The search included meta-analyses, randomized clinical trials, clinical trials, and reviews. A 47-year-old woman presents with concerns of chronic right shoulder pain and stiffness without antecedent trauma. Search dates: January 15, 2012; June 27, 2012; and December 5, 2013. At the upper end of the ulna is the olecranon, the bony point of the elbow that can easily be felt beneath the skin. A patient sustains the injury seen on the radiograph in Figure A. A patient undergoes an MRI arthrogram for recurrent shoulder instability. [1][2] Medial epicondylitis, also known as golfers elbow or throwers elbow, refers to the chronic tendinosis of the flexor This ligament is in relation with the triceps brachii and flexor carpi ulnaris and the ulnar nerve, and gives origin to part of the flexor digitorum superficialis. What is the most common finding during surgery for traumatic anterior shoulder instability? In the case of younger athletes, pitching guidelines including pitch count limits and required rest recommendations have been developed to protect children from injury. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Laterjet procedure). A 17-year-old football player sustained an injury to his shoulder. WebLittle league elbow refers to a continuous spectrum of injuries to the medial side of the elbow seen in adolescent pitchers, which includes: medial epicondyle stress fractures, ulnar collateral ligament (UCL) injuries and flexor-pronator mass strains. Which of the following statements is true regarding the anatomical boundaries of the rotator interval in the shoulder? Elbow Varus Stress Test. patients with pacemakers and/or cochlear implants, due to limited soft-tissue contrast, CT arthrogram not as effective at visualizing internal soft-tissue derangements as MR arthrogram, has been validated as an imaging modality through which to assess bone loss, increases sensitivity and specificity (86-91% and 86-96%) for detecting soft-tissue injuries when compared to conventional MRI (44-100% and 66-95%), acute reduction, immobilization, followed by therapy, management of first-time dislocators remains controversial, current ASES recommendations are for surgical intervention for athletes aged 14 to 30 at the end of their competitive season if they have positive apprehension testing and bone loss, simple traction-countertraction is most commonly used, Kocher: arm at side in external rotation is forward-flexed and then internally rotated, Hippocratic: traction against a heel placed in the patients axilla, Stimson's: weight is hung from the affected arm of a patient in the prone position, studies have not shown any benefit of immobilization > 1 week for decreasing recurrence rates, some studies show immobilization in external rotation, thought to reduce the anterior labrum to the glenoid leading to more anatomic healing, subsequent studies have refuted this finding, strengthening of dynamic stabilizers (rotator cuff and periscapular musculature), goal is return to sport within 7 to 21 days, military and overhead and/or contact athletes experience an unacceptably high rate of recurrent instability, Arthroscopic Bankart repair +/- capsular plication, recurrent dislocation/subluxation (> one dislocation) following nonoperative management, remplissage augmentation with arthroscopic Bankart may be considered if Hills-Sachs "off-track", at least three (preferably four) anchor points shoulder be used, paramount that labrum is fully mobilized prior to repair, results now equally efficacious as open repair with the advantage of less pain and greater motion preservation, increased failure rates seen in patients with global hyperlaxity, glenoid bone loss, or too few fixation points, too many anchors does pose a risk for fracture through the anchor holes (postage stamp fracture), can be considered when there is a concomitant acute glenoid fracture, or if the patient is hyperlax and requires a formal capsular shift during the same procedure, humeral avulsion of the glenohumeral ligament (, can also be performed arthroscopically but is technically challenging, generally accessed through a deltopectoral approach, can fix bony bankart with screws or suture in a linear or bridge technique, results are equivalent to arthroscopic repair, although patients have more pain and less range of motion postoperatively, patients with greater than 13.5% glenoid bone loss have higher rates of recurrent instability, Latarjet (coracoid transfer) or Bristow Procedure, in the setting of glenoid bone loss, excessive stress is transferred to labrum and attenuated anterior soft tissues, increasing the risk of failure of labral repair alone, transfer of coracoid bone with attached conjoined tendon and CA ligament, Latarjet procedure performed more commonly than Bristow, Latarjet triple effect = bony (increases glenoid track), sling (conjoined tendon on top of subscapularis), capsule reconstruction (CA ligament), over recurrent instability rate ranges from 0% to 8%, good to excellent outcomes are seen in over 90% of patients, bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid), distal tibia gaining popularity since graft is a true osteochondral graft, engaging large (>25-40%) Hill-Sachs defect, "off-track" Hill-Sachs lesions with <20-25% glenoid bone loss, posterior capsule and infraspinatus tendon sutured into the Hill-Sachs lesion, may be performed with concomitant Bankart repair, by decreasing size of Hill-Sachs, converts on off-track lesion into an on-track lesion, when compared to latarjet with 2-year outcomes, remplissage + bankart had lower recurrent instability rates (1.4% vs. 3.2%) despite greater bipolar bone loss, Bone graft reconstruction for Hill Sachs defects, may better replicate line of pull of native subscapularis, Putti-Platt is performed by lateral advancement of subscapularis and medial advancement of the shoulder capsule, Magnuson-Stack is performed with lateral advancement of subscapularis (lateral to bicipital groove and at times to greater tuberosity), transfer of biceps laterally and posteriorly, high rate of post-operative stiffness and subsequent osteoarthritis, typical presentation of open procedure performed in 1970s-80s, now with presenting complaint of pain and stiffness from glenohumeral OA, especially lack of ER, and signigicant posterior glenoid wear and retroversion, high rate of recurrent instability with Boyd-Sisk, relaxation of patient with sedation or intraarticular lidocaine is essential, drive through sign might be present prior to labral repair and capsulorraphy, studies support use of > 3 anchors (< 4 anchors is a risk factor for failure), recurrence, most often due to unrecognized glenoid bone loss or lack of concomitantly addressing "off-track" HS lesion, stiffness, especially in external rotation, further loss of ER may occur with the addition of remplissage, over-tightening increases the risk of post-capsulorrhaphy arthropathy, especially in older patients, axillary nerve is on average 12mm from infra-glenoid tubercle, chondrolysis (from use of thermal capsulorraphy which is no longer used), shoulder anterior (deltopectoral) approach, subscapularis transverse split or tenotomy, most often due to unrecognized glenoid bone loss, post-operative physical exam will show a positive lift off and excessive ER, treat with Z lengthening of subscapularis, iatrogenic injury with surgery (avoid by abduction and ER of arm during procedure), seen with Putti-Platt and Magnuson-Stack procedures, coracoid transfer to anterior inferior glenoid bone defect, traditional or congruent arc technique for coracoid graft placement, after harvest, coracoid is passed through a split in the distal 1/3 or middle 1/2 subscapularis, traditional versus congruent arc technique, in the congruent arc technique, the undersurface of the coracoid ends up articulating with the humeral head, graft can be placed intraarticularly (capsular repaired to CA ligament stump) or extraarticularly (capsule repaired to native glenoid rim), concerns exist for increased rates of subsequent osteoarthritis with intraarticular placement, although this isn't fully supported by high-quality literature, generally higher than arthroscopic or open Bankart, some studies report up to 25% incidence, up to 90% of patients undergo some degree of resorption within the first six months, stiffness, particularly in external rotation, will rapidly occur with lateral overhang of graft into the joint space, majority are traction or contusion neuropraxias and resolve spontaneously, treat with observation for 3-6 weeks; delayed EMG if deficits persist, occurs during instrumentation around the conjoint tendon, pieces conjoint tendon, on average, 5.6 cm distally to the tip of the coracoid, located, on average, 12mm from infra-glenoid tubercle, Boyd-Sisktransfer of biceps laterally and posteriorly, Putti-Platt and Magnuson-Stackboth lead to decreased external rotation and increased loading on the posterior glenoid, which can lead to post-capsulorraphy arthropathy, often due to unrecognized glenoid bone loss treated with a soft tissue only procedure (especially with glenoid bone loss >20-25%), can be due to poor surgical technique (ie, < 4 suture anchors), increased risk with preoperative risk factors including age < 20, male sex, contact/collision sport, ligamentous laxity, and unrecognized glenoid and/or humeral head bone loss (critical bone loss or "off-track" lesion), medical management should be exhausted prior to surgery in patients with seizures, as there is a high recurrence risk even when bony augmentation techniques are used, high incidence of posterior and/or combined front-to-back tears in the military population, overtightening during labral repair can lead to post-capsulorrhaphy arthropathy, especially in external rotation (particularly with Latarjet and additional remplissage), present in up to 90% of patients at six-months, historically due to use of thermal capsulorraphy (now contraindicated) or intra-articular pain pumps (now contraindicated), Arthroscopy, shoulder, surgical; capsulorrhaphy, - Traumatic Anterior Shoulder Instability (TUBS), Capsulorrhaphy, anterior, any type; with coracoid process transfer. A preoperative MRI of the right elbow is found in Figure A. Web(OBQ18.137) A 20-year-old male college-level thrower complains of chronic right shoulder pain and has been prescribed formal physical therapy with stretches consisting of laying in the lateral position on the affected side with your arm forward flexed 90, elbow flexed 90, and pushing the ipsilateral forearm towards the table. WebDuring activities such as overhand baseball pitching, this ligament is subjected to extreme tension, which places the overhand-throwing athlete at risk for injury. Though return to play is not guaranteed, the procedure has helped professional and college athletes continue to compete in a range of sports. His MRI images are seen in Figures A-C. What would be the most appropriate treatment? A 22-year-old basketball player has recurrent instability of the left shoulder. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. All rights reserved. This test is performed with the shoulder in 90 degrees of abduction and external rotation. Medial epicondylitis is much less common than lateral epicondylitis and typically occurs in athletes or workers who participate in activities that involve repetitive valgus stress and flexion at the elbow, as well as repetitive wrist flexion and pronation. On physical examination, with the elbow flexed to 90 degrees, passive supination and pronation of the forearm should reveal a normal piston-like movement of the biceps muscle belly. WebWright leads the way with an impressive history of ground-breaking products for the foot and ankle industry. 1/31/2020. Copyright 2022 Lineage Medical, Inc. All rights reserved. Which patient would be ideal for an open shoulder reduction and glenoid bone augmentation? In many cases, pain will resolve when the athlete stops throwing. What is the most likely diagnosis? These scans are not typically used to help diagnose problems in throwers' elbows. It can be septic or aseptic, and is diagnosed based on history, physical examination, and bursal fluid analysis if necessary. When the elbow is bent, the ulnar nerve stretches around the bony bump at the inner end of the humerus. The examiner should stabilize patients elbow in 90 flexion with one hand on the lateral epicondyle. The other hand is on the forearm applying valgus stress. Symptoms may include locking, catching, or inability to fully extend the elbow.16, Olecranon bursitis is the most common superficial bursitis and is a common cause of posterior elbow pain and swelling.24 Olecranon bursitis can be septic or aseptic. Pronate and supinate the forearm while maintaining axial force. On examination 3 days later, he has weakness in the deltoid. Figure A is an image taken during diagnostic arthroscopy in the lateral decubitus position viewing from the posterior portal with instrument through a rotator interval anterior portal. WebPlantar fasciitis or plantar heel pain (PHP) is a disorder of the plantar fascia, which is the connective tissue which supports the arch of the foot. An MRI scan and X-ray may also be used to see the changes in the ulnar collateral ligament related to stress. Patients with a UCL injury will have pain, instability, and apprehension.11, Cubital tunnel syndrome is a compressive or traction neuropathy of the ulnar nerve as it passes through the cubital tunnel of the medial elbow (Figure 3). (SBQ05UE.87) His preoperative MRI is seen in Figure A and the initial arthroscopic examination as viewed from an anterior portal in the lateral decubitus position is demonstrated in Figure B. In many cases, overuse injuries develop when an athletic movement is repeated often during single periods of play; when these periods of play (including games and practices) are so frequent, the body does not have enough time to rest and heal. (OBQ07.216) The hook test, which involves the examiner hooking the biceps tendon with his or her fingertip, will confirm an intact tendon and may assist in localizing the pain generator (Figure 2). Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain. He works as a lawyer and has been treating the pain with non-steroidal anti-inflammatory drugs with little improvement. Journal of Shoulder and Elbow Surgery. Arthroscopy. He admits to multiple previous shoulder dislocations in the past which were treated conservatively with physical therapy. In 2014, Wright transformed itself from a During this test, the doctor holds the arm still and applies pressure against the side of the elbow. Which of the following patients is most likely to have a fibroblastic proliferative process as a cause for their shoulder complaints? See permissionsforcopyrightquestions and/or permission requests. Tenderness over the UCL has a sensitivity of 81% to 94%, but a specificity of only 22% for UCL tears.11, The most important examination for a possible UCL injury is assessment of the medial joint space laxity or instability against valgus forces. This is sometimes called the middle finger extension test. 10/15/2019. The examiner uses the other hand to passively supinate the arm and extend the elbow and wrist. Physical examination typically reveals a positive Tinel sign at the radial tunnel. An MR arthrogram is most likely to show which of the following? Wartenberg sign (the inability to adduct the little finger), a clawhand deformity, and flexion of the proximal interphalangeal joint and the distal interphalangeal joint of the ring and small fingers may also be present (Table 23,7,8,11,1317 ). The remnant of the CA ligament can be used to aid in repair of the capsular tissues. To avoid introducing infection, aspiration of olecranon bursitis should be performed only when the diagnosis is uncertain or to relieve symptoms in refractory cases. The patient cant be seated or standing. Computed tomography (CT) scans. 4.0 is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid. The initial doctor visit includes discussion about the athlete's general medical health, symptoms and when they first began, and the nature and frequency of athletic participation. Throwers with ulnar neuritis will notice pain that resembles electric shocks starting at the inner elbow (often called the "funny bone") and running along the nerve as it passes into the forearm. MRI is the preferred imaging modality for chronic elbow pain.37,38 MRI can identify pathologic conditions such as bone marrow edema, tendinopathy, nerve entrapments, and joint effusions. A 51-year-old diabetic female has been treated with non-operatively for left shoulder stiffness for the last six months. Copyright 2022 American Academy of Family Physicians. What other pathology, besides the Bankart lesion, is likely contributing to this patient's recurrent instability? Other specialized physical examination maneuvers may be necessary, as well. Most conditions that cause chronic elbow pathology are clinical diagnoses; imaging may be used to confirm the diagnosis before further intervention or referral. This surgical procedure is often referred to as "Tommy John surgery," named after the former major league pitcher who underwent the first successful UCL reconstruction in 1974. The elbow is passively placed at 90 of flexion. This special maneuver is used to diagnose a series of neuropathies, most commonly carpal tunnel syndrome. Athletes with VEO experience swelling and pain at the site of maximum contact between the bones in the back part of the elbow. 196 0 EN. Ehlers-Danlos Syndrome, collagen disorders), often associated with atraumatic instability, global hyperlaxity confers an odds ratio (OR) of 2.68 for the development of anterior shoulder instability, individuals with global hyperlaxity have a 3x higher rate of recurrent instability, patients with global hyperlaxity are less likely to develop capsulolabral lesions, labrum contributes 50% of additional glenoid depth, Anterior static shoulder stability is provided by, Anteroposterior Translation Grading Scheme, Humeral head translation up to glenoid rim, Humeral head translation over glenoid rim with spontaneous reduction once force withdrawn, Humeral head translation over glenoid rim without spontaneous reduction. The patient is asked to perform a pushup from the floor. The pain is usually associated with numbness and tingling in the ulnar border of the forearm and hand, and in the ring and little fingers. J Am Acad Orthop Surg 1994; 2:261-269. In some cases, if the ligament is in good condition but is torn at the bony attachment, it can be reattached to the arm, eliminating the need for a graft. Oct 2022 . Musculoskeletal ultrasonography is more operator-dependent than MRI but allows for an inexpensive dynamic evaluation of commonly injured structures. Taller and heavier pitchers, pitchers who throw with higher velocity, and those who participate in showcases are also at higher risk of injury. Which of the following is a known risk factor for the development of adhesive capsulitis of the shoulder? A 25-year-old basketball player sustains an anterior shoulder dislocation during a game that is subsequently reduced with traction. The doctor will ask the athlete to identify the area of greatest pain, and will frequently use direct pressure over several distinct areas to try to pinpoint the exact location of the pain. A 38-year-old former professional football player complains of longstanding left shoulder pain. Which of the following is the most common outcome following non-operative management of adhesive capsulitis with a stretching program? Tinels Test. Maudsleys Test. ankylosis. origin. The olecranon is the most common location for stress fractures in throwers. It runs from the inner side of the humerus to the inner side of the ulna and must withstand extreme stresses as it stabilizes the elbow during overhand throwing. Guests include Dr. Steven Jones, PGY-3 at the University of Colorado in Denver; Dr. Ben Zmistowski, shoulder and elbow surgery fellow A neurapraxic musculocutaneous nerve injury, An axonotmetic musculocutaneous nerve injury. The presence of weakness with resisted supination of the forearm and extension of the middle finger (middle finger test; Figure 7) is common with posterior interosseous nerve syndrome 20 (Table 23,7,8,11,1317 ). (OBQ18.108) Pitchers who throw with arm pain or while fatigued have the highest rate of injury. In cases of ulnar neuritis, the nerve can be moved to the front of the elbow to prevent stretching or snapping. What is the pathophysiology of her diagnosis and what other findings would most likely be observed? Most ligament tears cannot be sutured (stitched) back together. Webstand behind patient, flex elbow to 90, hold shoulder at 20 elevation and 20 extension. 340 plays. The purpose of todays post is to review some of the special tests for the elbow exam that all members of the sports medicine team should be familiar with. Imaging is obtained and demonstrates a bony Bankart lesion involving 40% of the glenoid. Web(OBQ12.90) A 23-year-old right hand dominant minor league baseball pitcher presents with symptoms of right elbow valgus instability. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, University of Pittsburgh Physicians, Department of Orthopaedic Surgery, Bankart Repair with capsular plication- Arthroscopic, Latarjet Procedure for Glenoid Deficit - Open, Bankart Repair with Remplissage Procedure - Arthroscopic, Bankart Repair - Arthroscopic - Dr. Stephen Snyder, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Pro: Facts: The Performance On The Field After Nonop Versus Surgery For Anterior Shoulder Instability & No Bone Loss - Kevin E. Wilk, PT, DPT, FAPTA, Pro: Nonoperative Treatment Will Do Just Fine - Ellen Shanley, PhD, PT, OCS, Pro: Fix it Now: My Indications For Surgery In This Patient - Raffy Mirzayan, MD, Shoulder & Elbow Traumatic Anterior Shoulder Instability (ft. Dr. Anthony Romeo), Shoulder & ElbowTraumatic Anterior Shoulder Instability (TUBS), Question SessionTraumatic Anterior Shoulder Instability (TUBS), Bony Bankart fracture in nondominant shoulder, Recurrent Shoulder Instability s/p Bankart Repair in 21M. In some cases, they will assess sensation and individual muscle strength. Which of the following ligaments is injured? However, he feels the shoulder is still unstable and cannot return to play at his desired level. The elbow joint is where three bones in the arm meet: the upper arm bone (humerus) and the two bones in the forearm (radius and ulna). The examiner then pulls the patient's thumb posteriorly, creating a valgus force (Table 23,7,8,11,1317 ). ; Foot and ankle our experts will investigate your foot problem and restore stability, whether it's through rehab or foot or ankle surgery. She has significantly limited right shoulder active and passive range of motion (ROM) in all planes but full left shoulder active and passive ROM. Traumatic Anterior Shoulder Instability (TUBS), Traumatic Anterior Shoulder Instability, also referred to as TUBS (. Specific exercises can restore flexibility and strength. 2021 The Sports Medicine Review. Joint fracture, with marked cubitus varus or cubitus valgus . Read more about the elbow exam @ Wiki Sports Medicine:https://wikism.org/Physical_Exam_Elbow. (OBQ18.210) As with other musculoskeletal problems, the keys to diagnosing elbow pain are a history to include mechanism of injury or exacerbating movements, and a focused physical examination. Webin athletes, may develop in response to large valgus forces on elbow. (OBQ12.71) The normal anatomy of the elbow joint shown from the side closest to the body. WebUCL injuries commonly occur in athletes participating in sports that involve overhead throwing, such as baseball, javelin, and volleyball. Repetitive throwing can irritate and inflame the flexor/pronator tendons where they attach to the humerus bone on the inner side of the elbow. A MRI will most likely show which of the following? the athletes or coaches may also notice that pitches are starting to sail high. (OBQ13.165) He denies any trauma or prior shoulder problems, and has good rotator cuff strength. Elbow Valgus Stress Test. WebValgus Extension Overload (Pitcher's Elbow) anterior shoulder pain with resisted forearm supination with the arm at the side and the elbow flexed to 90 degrees. Reproduced and adapted with permission from J Bernstein, ed: Musculoskeletal Medicine. (OBQ06.256) (OBQ05.42) Internally rotate shoulder to near maximum holding the wrist by passively lifting the dorsum of the hand away from the lumbar spine then supporting the elbow, tell patient to maintain position and release the wrist while looking for a lag. Elbow pain with supination which improves with pronation is also considered a positive finding. If an ulnar collateral ligament injury is suspected, the medial joint space of the symptomatic elbow should be compared with the asymptomatic side for the amount of opening, the subjective quality of the end point while a valgus force is applied across the joint, and pain. The pathology seen in Figure A is most likely to result from trauma that occurred with the shoulder in which of the following positions? It can occur both at the medial and lateral epicondyle with medial epicondylitis occurring less frequently than lateral epicondylitis. sometimes, the ligament is reinforced with a high-strength suture to add to the strength of the construct and potentially allow for a quicker return to play. Pain during resisted pronation is the most sensitive physical examination finding. Problems most often occur at the inside of the elbow because considerable force is concentrated over the inner elbow during throwing. The elbow: Physeal fractures, apophyseal injuries of the distal humerus, avascular necrosis of the trochlea, and T-condylar fractures. Throwing Injuries in the Elbow in Children. Web5052 Elbow replacement (prosthesis). (OBQ06.128) Copyright 2014 by the American Academy of Family Physicians. Pain is also frequently brought on by bending the foot and toes up towards the shin. Acute or chronic disruption and/or attenuation of the ulnar collateral ligament often result in medial elbow pain, valgus instability, neurologic deficiency, and impaired throwing performance. A collegiate waterpolo player presents to your office for a second opinion. WebValgus Extension Overload (Pitcher's Elbow) Posterior shoulder instability and dislocations are less common than anterior shoulder instability and dislocations, but are much more commonly missed. (OBQ10.63) Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. CT axial image is displayed in Figure A. This graft acts as a scaffolding for a new ligament to grow on. 65-year-old woman with ulnar drift of the fingers and shoulder pain and stiffness. Recent research has focused on identifying risk factors for elbow injury and strategies for injury prevention. What is the most common neurologic problem associated with a simple shoulder dislocation? Superior border is defined by the biceps long head tendon, Inferior border is defined by anterior band of inferior glenohumeral ligament, Contains the axillary pouch which is a common site for intra-articular loose bodies, Superior border is defined by anterior edge of supraspinatus tendon, Inferior border is defined by middle glenohumeral ligament. His medical history is significant for Crohn's disease which is controlled medically with prednisone therapy during flares. Although a change of position or even a change in sport can eliminate repetitive stresses on the elbow and provide lasting relief, this is often undesirable, especially in high level athletes. A 20-year-old female presents with recurrent anterior shoulder instability. Radiographs of the shoulder are normal. During the procedure, the doctor replaces the torn ligament with a tissue graft. Started in 1995, this collection now contains 7146 interlinked topic pages divided into a tree of 31 specialty books and 738 chapters. To recreate the stresses placed on the elbow during throwing, the doctor will perform the valgus stress test. the MCL provides resistance to valgus and distractive stresses. (OBQ11.19) Instability causes repeated and unnatural wear and tear leading to early onset of osteoarthritis. The right shoulder exercise seen in Figure A will put the LEAST amount of stretch on which structure? Radiographs of both shoulders are seen in Figure A. CT scan of his left shoulder is seen in Figure B. A positive test is reproduction of the pain. All material on this website is protected by copyright. A valgus stress test, during which a physician tests your elbow for instability, is the best way to assess the condition of the UCL. WebThis finding is consistent with the anterior glenohumeral instability found in many throwing athletes and emphasizes the importance of proper mechanics throughout the entire kinematic chain . Plain radiography also has a role in the evaluation of chronic conditions such as enthesopathy, bone spurs, and osteochondral diseases.18 At a minimum, anteroposterior and lateral plain radiography should be performed at the initial visit.37. If nonsurgical treatment is effective, the athlete can often return to throwing in 6 to 9 weeks. You may feel locking or catching from loose bodies. Elbow instability when pushing oneself up from a seated position in a chair. The other arm holds the wrist and applies a varus stress to the joint. (OBQ07.130) The examiner then uses their index finger to hook the lateral edge of the biceps tendon. This stress causes impingement of the olecranon tip in the olecranon fossa, which may cause osteophyte formation and a fixed flexion deformity over time. He continues to experience instability postoperatively. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. post-traumatic (following proximal humerus fracture or immobilization for other upper extremity injury), post-surgical (following rotator cuff repair or axillary dissection for malignancy), inflammatory process causing fibroblastic proliferation of joint capsule leading to thickening, fibrosis, and adherence of the capsule to itself and humerus, fibroblasts/myofibroblasts with abundant Type III collagen present, stiffness may be first manifestation of diabetes and warrants further workup, increased risk with older age, increased duration of DM, autonomic neuropathy, history of MI, contribute to stability of the glenohumeral joint, act as check reins at extremes of motion in their non-pathologic state, inferior glenohumeral ligament (IGHL) complex with the following components, a triangular region between the anterior border of supraspinatus and the superior border of subscapularis, Gradual onset of diffuse pain (6 wks to 9 months), Decreased ROM affecting activities of daily living (4 to 9 months or more), Gradual return of motion (5 to 26 months), Capsular contraction and fibrinous adhesions, Increasing contraction, synovitis resolving, variable character and severity of pain, loss of motion dependent on the stage of disease at presentation, freezing- insidious onset of pain at rest and with movement, difficulty sleeping, frozen- pain lessens but significant motion limitations affecting ADLs, thawing- pain is gone and motion improves but less than normal, note any muscle atrophy or scars denoting prior surgery, document all motion planes and compare to contralateral side, pain throughout motion arc or at terminal motion depending on stage of disease, impingement, biceps, and SLAP maneuvers often positive, rotator cuff testing may be limited given loss of motion, Metabolic panel and endocrine labs (TSH, A1c), must be obtained to evaluate for osteoarthritis, posterior dislocation, or surgical hardware, not necessary for diagnosis but can evaluate for other pathology, physical therapy program of gentle, pain-free, should be supervised and last for 3-6 months, failure to improve with non-operative modalities, controversial if done during freezing/inflammatory phase, after extensive therapy has failed (3 months), arthroscopy will spare subscapularis tendon with the advantage of releasing intra-articular and subacromial adhesions, daily progressive stretching exercises to point of pain, in-dwelling catheter for regional anesthesia often used to aid in therapy, steady force applied after full muscle paralysis achieved, fracture, dislocation, rotator cuff and labral tears, standard skin incisions with portal placement slightly higher than normal given contracted and thickened capsule, intra-articular structures may be obscured by adhesions and contractures, coracohumeral ligament can then be visualized and released, subacromial bursectomy and adhesions released as needed, no acromioplasty done, MUA may be done before or after release to increase to range of motion, perform inferior release near to glenoid rim, Proximal humerus fracture, dislocation, rotator cuff tears or brachial plexopathy, following overzealous manipulation with osteoporotic bone, After surgical treatment, gains in range of motion and improved function are maintained at long-term follow, Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Traumatic Anterior Shoulder Instability (TUBS), Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Multidirectional Shoulder Instability (MDI), Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. 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