate systems in a simulated 2-part fracture of proximal humerus, in an osteoporotic bone model.

Materials and Methods: A Biomechanical laboratory study was undertaken. Third generation composite Humerus model was used, with short e-glass epoxy fibres forming cortex and polyurethane cancellous core. Low-density polyurethane core (1.2gm/cc) was used to simulate an osteoporotic model. Osteotomy at surgical neck of humerus was carried out to create 2-part fracture of proximal humerus. Samples were fixed using one of the implants- the Polarus nail, the European Humeral Nail, PHILOS Plate, Clover Leaf Plate or T-Plate. Following fixation samples were placed in a custom made jig to fix proximal and distal ends without interfering with implants and osteotomy site. All samples were subjected to cyclical torque, torque to failure, cyclical compression and Compression loading to failure.

Results: The two Nail systems that are specifically designed for fixation of proximal humerus fracture provided significantly better fixation in all the test modalities. PHILOS construct shows less plastic deformation in cyclical torque and cyclical compression when compared to the other plates but the 2 nail systems were far superior. Locking screws did not ‘back off’ in any of the experiments involving the Polarus, European Humeral Nail and PHILOS construct, however ordinary screws used with the conventional plates did back off both in ‘torque and compression’ testing.

Conclusions: Polarus and European Humeral Nail constructs provide better stability in torque and compression as compared to PHILOS, which in turn is a more stable construct in comparison to conventional plating devices.

Aim: To investigate in vitro the mechanical stability of a locking compression plate (LCP) construct in a simulated diaphyseal fracture of the humerus at increasing distances between the plate and bone.

Materials & Method: A series of biomechanical in vitro experiments were performed using Composite Humerus Sawbone as the bone model. Osteotomy created in the mid-diaphyseal region. A 10mm osteotomy gap was bridged with a 7-hole 4.5 stainless steel plate with one of four methods: a control group consisted of a Dynamic Compression Plate applied flush to the bone and three study groups which comprised of a LCP applied flush to the bone, at 2mm and at 5mm from the bone. Standard AO technique used with locking head screws used for LCP fixation. Static and dynamic loading tests performed in a jig with the bone model fixed both proximally and distally. Samples were subjected to cyclical compression, compression load to failure, cyclical torque and torque to failure. Plastic deformation and failure was assessed. Scanning electron microscopy of the plate and screw surface allowed detailed inspection of micro-fracture in areas of fatigue.

Results: Consistent results were achieved in LCP constructs in which the plate was applied at or less than 2mm from the bone. When applied 5mm from the bone the LCP demonstrated significantly increased plastic deformation during cyclical compression and required lower loads to induce construct failure.

Conclusion: In our laboratory model a significant decrease in axial stiffness and torsional rigidity becomes evident at a distance of 5mm between plate and bone.

Introduction: Many authors have stated that open reduction and internal fixation of displaced ankle fractures give better results than conservative management (Hughes et al, Clin Orthop 1979; Tunturi et al, Acta Orthop Scand 1983; Philips et al, JBJS 1985 and ). However, there is little information on the long-term outcome of operated ankle fractures. There is inadequate knowledge of patient perception of ankle function following operative treatment of these injuries.

Aim: To analyse long-term results following operative treatment of these fractures using a patient centred outcome measure.

Methods: 112 patients had undergone operative fixation of isolated, closed bi-malleolar ankle fractures between 1992 and 1996 at Middlesbrough General Hospital. All patients had undergone operative fixation using standard AO principles. An independent assessor ascertained the quality of reduction using standardised radiological parameters (Joy et al JBJS 1974, Sarkisian & Cody J Trauma 1976, Mont et al J Ortop Trauma 1992) to assess the post-operative X-ray films. All postoperative reductions were within the parameters of a good reduction.

The modified Olerud & Molander ankle score questionnaire was sent by post to all patients identified living in the region.

Results: 66 out of 112 patients responded; 34 (52%) leading a sedentary lifestyle and 32 (48%) a moderate/ active lifestyle. Mean age of the patients was 47 years. The follow-up period ranged from 5 to 11 years (average 7 years).

Olerud and Molander scores ranged from 5 to 100, with a mean score of 66.5 (SD 27.6), and median score of 70. Only 9 (13.6%) patients had a score of 100. Comparisons between Olerud and Molander scores were made with regard to: gender, whether metal work was removed at a second operation, Weber classification (B vs C) and patient’s lifestyle. No significant differences were observed

The associations between Olerud and Molander score and the key variables were assessed using non-parametric (Spearman’s) correlation coefficients. None of the variables considered were significantly associated with Olerud and Molander score.

Conclusion: The study would suggest that, despite modern fixation techniques, few patients following bi-malleolar ankle fracture have a symptom free ankle. There is no obvious parameter to predict outcome in patients who are managed appropriately for these injuries.

Background: Prevalence of rotator cuff tears increases with advancing age (Ellman et al). In spite of proximal humeral fractures being common in the elderly, the influence of a coexistent rotator cuff tear on outcome has, to our knowledge, not been previously investigated.

Aim: This study assess whether the presence of a rotator cuff tear in association with a proximal humeral fracture influences prognosis.

Methods: 85 patients treated conservatively for proximal humeral fractures were evaluated prospectively with Ultrasonography to determine the status of the rotator cuff. Every patient was managed by immobilisation of the arm in a sling for three weeks followed by a course of physiotherapy based on the Neer regime. Functional outcome was measured using the Constant shoulder score and the Oxford shoulder score, at 3-months and 12-months post injury.

Results: Sixty-Six of the 85 patients were female. The fractures were equally distributed for hand dominance. There were 27 patients with an undisplaced fracture, 34 patients with Neer’s Type II fracture and 24 patients with Neer’s Type III and IV fracture. There were 43 patients with full thickness cuff tears and 42 patients with no cuff tear or a partial thickness tear. Full thickness cuff tears were much more frequent in the over 60 year age group, which is consistent with the known increased incidence of cuff tears with increasing age.

The outcome scores at 3 and 12 months showed no statistically significant difference for either the Constant score or the Oxford score with regards to cuff integrity. Analysis of these scores showed no correlation between presence or absence of a full thickness cuff tear and shoulder function

Conclusion: The results of this study indicate that rotator cuff integrity is not a predictor of shoulder function at 12 months following proximal humeral fracture, as measured by outcome scores. This suggests that there is therefore no clinical indication for routine imaging of the rotator cuff in patients for whom conservative management is the preferred treatment option.

Background: The incidence of proximal humeral fractures is increasing with time. There is continuing debate about the indications for surgical intervention for this relatively common injury. Baseline data on functional outcome is essential in order to study the effect of surgical intervention. Functional outcome scores provide reliable and valid judgments of health status and the benefits of treatment. During our preparation of a study proposal on this topic to the Health Technology Assessment Program recently, we noted the lack of such data on outcome scores in the current literature.

Aim: To assess the functional outcome using the Constant and Oxford scores in patients treated conservatively for proximal humeral fractures.

Methods: We prospectively studied 103 consecutive patients who were treated conservatively for proximal humeral fractures. Patient demographics, fracture type (Neer), hand dominance and comorbidity were recorded. Constant and Oxford shoulder scores were recorded 3 and 12 months post injury.

Results: The average Constant shoulder score for males was significantly higher (better outcome) and the Oxford shoulder score significantly lower (better outcome) as compared to females. The scores were not affected by hand dominance. Although the raw scores tended to be worse with 3 or 4 part fractures the difference in the mean scores between the various Neer fracture types did not reach convential levels of significance.

A trend towards lesser degrees of improvement in the outcome scores was noted with increasing age. The degree of improvement in the outcome scores was not affected by sex, limb dominance or fracture type (Neer’s classification).

Conclusion: This study indicates the average behaviour of the Constant and Oxford scores with conservative treatment of proximal humeral fractures. This data should help with sample size and power calculations when studying interventions for this injury. We hope that this data will provide a baseline to help inform future study designs on proximal humeral fractures.

Systematic studies are required to examine the effects on outcomes of alternative treatments and surgical techniques in the management of Orthopaedic conditions. Functional outcome scores provide reliable and valid judgments of health status and benefits of the treatment. We undertook a prospective study to assess the functional outcome in patients treated conservatively for proximal humeral fractures.

103 patients treated conservatively for a proximal humeral fracture were followed prospectively. Constant shoulder score and Oxford shoulder score were recorded at 3 months and 12 months follow-up.

A trend towards lesser degrees of improvement in the outcome scores was noted with increasing age. The degree of improvement in the outcome scores was not affected by sex, limb dominance or fracture type (Neer’s classification).

This information gives a guide to average behaviour in different groups of individuals with conservative treatment for proximal humeral fractures. We could then using this data postulate what would constitute a clinically relevant difference and calculate study numbers required while assessing other form of treatments for such fractures

Aim: The prevalence of rotator cuff tears increases with advancing age. Proximal humeral fracture are also common in the elderly, but the influence of a coexistent rotator cuff tear on clinical outcome following fracture has not been previously investigated.

Method: In this study 85 patients treated conservatively for proximal humeral fractures were evaluated with ultrasonography to determine the status of the rotator cuff. Outcome was evaluated using the Constant shoulder score and Oxford shoulder score, and recorded at 3 months and 12 months follow up. The null hypothesis is that there is no correlation between the presence of absence of cuff tear following fracture and clinical outcome.

The data was analysed to determine if the presence of a full thickness rotator cuff tear influenced functional outcome in these patients.

The null hypothesis has not been disproved. There is no statistically significant difference in outcome with presence of an associated full thickness rotator cuff tear with proximal humeral fractures.

Conclusion: At present this study suggests that there is no indication for routine ultrasonography evaluation of the rotator cuff following proximal humerus fracture.

Aim: We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease.

Methods: Fifty patients with history of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy.

Results: The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons: 100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears.

Conclusion: The Neer’s and Hawkins’ signs were the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear.