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An analysis of the efficacy of corticosteroid injections for the treatment of subacromial impingement syndrome
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J. Shoulder Elbow Surg. March/April 1996
Abstracts
T E N D O N H E A L I N G TO C O R T I C A L B O N E V E R S U S A C A N C E L L O U S T R O U G H . Patrick St. Pierre, M D , W e s t Point, NY, Eric J. Olson, M D , James J. Elliott, D V M , K e v i n C. O'Hair, D V M , Lu A n n M c K i n n e y , D V M , N e v e n Popovic, MD, Jack Ryan, MD. This study tests the hypothesis that tendon heals in a biomechanically and histologically superior m a n n e r w h e n attached to a trough in cancellous bone compared w i t h direct fixation to cortical bone. T w e n t y adult female goats u n d e r w e n t bilateral tenotomy of the infraspinatus tendon with subsequent reattachment of the tendon to cortical bone in one shoulder add to a cancellous trough in the other. U s i n g Student's t-test and analysis of variance, the differences between types of repair for all biomechanical outcome measures (load to failure, e n e r g y to failure, and stiffness) at 6- and 12-wk were not significant (p > 0.50). C o m b i n i n g both the 6- and 12-wk data, an average percent difference in load to failure of 3.9% in favor of cancellous repair was observed and was not significant (p = 0.78). Histological analysis at 6- and 12-wk revealed progressive maturation and reorganization of the thin fibrous tissue bone-tendon interface with re-establishment of collagen fiber continuity between the bone and tendon. This process was indistinguishable between cortical and cancellous specimens at both time periods. This study demonstrates no significant benefit from m a k i n g a trough to expose the tendon to cancellous bone; the tendon to bone healing process appears similar and the biomechanical properties are a p p r o x i m a t e l y equal.
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A N A N A L Y S I S OF T H E E F F I C A C Y OF C O R T I C O S T E R O I D I N J E C T I O N S F O R T H E T R E A T M E N T OF SUBACROMIAL IMPINGEMENT SYNDROME. F. Cuomo, MD, B. Blair, MD, A. Rokito, MD, J.D. Z u c k e r man, MD, K. Jarolem, MD. Dept. of Orthopaedic Surg., Hospital for Joint Diseases, N e w York, NY. S u m m a r y Methods and Results: A prospective, controlled, randomized, double-blind clinical study was performed. For inclusion in the study all patients met the following criteria: (I) a diagnosis of i m p i n g e m e n t s y n d r o m e by lidocaine injection test; (2) s y m p t o m s for at least three months, (3) no previous subacromial injection; (4) no evidence of rotator cuff tear. The patients were randomized to receive either 6 cc 1% lidocaine without epinephrine or 1 cc of 10 mg/r Triamcinolone Acetonide with 5 cc 1% lidocaine. At last follow-up only 16% o f the steroid group, compared to 67% o f the control group reported that their pain was moderate or severe. 84% o f patients in the steroid group stated that their pain improved after treatment, 16% said it was unchanged. W i t h i n the control group 36% reported improvement, w h i l e 64% were either unchanged or w o r s e compared to pre-treatment. 74% o f the steroid group had i m p r o v e m e n t of activities of daily l i v i n g compared to 23% of the lidocaine group. W e conclude that the use of subacromial steroid injection is an effective therapy for the treatment of subacromial i m p i n g e m e n t syndrome.
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THE PATTERN OF pAIN PRODUCED BY IRRITATION OF THE A~U JOINT AND THE SUBACROMIAL SPACE RESPECTIVELY. C. Gerber,
MD & R.V. Galantay,MD, Deptof Orthopaedics,n6pital Cantonal,Fribonrg, Switzerland. The characterof painproducedin the a--cjoint and / or in the subaeromial spaceare poorlydescribed,Thisstudywasto analyzethe pain patterngeneratedby selectiveirritationof eitherthe a--cjoint or the subacromialspace. METHOD: 15 injectionsof 0.5 ml of hypartenicsalineinto 12 a-cjoints of 10 healthy male,fullyinformedand consentingvolunteerswereperformed.The pain so generated was documentedand a varietyof clinicaltestswerecarriedout duringthe painfulperiod. Another9 injectionsof 1 to 2 ml of hypartonicsalinewereperformedinto 10 subaeromialspacesof 9 volunteers.All injectionswerecarriedout underfluoroscopic control RESULTS: Therewereno complications of the injections. AC JOINT: All subjectsexperiencedmoderateto severepain in the regionof the a-c j oint and the lateralclavicle. In 12/15 the pain was referredto boththe supraspinatusand trapezinsregions.In 9 casestherewas pain in the anterolateraldeltoid, in 6 casesin the sternoeleidomastoid.Pain was felt in the anterioraspectof the ann (biceps)fourtimes,in the thumb 5 timesand in the radialforearmonce. Palpationof the a-ejoint and of the coracoidwerealwayspainful.The esogsbodytest neveraggravated the pain. The palm-uptestwas painfulin two cases. SUBACROMIALSPACE:Allten injectionsprovokedpain at the anterolateralborderof the aeromion,4 in the anterior,4 in the lateraland 3 in the posteriordeltoid. Painin the arm was observed6 times.Therewas neverpainon palpationof the a-cjoint, at the anteriorneck,in the trapezinsor tricepsregionor over the lateralclavicle. CONCLUSIONS: Irritationof the a-c Joint producespain in the a-cjoint, in the anterolateralneckand in the trapezius- supraspinatusregionverysimilarto neckpain. It may evenbe aggravatedby motionof the cervicalspine.Irritationof the subaeromlal space causesintensepain in the regionof the lateralacromion,in the anterolateralparts of the arm and occasionallyin forearmand fingers.R does not produce pain in the anteriorneck,in the supraspinatusor infraspinatusfossa.The two patternsof pain can be distinguishedclinically.The informationconcerningthe type of pain may be criticalin selectingfurtherdiagnosticstudiesand treatment.
THE EFFECT OF ANTERIOR ACROMIOPLASTY ON ROTATOR CUFF CONTACT: AN EXPERIMENTAL AND COMPUTER SIMULATION. W. W. Colman, R. Kelkar, E. L. Flatow, R. G. Pollock, L. J. Soslowsky, V. C. Mow and L. U. Bigliani. New York, NY. Anterior acromioplasty is a common shoulder procedure, yet little quantitative data exist regarding the optimal location and amount of bone resection necessary for effective reduction of subacromial impingement. Insufficient removal of acromial bone may inadequately reduce pathological tendon compression, while excessive bone excision may compromise the deltoid origin or allow superior migration of the humeral head by reducing the passive buffering effect of the acromion. In this study, we report a new technique for simulating anterior acromioplasty on the computer using experimentally determined glenohumeral kinematics as well as three-dimensional acromion and tendon surface geometry. METHODS: Seven human cadaveric shoulders were abducted in the scapular plane using simulated muscle forces. Six flexible cables, three simulating rotator cuff muscles (infraspinatus and teres minor combined) and three simulating the heads of the deltoid, were attached to six adjustable turnbuckles each in series with a calibrated spring scale. By coordinating the tensile force in each cable the arm was abducted in 30 degree increments. Stereograrns (pairs of convergent photographs) were obtained until maximum elevation was achieved for each specimen. Each joint was abducted in two humeral rotations: 1) SR (Starting Rotation), defined by the amount of external rotation necessary for maximum elevation; and 2) NR (Neutral), defined as 20 degrees internal to SR. Three different acromioplasties were simulated by defining tangent planes at three locations on the acromion: anterior (representing a flattening of the anterior ridge), middle (representing a flattening of the anterior third to the midline) and posterior (representing a flattening of the entire acromion). The subacromial contact patterns in the midrange of motion (e.g., at 60 ~ 90 ~ and 120 ~ before and after the three simulated acromioplasties were obtained and analyzed. RESULTS: Flattening of the anterior ridge removed an average thickness of 1.9 + 0.5 mm of bone. Of the 6 specimens demonstrating impingement, flattening the anterior ridge cont.
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19
J. Shoulder Elbow Surg. March/April 1996
Abstracts
T E N D O N H E A L I N G TO C O R T I C A L B O N E V E R S U S A C A N C E L L O U S T R O U G H . Patrick St. Pierre, M D , W e s t Point, NY, Eric J. Olson, M D , James J. Elliott, D V M , K e v i n C. O'Hair, D V M , Lu A n n M c K i n n e y , D V M , N e v e n Popovic, MD, Jack Ryan, MD. This study tests the hypothesis that tendon heals in a biomechanically and histologically superior m a n n e r w h e n attached to a trough in cancellous bone compared w i t h direct fixation to cortical bone. T w e n t y adult female goats u n d e r w e n t bilateral tenotomy of the infraspinatus tendon with subsequent reattachment of the tendon to cortical bone in one shoulder add to a cancellous trough in the other. U s i n g Student's t-test and analysis of variance, the differences between types of repair for all biomechanical outcome measures (load to failure, e n e r g y to failure, and stiffness) at 6- and 12-wk were not significant (p > 0.50). C o m b i n i n g both the 6- and 12-wk data, an average percent difference in load to failure of 3.9% in favor of cancellous repair was observed and was not significant (p = 0.78). Histological analysis at 6- and 12-wk revealed progressive maturation and reorganization of the thin fibrous tissue bone-tendon interface with re-establishment of collagen fiber continuity between the bone and tendon. This process was indistinguishable between cortical and cancellous specimens at both time periods. This study demonstrates no significant benefit from m a k i n g a trough to expose the tendon to cancellous bone; the tendon to bone healing process appears similar and the biomechanical properties are a p p r o x i m a t e l y equal.
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A N A N A L Y S I S OF T H E E F F I C A C Y OF C O R T I C O S T E R O I D I N J E C T I O N S F O R T H E T R E A T M E N T OF SUBACROMIAL IMPINGEMENT SYNDROME. F. Cuomo, MD, B. Blair, MD, A. Rokito, MD, J.D. Z u c k e r man, MD, K. Jarolem, MD. Dept. of Orthopaedic Surg., Hospital for Joint Diseases, N e w York, NY. S u m m a r y Methods and Results: A prospective, controlled, randomized, double-blind clinical study was performed. For inclusion in the study all patients met the following criteria: (I) a diagnosis of i m p i n g e m e n t s y n d r o m e by lidocaine injection test; (2) s y m p t o m s for at least three months, (3) no previous subacromial injection; (4) no evidence of rotator cuff tear. The patients were randomized to receive either 6 cc 1% lidocaine without epinephrine or 1 cc of 10 mg/r Triamcinolone Acetonide with 5 cc 1% lidocaine. At last follow-up only 16% o f the steroid group, compared to 67% o f the control group reported that their pain was moderate or severe. 84% o f patients in the steroid group stated that their pain improved after treatment, 16% said it was unchanged. W i t h i n the control group 36% reported improvement, w h i l e 64% were either unchanged or w o r s e compared to pre-treatment. 74% o f the steroid group had i m p r o v e m e n t of activities of daily l i v i n g compared to 23% of the lidocaine group. W e conclude that the use of subacromial steroid injection is an effective therapy for the treatment of subacromial i m p i n g e m e n t syndrome.
2]
THE PATTERN OF pAIN PRODUCED BY IRRITATION OF THE A~U JOINT AND THE SUBACROMIAL SPACE RESPECTIVELY. C. Gerber,
MD & R.V. Galantay,MD, Deptof Orthopaedics,n6pital Cantonal,Fribonrg, Switzerland. The characterof painproducedin the a--cjoint and / or in the subaeromial spaceare poorlydescribed,Thisstudywasto analyzethe pain patterngeneratedby selectiveirritationof eitherthe a--cjoint or the subacromialspace. METHOD: 15 injectionsof 0.5 ml of hypartenicsalineinto 12 a-cjoints of 10 healthy male,fullyinformedand consentingvolunteerswereperformed.The pain so generated was documentedand a varietyof clinicaltestswerecarriedout duringthe painfulperiod. Another9 injectionsof 1 to 2 ml of hypartonicsalinewereperformedinto 10 subaeromialspacesof 9 volunteers.All injectionswerecarriedout underfluoroscopic control RESULTS: Therewereno complications of the injections. AC JOINT: All subjectsexperiencedmoderateto severepain in the regionof the a-c j oint and the lateralclavicle. In 12/15 the pain was referredto boththe supraspinatusand trapezinsregions.In 9 casestherewas pain in the anterolateraldeltoid, in 6 casesin the sternoeleidomastoid.Pain was felt in the anterioraspectof the ann (biceps)fourtimes,in the thumb 5 timesand in the radialforearmonce. Palpationof the a-ejoint and of the coracoidwerealwayspainful.The esogsbodytest neveraggravated the pain. The palm-uptestwas painfulin two cases. SUBACROMIALSPACE:Allten injectionsprovokedpain at the anterolateralborderof the aeromion,4 in the anterior,4 in the lateraland 3 in the posteriordeltoid. Painin the arm was observed6 times.Therewas neverpainon palpationof the a-cjoint, at the anteriorneck,in the trapezinsor tricepsregionor over the lateralclavicle. CONCLUSIONS: Irritationof the a-c Joint producespain in the a-cjoint, in the anterolateralneckand in the trapezius- supraspinatusregionverysimilarto neckpain. It may evenbe aggravatedby motionof the cervicalspine.Irritationof the subaeromlal space causesintensepain in the regionof the lateralacromion,in the anterolateralparts of the arm and occasionallyin forearmand fingers.R does not produce pain in the anteriorneck,in the supraspinatusor infraspinatusfossa.The two patternsof pain can be distinguishedclinically.The informationconcerningthe type of pain may be criticalin selectingfurtherdiagnosticstudiesand treatment.
THE EFFECT OF ANTERIOR ACROMIOPLASTY ON ROTATOR CUFF CONTACT: AN EXPERIMENTAL AND COMPUTER SIMULATION. W. W. Colman, R. Kelkar, E. L. Flatow, R. G. Pollock, L. J. Soslowsky, V. C. Mow and L. U. Bigliani. New York, NY. Anterior acromioplasty is a common shoulder procedure, yet little quantitative data exist regarding the optimal location and amount of bone resection necessary for effective reduction of subacromial impingement. Insufficient removal of acromial bone may inadequately reduce pathological tendon compression, while excessive bone excision may compromise the deltoid origin or allow superior migration of the humeral head by reducing the passive buffering effect of the acromion. In this study, we report a new technique for simulating anterior acromioplasty on the computer using experimentally determined glenohumeral kinematics as well as three-dimensional acromion and tendon surface geometry. METHODS: Seven human cadaveric shoulders were abducted in the scapular plane using simulated muscle forces. Six flexible cables, three simulating rotator cuff muscles (infraspinatus and teres minor combined) and three simulating the heads of the deltoid, were attached to six adjustable turnbuckles each in series with a calibrated spring scale. By coordinating the tensile force in each cable the arm was abducted in 30 degree increments. Stereograrns (pairs of convergent photographs) were obtained until maximum elevation was achieved for each specimen. Each joint was abducted in two humeral rotations: 1) SR (Starting Rotation), defined by the amount of external rotation necessary for maximum elevation; and 2) NR (Neutral), defined as 20 degrees internal to SR. Three different acromioplasties were simulated by defining tangent planes at three locations on the acromion: anterior (representing a flattening of the anterior ridge), middle (representing a flattening of the anterior third to the midline) and posterior (representing a flattening of the entire acromion). The subacromial contact patterns in the midrange of motion (e.g., at 60 ~ 90 ~ and 120 ~ before and after the three simulated acromioplasties were obtained and analyzed. RESULTS: Flattening of the anterior ridge removed an average thickness of 1.9 + 0.5 mm of bone. Of the 6 specimens demonstrating impingement, flattening the anterior ridge cont.