Shoulder Proprioception: A Review.

The purpose of this review is to provide a comprehensive resource for shoulder proprioception assessment and its integration into clinical decision making as well as targeted rehabilitation protocols. Data for this review were acquired from peer-reviewed articles from computerized online databases, namely PubMed and Medline, published between 1906 and 2021. The development of digital/smart phone goniometers can improve shoulder joint range of motion (ROM) measurements and demonstrate comparable measurement accuracy to the universal standard goniometer. The inclinometer offers a portable and cost-effective method for measuring shoulder joint angles and arcs of motion in the vertical plane. Two types of dynamometers, the computerized isokinetic machine and the handheld hydraulic dynamometer, are reliable tools for objective shoulder rotator cuff strength assessment. Motion analysis systems are highly advanced modalities that create three-dimensional models of motion arcs using a series of cameras and reflective beads, offering unparalleled precision in shoulder proprioception measurement; however, they require time-consuming calibration and skilled operators. Advancements in wearable devices and compact mobile technology such as iPhone applications may make three-dimensional motion analysis more affordable and practical for outpatient settings in the future. The complex interplay between proprioception and shoulder dysfunction is not fully understood; however, shoulder proprioception can likely both contribute to and be caused by shoulder pathology. In patients with rotator cuff tears, glenohumeral osteoarthritis, and shoulder instability, clinicians can track proprioception to understand a patient's disease progression or response to treatment. Finally, rehabilitation programs targeting shoulder proprioception have shown promising initial results in restoring function and returning athletes to play.

Retrograde Intramedullary Nailing Versus Locked Plating for Extreme Distal Periprosthetic Femur Fractures: A Multicenter Retrospective Cohort Study.

OBJECTIVES: To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange. DESIGN: Retrospective review. SETTING: Eight academic level I trauma centers. PATIENT SELECTION CRITERIA: Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP. OUTCOME MEASURES AND COMPARISONS: The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP. RESULTS: Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008). CONCLUSIONS: rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Increasing rates of ulnar collateral ligament repair outpace reconstruction in isolated injuries: review of a Texas surgical database.

Background: The gold standard of treatment for ulnar collateral ligament (UCL) injuries has been reconstruction. Despite early repair studies yielding less than satisfactory results, there has been recent renewed interest in UCL repair due to improved outcomes and new technologies. Data regarding clinical use of these procedures are lacking. The purpose of this study was to define the epidemiological trends of UCL repair and reconstruction surgery from 2010 to 2019, compare demographic characteristics of patients undergoing either procedure, and determine incidence of concomitant procedures in each surgical group as well as comparing respective patient-level charges. Methods: A retrospective database analysis of UCL surgeries was performed through the Texas Healthcare Information Collection database, a comprehensive and publicly available statewide billing dataset. Inclusion criteria were defined using Current Procedural Terminology billing codes for elbow UCL repair and reconstruction between 2010 through 2019, excluding patients who had concomitant elbow fractures or lateral collateral ligament tears indicative of high-energy trauma. Procedural volume changes, patient demographics, and commonly performed concomitant procedures including elbow arthroscopy, ulnar nerve surgery, and platelet-rich plasma injection were compared. Total patient-level charges were compared across groups. Results: A total of 1664 patients were included, consisting of 484 UCL repairs and 1180 reconstructions. Total UCL surgeries increased eleven-fold when corrected for population growth from 2010 (N = 25) to 2019 (N = 315). In 2010, repair constituted 23% of all UCL tear surgeries and increased to 40% by the end of 2019. The annual frequency of UCL repair increased at a 5.4% faster rate than UCL reconstruction from 2010 to 2019 (P < .001). There were no significant differences between any demographic data between UCL repair and reconstruction except for rural surgical settings which demonstrated 1.8 times greater odds of undergoing reconstruction (P = .05). There were no differences among commonly associated procedures including ulnar nerve surgery (P = .217), elbow arthroscopy (P = .092), and platelet-rich plasma injection (P = .837) with no differences in patient-level charges at any time point (P = .47). Conclusion: While reconstruction remains more common, the annual frequency of UCL repair is increasing at a faster rate. Since were no demographic differences aside from surgical setting, it can be inferred that patients who were previously receiving reconstruction are instead undergoing repair. This highlights the need for future studies to further identify surgical indications for the two interventions.

Blood Flow Restriction Training for the Shoulder: A Case for Proximal Benefit.

BACKGROUND: Although blood flow restriction (BFR) is becoming increasingly popular in physical therapy and athletic training settings, little is known about the effects of BFR combined with low-intensity exercise (LIX) on muscles proximal to the site of occlusion. HYPOTHESIS/PURPOSE: Determine whether LIX combined with BFR applied distally to the shoulder on the brachial region of the arm (BFR-LIX) promotes greater increases in shoulder lean mass, rotator cuff strength, endurance, and acute increases in shoulder muscle activation compared with LIX alone. We hypothesized that BFR-LIX would elicit greater increases in rotator cuff strength, endurance, and muscle mass. We also hypothesized that the application of BFR would increase EMG amplitude in the shoulder muscles during acute exercise. STUDY DESIGN: Controlled laboratory study. METHODS: 32 healthy adults were randomized into 2 groups (BFR group, 13 men, 3 women; No-BFR group, 10 men, 6 women) who performed 8 weeks of shoulder LIX (2 times per week; 4 sets [30/15/15/fatigue]; 20% maximum) using common rotator cuff exercises (cable external rotation [ER], cable internal rotation [IR], dumbbell scaption, and side-lying dumbbell ER). The BFR group also trained with an automated tourniquet placed at the proximal arm (50% occlusion). Regional lean mass (dual-energy x-ray absorptiometry), isometric strength, and muscular endurance (repetitions to fatigue [RTF]; 20% maximum; with and without 50% occlusion) were measured before and after training. Electromyographic amplitude (EMGa) was recorded from target shoulder muscles during endurance testing. A mixed-model analysis of covariance (covaried on baseline measures) was used to detect within-group and between-group differences in primary outcome measures (α = .05). RESULTS: The BFR group had greater increases in lean mass in the arm (mean ± 95% CI: BFR, 175 ± 54 g; No BFR, -17 ± 77 g; P < .01) and shoulder (mean ± 95% CI: BFR, 278 ± 90 g; No BFR, 96 ± 61 g; P < .01), isometric IR strength (mean ± 95% CI: BFR, 2.9 ± 1.3 kg; No BFR, 0.1 ± 1.3 kg; P < .01), single-set RTF volume (repetitions × resistance) for IR (~1.7- to 2.1-fold higher; P < .01), and weekly training volume (weeks 4, 6-8, ~5%-22%; P < .05). Acute occlusion (independent of group or timepoint) yielded increases in EMGa during RTF (~10%-20%; P < .05). CONCLUSION: Combined BFR-LIX may yield greater increases in shoulder and arm lean mass, strength, and muscular endurance compared with fatiguing LIX alone during rotator cuff exercises. These findings may be due, in part, to a greater activation of shoulder muscles while using BFR. CLINICAL RELEVANCE: The present study demonstrates that BFR-LIX may be a suitable candidate for augmenting preventive training or rehabilitation outcomes for the shoulder.