Nonoperative treatment of five common shoulder injuries

Jonas Pogorzelski; Erik Fritz; Jonathan Godin; Andreas Imhoff; Peter Millett

doi:10.1007/s11678-018-0449-1

Nonoperative treatment of five common shoulder injuries

Pogorzelski, Jonas; Fritz, Erik; Godin, Jonathan; Imhoff, Andreas; Millett, Peter 2018-02-19 00:00:00 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. Court-Brown CM, Cattermole H, Mcqueen MM License (http://creativecommons.org/licenses/by/ (2002) Impacted valgus fractures (B1.1) of the 4 The general consensus regarding 4.0/), which permits unrestricted use, distribution, proximal humerus. The results of non-operative management of AC joint injuries sug- and reproduction in any medium, provided you give treatment. JBoneJointSurgBr84:504–508 appropriate credit to the original author(s) and the gests initial nonoperative treatment 18. Court-Brown CM, Garg A, Mcqueen MM (2001) source, providealinktotheCreativeCommonslicense, The translated two-part fracture of the proximal for Rockwood types I–II, and oper- and indicate if changes were made. humerus. Epidemiology and outcome in the older ative intervention for types IV–VI. patient. JBoneJointSurgBr83:799–804 For patients with type III lesions, 19. Eakin CL, Faber KJ, Hawkins RJ et al (1999) Biceps tendon disorders in athletes. J Am Acad Orthop a pathologic instability of the clav- References Surg7:300–310 icle potentially requiring surgical 20. Finestone A, Milgrom C, Radeva-Petrova DR et al 1. Allen L (2013) Long head of biceps tendon: stabilization should be considered. (2009) Bracing in external rotation for traumatic anatomy, biomechanics, pathology, diagnosis and anterior dislocation of the shoulder. J Bone Joint 4 Tuberosity fractures with >5mm management. UnivNMOrthopResJ2:21–23 SurgBr91:918–921 of displacement may beneﬁt from 2. Andres BM, Murrell GA (2008) Treatment of 21. Finnoﬀ JT, Fowler SP, Lai JK et al (2011) Treat- tendinopathy: what works, what does not, and surgical ﬁxation to reduce the risk of ment of chronic tendinopathy with ultrasound- what is on the horizon. Clin Orthop Relat Res guided needle tenotomy and platelet-rich plasma subacromial impingement as well as 466:1539–1554 injection. PMR3:900–911 displaced multifragment fractures in 3. Balg F, Boileau P (2007) The instability severity 22. FucenteseSF,VonRollAL,PﬁrrmannCWetal(2012) index score. A simple pre-operative score to young and active patients. Evolution of nonoperatively treated symptomatic select patients for arthroscopic or open shoulder isolated full-thickness supraspinatus tears. J Bone stabilisation. JBoneJointSurgBr89:1470–1477 JointSurgAm94:801–808 4. Barber FA, Field LD, Ryu RK (2008) Biceps tendon 23. FullertonBD,ReevesKD(2010)Ultrasonographyin and superior labrum injuries: decision making. regenerative injection (prolotherapy) using dex- InstrCourseLect57:527–538 trose, platelet-rich plasma, and other injectants. 5. Barnes LA, Kim HM, Caldwell JM et al (2017) PhysMedRehabilClinNAm21:585–605 Satisfaction, function and repair integrity after 24. Galatz LM, Ball CM, Teefey SA et al (2004) The arthroscopic versus mini-open rotator cuﬀ repair. outcome and repair integrity of completely BoneJointJ99-B:245–249 arthroscopicallyrepairedlargeandmassiverotator 6. BeitzelK,CoteMP,ApostolakosJetal(2013)Current cuﬀtears. JBoneJointSurgAm86-a:219–224 concepts in the treatment of acromioclavicular jointdislocations. Arthroscopy29:387–397 96 Obere Extremität 2 · 2018 25. Gladstone JN, Wilk KE, Andrews JR (1997) 43. Mather RC, Koenig L, Acevedo D et al (2013) The 63. Platzer P, Kutscha-Lissberg F, Lehr Setal (2005)The Nonoperative treatment ofacromioclavicular joint societal and economic value of rotator cuﬀ repair. inﬂuence of displacement on shoulder function in injuries. OperTechSportsMed5:78–87 JBoneJointSurgAm95:1993–2000 patients with minimally displaced fractures of the 26. Godin JA, Katthagen JC, Fritz EM et al (2017) 44. MatherRC,OrlandoLA,HendersonRAetal(2011)A greatertuberosity. Injury36:1185–1189 Arthroscopic treatment of greater tuberosity predictivemodelofshoulderinstabilityafteraﬁrst- 64. Pope D, Croft P, Pritchard C et al (1997) Prevalence avulsionfractures. ArthroscTech6:e777–e783 time anterior shoulder dislocation. J Shoulder of shoulder pain in the community: the inﬂuence 27. Greiwe RM, Galano G, Grantham J et al (2012) ElbowSurg20:259–266 ofcasedeﬁnition. AnnRheumDis56:308–312 Arthroscopic stabilization for voluntary shoulder 45. Mautner K, Blazuk J (2015) Where do injectable 65. Rouleau DM, Hébert-Davies J, Djahangiri A et al instability. JPediatrOrthop32:781–786 stemcell treatments applyin treatmentof muscle, (2013) Validation of the instability shoulder index 28. Hanson B, Neidenbach P, De Boer P et al tendon,andligamentinjuries? PMR7:S33–S40 score in a multicenter reliability study in 114 (2009) Functional outcomes after nonoperative 46. Mautner K, Malanga GA, Smith J et al (2015) A consecutivecases. AmJSportsMed41:278–282 managementoffracturesoftheproximalhumerus. call for a standard classiﬁcation system for future 66. Rowe CR, Pierce DS, Clark JG (1973) Voluntary JShoulderElbowSurg18:612–621 biologic research: the rationale for new PRP dislocation of the shoulder. A preliminary report 29. Hodgson SA, Mawson SJ, Saxton JM et al (2007) nomenclature. PMR7:S53–S59 on a clinical, electromyographic, and psychiatric Rehabilitation of two-part fractures of the neck 47. Meislin RJ, Sperling JW, Stitik TP (2005) Persistent study of twenty-six patients. J Bone Joint Surg Am of the humerus (two-year follow-up). J Shoulder shoulder pain: epidemiology, pathophysiology, 55:445–460 ElbowSurg16:143–145 anddiagnosis. AmJOrthop(BelleMead,NJ)34:5–9 67. Ryu JH, Pedowitz RA (2010) Rehabilitation of 30. Hovelius L, Augustini BG, Fredin H et al (1996) 48. Millett PJ, Wilcox RB 3rd, O’holleran JD et al biceps tendon disorders in athletes. Clin Sports Primary anterior dislocation of the shoulder in (2006) Rehabilitation of the rotator cuﬀ: an Med29:229–246(vii–viii) young patients. A ten-year prospective study. evaluation-based approach. J Am Acad Orthop 68. Safran O, Schroeder J, Bloom R et al (2011) Natural JBoneJointSurgAm78:1677–1684 Surg14:599–609 history of nonoperatively treated symptomatic 31. Itoi E, Sashi R, Minagawa H et al (2001) Position 49. Moon YL, Ha SH, Lee YK et al (2011) Comparative rotator cuﬀ tears in patients 60 years old or of immobilization after dislocation of the gleno- studiesofplatelet-richplasma(PRP)andprolother- younger. AmJSportsMed39:710–714 humeral joint. A study with use of magnetic apy for proximal biceps tendinitis. Clin Shoulder 69. Schlegel TF, Hawkins RJ (1994) Displaced proximal Elbow14:153–158 humeral fractures: evaluation andtreatment.JAm resonance imaging. J Bone Joint Surg Am 83- 50. Moosmayer S, Lund G, Seljom US et al (2014) AcadOrthopSurg2:54–66 A:661–667 Tendon repair compared with physiotherapy in 70. Takwale VJ, Calvert P, Rattue H (2000) Involuntary 32. Iyengar JJ, Devcic Z, Sproul RC et al (2011) the treatment of rotator cuﬀ tears: a randomized positionalinstabilityoftheshoulderinadolescents Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma controlled study in 103 cases with a ﬁve-year and young adults. Is there any beneﬁt from 25:612–617 follow-up. JBoneJointSurgAm96:1504–1514 treatment? JBoneJointSurgBr82:719–723 33. Jaggi A, Noorani A, Malone A et al (2012) Muscle 51. Moroder P, Minkus M, Bohm E et al (2017) Use of 71. Taylor DC, Arciero RA (1997) Pathologic changes activation patterns in patients with recurrent shoulder pacemaker for treatment of functional associated with shoulder dislocations. Arthro- shoulderinstability. IntJShoulderSurg6:101–107 shoulder instability: proof of concept. Obere scopic and physical examination ﬁndings in ﬁrst- 34. Katolik LI, Romeo AA, Cole BJ et al (2005) Extremitat12:103–108 time, traumatic anterior dislocations. Am J Sports Normalization of the constant score. J Shoulder 52. Neer CS 2nd, Craig EV, Fukuda H (1983) Cuﬀ-tear Med25:306–311 ElbowSurg14:279–285 arthropathy. JBoneJointSurgAm65:1232–1244 72. Tejwani NC, Liporace F, Walsh M et al (2008) 35. Kirkley A, Griﬃn S, Richards C et al (1999) 53.Nho SJ,Strauss EJ,Lenart BA et al (2010) Long Functional outcome following one-part proximal Prospective randomized clinical trial comparing head of the biceps tendinopathy: diagnosis and humeral fractures: a prospective study. J Shoulder the eﬀectiveness of immediate arthroscopicstabi- management. JAmAcadOrthopSurg18:645–656 ElbowSurg17:216–219 lizationversusimmobilizationandrehabilitationin 54. Norte GE, West A, Gnacinski M et al (2011) On-ﬁeld 73. Thomazeau H, Courage O, Barth J et al (2010) Can ﬁrsttraumaticanteriordislocationsoftheshoulder. management of the acute anterior glenohumeral weimprovetheindicationforBankartarthroscopic Arthroscopy15:507–514 dislocation. PhysSportsmed39:151–162 repair? A preliminary clinical study using the ISIS 36. Kirkley A, Werstine R, Ratjek A et al (2005) 55. Oh LS, Wolf BR, Hall MP et al (2007) Indications for score. OrthopTraumatolSurgRes96:S77–83 Prospective randomized clinical trial comparing rotatorcuﬀrepair: asystematicreview. ClinOrthop 74. Tossy JD, Mead NC, Sigmond HM (1963) Acromio- the eﬀectiveness of immediate arthroscopicstabi- RelatRes455:52–63 clavicular separations: useful and practical lization versus immobilization and rehabilitation 56. Olerud P, Ahrengart L, Ponzer S et al (2011) classiﬁcation for treatment. Clin Orthop Relat Res in ﬁrst traumatic anterior dislocations of the Internal ﬁxation versus nonoperative treatment 28:111–119 shoulder: long-term evaluation. Arthroscopy of displaced 3-part proximal humeral fractures in 75. VanDer MeijdenOA, Westgard P, Chandler Z et 21:55–63 elderly patients: a randomized controlled trial. J al (2012) Rehabilitation after arthroscopic rotator 37. Kuhn JE, Dunn WR, Sanders R et al (2013) ShoulderElbowSurg20:747–755 cuﬀ repair: currentconcepts review andevidence- Eﬀectiveness of physical therapy in treating 57. Owens BD, Dickens JF, Kilcoyne KG et al (2012) basedguidelines. IntJSportsPhysTher7:197–218 atraumatic full-thickness rotator cuﬀ tears: Management of mid-season traumatic anterior 76. Vavken P, Sadoghi P, Quidde J et al (2014) a multicenter prospective cohortstudy. J Shoulder shoulder instability in athletes. J Am Acad Orthop Immobilization in internal or external rotation ElbowSurg22:1371–1379 Surg20:518–526 does not change recurrence rates after traumatic 38. Kukkonen J, Joukainen A, Lehtinen J et al (2014) 58. Park TS, Choi IY, Kim YH et al (1997) A new anterior shoulder dislocation. J Shoulder Elbow Treatment of non-traumatic rotator cuﬀ tears: a suggestion for the treatment of minimally Surg23:13–19 randomised controlled trial with one-year clinical displaced fractures of the greater tuberosity of the 77. Whelan DB, Kletke SN, Schemitsch G et al results. BoneJointJ96-B:75–81 proximalhumerus. BullHospJtDis56:171–176 (2016) Immobilization in external rotation versus 39. Kukkonen J, Joukainen A, Lehtinen J et al (2015) 59. Petri M, Ettinger M, Brand S et al (2016) Non- internal rotation after primary anterior shoulder Treatment of nontraumatic rotator cuﬀ tears: a operative management of rotator cuﬀ tears. Open dislocation: a meta-analysis of randomized randomized controlled trial with two years of OrthopJ10:349–356 controlledtrials. AmJSportsMed44:521–532 clinical and imaging follow-up. J Bone Joint Surg 60. Petri M, Warth RJ, Greenspoon JA et al (2016) 78. Whelan DB, Litchﬁeld R, Wambolt E et al (2014) Am97:1729–1737 Clinical results after conservative management External rotation immobilization for primary 40. Li Y, Zhao L, Zhu L et al (2013) Internal ﬁxation for grade III acromioclavicular joint injuries: shoulder dislocation: a randomized controlled versus nonoperative treatment for displaced does eventual surgery aﬀect overall outcomes? trial. ClinOrthopRelatRes472:2380–2386 3-part or 4-part proximal humeral fractures in Arthroscopy32:740–746 79. Williams G, Nguyen V, Rockwood C (1989) Classiﬁ- elderly patients: a meta-analysis of randomized 61. Phadnis J, Arnold C, Elmorsy A et al (2015) Utility cation and radiographic analysis of acromioclavic- controlledtrials. PLoSONE8:e75464 of the instability severity index score in predicting ulardislocations. ApplRadiol18:29–34 41. LinJC,WeintraubN,AragakiDR(2008)Nonsurgical failure after arthroscopic anterior stabilization of 80. 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 http://www.deepdyve.com/lp/springer-journals/nonoperative-treatment-of-five-common-shoulder-injuries-Bo0UErLgEZ

Loading next page...

Publisher: Springer Journals
Copyright: Copyright © 2018 by The Author(s)
Subject: Medicine & Public Health; Orthopedics; Surgical Orthopedics; Medicine/Public Health, general
ISSN: 1862-6599
eISSN: 1862-6602
DOI: 10.1007/s11678-018-0449-1
Publisher site: See Article on Publisher Site

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. Court-Brown CM, Cattermole H, Mcqueen MM License (http://creativecommons.org/licenses/by/ (2002) Impacted valgus fractures (B1.1) of the 4 The general consensus regarding 4.0/), which permits unrestricted use, distribution, proximal humerus. The results of non-operative management of AC joint injuries sug- and reproduction in any medium, provided you give treatment. JBoneJointSurgBr84:504–508 appropriate credit to the original author(s) and the gests initial nonoperative treatment 18. Court-Brown CM, Garg A, Mcqueen MM (2001) source, providealinktotheCreativeCommonslicense, The translated two-part fracture of the proximal for Rockwood types I–II, and oper- and indicate if changes were made. humerus. Epidemiology and outcome in the older ative intervention for types IV–VI. patient. JBoneJointSurgBr83:799–804 For patients with type III lesions, 19. Eakin CL, Faber KJ, Hawkins RJ et al (1999) Biceps tendon disorders in athletes. J Am Acad Orthop a pathologic instability of the clav- References Surg7:300–310 icle potentially requiring surgical 20. Finestone A, Milgrom C, Radeva-Petrova DR et al 1. Allen L (2013) Long head of biceps tendon: stabilization should be considered. (2009) Bracing in external rotation for traumatic anatomy, biomechanics, pathology, diagnosis and anterior dislocation of the shoulder. J Bone Joint 4 Tuberosity fractures with >5mm management. UnivNMOrthopResJ2:21–23 SurgBr91:918–921 of displacement may beneﬁt from 2. Andres BM, Murrell GA (2008) Treatment of 21. Finnoﬀ JT, Fowler SP, Lai JK et al (2011) Treat- tendinopathy: what works, what does not, and surgical ﬁxation to reduce the risk of ment of chronic tendinopathy with ultrasound- what is on the horizon. Clin Orthop Relat Res guided needle tenotomy and platelet-rich plasma subacromial impingement as well as 466:1539–1554 injection. PMR3:900–911 displaced multifragment fractures in 3. Balg F, Boileau P (2007) The instability severity 22. FucenteseSF,VonRollAL,PﬁrrmannCWetal(2012) index score. A simple pre-operative score to young and active patients. Evolution of nonoperatively treated symptomatic select patients for arthroscopic or open shoulder isolated full-thickness supraspinatus tears. J Bone stabilisation. JBoneJointSurgBr89:1470–1477 JointSurgAm94:801–808 4. Barber FA, Field LD, Ryu RK (2008) Biceps tendon 23. FullertonBD,ReevesKD(2010)Ultrasonographyin and superior labrum injuries: decision making. regenerative injection (prolotherapy) using dex- InstrCourseLect57:527–538 trose, platelet-rich plasma, and other injectants. 5. Barnes LA, Kim HM, Caldwell JM et al (2017) PhysMedRehabilClinNAm21:585–605 Satisfaction, function and repair integrity after 24. Galatz LM, Ball CM, Teefey SA et al (2004) The arthroscopic versus mini-open rotator cuﬀ repair. outcome and repair integrity of completely BoneJointJ99-B:245–249 arthroscopicallyrepairedlargeandmassiverotator 6. BeitzelK,CoteMP,ApostolakosJetal(2013)Current cuﬀtears. JBoneJointSurgAm86-a:219–224 concepts in the treatment of acromioclavicular jointdislocations. Arthroscopy29:387–397 96 Obere Extremität 2 · 2018 25. Gladstone JN, Wilk KE, Andrews JR (1997) 43. Mather RC, Koenig L, Acevedo D et al (2013) The 63. Platzer P, Kutscha-Lissberg F, Lehr Setal (2005)The Nonoperative treatment ofacromioclavicular joint societal and economic value of rotator cuﬀ repair. inﬂuence of displacement on shoulder function in injuries. OperTechSportsMed5:78–87 JBoneJointSurgAm95:1993–2000 patients with minimally displaced fractures of the 26. Godin JA, Katthagen JC, Fritz EM et al (2017) 44. MatherRC,OrlandoLA,HendersonRAetal(2011)A greatertuberosity. Injury36:1185–1189 Arthroscopic treatment of greater tuberosity predictivemodelofshoulderinstabilityafteraﬁrst- 64. Pope D, Croft P, Pritchard C et al (1997) Prevalence avulsionfractures. ArthroscTech6:e777–e783 time anterior shoulder dislocation. J Shoulder of shoulder pain in the community: the inﬂuence 27. Greiwe RM, Galano G, Grantham J et al (2012) ElbowSurg20:259–266 ofcasedeﬁnition. AnnRheumDis56:308–312 Arthroscopic stabilization for voluntary shoulder 45. Mautner K, Blazuk J (2015) Where do injectable 65. Rouleau DM, Hébert-Davies J, Djahangiri A et al instability. JPediatrOrthop32:781–786 stemcell treatments applyin treatmentof muscle, (2013) Validation of the instability shoulder index 28. Hanson B, Neidenbach P, De Boer P et al tendon,andligamentinjuries? PMR7:S33–S40 score in a multicenter reliability study in 114 (2009) Functional outcomes after nonoperative 46. Mautner K, Malanga GA, Smith J et al (2015) A consecutivecases. AmJSportsMed41:278–282 managementoffracturesoftheproximalhumerus. call for a standard classiﬁcation system for future 66. Rowe CR, Pierce DS, Clark JG (1973) Voluntary JShoulderElbowSurg18:612–621 biologic research: the rationale for new PRP dislocation of the shoulder. A preliminary report 29. Hodgson SA, Mawson SJ, Saxton JM et al (2007) nomenclature. PMR7:S53–S59 on a clinical, electromyographic, and psychiatric Rehabilitation of two-part fractures of the neck 47. Meislin RJ, Sperling JW, Stitik TP (2005) Persistent study of twenty-six patients. J Bone Joint Surg Am of the humerus (two-year follow-up). J Shoulder shoulder pain: epidemiology, pathophysiology, 55:445–460 ElbowSurg16:143–145 anddiagnosis. AmJOrthop(BelleMead,NJ)34:5–9 67. Ryu JH, Pedowitz RA (2010) Rehabilitation of 30. Hovelius L, Augustini BG, Fredin H et al (1996) 48. Millett PJ, Wilcox RB 3rd, O’holleran JD et al biceps tendon disorders in athletes. Clin Sports Primary anterior dislocation of the shoulder in (2006) Rehabilitation of the rotator cuﬀ: an Med29:229–246(vii–viii) young patients. A ten-year prospective study. evaluation-based approach. J Am Acad Orthop 68. Safran O, Schroeder J, Bloom R et al (2011) Natural JBoneJointSurgAm78:1677–1684 Surg14:599–609 history of nonoperatively treated symptomatic 31. Itoi E, Sashi R, Minagawa H et al (2001) Position 49. Moon YL, Ha SH, Lee YK et al (2011) Comparative rotator cuﬀ tears in patients 60 years old or of immobilization after dislocation of the gleno- studiesofplatelet-richplasma(PRP)andprolother- younger. AmJSportsMed39:710–714 humeral joint. A study with use of magnetic apy for proximal biceps tendinitis. Clin Shoulder 69. Schlegel TF, Hawkins RJ (1994) Displaced proximal Elbow14:153–158 humeral fractures: evaluation andtreatment.JAm resonance imaging. J Bone Joint Surg Am 83- 50. Moosmayer S, Lund G, Seljom US et al (2014) AcadOrthopSurg2:54–66 A:661–667 Tendon repair compared with physiotherapy in 70. Takwale VJ, Calvert P, Rattue H (2000) Involuntary 32. Iyengar JJ, Devcic Z, Sproul RC et al (2011) the treatment of rotator cuﬀ tears: a randomized positionalinstabilityoftheshoulderinadolescents Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma controlled study in 103 cases with a ﬁve-year and young adults. Is there any beneﬁt from 25:612–617 follow-up. JBoneJointSurgAm96:1504–1514 treatment? JBoneJointSurgBr82:719–723 33. Jaggi A, Noorani A, Malone A et al (2012) Muscle 51. Moroder P, Minkus M, Bohm E et al (2017) Use of 71. Taylor DC, Arciero RA (1997) Pathologic changes activation patterns in patients with recurrent shoulder pacemaker for treatment of functional associated with shoulder dislocations. Arthro- shoulderinstability. IntJShoulderSurg6:101–107 shoulder instability: proof of concept. Obere scopic and physical examination ﬁndings in ﬁrst- 34. Katolik LI, Romeo AA, Cole BJ et al (2005) Extremitat12:103–108 time, traumatic anterior dislocations. Am J Sports Normalization of the constant score. J Shoulder 52. Neer CS 2nd, Craig EV, Fukuda H (1983) Cuﬀ-tear Med25:306–311 ElbowSurg14:279–285 arthropathy. JBoneJointSurgAm65:1232–1244 72. Tejwani NC, Liporace F, Walsh M et al (2008) 35. Kirkley A, Griﬃn S, Richards C et al (1999) 53.Nho SJ,Strauss EJ,Lenart BA et al (2010) Long Functional outcome following one-part proximal Prospective randomized clinical trial comparing head of the biceps tendinopathy: diagnosis and humeral fractures: a prospective study. J Shoulder the eﬀectiveness of immediate arthroscopicstabi- management. JAmAcadOrthopSurg18:645–656 ElbowSurg17:216–219 lizationversusimmobilizationandrehabilitationin 54. Norte GE, West A, Gnacinski M et al (2011) On-ﬁeld 73. Thomazeau H, Courage O, Barth J et al (2010) Can ﬁrsttraumaticanteriordislocationsoftheshoulder. management of the acute anterior glenohumeral weimprovetheindicationforBankartarthroscopic Arthroscopy15:507–514 dislocation. PhysSportsmed39:151–162 repair? A preliminary clinical study using the ISIS 36. Kirkley A, Werstine R, Ratjek A et al (2005) 55. Oh LS, Wolf BR, Hall MP et al (2007) Indications for score. OrthopTraumatolSurgRes96:S77–83 Prospective randomized clinical trial comparing rotatorcuﬀrepair: asystematicreview. ClinOrthop 74. Tossy JD, Mead NC, Sigmond HM (1963) Acromio- the eﬀectiveness of immediate arthroscopicstabi- RelatRes455:52–63 clavicular separations: useful and practical lization versus immobilization and rehabilitation 56. Olerud P, Ahrengart L, Ponzer S et al (2011) classiﬁcation for treatment. Clin Orthop Relat Res in ﬁrst traumatic anterior dislocations of the Internal ﬁxation versus nonoperative treatment 28:111–119 shoulder: long-term evaluation. Arthroscopy of displaced 3-part proximal humeral fractures in 75. VanDer MeijdenOA, Westgard P, Chandler Z et 21:55–63 elderly patients: a randomized controlled trial. J al (2012) Rehabilitation after arthroscopic rotator 37. Kuhn JE, Dunn WR, Sanders R et al (2013) ShoulderElbowSurg20:747–755 cuﬀ repair: currentconcepts review andevidence- Eﬀectiveness of physical therapy in treating 57. Owens BD, Dickens JF, Kilcoyne KG et al (2012) basedguidelines. IntJSportsPhysTher7:197–218 atraumatic full-thickness rotator cuﬀ tears: Management of mid-season traumatic anterior 76. Vavken P, Sadoghi P, Quidde J et al (2014) a multicenter prospective cohortstudy. J Shoulder shoulder instability in athletes. J Am Acad Orthop Immobilization in internal or external rotation ElbowSurg22:1371–1379 Surg20:518–526 does not change recurrence rates after traumatic 38. Kukkonen J, Joukainen A, Lehtinen J et al (2014) 58. Park TS, Choi IY, Kim YH et al (1997) A new anterior shoulder dislocation. J Shoulder Elbow Treatment of non-traumatic rotator cuﬀ tears: a suggestion for the treatment of minimally Surg23:13–19 randomised controlled trial with one-year clinical displaced fractures of the greater tuberosity of the 77. Whelan DB, Kletke SN, Schemitsch G et al results. BoneJointJ96-B:75–81 proximalhumerus. BullHospJtDis56:171–176 (2016) Immobilization in external rotation versus 39. Kukkonen J, Joukainen A, Lehtinen J et al (2015) 59. Petri M, Ettinger M, Brand S et al (2016) Non- internal rotation after primary anterior shoulder Treatment of nontraumatic rotator cuﬀ tears: a operative management of rotator cuﬀ tears. Open dislocation: a meta-analysis of randomized randomized controlled trial with two years of OrthopJ10:349–356 controlledtrials. AmJSportsMed44:521–532 clinical and imaging follow-up. J Bone Joint Surg 60. Petri M, Warth RJ, Greenspoon JA et al (2016) 78. Whelan DB, Litchﬁeld R, Wambolt E et al (2014) Am97:1729–1737 Clinical results after conservative management External rotation immobilization for primary 40. Li Y, Zhao L, Zhu L et al (2013) Internal ﬁxation for grade III acromioclavicular joint injuries: shoulder dislocation: a randomized controlled versus nonoperative treatment for displaced does eventual surgery aﬀect overall outcomes? trial. ClinOrthopRelatRes472:2380–2386 3-part or 4-part proximal humeral fractures in Arthroscopy32:740–746 79. Williams G, Nguyen V, Rockwood C (1989) Classiﬁ- elderly patients: a meta-analysis of randomized 61. Phadnis J, Arnold C, Elmorsy A et al (2015) Utility cation and radiographic analysis of acromioclavic- controlledtrials. PLoSONE8:e75464 of the instability severity index score in predicting ulardislocations. ApplRadiol18:29–34 41. LinJC,WeintraubN,AragakiDR(2008)Nonsurgical failure after arthroscopic anterior stabilization of 80. 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 Extremität – Springer Journals

Published: Feb 19, 2018

References

Long head of biceps tendon: anatomy, biomechanics, pathology, diagnosis and management

Allen, L
Treatment of tendinopathy: what works, what does not, and what is on the horizon

Andres, BM; Murrell, GA
The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation

Balg, F; Boileau, P
Biceps tendon and superior labrum injuries: decision making

Barber, FA; Field, LD; Ryu, RK
Satisfaction, function and repair integrity after arthroscopic versus mini-open rotator cuff repair

Barnes, LA; Kim, HM; Caldwell, JM
Current concepts in the treatment of acromioclavicular joint dislocations

Beitzel, K; Cote, MP; Apostolakos, J
ISAKOS upper extremity committee consensus statement on the need for diversification of the Rockwood classification for acromioclavicular joint injuries

Beitzel, K; Mazzocca, AD; Bak, K
Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study

Bishop, J; Klepps, S; Lo, IK
Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis

Bishop, JA; Crall, TS; Kocher, MS
The rotator cuff quality-of-life index predicts the outcome of nonoperative treatment of patients with a chronic rotator cuff tear

Boorman, RS; More, KD; Hollinshead, RM
Results of 45 arthroscopic Bankart procedures: Does the ISIS remain a reliable prognostic assessment after 5 years?

Boughebri, O; Maqdes, A; Moraiti, C
Nonoperative management for in-season athletes with anterior shoulder instability

Buss, DD; Lynch, GP; Meyer, CP
Management of chronic tendon injuries

Childress, MA; Beutler, A
A clinical method of functional assessment of the shoulder

Constant, CR; Murley, AH
Rehabilitation of acromioclavicular joint separations: operative and nonoperative considerations

Cote, MP; Wojcik, KE; Gomlinski, G
Multicenter randomized clinical trial of nonoperative versus operative treatment of acute acromio-clavicular joint dislocation

Cots
Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment

Court-Brown, CM; Cattermole, H; Mcqueen, MM
The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient

Court-Brown, CM; Garg, A; Mcqueen, MM
Biceps tendon disorders in athletes

Eakin, CL; Faber, KJ; Hawkins, RJ
Bracing in external rotation for traumatic anterior dislocation of the shoulder

Finestone, A; Milgrom, C; Radeva-Petrova, DR
Treatment of chronic tendinopathy with ultrasound-guided needle tenotomy and platelet-rich plasma injection

Finnoff, JT; Fowler, SP; Lai, JK
Evolution of nonoperatively treated symptomatic isolated full-thickness supraspinatus tears

Fucentese, SF; Roll, AL; Pfirrmann, CW
Ultrasonography in regenerative injection (prolotherapy) using dextrose, platelet-rich plasma, and other injectants

Fullerton, BD; Reeves, KD
The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears

Galatz, LM; Ball, CM; Teefey, SA
Nonoperative treatment ofacromioclavicular joint injuries

Gladstone, JN; Wilk, KE; Andrews, JR
Arthroscopic treatment of greater tuberosity avulsion fractures

Godin, JA; Katthagen, JC; Fritz, EM
Arthroscopic stabilization for voluntary shoulder instability

Greiwe, RM; Galano, G; Grantham, J
Functional outcomes after nonoperative management of fractures of the proximal humerus

Hanson, B; Neidenbach, P; Boer, P
Rehabilitation of two-part fractures of the neck of the humerus (two-year follow-up)

Hodgson, SA; Mawson, SJ; Saxton, JM
Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study

Hovelius, L; Augustini, BG; Fredin, H
Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging

Itoi, E; Sashi, R; Minagawa, H
Nonoperative treatment of proximal humerus fractures: a systematic review

Iyengar, JJ; Devcic, Z; Sproul, RC
Muscle activation patterns in patients with recurrent shoulder instability

Jaggi, A; Noorani, A; Malone, A
Normalization of the constant score

Katolik, LI; Romeo, AA; Cole, BJ
Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder

Kirkley, A; Griffin, S; Richards, C
Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long-term evaluation

Kirkley, A; Werstine, R; Ratjek, A
Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study

Kuhn, JE; Dunn, WR; Sanders, R
Treatment of non-traumatic rotator cuff tears: a randomised controlled trial with one-year clinical results

Kukkonen, J; Joukainen, A; Lehtinen, J
Treatment of nontraumatic rotator cuff tears: a randomized controlled trial with two years of clinical and imaging follow-up

Kukkonen, J; Joukainen, A; Lehtinen, J
Internal fixation versus nonoperative treatment for displaced 3‑part or 4‑part proximal humeral fractures in elderly patients: a meta-analysis of randomized controlled trials

Li, Y; Zhao, L; Zhu, L
Nonsurgical treatment for rotator cuff injury in the elderly

Lin, JC; Weintraub, N; Aragaki, DR
Current concepts in arthroscopic rotator cuff repair

Lo, IK; Burkhart, SS
The societal and economic value of rotator cuff repair

Mather, RC; Koenig, L; Acevedo, D
A predictive model of shoulder instability after a first-time anterior shoulder dislocation

Mather, RC; Orlando, LA; Henderson, RA
Where do injectable stem cell treatments apply in treatment of muscle, tendon, and ligament injuries?

Mautner, K; Blazuk, J
A call for a standard classification system for future biologic research: the rationale for new PRP nomenclature

Mautner, K; Malanga, GA; Smith, J
Persistent shoulder pain: epidemiology, pathophysiology, and diagnosis

Meislin, RJ; Sperling, JW; Stitik, TP
Rehabilitation of the rotator cuff: an evaluation-based approach

Millett, PJ; Wilcox, RB; O’holleran, JD
Comparative studies of platelet-rich plasma (PRP) and prolotherapy for proximal biceps tendinitis

Moon, YL; Ha, SH; Lee, YK
Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up

Moosmayer, S; Lund, G; Seljom, US
Use of shoulder pacemaker for treatment of functional shoulder instability: proof of concept

Moroder, P; Minkus, M; Bohm, E
Cuff-tear arthropathy

Neer, CS; Craig, EV; Fukuda, H
Long head of the biceps tendinopathy: diagnosis and management

Nho, SJ; Strauss, EJ; Lenart, BA
On-field management of the acute anterior glenohumeral dislocation

Norte, GE; West, A; Gnacinski, M
Indications for rotator cuff repair: a systematic review

Oh, LS; Wolf, BR; Hall, MP
Internal fixation versus nonoperative treatment of displaced 3‑part proximal humeral fractures in elderly patients: a randomized controlled trial

Olerud, P; Ahrengart, L; Ponzer, S
Management of mid-season traumatic anterior shoulder instability in athletes

Owens, BD; Dickens, JF; Kilcoyne, KG
A new suggestion for the treatment of minimally displaced fractures of the greater tuberosity of the proximal humerus

Park, TS; Choi, IY; Kim, YH
Non-operative management of rotator cuff tears

Petri, M; Ettinger, M; Brand, S
Clinical results after conservative management for grade III acromioclavicular joint injuries: does eventual surgery affect overall outcomes?

Petri, M; Warth, RJ; Greenspoon, JA
Utility of the instability severity index score in predicting failure after arthroscopic anterior stabilization of the shoulder

Phadnis, J; Arnold, C; Elmorsy, A
Comparison of ropivacaine and bupivacaine toxicity in human articular chondrocytes

Piper, SL; Kim, HT
The influence of displacement on shoulder function in patients with minimally displaced fractures of the greater tuberosity

Platzer, P; Kutscha-Lissberg, F; Lehr, S
Prevalence of shoulder pain in the community: the influence of case definition

Pope, D; Croft, P; Pritchard, C
Validation of the instability shoulder index score in a multicenter reliability study in 114 consecutive cases

Rouleau, DM; Hébert-Davies, J; Djahangiri, A
Voluntary dislocation of the shoulder. A preliminary report on a clinical, electromyographic, and psychiatric study of twenty-six patients

Rowe, CR; Pierce, DS; Clark, JG
Rehabilitation of biceps tendon disorders in athletes

Ryu, JH; Pedowitz, RA
Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger

Safran, O; Schroeder, J; Bloom, R
Displaced proximal humeral fractures: evaluation and treatment

Schlegel, TF; Hawkins, RJ
Involuntary positional instability of the shoulder in adolescents and young adults. Is there any benefit from treatment?

Takwale, VJ; Calvert, P; Rattue, H
Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations

Taylor, DC; Arciero, RA
Functional outcome following one-part proximal humeral fractures: a prospective study

Tejwani, NC; Liporace, F; Walsh, M
Can we improve the indication for Bankart arthroscopic repair? A preliminary clinical study using the ISIS score

Thomazeau, H; Courage, O; Barth, J
Acromioclavicular separations: useful and practical classification for treatment

Tossy, JD; Mead, NC; Sigmond, HM
Rehabilitation after arthroscopic rotator cuff repair: current concepts review and evidence-based guidelines

Der Meijden, OA; Westgard, P; Chandler, Z
Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder dislocation

Vavken, P; Sadoghi, P; Quidde, J
Immobilization in external rotation versus internal rotation after primary anterior shoulder dislocation: a meta-analysis of randomized controlled trials

Whelan, DB; Kletke, SN; Schemitsch, G
External rotation immobilization for primary shoulder dislocation: a randomized controlled trial

Whelan, DB; Litchfield, R; Wambolt, E
Classification and radiographic analysis of acromioclavicular dislocations

Williams, G; Nguyen, V; Rockwood, C
Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically

Yamaguchi, K; Tetro, AM; Blam, O

Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Nonoperative treatment of five common shoulder injuries

Nonoperative treatment of five common shoulder injuries

Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Nonoperative treatment of five common shoulder injuries

Nonoperative treatment of five common shoulder injuries

Abstract

Journal

Recommended Articles

References

Our policy towards the use of cookies