High-intensity stretch treatment for severe postoperative adhesive capsulitis of the shoulder.

BACKGROUND: Some patients with postoperative adhesive capsulitis reach a plateau in their recovery with a standard protocol of physical therapy (PT), which puts them at risk for further surgical intervention. OBJECTIVES: We aimed to evaluate therapy for postoperative adhesive capsulitis of the shoulder in 2 groups of patients: (1) those who used a high-intensity stretch (HIS) device after reaching a plateau in their recovery with a standard protocol of traditional PT (PT+HIS) and (2) those who showed no plateau in their recovery with a standard protocol of traditional PT alone (PT only). METHODS: We retrospectively reviewed the records for 60 patients (51 males; mean age 46.7±12.6years) with postoperative adhesive capsulitis who received treatment between March 2007 and May 2010. Forward elevation and combined internal/external rotation at the initial postoperative visit and final visit were measured. The measurements from group 2 patients were used as an observational benchmark. RESULTS: The PT+HIS (n=42) and PT-only (n=18) patients did not differ in total follow-up time. Initial elevation was worse for PT+HIS than PT-only patients (22.1° lower, P=0.02), but the final elevation was equivalent. Initial rotation was worse for PT+HIS than PT-only patients (16.6° lower, P=0.04), but the final rotation was higher for PT+HIS patients (10.6° higher, P=0.04). Gains in elevation and rotation were greater for the PT+HIS than PT-only patients (P=0.04 and P=0.01). CONCLUSIONS: Patients with postoperative adhesive capsulitis of the shoulder who are unable to reach their PT treatment goals with a standard protocol of PT may benefit from the addition of HIS to their treatment regimen. HIS could be a valuable adjunct to PT for treating postoperative adhesive capsulitis in appropriate patients.

Correlation of preoperative MRI and MRA with arthroscopically proven articular cartilage lesions of the elbow.

OBJECTIVE: The purpose of this study was to evaluate the usefulness of magnetic resonance imaging (MRI) in detecting elbow articular cartilage injuries through comparison of preoperative MRI and magnetic resonance arthrography (MRA) with arthroscopic findings. DESIGN: Retrospective case analysis. SETTING: Tertiary care orthopedic private practice. PATIENTS: Consecutive series of 31 patients presenting with elbow pain and diagnosed at arthroscopy with articular cartilage defects of the elbow. All patients had a preoperative MRI or MRA using a 1.5 T magnet. INTERVENTIONS: Each patient had a systematic elbow arthroscopy, with careful inspection and recording of chondral injuries in 4 anatomical regions: capitellum, radius, trochlea, and ulna. Each MRI/MRA was then independently reviewed by 2 radiologists blinded to the arthroscopic findings. MAIN OUTCOME MEASURES: The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were calculated for MRI and MRI compared with arthroscopy as the gold standard, for each of the anatomical regions. RESULTS: The accuracy of MRI was 45% for chondral injuries of the radius, 65% for the capitellum, 20% for the ulna, and 30% for the trochlea. The accuracy of MRA was 45% for chondral injuries of the radius, 64% for the capitellum, 18% for the ulna, and 27% for the trochlea. CONCLUSION: We conclude that the ability of MRI and MRA using a 1.5 T magnet to detect articular cartilage lesions is limited. Neither MRI nor MRA demonstrates the intraarticular surface as accurately as direct visualization with the arthroscopy. This may be improved with the use of 3 T MRI. CLINICAL RELEVANCE: This study demonstrates that MRI and MRA with a 1.5 T magnet, as used in community practice, have limited ability to detect cartilage lesions of the elbow.

Arthroscopic release of flexor hallucis longus tendon using modified posteromedial and posterolateral portals in the supine position.

BACKGROUND: The flexor hallucis longus (FHL) is a known site of pathological conditions. FHL stenosing tenosynovitis presents as posterior medial ankle pain or great toe discomfort and is often associated with a catching sensation of the great toe. There are a wide variety of open procedures for the treatment of FHL stenosing tenosynovitis. OBJECTIVE: Arthroscopic treatment may circumvent some of the complications associated with open surgical treatment of the hindfoot. METHODS: Arthroscopic surgery was completed in the supine position using modified posteromedial and posterolateral portals. A 70 degrees arthroscope allowed for circumferential evaluation of the ankle through the posterolateral portal including the subtalar areas and the entire FHL tendon for release using basket forceps and a 3.5mm shaver. RESULTS: This method allows for decompression of the FHL from the entrance of the fibro-osseous tunnel to the knot of Henry. Active and passive range of motion of both the ankle and toes was encouraged postoperatively. The patient returned to sporting activity 6 weeks after surgery. CONCLUSIONS: Endoscopic treatment of the FHL stenosing tenosynovitis is presented as an alternative to an open surgical procedure; it may reduce wound complications and may allow for an earlier return to sport.