Shoulderology: Searching for “Whys” Related to the Shoulder

Description:

This Monograph is a compilation of clinical experience and basic research by the author on the function and anatomy of the shoulder joint, with particular emphasis on biomechanics. The book provides deep and comprehensive knowledge about the shoulder based on the author’s over forty years of career. This book is unique in that it emphasizes the process of discovering new knowledge through searching for clinical questions or “whys” and solving them. The author shows how he tackled various problems with a great deal of medical curiosity. The chapters place much space on anatomy, function, and pathology, for correct treatment through an accurate understanding of the pathology.

The first part of this book explains the basic examination methods as clearly as possible, with abundant figures taken during patient consultations. Part two through four describes some diseases of the shoulder joint, including rotator cuff tears, instability, frozen shoulder, biceps disorders, and throwing shoulder, all of which are frequently encountered in daily practice. In part five, biomechanical research related to suture anchors is presented, and correct insertion angles and intervals are described. It is crucial to understand the surgical method correctly and question the commonly used techniques for better patient care. A clear explanation of long-standing debates, such as the deadman theory, is explained based on the evidence from his research. The last part presents two cases that are rarely encountered but are interesting from the perspective of functional reconstruction of the shoulder.

Shoulderology – Searching for “Whys” Related to the Shoulder invites shoulder surgeons, fellows, residents, and medical students to read the thought-provoking collection of evidence and interpretations of the common knowledge. It will be of interest to orthopaedic surgeons specializing in other areas. The author places a strong emphasis on educating young researchers and provides valuable guidance apart from the basic research and clinical practice and hopes that the book will motivate the subsequent generations to pursue further study.

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Preface

I retired from Tohoku University in March 2021 after being an orthopedic surgeon for 40 years and a shoulder surgeon for 34 years. I came across so many people through my career and got a hint from them to answer some of the clinical questions that I had. On my retirement, I was offered an opportunity from Igaku-Shoin to write a monograph summarizing my career. Now that I am retiring from the front line of clinical and research works, I would like to send a message to the next generation and the generation after next. In 2018, Bill Mallon, Editor of J Shoulder Elbow Surg (JSES), asked me to write a short article entitled “What I’ve Learned” to send a message to the young. In this JSES article, I picked up three topics I found interesting to share. In each topic, I found various whys, and after confirming that no studies on the topic had been found in the literature, I performed basic research and clinical studies to find out the answer. This was how I approached my “whys.” In the Introduction of this monograph, these three topics are introduced, showing the importance of searching for whys and the process of solving the clinical questions. In Part I “Shoulder Examination,” I show how I performed physical examinations of the shoulder using many photographs I took during the examinations so that the readers can easily follow the text. In Parts II–IV “Main Shoulder Diseases,” I have selected very common shoulder diseases such as rotator cuff tears, shoulder instability, frozen shoulder, long head of the biceps tendon pathologies, and baseball shoulders. Especially, shoulder instability is the one I found most exciting, and as a result, so many research works have been done. I have tried to systematically construct the contents of these topics in this book. In Part V “Biomechanical Research Related to Suture Anchors,” I show our research studies to clarify the misunderstanding regarding the appropriate insertion angle of a suture anchor and the safe distance between two suture anchors. In Part VI “Rare Cases,” I show two cases, which were rare but quite interesting in terms of restoring the shoulder function. In the Front Matter “Message to the Young,” I have talked about the importance of making friends in and outside of your own country, studying English hard, and keeping on searching for whys. This book is a compilation of my own experience and research works, so it does not cover the whole spectrum of shoulder diseases. The basic philosophy of this book is that it is not the outcome or solution but the process to solve a problem that matters. I hope that the readers enjoy this book and would be persuaded to be involved in various research works. This English edition was published as a co-edition with its original Japanese language edition, Kata Gaku Rinsho No “Naze” to Sono Tsuikyu, first edition, copyright ©2021 by IgakuShoin Ltd., Tokyo, Japan. I would like to thank the staff members of Igaku-Shoin and Springer for their support.
Sendai, Miyagi, Japan Eiji Itoi

Table of contents :
Foreword
Foreword
Preface
Message to the Young
Make Friends in and Outside of Your Country
Importance of English
Always Search for Whys
Acknowledgments
Contents
Chapter 1: Introduction
References
Part I: Shoulder Examination
Chapter 2: Physical Examination of the Shoulder
1 Inspection
2 Palpation
3 Shoulder Motion
4 Muscle Strength
5 Physical Examination of Rotator Cuff Tear Patient
5.1 Pain Induction
5.2 Supraspinatus Tear
5.3 Infraspinatus/Teres Minor Tear
5.4 Subscapularis Tear
6 Physical Examination of Shoulder Instability Patient
6.1 Traumatic Instability
6.2 Multidirectional Instability
References
Part II: Main Shoulder Diseases—Rotator Cuff Tear
Chapter 3: Rotator Cuff Tear
1 Anatomy
2 Function of the Rotator Cuff
3 Epidemiology
4 Mechanism of Tear
4.1 Degeneration of the Tendon
4.2 Stress Concentration
4.3 Impingement Between the Tendon and the Coracoacromial Arch
4.4 Smoking
5 Tear Propagation
6 Muscle Changes with Cuff Tear
6.1 Mechanism of Fatty Change
6.2 Extensibility of the Muscle
7 Pain
8 Diagnosis
8.1 Plain X-rays
8.2 Ultrasonography
8.3 MRI
9 Conservative Treatment
9.1 Pain Relief
9.2 Modalities
9.3 Exercises
10 Surgical Treatment
10.1 Basic Research for Tendon Repair
10.1.1 Tendon Healing
10.1.2 Repair Method
10.2 Indication for Surgical Repair
10.3 Subacromial Decompression
10.4 Repair Technique
10.5 Research on the Position of Postoperative Immobilization
References
Part III: Main Shoulder Diseases—Shoulder Instability
Chapter 4: Stabilizing Mechanisms
1 Anatomy
2 End-Range Stabilizers
3 Mid-Range Stabilizers
3.1 At Rest
3.2 During Motion
References
Chapter 5: Traumatic Dislocation
1 Epidemiology
2 Pathophysiology
2.1 Arm Position at the Time of Dislocation and Location of the Lesion
2.2 Bone Loss
2.2.1 Glenoid Bone Loss
Necessity to Quantify a Bone Loss
Bone Loss and Instability
Mechanism of Instability by a Bone Loss
Critical Bone Loss, Subcritical Bone Loss
2.2.2 Hill–Sachs Lesion
Mechanism of Instability by Hill–Sachs Lesion
How to Assess the Risk of Hill–Sachs Lesion
2.2.3 Risk Assessment of Bipolar Lesion
Dynamic Examination
Glenoid Track: A New Concept
Measurement of Glenoid Track Width
Clinical Application of Glenoid Track
Factors Affecting the Glenoid Track Width
2.2.4 Mechanism of Bone Loss
2.3 Transition to Recurrent Instability
2.4 Healing of Bankart Lesion
3 Diagnosis
3.1 Plain X-rays
3.2 CT
3.3 MRI
4 Treatment
4.1 Position of Immobilization After Reduction
4.1.1 Basic Research
Arm Position and Bankart Reduction
4.1.2 Clinical Studies
Searching for a Better Position
Acceptability of the Brace
4.1.3 Meta-Analysis
4.2 Surgical Treatment
4.2.1 Surgical Indications for First-Time Dislocators
4.2.2 Bankart Repair
Transition of Surgical Procedures
Location of Suture Anchor Insertion
Remove Cartilage or Leave It On
4.3 Management of Bone Loss
4.3.1 Selection of Surgical Procedures
4.3.2 Coracoid Transfer
From Bristow to Latarjet
Stabilizing Mechanism of Latarjet
Capsular Repair in Latarjet
References
Chapter 6: Multidirectional Instability (Loose Shoulder)
1 Pathophysiology
2 Diagnosis
2.1 Physical Findings
2.2 Imaging
2.2.1 Plain X-rays
2.2.2 CT, MRI
3 Treatment
3.1 Conservative Treatment
3.2 Mechanism of Capsular Plication and Its Clinical Outcome
3.3 Pectoralis Major Transfer
3.4 Glenoid Osteotomy
References
Part IV: Main Shoulder Diseases—Others
Chapter 7: Frozen Shoulder
1 Definition and Classification
1.1 Definition
1.2 Classification
2 Pathophysiology
2.1 Rat Knee Contracture Model
2.2 Rat Shoulder Contracture Model [10] 2.3 Specimens from Patients with Frozen Shoulder
2.4 Posture and Blood Circulation of the Shoulder
3 Diagnosis
3.1 Clinical Pictures in Each Phase
3.2 Physical Findings
3.3 Imaging
4 Treatment
4.1 Conservative Treatment
4.1.1 Freezing Phase
4.1.2 Frozen and Thawing Phases
4.1.3 Joint Distension
4.2 Manipulation Under Anesthesia
4.3 Surgical Treatment
References
Chapter 8: Long Head of the Biceps
1 Anatomy and Function
1.1 Anatomy
1.1.1 Widening of the LHB Tendon in Cuff Tear Patients
1.1.2 LHB Tendon and IGHL (Inferior Glenohumeral Ligament)
1.2 Function
1.2.1 Function as a Stabilizer
Stabilizing Function of LHB
Muscle Activity of LHB During Arm Elevation
LHB as a Superior Stabilizer in Cuff Tear Shoulders
1.2.2 Function as a Mover
2 Pathophysiology
2.1 LHB Tendinitis
2.2 Tear of the LHB Tendon
3 Diagnosis
3.1 LHB Tendinitis
3.2 Tear of LHB Tendon
4 Diagnosis
4.1 Arthrography
4.2 MRI
5 Treatment
5.1 LHB Tendinitis
5.2 Tear of the LHB Tendon
References
Chapter 9: Throwing Shoulder
1 Throwing Shoulder and Throwing Motion
1.1 Baseball Pitching and Pitching Phase
1.2 Injuries in Each Pitching Phase
2 Pathophysiology
2.1 Glenohumeral Internal Rotation Deficit (GIRD)
2.1.1 Physiologic GIRD and Pathologic GIRD
2.1.2 Causes of GIRD
2.2 Changes of Humeral Retroversion with Age
2.2.1 Measurement of Retroversion (First to Eighth Graders)
2.2.2 Measurement of Retroversion (First to Sixth Graders)
2.3 Tightness of the Posterior Capsule
2.4 Injury of the Labrum: Traction by the LHB Tendon and Labral Strain
2.5 Pain from the Acromioclavicular Joint
3 Epidemiological Survey
3.1 Shoulder/Elbow Pain and Pain from Other Body Parts
3.2 Shoulder/Elbow Pain and Videogames
3.3 Verbal and Physical Abuse by the Coaches
4 Diagnosis
5 Treatment
5.1 Conservative Treatment
5.1.1 Scapular Dyskinesis
5.1.2 Muscle Strengthening and Stretching
5.2 Surgical Treatment
References
Part V: Biomechanical Research Related to Suture Anchors
Chapter 10: Anchor Insertion Angle: Deadman Theory and Its Interpretation
1 Deadman Theory
2 Discrepancy Between the Theory and Experiments
3 Friction Around the Anchor Affects the Theory
4 Conclusions
References
Chapter 11: Minimal Safe Distance Between Suture Anchors: Relationship Between the Anchor Distance and Pullout Strength
Reference
Part VI: Rare Shoulder Diseases
Chapter 12: Facioscapulohumeral Muscular Dystrophy (FSHD)
1 Facioscapulohumeral Muscular Dystrophy (FSHD)
2 Diagnosis and Treatment
3 Case Presentation
3.1 Surgery
3.2 Post-operative Treatment
References
Chapter 13: Trapezius Paralysis
1 Diagnosis and Treatment
2 Case Presentation
2.1 Surgery
2.2 Post-operative Treatment
References
Index