Nonoperative treatment of five common shoulder injuries

Nonoperative treatment of five common shoulder injuries Review article 1,2 1 1,3 2 Obere Extremität 2018 · 13:89–97 Jonas Pogorzelski · Erik M. Fritz · Jonathan A. Godin · Andreas B. Imhoff · 1,3 https://doi.org/10.1007/s11678-018-0449-1 Peter J. Millett Received: 30 November 2017 Steadman Philippon Research Institute, Vail, USA Accepted: 29 January 2018 Department of Orthopedic Sports Medicine, Technical University of Munich, Klinikum rechts der Isar, Published online: 19 February 2018 Munich, Germany © The Author(s) 2018. This article is an open The Steadman Clinic, Vail, USA access publication. Nonoperative treatment of five common shoulder injuries A critical analysis including rotator cuff tears, anterior treatment show promising results with Introduction shoulder instability, biceps tendinitis, good clinical outcomes, studies with Shoulder pain is one of the most common lesions to the acromioclavicular (AC) mid-term follow-up are more disillu- musculoskeletal complaints accounting joint, and proximal humeral fractures. sioning [10, 22, 38, 39, 50]. This could for at least 4.5 million patient visits an- Moreover, we aim to provide a short be explained by the fact that smaller nually in the United States [43, 55]and overview of the nonoperative manage- tears may not affect the force couples in occurring in as many as 51% of indi- ment of each of these pathologies. the shoulder, thus a reasonable degree viduals in a lifetime [64]. Moreover, the of shoulder function may be maintained economic burden of shoulder pathology [42]. As there is strong evidence that Rotator cuff tears is vast with annual direct costs for treat- the natural history of nonoperatively ment of shoulder dysfunction totaling treated rotator cuff tears leads to tear Indications for nonoperative at least $7 billion in the United States, progression over time, nonoperative treatment of symptomatic full- mostly due to operative treatment [47]. outcomes studies with longer follow-up thickness rotator cuff tears InGermanythepercentageofaffectedpa- may include more patients whose tears tients and associated costs are expected Although symptomatic rotator cuff tears have progressed to the point of destroyed to be similar. Moreover, with an aging are common and affect between 4% and force couples [80]. and increasingly active patient popula- 32% of the general population, the most Kukkonen et al. [38, 39]published tion in the Western world, the absolute appropriate therapy is still debatable a randomized controlled trial for the number of shoulder pathologies is likely [59, 75]. While there is agreement that treatment of supraspinatus tendon tears to grow, further increasing costs. traumatic rotator cuff tears should be in patients older than 55 years. A total of These economic implications high- treated operatively, the treatment choice 180 shoulders with supraspinatus tendon light the critical need for appropriate for atraumatic rotator cuff tears remains tears were randomly allocated into one diagnosis and treatment of various shoul- unclear [38, 39]. This is mainly due of three treatment groups: der pathologies, as under-diagnosis and to the fact that the radiological failure 1. Isolated physiotherapy under-treatment can result in increased rate following rotator cuff repair surgery 2. Acromioplasty and physiotherapy costs to society with disability and lost can be as high as 70% depending on 3. Rotator cuff repair with acromio- production. On the other hand, aggres- the patient cohort, thus leading to the plasty and physiotherapy sive over-treatment can further inflate assumption that nonoperative treatment already burgeoning health-care costs and may be equivalent [5, 8, 24, 41]. This After 1 year of follow-up, no statistically potentially harm the patient. conjecture is further strengthened by the significant differences in outcomes were Therefore, the purpose of this review fact that pain relief and improvement of detected, thus leading to the conclusion is to distinguish the indications between symptoms do not necessarily go hand that surgical therapy is not superior in operative and nonoperative management in hand with structural healing of the these patients [38]. Later, with an addi- for five common shoulder pathologies, tendon [59]. tional year of follow-up, the groups still However, when taking a closer look did not differ significantly in outcomes; at published outcomes in the literature, however, tear progression measured with Research performed at the Steadman Philippon nonsurgical treatment appears to have magnetic resonance imaging (MRI) sug- ResearchInstitute, Vail, CO,USA andthe Depart- limitations. While multiple studies with gested that only patients with lower phys- ment of Orthopedic Sports Medicine, Technical UniversityofMunich,Munich,Germany. short-term follow-up of nonsurgical ical demands should be treated nonoper- Obere Extremität 2 · 2018 89 Review article formed. MRI of a known rotator cuff tear Treatment can be performed on patients who want While multiple rehabilitation protocols to progress with surgical refixation of the for the postoperative treatment follow- tear and those who wish to monitor tear ing rotator cuff repair have been pro- progression to consider surgery at some posed, there are only a few published future time point. studies focusing on treatment protocols for primary nonoperative management Anterior shoulder instability of rotator cuff tears [37, 48, 59, 75]. In general, conservative treatment options Indications for nonoperative include 3–6 months of activity modifica- treatment of anterior shoulder Fig. 1 8 Axial T2-weighted magnetic res- tion, physical therapy such as strength- instability onance imaging sequence of a 36-year-old ening and stretching of the muscles of the patient after a first-time shoulder dislocation. Givenhis age andthe absence ofany rotatorcuff shouldergirdle, andinjectionororalanti- There is consensus in the literature that tear or other concomitant pathology, he was inflammatory and pain-relieving medi- a detailed analysis of individual risk fac- deemed low risk for re-dislocation. Therefore, cation [37, 48, 59]. tors for recurrent instability should be nonoperative treatment was pursued, which A prospective multicenter study pub- made for each patient presenting with an- was successful with no recurrent subluxation or lished in 2013 by the MOON shoulder terior instability to determine the most dislocation group of 452 patients treated with a stan- appropriate treatment [3, 61]. In gen- dardized physical therapy program for eral, knownfactorsassociated witha high atively and patient counseling is critical atraumatic full-thickness rotator cuff risk of recurrent instability when treated [39]. tears revealed a 75% satisfaction rate in nonoperatively are young age, an active In another randomized controlled patients aer ft 2 years of follow-up. Phys- lifestyle, bone loss of more than 20% of trial of 103 patients, which compared ical therapy included daily postural and the glenoid surface, and engaging or off- rotator cuff repair with nonoperative stretching exercising as well as strength- track Hill–Sachs lesions[3, 9, 11, 44, 61, physiotherapy for tears not exceeding ening of the rotator cuff three times 65, 73]. 3 cm, Moosmayer et al. [50]found sev- a week. If needed, patients were seen by In patients younger than 30 years eral additional factors that may influence a physical therapist, especiallyformanual of age, the risk of re-dislocation when the outcome. With a minimum follow- mobilization of the glenohumeral joint. treated nonoperatively is between 70 and up of 5 years, the results for the group Although less than a quarter of patients 90% compared with up to 25% when of patients who had immediate tendon underwent surgery in the short-term treated operatively [9, 30, 71]. repair were generally superior to those of follow-up period, the lack of imaging When nonoperative treatment is ap- patients who underwent physiotherapy follow-up raises doubts about the long- plied to overhead athletes and active as primary treatment and decided later term success. patients, the re-dislocation rate is even to progress with surgery. Furthermore, In summary, careful patient selection higher [3, 61]. However, with increasing treatment failed in almost 24% of the is necessary when nonoperative treat- age, the re-dislocation rate in patients patients who received physiotherapy as ment for full-thickness rotator cuff tears treated nonoperatively decreases sub- primary therapy, and they underwent is chosen. The best possible outcomes stantially making nonoperative treat- subsequent rotator cuff repair. In 37% of are generally achieved in patients pre- ment an option [12]. patients who did not undergo surgery, senting with pain as the primary symp- In general, patients without structural thetear sizeincreased morethan 5mm tom, those having largely intact coronal lesions of the glenohumeral joint can be over 5 years with associated inferior and axial force couples, and patients who treated nonoperatively, especially when outcomes [50]. are willing to trade functional deficits older than 35 years (. Fig. 1). However, SimilarresultswerereportedbySafran of their shoulder to avoid surgical risks. the treating physician must ensure that et al. [68], who followed up 51 patients However, as there is no evidence that the concomitant injuries such as rotator cuff younger than 60 years with full-thick- torn tendon actually heals without surgi- tears, Hill–Sachs lesions of more than ness rotator cuff tears in a longitudinal cal re-fixation, patient counseling about 25% of the humeral surface, or glenoid study. In this particularly young patient tear size progression is indicated. This bone loss are excluded as those would cohort, almost half of the tears increased includes the progression from an initially need surgical intervention [3, 11, 44, 66]. aer ft a mean follow-up of 29 months. reparable tear to an irreparable tear, as The “critical” amount of glenoid bone Moreover, the authors found a signifi- well as inferior postoperative outcomes of loss is typically defined as a loss of more cant association between the size of the chronic tearscompared withacutelyfixed than 20% of the glenoid surface [11, 44]. rotator cuff tear and pain, which led to tears. If treated nonoperatively, a combi- Another risk factor for recurrent insta- the conclusion that young patients in par- nation of activity modification, stretch- bility is engaging or off-track Hill–Sachs ticular benefit from surgery [68]. ing and strengthening of the periscapular lesions, as reported in recent literature muscles and the deltoid should be per- 90 Obere Extremität 2 · 2018 Hier steht eine Anzeige. K Abstract · Zusammenfassung recommending operative treatment [57, Obere Extremität 2018 · 13:89–97 https://doi.org/10.1007/s11678-018-0449-1 © The Author(s) 2018. This article is an open access publication. 73]. Furthermore, the injury pattern J. Pogorzelski · E. M. Fritz · J. A. Godin · A. B. Imhoff · P. J. Millett should be taken into account. High- energy trauma oen ft results in a locked Nonoperative treatment of five common shoulder injuries. dislocation or displaced fracture of the A critical analysis glenoid or the humeral head and is Abstract generally best approached with surgical to the acromioclavicular joint, and proximal Economic pressure highlights the critical need treatment. Finally, patients who have humeral fractures. As a result, a detailed for appropriate diagnosis and treatment of the ability to voluntarily dislocate their analysis of individual risk factors for potential various shoulder pathologies since under- shoulder without discomfort should be failures should be performed and treatment diagnosis and under-treatment can result treated nonsurgically in most cases, as should be based on individualized care in increased costs to society in the form of withconsideration givento eachpatient’s these patients likely suffer not from disability and lost production. On the other particular injury pattern, functional demands, hand, aggressive over-treatment can further structural instability but rather from and long-term goals. inflate already burgeoning health-care costs functional instability, which can be due and potentially harm the patient. Therefore, to a pathological functional activation Keywords it is crucial to distinguish the indications pattern [27, 33] and may respond better Rotator cuff tears · Shoulder injuries · between operative and nonoperative Tendinitis · Acromioclavicular joint · Humeral to functional conservative treatments management, especially in common shoulder fractures, proximal pathologies such as rotator cuff tears, anterior [70] or even electrical muscle stimu- shoulder instability, biceps tendinitis, lesions lation in some therapy-resistant cases [51]. Konservative Therapie von 5 häufigen Schulterläsionen. Eine Treatment kritische Analyse In order to manage shoulder instability Zusammenfassung without surgical intervention, a combi- Schulterinstabilität, Bizepssehnentendinitis, Der zunehmende Kostendruck in der Medizin Akromioklavikular Gelenkluxationen und pro- nation of immobilization and physical verstärkt die Notwendigkeit einer rasch ximale Humerusfrakturen. Grundsätzlich ist zielführenden Diagnose und Therapie therapy is oeft n used before the patient es dabei wichtig, individuelle Risikofaktoren verschiedener pathologischer Veränderungen can return to activity [12, 35, 36, 54]. für ein Therapieversagen zu erkennen, den im Bereich der Schulter. Unterversorgte Physical therapyprotocols mayeitherfol- Erwartungshorizont des Patienten bezüglich Patienten erhöhen die Kosten für die low a period of immobilization of about funktionaler Ansprüche und Langzeitziele Gemeinschaft durch längere Ausfallzeiten abzuklären und auch das Verletzungsmuster 3 weeks in internal or external rotation und damit erniedrigte Produktion, während zu analysieren, um so letztendlich die überzogene Therapien die bereits ausufern- of the shoulderorbeinitiated immedi- Therapie individuell an den jeweiligen den Kosteninder medizinischenVersorgung ately. The overall goal of physical ther- Patienten anpassen zu können. weiter erhöhen und den Patienten sogar apy is to progress through glenohumeral potenziell schädigen können. Deshalb ist es strengthening and stabilization, thus re- unabdingbar, die Indikationen für operative Schlüsselwörter und konservative Therapien zu kennen und Rotatorenmanschettenläsionen · ducing the probability of recurrent in- anzuwenden, besonders im Hinblick auf Schulterverletzungen · Tendinitis · stability. Return to full activity is mostly Akromioklavikulargelenk · Proximale häufige pathologische Veränderungen wie allowed whenthere is symmetrical shoul- Humerusfrakturen Rotatorenmanschettenläsionen, vordere der strength of the scapulothoracic and glenohumeral joints, as well as functional shoulder range of motion [12, 57]. More recently, several studies have fo- preventing recurrent shoulder instability Overall, careful consideration of the cused on the position of the arm during [20, 78], including a recent randomized injury mechanism, patient demands, immobilization after a traumatic anterior controlled multicenter trial published in and concomitant injuries associated shoulder dislocation. In an MRI study 2014 [78]. Additionally, the conclusion with anterior shoulder instability are by Itoi et al. [31], immobilization with that “immobilization in internal or exter- crucial when deciding on nonopera- the arm in external rotation resulted in nal rotation does not change recurrence tive vs. operative intervention. Patients reduction of the Bankart lesion after trau- rates after traumatic anterior shoulder younger than 35 years of age should matic shoulderdislocation, thus support- dislocation” was confirmed in a 2014 sys- rarely be treated nonoperatively as the ing the hypothesis that immobilization in tematic review of the literature [76]and recurrence rate is unacceptably high. If external rotation may be superior to im- a 2016 meta-analysis of randomized con- treated nonoperatively, immobilization mobilization in internal rotation. How- trolled trials [77]. Of note, immobiliza- in internal rotation seems to be more ever, published clinical trials have not tion in external rotation is reported to be comfortable and shows equal outcomes been able to demonstrate similar efficacy very uncomfortable and, therefore, could to immobilization in external rotation of external rotation immobilization for reduce patient compliance. 92 Obere Extremität 2 · 2018 inflammatory effects for most LHBT dis- orders. However, they should be used for short-term pain relief and as an adjunct for the patient to initiate and tolerate a physical therapy program, rather than as a long-term treatment option. Be- cause these injections have the potential toreachthe glenohumeral joint, the anes- theticofchoice, usedincombinationwith corticosteroid, should be ropivacaine, as it is found to be less chondrotoxic than Fig. 2 8 Images of a 46-year-old man with right-sided biceps tendonitis, diagnosed via history, phys- bupivacaine [62]. ical examination, and a T2-weighted magnetic resonance imaging with a clear halo sign (yellow circle) The initiation of a 3–6-month physical around the long head of the biceps tendon indicating inflammation.The patient was treated conser- vatively with physical therapy and NSAIDs but continued to experience symptoms 6 months later.He therapy program allows for progressive thus underwent operative management as seen in b with the long head of the biceps tendon (BT)and increase in muscle strength while pro- biceps reflection pulley visualized through the standard posterior viewing portal.HH humeral head viding protection against further LHBT and associated structure injury during andthus shouldbe preferred,according patients suffering from biceps reflection rehabilitation [1, 4, 19, 53, 67]. to current literature findings. pulley lesions because these lesions do Other evolving nonoperative treat- not heal and symptoms worsen over time. ment options for LHBT disorders include In general, patients suitable for surgical prolotherapy (dextrose solution, sodium Biceps tendinitis evaluation include the following: young, morrhuate), platelet-rich plasma (dif- highly motivated patients with instabil- fering concentrations of platelets, white Indications for nonoperative ity or complete LHBT rupture; man- blood cells, red blood cells, and activated treatment of long head biceps ual laborers with significant instability or and inactivated platelets), and stem cells tendinitis complete LHBT rupture; elite-level ath- (circulating stem cells, adipose-derived, Inflammation of the long head biceps letes with instability or complete LHBT bone marrow aspirate, bone marrow tendon (LHBT) can lead to damage and rupture; any individual with a complete aspirate concentrate, amniotic mem- weakening of surrounding supporting LHBT rupture who is not agreeable to brane-derived). The choice to utilize one structures, thereby causing LHBT in- a potential loss of elbow flexion or fore- of these treatment options varies from stability. In turn, instability can place arm supination strength and long-stand- patient to patient and condition to condi- increased stresses on the LHBT, which ing “Popeye” deformity; and any individ- tion, and current research is beginning to subsequently increase inflammation. ual who has progressed through all stages thoroughly evaluate these interventions This cycle can predispose the LHBT to of nonoperative treatment and continues and to standardize treatment protocols rupture. to have symptoms of pain and/or weak- [21, 23, 45, 46, 49]. Indications for Given the potential success of non- ness that affects their quality of life. these injections include pain impairing operative management for most LHBT athletic performance, connective tissue tendinopathies, a management strategy laxity impairing athletic performance, Treatment involving medications and physical ther- and pain impairing rest and quality of apy should be the first step in treating After identification of the underlying life [49]. Future research is needed to de- these conditions. After progressing a pa- pathologic condition of the LHBT, treat- termine which LHBT disorders respond tient through physical therapy, a course ment generally begins with activity best to, and what patient populations are of nonsteroidal anti-inflammatory drugs modification, NSAIDs, and/or cortico- the most suitable candidates for, such (NSAIDs) and/or injections, it is impor- steroid injections [1, 53]. NSAIDs can procedures. tant tore-evaluate the patientforprogres- provide short-term benefit for swelling sion of pain, weakness, and mechanical and pain control. However, there is Acromioclavicular joint injuries symptoms. Atthattime, continuation of little evidence that they are efficacious a home exercise program vs. consider- in treating chronic tendon injuries [13]. Indications for nonoperative ation of additional interventions will be Useofcorticosteroidinjectionsshould treatment of acromioclavicular discussed based on symptom progres- follow a similar treatment protocol to joint injury sion. NSAIDs. Multiple case reports discuss If a patient progresses through all non- the risk of tendon rupture with steroid Injury classification is the single most im- operative treatment options and notes no injections, and caution should be exer- portant factor in determining the most improvement of pain or weakness, he or cised when injecting steroid around the appropriate treatment of acromioclavic- she should progress to surgical evalua- LHBT [2, 13]. Corticosteroid injections ular (AC) joint injuries. In 1989, Rock- tion (. Fig. 2). Thisisalso the case for alone will likely provide short-term anti- wood and colleagues developed the clas- Obere Extremität 2 · 2018 93 Review article Fig. 3 8 Radiographs of a 26-year-old male patient after a direct fall onto his right shoulder.a Panoramic view after in- jury showing a probable Rockwood type II injury.b However, the Alexander view demonstrates the clavicle overriding the acromion, thus indicating horizontal instability and defining this as a Rockwood type IV injury.Accordingly, the patient un- derwent operative therapy with twodog-bones insteadofone in ordertobetteraddress the horizontal instability,as pictured in c, the postoperative panoramic radiograph.d Postoperatively, the horizontal instability was resolved as demonstrated on the Alexander view 6 weeks after surgery sification system that is most widely used Although high-level studies are rare by patient tolerance and evidence of for AC joint injuries today [79]. No- intheorthopedicliteraturetodefinitively improved scapulohumeral kinematics. tably, this system, which is based on the guide optimal treatment, there is a com- Nonoperative treatment failed in 12 pa- work of Tossy et al. [74], recognizes the mon consensus regarding the most ap- tients, who ultimately required surgery. importance of the coracoclavicular (CC) propriate treatments based on Rockwood Reasons cited for nonoperative failure ligaments in joint stability [79]. type [6]. included unremitting pain, weakness, Rockwood type I injuries are charac- It is generally agreed that type I and instability, and dysfunction in spite of terized by a sprain without rupture of II injuries should undergo initial nonop- physical therapy. At a mean follow-up the AC ligaments with no anatomic dis- erative treatment while types IV–VI re- of 3.3 years, patient-reported outcome location and intact trapezius and deltoid quire surgery [6]. Optimal management scores—including the American Shoul- fascia. Type II injuries involve rupture of of type III injuries has been controver- der and Elbow Surgeons score (ASES), the AC joint ligaments but are otherwise sial. In the highest-level study to date, Quick Disabilities of the Arm, Shoul- similar to type I. Type III injuries are the Canadian Orthopedic Trauma Soci- der, and Hand score (QuickDASH), characterized by rupture of both the AC ety [16] recently completed a prospective Single Assessment Numeric Evalua- and CC ligaments with superior displace- randomized trial of 83 patients compar- tion score (SANE), and Short Form ment of the clavicle of 25–100% com- ing nonoperative treatment of grade III, 12 Physical Component Summary (SF- pared with the contralateral shoulder; IV, or V AC joint injuries with operative 12 PCS)—did not significantly differ be- notably, the trapezius and deltoid fascia intervention using a hook plate. Out- tween those who successfully completed are disrupted with this injury. Type IV come scores at short-term follow-up as nonoperative therapy and those who injuries generally present with additional far as 2 years demonstrated no signifi- required eventual surgery [60]. horizontal instability (. Fig. 3). Type V cant difference between the groups with In general, there is consensus that injuries are similar to type-III injuries, the exception of superior radiographic the horizontal stability of the clavicle but the clavicle is superiorly displaced results in the operative group [16]. is considered a potential key factor for more than 100% compared with the con- Moreover, Petri and colleagues re- a successful postoperative outcome. It tralateral side. Type-VI injuries, which viewed 41 patients with Rockwood is hypothesized that an unstable clavi- are rarely seen, involve rupture of both grade III AC joint injuries who were cle causes pain and functional deficits. AC and CC ligaments with inferior dis- initially treated nonoperatively [60]. Therefore, the ISAKOS shoulder com- placement of the distal clavicle under- Nonoperative management consisted of mittee [7] recently proposed a modifica- neath the acromion; the trapezius and formalphysicaltherapytwotothreetimes tion to the classic Rockwood classifica- deltoid fascia are disrupted [74, 79]. per week for at least 6 weeks using a pha- tion in which type III injuries may be fur- sic approach with progression dictated ther subdivided into types IIIA and IIIB; 94 Obere Extremität 2 · 2018 type IIIA injuries are horizontally stable Better outcomes may be achieved with to the head fragment, nonsurgical treat- and may respond well to conservative surgical fixation in cases with signifi- ment may yield good-to-excellent results management, but type IIIB injuries are cant displacement, a bony avulsion of the [17]. unstable and should therefore be treated supraspinatus tendon, a block to range of Although surgical treatment of com- surgically [7]. motion, and involvement of the anatomic plex fracture patterns is generally advo- neck. However, well-designed compar- cated, the efficacy of operative vs. nonop- ative studies of operative vs. nonoper- erative management remains to be clearly Treatment ative management of two-part fractures delineated. In a study of 60 elderly pa- Typical nonoperative treatment consists are lacking [26]. tients with a displaced three-part frac- of primary immobilization and subse- Some authors have found that greater ture of the proximal humerus, Olerud quent active rehabilitation [15]. How- tuberosity fractures with >5 mm of dis- et al. found that surgical management ever, evidence to support the efficacy of placement may benefit from surgical fix- with a locking plate resulted in better specific rehabilitation protocols is limited ation to reduce the risk of subacromial functional outcomes and health-related [15]. impingement [58, 63]. Lesser tuberosity quality of life than did nonsurgical treat- Gladstone et al. [25] published a phys- fractures with internal rotation impinge- ment, butata costofadditional surgeryin ical therapy regimen for the nonoperative ment may also benefit from surgery if 30% of patients [56]. By contrast, a meta- treatment of AC joint injuries types I, II, nonoperative management fails [52]. In analysis of randomized controlled trials and III in athletes. Phase 1 lasts 3–10 days contrast to other parts of the proximal didnot findimproved functional out- and focuses on elimination of pain and humerus, the anatomic neck is devoid of comes with open reduction and internal sling immobilization to protect the AC soft-tissue attachments and has a tenu- fixation (ORIF) compared with nonsur- joint. Range-of-motion exercises begin ous blood supply, which may result in an gical treatment in elderly patients with in phase 2 with gradual progression increased risk of osteonecrosis. displaced three-part or four-part prox- of isotonic exercise for strengthening. Court-Brown et al. recommend imal humeral fractures [40]. The study Phase 3 involves advanced strengthen- 2 weeks of sling immobilization followed concluded that these results must be con- ing, and phase 4 involves sports-specific by physical therapy for patients with two- sidered in the context of variable patient training before full return to activity [25]. part surgical neck fractures and valgus- demographics. The total length of rehabilitation can last impacted fractures [17, 18]. Two-part A systematic review supported the 3–6 months. Moreover, it is important proximal humeral fractures with >66% use of nonsurgical treatment of proximal to check on the scapula movement since translation were treated with either sling humeral fractures and noted a 2% rate a significant number of patients suffering immobilization or with internal fixation of osteonecrosis mainly associated with from AC joint injuries also present with with flexible intramedullary nailing and three-part and four-part fractures, high scapula dyskinesis. tension-band wires [17, 18]. No statis- rates of radiographic union, and modest Overall, the general consensus re- tical difference was reported between complication rates [32]. Ultimately, the garding management of AC joint in- the groups with regard to Neer score, patient’s baseline physiology and func- juries is fairly straightforward: initial return to activities of daily living, and tion may help to quantify the potential nonoperative treatment for Rockwood union rates [17, 18]. The data demon- advantages of nonsurgical management, grades I–II, and operative intervention strate that the Constant score diminishes even in the setting of complex fracture for grades IV–VI. For patients with with advancing age and degree of dis- patterns. grade III lesions, a closer look con- placement. However, when calculated cerning the stability of the clavicle is basedon age-adjustedConstant score, Treatment necessary. the older patients actually had better scores than the younger patients [14, 17, A number of proximal humeral fractures 18, 34]. Therefore, sling immobilization may be treated nonoperatively. However, Proximal humeral fracture is an appropriate treatment option for patients must understand the expecta- patients older than age 60 years with tions with this treatment approach and Indications for nonoperative valgus-impacted, two-part surgical neck comply with the accompanying restric- treatment of proximal humeral or two-part tuberosity fractures. tions. In general, excellent results have fractures Although three-part and four-part been achieved with short-term immobi- The number of bone parts and concomi- fractures oeft n require surgical fixation, lization (<2 weeks) in a sling and early tant displacement mainly influences the nonoperative management can be con- physical therapy [28, 63, 72]. While the treatment strategy of proximal humeral sidered for patients with poor baseline literature supports early mobilization, it fractures. Nonoperative treatment of function and/or an inability to toler- is important to ensure that further frac- two-part fractures with early rehabil- ate surgery. In select three-part and ture displacement does not occur. Sling itation has been found to be at least four-part fractures, particularly valgus- immobilization with or without closed as efficacious as surgical treatment in impacted fractures with <1 cm of dis- reduction also has a role in the man- injuries with minimal displacement [29]. placement of the tuberosities in relation Obere Extremität 2 · 2018 95 Review article 7. Beitzel K, Mazzocca AD, Bak K et al (2014) ISAKOS agement of displaced proximal humeral Corresponding address upper extremity committee consensus statement fractures [69]. on the need for diversification of the Rockwood classification for acromioclavicular joint injuries. P. J. Millett, M.D., M.Sc. Arthroscopy30:271–278 The Steadman Clinic Practical conclusion 8. Bishop J, Klepps S, Lo IK et al (2006) Cuff integrity 181 West Meadow Drive after arthroscopic versus open rotator cuff repair: suite 400, 81657 Vail, CO, USA 4 For rotator cuff tears, the best pos- a prospective study. J Shoulder Elbow Surg drmillett@ 15:290–299 sible outcomes with nonoperative thesteadmanclinic.com 9. Bishop JA, Crall TS, Kocher MS (2011) Operative therapy are generally achieved for pa- versus nonoperative treatment after primary tients presenting pain as the primary traumatic anterior glenohumeral dislocation: expected-value decision analysis. J Shoulder symptom of an atraumatic rotator Compliance with ethical ElbowSurg20:1087–1094 cuff tear, largely intact coronal and guidelines 10. Boorman RS, More KD, Hollinshead RM et al (2014) axial force couples, and a willingness The rotator cuff quality-of-life index predicts the outcome of nonoperative treatment of patients to trade functional deficits to avoid Conflict of interest. A.B.Imhoffservesasaboardor with a chronic rotator cuff tear. J Bone Joint Surg surgical risks. committee member for AGA, serves on the editorial Am96:1883–1888 board of Archives of Orthopaedic and Trauma Surgery, 4 In patients suffering from anterior 11. Boughebri O, Maqdes A, Moraiti C et al (2015) is a paid consultant and receives royalties and research Results of 45 arthroscopic Bankart procedures: shoulder instability, careful consid- support from Arthrex, Inc., serves on the editorial Does the ISIS remain a reliable prognostic eration of the injury mechanism, board of Arthroskopie, is a paidconsultantandreceives assessment after 5 years? Eur J Orthop Surg royaltiesfromArthrosurface,servesasaboardor patient demands, and concomitant Traumatol25:709–716 committee member for DGOOC, serves as a board or 12. Buss DD, Lynch GP, Meyer CP et al (2004) injuries associated with anterior committee member for DGOU, serves as a board or Nonoperative managementfor in-season athletes shoulder instability are crucial when committee member for ISAKOS, serves on the editorial with anterior shoulder instability. Am J Sports Med board of KSSTA, is a paid consultant for medi-bayreuth, 32:1430–1433 deciding on nonoperative vs. opera- serves on the editorial board of OOTR,andreceives 13. Childress MA, Beutler A (2013) Management tive intervention. Patients <35 years royalties and financial support from Springer and of chronic tendon injuries. Am Fam Physician should rarely be treated nonopera- Thieme. P.J. Millett is a paid consultant for Arthrex, 87:486–490 Inc., receives royalties from Arthrex, Inc., Medbridge, tively. 14. ConstantCR,MurleyAH(1987)Aclinicalmethodof and Springer Publishing, owns stock or stock options functionalassessmentoftheshoulder. ClinOrthop 4 For tendinitis of the LHBT, treatment in Game Ready and VuMedi, and receives research Relat Res. https://doi.org/10.1097/00003086- generally begins with a nonoperative support from Arthrex, Inc., Ossur, Siemens, and Smith 198701000-00023 and Nephew. J. Pogorzelski, E.M. Fritz, and J.A. Godin treatment protocol including activity 15. Cote MP, Wojcik KE, Gomlinski G et al (2010) Re- declare that they have no competing interests. habilitation of acromioclavicular jointseparations: modificationand NSAIDs. Inpatients operative and nonoperative considerations. Clin with structural instability of the This article does not contain any studies with human SportsMed29:213–228(vii) participants or animals performed by any of the au- biceps tendon complex, or in any 16. Cots (2015)Multicenter randomizedclinical trial of thors. nonoperative versus operative treatment of acute individual who continues to have acromio-clavicular joint dislocation. J Orthop symptoms of pain after nonoperative OpenAccess. Thisarticleisdistributedundertheterms Trauma29:479–487 of the Creative Commons Attribution 4.0 International treatment, surgery is favored. 17. 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Yamaguchi K, Tetro AM, Blam O et al (2001) treatmentfor rotator cuff injury in the elderly.J Am theshoulder. AmJSportsMed43:1983–1988 Natural history of asymptomatic rotator cuff tears: MedDirAssoc9:626–632 62. Piper SL, KimHT(2008)Comparison of ropivacaine a longitudinal analysis of asymptomatic tears 42. Lo IK, Burkhart SS (2003) Current concepts in and bupivacaine toxicity in human articular detected sonographically. J Shoulder Elbow Surg arthroscopic rotator cuff repair. Am J Sports Med chondrocytes. JBoneJointSurgAm90:986–991 10:199–203 31:308–324 Obere Extremität 2 · 2018 97 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Obere Extremität Springer Journals

Nonoperative treatment of five common shoulder injuries

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Medicine & Public Health; Orthopedics; Surgical Orthopedics; Medicine/Public Health, general
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Abstract

Review article 1,2 1 1,3 2 Obere Extremität 2018 · 13:89–97 Jonas Pogorzelski · Erik M. Fritz · Jonathan A. Godin · Andreas B. Imhoff · 1,3 https://doi.org/10.1007/s11678-018-0449-1 Peter J. Millett Received: 30 November 2017 Steadman Philippon Research Institute, Vail, USA Accepted: 29 January 2018 Department of Orthopedic Sports Medicine, Technical University of Munich, Klinikum rechts der Isar, Published online: 19 February 2018 Munich, Germany © The Author(s) 2018. This article is an open The Steadman Clinic, Vail, USA access publication. Nonoperative treatment of five common shoulder injuries A critical analysis including rotator cuff tears, anterior treatment show promising results with Introduction shoulder instability, biceps tendinitis, good clinical outcomes, studies with Shoulder pain is one of the most common lesions to the acromioclavicular (AC) mid-term follow-up are more disillu- musculoskeletal complaints accounting joint, and proximal humeral fractures. sioning [10, 22, 38, 39, 50]. This could for at least 4.5 million patient visits an- Moreover, we aim to provide a short be explained by the fact that smaller nually in the United States [43, 55]and overview of the nonoperative manage- tears may not affect the force couples in occurring in as many as 51% of indi- ment of each of these pathologies. the shoulder, thus a reasonable degree viduals in a lifetime [64]. Moreover, the of shoulder function may be maintained economic burden of shoulder pathology [42]. As there is strong evidence that Rotator cuff tears is vast with annual direct costs for treat- the natural history of nonoperatively ment of shoulder dysfunction totaling treated rotator cuff tears leads to tear Indications for nonoperative at least $7 billion in the United States, progression over time, nonoperative treatment of symptomatic full- mostly due to operative treatment [47]. outcomes studies with longer follow-up thickness rotator cuff tears InGermanythepercentageofaffectedpa- may include more patients whose tears tients and associated costs are expected Although symptomatic rotator cuff tears have progressed to the point of destroyed to be similar. Moreover, with an aging are common and affect between 4% and force couples [80]. and increasingly active patient popula- 32% of the general population, the most Kukkonen et al. [38, 39]published tion in the Western world, the absolute appropriate therapy is still debatable a randomized controlled trial for the number of shoulder pathologies is likely [59, 75]. While there is agreement that treatment of supraspinatus tendon tears to grow, further increasing costs. traumatic rotator cuff tears should be in patients older than 55 years. A total of These economic implications high- treated operatively, the treatment choice 180 shoulders with supraspinatus tendon light the critical need for appropriate for atraumatic rotator cuff tears remains tears were randomly allocated into one diagnosis and treatment of various shoul- unclear [38, 39]. This is mainly due of three treatment groups: der pathologies, as under-diagnosis and to the fact that the radiological failure 1. Isolated physiotherapy under-treatment can result in increased rate following rotator cuff repair surgery 2. Acromioplasty and physiotherapy costs to society with disability and lost can be as high as 70% depending on 3. Rotator cuff repair with acromio- production. On the other hand, aggres- the patient cohort, thus leading to the plasty and physiotherapy sive over-treatment can further inflate assumption that nonoperative treatment already burgeoning health-care costs and may be equivalent [5, 8, 24, 41]. This After 1 year of follow-up, no statistically potentially harm the patient. conjecture is further strengthened by the significant differences in outcomes were Therefore, the purpose of this review fact that pain relief and improvement of detected, thus leading to the conclusion is to distinguish the indications between symptoms do not necessarily go hand that surgical therapy is not superior in operative and nonoperative management in hand with structural healing of the these patients [38]. Later, with an addi- for five common shoulder pathologies, tendon [59]. tional year of follow-up, the groups still However, when taking a closer look did not differ significantly in outcomes; at published outcomes in the literature, however, tear progression measured with Research performed at the Steadman Philippon nonsurgical treatment appears to have magnetic resonance imaging (MRI) sug- ResearchInstitute, Vail, CO,USA andthe Depart- limitations. While multiple studies with gested that only patients with lower phys- ment of Orthopedic Sports Medicine, Technical UniversityofMunich,Munich,Germany. short-term follow-up of nonsurgical ical demands should be treated nonoper- Obere Extremität 2 · 2018 89 Review article formed. MRI of a known rotator cuff tear Treatment can be performed on patients who want While multiple rehabilitation protocols to progress with surgical refixation of the for the postoperative treatment follow- tear and those who wish to monitor tear ing rotator cuff repair have been pro- progression to consider surgery at some posed, there are only a few published future time point. studies focusing on treatment protocols for primary nonoperative management Anterior shoulder instability of rotator cuff tears [37, 48, 59, 75]. In general, conservative treatment options Indications for nonoperative include 3–6 months of activity modifica- treatment of anterior shoulder Fig. 1 8 Axial T2-weighted magnetic res- tion, physical therapy such as strength- instability onance imaging sequence of a 36-year-old ening and stretching of the muscles of the patient after a first-time shoulder dislocation. Givenhis age andthe absence ofany rotatorcuff shouldergirdle, andinjectionororalanti- There is consensus in the literature that tear or other concomitant pathology, he was inflammatory and pain-relieving medi- a detailed analysis of individual risk fac- deemed low risk for re-dislocation. Therefore, cation [37, 48, 59]. tors for recurrent instability should be nonoperative treatment was pursued, which A prospective multicenter study pub- made for each patient presenting with an- was successful with no recurrent subluxation or lished in 2013 by the MOON shoulder terior instability to determine the most dislocation group of 452 patients treated with a stan- appropriate treatment [3, 61]. In gen- dardized physical therapy program for eral, knownfactorsassociated witha high atively and patient counseling is critical atraumatic full-thickness rotator cuff risk of recurrent instability when treated [39]. tears revealed a 75% satisfaction rate in nonoperatively are young age, an active In another randomized controlled patients aer ft 2 years of follow-up. Phys- lifestyle, bone loss of more than 20% of trial of 103 patients, which compared ical therapy included daily postural and the glenoid surface, and engaging or off- rotator cuff repair with nonoperative stretching exercising as well as strength- track Hill–Sachs lesions[3, 9, 11, 44, 61, physiotherapy for tears not exceeding ening of the rotator cuff three times 65, 73]. 3 cm, Moosmayer et al. [50]found sev- a week. If needed, patients were seen by In patients younger than 30 years eral additional factors that may influence a physical therapist, especiallyformanual of age, the risk of re-dislocation when the outcome. With a minimum follow- mobilization of the glenohumeral joint. treated nonoperatively is between 70 and up of 5 years, the results for the group Although less than a quarter of patients 90% compared with up to 25% when of patients who had immediate tendon underwent surgery in the short-term treated operatively [9, 30, 71]. repair were generally superior to those of follow-up period, the lack of imaging When nonoperative treatment is ap- patients who underwent physiotherapy follow-up raises doubts about the long- plied to overhead athletes and active as primary treatment and decided later term success. patients, the re-dislocation rate is even to progress with surgery. Furthermore, In summary, careful patient selection higher [3, 61]. However, with increasing treatment failed in almost 24% of the is necessary when nonoperative treat- age, the re-dislocation rate in patients patients who received physiotherapy as ment for full-thickness rotator cuff tears treated nonoperatively decreases sub- primary therapy, and they underwent is chosen. The best possible outcomes stantially making nonoperative treat- subsequent rotator cuff repair. In 37% of are generally achieved in patients pre- ment an option [12]. patients who did not undergo surgery, senting with pain as the primary symp- In general, patients without structural thetear sizeincreased morethan 5mm tom, those having largely intact coronal lesions of the glenohumeral joint can be over 5 years with associated inferior and axial force couples, and patients who treated nonoperatively, especially when outcomes [50]. are willing to trade functional deficits older than 35 years (. Fig. 1). However, SimilarresultswerereportedbySafran of their shoulder to avoid surgical risks. the treating physician must ensure that et al. [68], who followed up 51 patients However, as there is no evidence that the concomitant injuries such as rotator cuff younger than 60 years with full-thick- torn tendon actually heals without surgi- tears, Hill–Sachs lesions of more than ness rotator cuff tears in a longitudinal cal re-fixation, patient counseling about 25% of the humeral surface, or glenoid study. In this particularly young patient tear size progression is indicated. This bone loss are excluded as those would cohort, almost half of the tears increased includes the progression from an initially need surgical intervention [3, 11, 44, 66]. aer ft a mean follow-up of 29 months. reparable tear to an irreparable tear, as The “critical” amount of glenoid bone Moreover, the authors found a signifi- well as inferior postoperative outcomes of loss is typically defined as a loss of more cant association between the size of the chronic tearscompared withacutelyfixed than 20% of the glenoid surface [11, 44]. rotator cuff tear and pain, which led to tears. If treated nonoperatively, a combi- Another risk factor for recurrent insta- the conclusion that young patients in par- nation of activity modification, stretch- bility is engaging or off-track Hill–Sachs ticular benefit from surgery [68]. ing and strengthening of the periscapular lesions, as reported in recent literature muscles and the deltoid should be per- 90 Obere Extremität 2 · 2018 Hier steht eine Anzeige. K Abstract · Zusammenfassung recommending operative treatment [57, Obere Extremität 2018 · 13:89–97 https://doi.org/10.1007/s11678-018-0449-1 © The Author(s) 2018. This article is an open access publication. 73]. Furthermore, the injury pattern J. Pogorzelski · E. M. Fritz · J. A. Godin · A. B. Imhoff · P. J. Millett should be taken into account. High- energy trauma oen ft results in a locked Nonoperative treatment of five common shoulder injuries. dislocation or displaced fracture of the A critical analysis glenoid or the humeral head and is Abstract generally best approached with surgical to the acromioclavicular joint, and proximal Economic pressure highlights the critical need treatment. Finally, patients who have humeral fractures. As a result, a detailed for appropriate diagnosis and treatment of the ability to voluntarily dislocate their analysis of individual risk factors for potential various shoulder pathologies since under- shoulder without discomfort should be failures should be performed and treatment diagnosis and under-treatment can result treated nonsurgically in most cases, as should be based on individualized care in increased costs to society in the form of withconsideration givento eachpatient’s these patients likely suffer not from disability and lost production. On the other particular injury pattern, functional demands, hand, aggressive over-treatment can further structural instability but rather from and long-term goals. inflate already burgeoning health-care costs functional instability, which can be due and potentially harm the patient. Therefore, to a pathological functional activation Keywords it is crucial to distinguish the indications pattern [27, 33] and may respond better Rotator cuff tears · Shoulder injuries · between operative and nonoperative Tendinitis · Acromioclavicular joint · Humeral to functional conservative treatments management, especially in common shoulder fractures, proximal pathologies such as rotator cuff tears, anterior [70] or even electrical muscle stimu- shoulder instability, biceps tendinitis, lesions lation in some therapy-resistant cases [51]. Konservative Therapie von 5 häufigen Schulterläsionen. Eine Treatment kritische Analyse In order to manage shoulder instability Zusammenfassung without surgical intervention, a combi- Schulterinstabilität, Bizepssehnentendinitis, Der zunehmende Kostendruck in der Medizin Akromioklavikular Gelenkluxationen und pro- nation of immobilization and physical verstärkt die Notwendigkeit einer rasch ximale Humerusfrakturen. Grundsätzlich ist zielführenden Diagnose und Therapie therapy is oeft n used before the patient es dabei wichtig, individuelle Risikofaktoren verschiedener pathologischer Veränderungen can return to activity [12, 35, 36, 54]. für ein Therapieversagen zu erkennen, den im Bereich der Schulter. Unterversorgte Physical therapyprotocols mayeitherfol- Erwartungshorizont des Patienten bezüglich Patienten erhöhen die Kosten für die low a period of immobilization of about funktionaler Ansprüche und Langzeitziele Gemeinschaft durch längere Ausfallzeiten abzuklären und auch das Verletzungsmuster 3 weeks in internal or external rotation und damit erniedrigte Produktion, während zu analysieren, um so letztendlich die überzogene Therapien die bereits ausufern- of the shoulderorbeinitiated immedi- Therapie individuell an den jeweiligen den Kosteninder medizinischenVersorgung ately. The overall goal of physical ther- Patienten anpassen zu können. weiter erhöhen und den Patienten sogar apy is to progress through glenohumeral potenziell schädigen können. Deshalb ist es strengthening and stabilization, thus re- unabdingbar, die Indikationen für operative Schlüsselwörter und konservative Therapien zu kennen und Rotatorenmanschettenläsionen · ducing the probability of recurrent in- anzuwenden, besonders im Hinblick auf Schulterverletzungen · Tendinitis · stability. Return to full activity is mostly Akromioklavikulargelenk · Proximale häufige pathologische Veränderungen wie allowed whenthere is symmetrical shoul- Humerusfrakturen Rotatorenmanschettenläsionen, vordere der strength of the scapulothoracic and glenohumeral joints, as well as functional shoulder range of motion [12, 57]. More recently, several studies have fo- preventing recurrent shoulder instability Overall, careful consideration of the cused on the position of the arm during [20, 78], including a recent randomized injury mechanism, patient demands, immobilization after a traumatic anterior controlled multicenter trial published in and concomitant injuries associated shoulder dislocation. In an MRI study 2014 [78]. Additionally, the conclusion with anterior shoulder instability are by Itoi et al. [31], immobilization with that “immobilization in internal or exter- crucial when deciding on nonopera- the arm in external rotation resulted in nal rotation does not change recurrence tive vs. operative intervention. Patients reduction of the Bankart lesion after trau- rates after traumatic anterior shoulder younger than 35 years of age should matic shoulderdislocation, thus support- dislocation” was confirmed in a 2014 sys- rarely be treated nonoperatively as the ing the hypothesis that immobilization in tematic review of the literature [76]and recurrence rate is unacceptably high. If external rotation may be superior to im- a 2016 meta-analysis of randomized con- treated nonoperatively, immobilization mobilization in internal rotation. How- trolled trials [77]. Of note, immobiliza- in internal rotation seems to be more ever, published clinical trials have not tion in external rotation is reported to be comfortable and shows equal outcomes been able to demonstrate similar efficacy very uncomfortable and, therefore, could to immobilization in external rotation of external rotation immobilization for reduce patient compliance. 92 Obere Extremität 2 · 2018 inflammatory effects for most LHBT dis- orders. However, they should be used for short-term pain relief and as an adjunct for the patient to initiate and tolerate a physical therapy program, rather than as a long-term treatment option. Be- cause these injections have the potential toreachthe glenohumeral joint, the anes- theticofchoice, usedincombinationwith corticosteroid, should be ropivacaine, as it is found to be less chondrotoxic than Fig. 2 8 Images of a 46-year-old man with right-sided biceps tendonitis, diagnosed via history, phys- bupivacaine [62]. ical examination, and a T2-weighted magnetic resonance imaging with a clear halo sign (yellow circle) The initiation of a 3–6-month physical around the long head of the biceps tendon indicating inflammation.The patient was treated conser- vatively with physical therapy and NSAIDs but continued to experience symptoms 6 months later.He therapy program allows for progressive thus underwent operative management as seen in b with the long head of the biceps tendon (BT)and increase in muscle strength while pro- biceps reflection pulley visualized through the standard posterior viewing portal.HH humeral head viding protection against further LHBT and associated structure injury during andthus shouldbe preferred,according patients suffering from biceps reflection rehabilitation [1, 4, 19, 53, 67]. to current literature findings. pulley lesions because these lesions do Other evolving nonoperative treat- not heal and symptoms worsen over time. ment options for LHBT disorders include In general, patients suitable for surgical prolotherapy (dextrose solution, sodium Biceps tendinitis evaluation include the following: young, morrhuate), platelet-rich plasma (dif- highly motivated patients with instabil- fering concentrations of platelets, white Indications for nonoperative ity or complete LHBT rupture; man- blood cells, red blood cells, and activated treatment of long head biceps ual laborers with significant instability or and inactivated platelets), and stem cells tendinitis complete LHBT rupture; elite-level ath- (circulating stem cells, adipose-derived, Inflammation of the long head biceps letes with instability or complete LHBT bone marrow aspirate, bone marrow tendon (LHBT) can lead to damage and rupture; any individual with a complete aspirate concentrate, amniotic mem- weakening of surrounding supporting LHBT rupture who is not agreeable to brane-derived). The choice to utilize one structures, thereby causing LHBT in- a potential loss of elbow flexion or fore- of these treatment options varies from stability. In turn, instability can place arm supination strength and long-stand- patient to patient and condition to condi- increased stresses on the LHBT, which ing “Popeye” deformity; and any individ- tion, and current research is beginning to subsequently increase inflammation. ual who has progressed through all stages thoroughly evaluate these interventions This cycle can predispose the LHBT to of nonoperative treatment and continues and to standardize treatment protocols rupture. to have symptoms of pain and/or weak- [21, 23, 45, 46, 49]. Indications for Given the potential success of non- ness that affects their quality of life. these injections include pain impairing operative management for most LHBT athletic performance, connective tissue tendinopathies, a management strategy laxity impairing athletic performance, Treatment involving medications and physical ther- and pain impairing rest and quality of apy should be the first step in treating After identification of the underlying life [49]. Future research is needed to de- these conditions. After progressing a pa- pathologic condition of the LHBT, treat- termine which LHBT disorders respond tient through physical therapy, a course ment generally begins with activity best to, and what patient populations are of nonsteroidal anti-inflammatory drugs modification, NSAIDs, and/or cortico- the most suitable candidates for, such (NSAIDs) and/or injections, it is impor- steroid injections [1, 53]. NSAIDs can procedures. tant tore-evaluate the patientforprogres- provide short-term benefit for swelling sion of pain, weakness, and mechanical and pain control. However, there is Acromioclavicular joint injuries symptoms. Atthattime, continuation of little evidence that they are efficacious a home exercise program vs. consider- in treating chronic tendon injuries [13]. Indications for nonoperative ation of additional interventions will be Useofcorticosteroidinjectionsshould treatment of acromioclavicular discussed based on symptom progres- follow a similar treatment protocol to joint injury sion. NSAIDs. Multiple case reports discuss If a patient progresses through all non- the risk of tendon rupture with steroid Injury classification is the single most im- operative treatment options and notes no injections, and caution should be exer- portant factor in determining the most improvement of pain or weakness, he or cised when injecting steroid around the appropriate treatment of acromioclavic- she should progress to surgical evalua- LHBT [2, 13]. Corticosteroid injections ular (AC) joint injuries. In 1989, Rock- tion (. Fig. 2). Thisisalso the case for alone will likely provide short-term anti- wood and colleagues developed the clas- Obere Extremität 2 · 2018 93 Review article Fig. 3 8 Radiographs of a 26-year-old male patient after a direct fall onto his right shoulder.a Panoramic view after in- jury showing a probable Rockwood type II injury.b However, the Alexander view demonstrates the clavicle overriding the acromion, thus indicating horizontal instability and defining this as a Rockwood type IV injury.Accordingly, the patient un- derwent operative therapy with twodog-bones insteadofone in ordertobetteraddress the horizontal instability,as pictured in c, the postoperative panoramic radiograph.d Postoperatively, the horizontal instability was resolved as demonstrated on the Alexander view 6 weeks after surgery sification system that is most widely used Although high-level studies are rare by patient tolerance and evidence of for AC joint injuries today [79]. No- intheorthopedicliteraturetodefinitively improved scapulohumeral kinematics. tably, this system, which is based on the guide optimal treatment, there is a com- Nonoperative treatment failed in 12 pa- work of Tossy et al. [74], recognizes the mon consensus regarding the most ap- tients, who ultimately required surgery. importance of the coracoclavicular (CC) propriate treatments based on Rockwood Reasons cited for nonoperative failure ligaments in joint stability [79]. type [6]. included unremitting pain, weakness, Rockwood type I injuries are charac- It is generally agreed that type I and instability, and dysfunction in spite of terized by a sprain without rupture of II injuries should undergo initial nonop- physical therapy. At a mean follow-up the AC ligaments with no anatomic dis- erative treatment while types IV–VI re- of 3.3 years, patient-reported outcome location and intact trapezius and deltoid quire surgery [6]. Optimal management scores—including the American Shoul- fascia. Type II injuries involve rupture of of type III injuries has been controver- der and Elbow Surgeons score (ASES), the AC joint ligaments but are otherwise sial. In the highest-level study to date, Quick Disabilities of the Arm, Shoul- similar to type I. Type III injuries are the Canadian Orthopedic Trauma Soci- der, and Hand score (QuickDASH), characterized by rupture of both the AC ety [16] recently completed a prospective Single Assessment Numeric Evalua- and CC ligaments with superior displace- randomized trial of 83 patients compar- tion score (SANE), and Short Form ment of the clavicle of 25–100% com- ing nonoperative treatment of grade III, 12 Physical Component Summary (SF- pared with the contralateral shoulder; IV, or V AC joint injuries with operative 12 PCS)—did not significantly differ be- notably, the trapezius and deltoid fascia intervention using a hook plate. Out- tween those who successfully completed are disrupted with this injury. Type IV come scores at short-term follow-up as nonoperative therapy and those who injuries generally present with additional far as 2 years demonstrated no signifi- required eventual surgery [60]. horizontal instability (. Fig. 3). Type V cant difference between the groups with In general, there is consensus that injuries are similar to type-III injuries, the exception of superior radiographic the horizontal stability of the clavicle but the clavicle is superiorly displaced results in the operative group [16]. is considered a potential key factor for more than 100% compared with the con- Moreover, Petri and colleagues re- a successful postoperative outcome. It tralateral side. Type-VI injuries, which viewed 41 patients with Rockwood is hypothesized that an unstable clavi- are rarely seen, involve rupture of both grade III AC joint injuries who were cle causes pain and functional deficits. AC and CC ligaments with inferior dis- initially treated nonoperatively [60]. Therefore, the ISAKOS shoulder com- placement of the distal clavicle under- Nonoperative management consisted of mittee [7] recently proposed a modifica- neath the acromion; the trapezius and formalphysicaltherapytwotothreetimes tion to the classic Rockwood classifica- deltoid fascia are disrupted [74, 79]. per week for at least 6 weeks using a pha- tion in which type III injuries may be fur- sic approach with progression dictated ther subdivided into types IIIA and IIIB; 94 Obere Extremität 2 · 2018 type IIIA injuries are horizontally stable Better outcomes may be achieved with to the head fragment, nonsurgical treat- and may respond well to conservative surgical fixation in cases with signifi- ment may yield good-to-excellent results management, but type IIIB injuries are cant displacement, a bony avulsion of the [17]. unstable and should therefore be treated supraspinatus tendon, a block to range of Although surgical treatment of com- surgically [7]. motion, and involvement of the anatomic plex fracture patterns is generally advo- neck. However, well-designed compar- cated, the efficacy of operative vs. nonop- ative studies of operative vs. nonoper- erative management remains to be clearly Treatment ative management of two-part fractures delineated. In a study of 60 elderly pa- Typical nonoperative treatment consists are lacking [26]. tients with a displaced three-part frac- of primary immobilization and subse- Some authors have found that greater ture of the proximal humerus, Olerud quent active rehabilitation [15]. How- tuberosity fractures with >5 mm of dis- et al. found that surgical management ever, evidence to support the efficacy of placement may benefit from surgical fix- with a locking plate resulted in better specific rehabilitation protocols is limited ation to reduce the risk of subacromial functional outcomes and health-related [15]. impingement [58, 63]. Lesser tuberosity quality of life than did nonsurgical treat- Gladstone et al. [25] published a phys- fractures with internal rotation impinge- ment, butata costofadditional surgeryin ical therapy regimen for the nonoperative ment may also benefit from surgery if 30% of patients [56]. By contrast, a meta- treatment of AC joint injuries types I, II, nonoperative management fails [52]. In analysis of randomized controlled trials and III in athletes. Phase 1 lasts 3–10 days contrast to other parts of the proximal didnot findimproved functional out- and focuses on elimination of pain and humerus, the anatomic neck is devoid of comes with open reduction and internal sling immobilization to protect the AC soft-tissue attachments and has a tenu- fixation (ORIF) compared with nonsur- joint. Range-of-motion exercises begin ous blood supply, which may result in an gical treatment in elderly patients with in phase 2 with gradual progression increased risk of osteonecrosis. displaced three-part or four-part prox- of isotonic exercise for strengthening. Court-Brown et al. recommend imal humeral fractures [40]. The study Phase 3 involves advanced strengthen- 2 weeks of sling immobilization followed concluded that these results must be con- ing, and phase 4 involves sports-specific by physical therapy for patients with two- sidered in the context of variable patient training before full return to activity [25]. part surgical neck fractures and valgus- demographics. The total length of rehabilitation can last impacted fractures [17, 18]. Two-part A systematic review supported the 3–6 months. Moreover, it is important proximal humeral fractures with >66% use of nonsurgical treatment of proximal to check on the scapula movement since translation were treated with either sling humeral fractures and noted a 2% rate a significant number of patients suffering immobilization or with internal fixation of osteonecrosis mainly associated with from AC joint injuries also present with with flexible intramedullary nailing and three-part and four-part fractures, high scapula dyskinesis. tension-band wires [17, 18]. No statis- rates of radiographic union, and modest Overall, the general consensus re- tical difference was reported between complication rates [32]. Ultimately, the garding management of AC joint in- the groups with regard to Neer score, patient’s baseline physiology and func- juries is fairly straightforward: initial return to activities of daily living, and tion may help to quantify the potential nonoperative treatment for Rockwood union rates [17, 18]. The data demon- advantages of nonsurgical management, grades I–II, and operative intervention strate that the Constant score diminishes even in the setting of complex fracture for grades IV–VI. For patients with with advancing age and degree of dis- patterns. grade III lesions, a closer look con- placement. However, when calculated cerning the stability of the clavicle is basedon age-adjustedConstant score, Treatment necessary. the older patients actually had better scores than the younger patients [14, 17, A number of proximal humeral fractures 18, 34]. Therefore, sling immobilization may be treated nonoperatively. However, Proximal humeral fracture is an appropriate treatment option for patients must understand the expecta- patients older than age 60 years with tions with this treatment approach and Indications for nonoperative valgus-impacted, two-part surgical neck comply with the accompanying restric- treatment of proximal humeral or two-part tuberosity fractures. tions. In general, excellent results have fractures Although three-part and four-part been achieved with short-term immobi- The number of bone parts and concomi- fractures oeft n require surgical fixation, lization (<2 weeks) in a sling and early tant displacement mainly influences the nonoperative management can be con- physical therapy [28, 63, 72]. While the treatment strategy of proximal humeral sidered for patients with poor baseline literature supports early mobilization, it fractures. Nonoperative treatment of function and/or an inability to toler- is important to ensure that further frac- two-part fractures with early rehabil- ate surgery. In select three-part and ture displacement does not occur. Sling itation has been found to be at least four-part fractures, particularly valgus- immobilization with or without closed as efficacious as surgical treatment in impacted fractures with <1 cm of dis- reduction also has a role in the man- injuries with minimal displacement [29]. placement of the tuberosities in relation Obere Extremität 2 · 2018 95 Review article 7. Beitzel K, Mazzocca AD, Bak K et al (2014) ISAKOS agement of displaced proximal humeral Corresponding address upper extremity committee consensus statement fractures [69]. on the need for diversification of the Rockwood classification for acromioclavicular joint injuries. P. J. Millett, M.D., M.Sc. Arthroscopy30:271–278 The Steadman Clinic Practical conclusion 8. Bishop J, Klepps S, Lo IK et al (2006) Cuff integrity 181 West Meadow Drive after arthroscopic versus open rotator cuff repair: suite 400, 81657 Vail, CO, USA 4 For rotator cuff tears, the best pos- a prospective study. J Shoulder Elbow Surg drmillett@ 15:290–299 sible outcomes with nonoperative thesteadmanclinic.com 9. Bishop JA, Crall TS, Kocher MS (2011) Operative therapy are generally achieved for pa- versus nonoperative treatment after primary tients presenting pain as the primary traumatic anterior glenohumeral dislocation: expected-value decision analysis. J Shoulder symptom of an atraumatic rotator Compliance with ethical ElbowSurg20:1087–1094 cuff tear, largely intact coronal and guidelines 10. Boorman RS, More KD, Hollinshead RM et al (2014) axial force couples, and a willingness The rotator cuff quality-of-life index predicts the outcome of nonoperative treatment of patients to trade functional deficits to avoid Conflict of interest. A.B.Imhoffservesasaboardor with a chronic rotator cuff tear. J Bone Joint Surg surgical risks. committee member for AGA, serves on the editorial Am96:1883–1888 board of Archives of Orthopaedic and Trauma Surgery, 4 In patients suffering from anterior 11. Boughebri O, Maqdes A, Moraiti C et al (2015) is a paid consultant and receives royalties and research Results of 45 arthroscopic Bankart procedures: shoulder instability, careful consid- support from Arthrex, Inc., serves on the editorial Does the ISIS remain a reliable prognostic eration of the injury mechanism, board of Arthroskopie, is a paidconsultantandreceives assessment after 5 years? Eur J Orthop Surg royaltiesfromArthrosurface,servesasaboardor patient demands, and concomitant Traumatol25:709–716 committee member for DGOOC, serves as a board or 12. Buss DD, Lynch GP, Meyer CP et al (2004) injuries associated with anterior committee member for DGOU, serves as a board or Nonoperative managementfor in-season athletes shoulder instability are crucial when committee member for ISAKOS, serves on the editorial with anterior shoulder instability. Am J Sports Med board of KSSTA, is a paid consultant for medi-bayreuth, 32:1430–1433 deciding on nonoperative vs. opera- serves on the editorial board of OOTR,andreceives 13. Childress MA, Beutler A (2013) Management tive intervention. Patients <35 years royalties and financial support from Springer and of chronic tendon injuries. Am Fam Physician should rarely be treated nonopera- Thieme. P.J. Millett is a paid consultant for Arthrex, 87:486–490 Inc., receives royalties from Arthrex, Inc., Medbridge, tively. 14. ConstantCR,MurleyAH(1987)Aclinicalmethodof and Springer Publishing, owns stock or stock options functionalassessmentoftheshoulder. ClinOrthop 4 For tendinitis of the LHBT, treatment in Game Ready and VuMedi, and receives research Relat Res. https://doi.org/10.1097/00003086- generally begins with a nonoperative support from Arthrex, Inc., Ossur, Siemens, and Smith 198701000-00023 and Nephew. J. Pogorzelski, E.M. Fritz, and J.A. Godin treatment protocol including activity 15. Cote MP, Wojcik KE, Gomlinski G et al (2010) Re- declare that they have no competing interests. habilitation of acromioclavicular jointseparations: modificationand NSAIDs. Inpatients operative and nonoperative considerations. Clin with structural instability of the This article does not contain any studies with human SportsMed29:213–228(vii) participants or animals performed by any of the au- biceps tendon complex, or in any 16. Cots (2015)Multicenter randomizedclinical trial of thors. nonoperative versus operative treatment of acute individual who continues to have acromio-clavicular joint dislocation. J Orthop symptoms of pain after nonoperative OpenAccess. Thisarticleisdistributedundertheterms Trauma29:479–487 of the Creative Commons Attribution 4.0 International treatment, surgery is favored. 17. 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Yamaguchi K, Tetro AM, Blam O et al (2001) treatmentfor rotator cuff injury in the elderly.J Am theshoulder. AmJSportsMed43:1983–1988 Natural history of asymptomatic rotator cuff tears: MedDirAssoc9:626–632 62. Piper SL, KimHT(2008)Comparison of ropivacaine a longitudinal analysis of asymptomatic tears 42. Lo IK, Burkhart SS (2003) Current concepts in and bupivacaine toxicity in human articular detected sonographically. J Shoulder Elbow Surg arthroscopic rotator cuff repair. Am J Sports Med chondrocytes. JBoneJointSurgAm90:986–991 10:199–203 31:308–324 Obere Extremität 2 · 2018 97

Journal

Obere ExtremitätSpringer Journals

Published: Feb 19, 2018

References

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