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Background:Active-assistive range of motion exercises to gain shoulder elevation have been subdivided into gravity-minimized and upright-assisted exercises, yet no study has evaluated differences in muscular demands.Hypothesis:Compared with gravity-minimized exercises, upright-assisted exercises will generate larger electromyographic (EMG) activity. Compared with all active-assistive exercises, upright active forward elevation will generate more EMG activity.Study design:Controlled laboratory study.Methods:Fifteen healthy individuals participated in this study. The supraspinatus, infraspinatus, and anterior deltoid were evaluated. The independent variables were 11 exercises performed in random order. The dependent variable was the maximum EMG amplitude of each muscle that was normalized to a maximal voluntary isometric contraction (MVIC).Results:Each muscle demonstrated significant differences between exercises ( P < .001), with upright active forward elevation producing the greatest EMG for all muscles (95% confidence interval [CI], 12% to 50% MVIC). The orders of exercise varied by muscle, but the 5 gravity-minimized exercises always generated the lowest EMG activity. The upright-assisted exercises (95% CI, 23% to 42% MVIC) for the anterior deltoid generated more EMG activity than did the gravity-minimized exercises (95% CI, 9% to 21% MVIC) ( P < .05). The infraspinatus and supraspinatus demonstrated increasing trends in EMG activity from gravity minimized to upright assisted ( P > .05).Conclusion:The results suggest a clear distinction between gravity-minimized exercises and upright-assisted exercises for the anterior deltoid but not for the supraspinatus and infraspinatus. Between the 2 types of assisted exercises, the results also suggest a clear distinction in terms of active elevation of the arm for the supraspinatus and anterior deltoid but not for the infraspinatus.Clinical Relevance:Muscle activation levels increase as support is removed, but subdivision of active-assistive range of motion to protect the supraspinatus and infraspinatus may not be necessary.

This manuscript describes the consensus rehabilitation guideline developed by the American Society of Shoulder and Elbow Therapists. The purpose of this guideline is to facilitate clinical decision making during the rehabilitation of patients following arthroscopic anterior capsulolabral repair of the shoulder. This guideline is centered on the principle of the gradual application of stress to the healing capsulolabral repair through appropriate integration of range of motion, strengthening, and shoulder girdle stabilization exercises during rehabilitation and daily activities. Components of this guideline include a 0- to 4-week period of absolute immobilization, a staged recovery of full range of motion over a 3-month period, a strengthening progression beginning at postoperative week 6, and a functional progression for return to athletic or demanding work activities between postoperative months 4 and 6. This document represents the first consensus rehabilitation guideline developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients following arthroscopic anterior capsulolabral repair of the shoulder.

Since the 17th century, the long head of the biceps tendon as a source of shoulder pain and its functional significance has been a source of debate. Although the term tendinitis is commonly used, overuse tendon injuries infrequently demonstrate inflammatory cells; instead, degenerative changes resulting from the failure of self-repair usually are found. Bicipital tendinitis or bicipital tenosynovitis is most often secondary to impingement beneath the coracoacromical arch. Primary bicipital tendinitis and tendinitis secondary to instability are possible, however. Through a careful history, physical examination, and appropriate imaging studies, the clinician can establish the diagnosis of disorders of the biceps tendon Arthroscopic evaluation greatly improves the diagnosis and treatment of biceps tendon and related shoulder pathology. Although the exact functional role of the biceps tendon remains incompletely defined, a growing body of evidence supports its role as a stabilizer of the glenohumeral joint. This stabilizing function should be incorporated into the treatment of biceps tendon disorders. Routine tenodesis has been replaced by a more individualized approach, taking into consideration physiologic age, activity level, expectations, and exact shoulder pathology present. New repair techniques are under development, and preservation of the biceps-labral complex is now preferred when possible.

The Bridle procedure is a tritendon anastomosis between the posterior tibialis, anterior tibialis, and peroneus longus, combined with an Achilles tendon lengthening for treating equinus and equinovarus deformities. The technique avoids problems of tendon attachment to bone and tendon placement for balance. One hundred seven procedures were performed on patients with cerebral palsy with 74% excellent and good results overall. The average follow-up was 5 years 9 months. The procedure was also performed with mixed results, on smaller groups of patients with other neuromuscular diseases.

Open shoulder procedures require a deltoid release for proper exposure. Arthroscopic techniques have progressed so that minimally invasive techniques give similar outcomes as more formal open procedures with less risk of morbidity. Arthroscopically assisted open rotator cuff repair offers advantages over open procedures with some diagnostic and decompression performed with the arthroscope. The mini-open technique has more aspects of a cuff repair performed through the arthroscope leaving a few steps to be done open. The modern use of arthroscopic techniques for minimally invasive rotator cuff surgery coupled with advances in rehabilitation is discussed.

In the late 1980s and early 1990s, several advances in arthroscopic shoulder stabilization procedures were made. However, these early techniques were associated with higher failure rates compared with the traditional open procedures and therefore were not widely disseminated throughout the orthopaedic community. Because of improved understanding in anatomy and pathology in conjunction with dramatic technologic advances, the past decade has demonstrated significant improvement in the arthroscopic management of the unstable shoulder Evolution of arthroscopic techniques over the past 5 years to more closely resemble open procedures has led to clinical outcomes previously seen only with open procedures. Arthroscopy is becoming an attractive treatment option for an increasing number of orthopaedic surgeons.

Superior labral lesions and internal impingement are believed to be the primary cause of shoulder pathology in the overhead athlete, particularly the baseball player. Increased shoulder external rotation can lead to repetitive impingement of the rotator cuff and superior labrum resulting in a superior labrum anterior and posterior lesion and partial articular-sided rotator cuff tearing. Although the etiology for this phenomenon remains controversial, the end result remains the same: pathology in the rotator cuff and superior labrum. Isolated treatment of the pathology alone, without addressing the capsular laxity, results in lower return to play rates. Addressing the capsular laxity arthroscopically at the same time as the intra-articular pathology is necessary to give these athletes the best chance to return to their prior competitive level. Although short-term results are promising, long-term follow-up is necessary to determine the ultimate usefulness of this treatment philosophy.

Surgical intervention for medial or lateral epicondylitis is only indicated when the physician is sure that the correct diagnosis has been made and the patient has not improved after an adequate nonoperative treatment program. Following the previously outlined surgical techniques gives the best likelihood of successful operative results. However, we cannot overemphasize the point that, with a proper course of rest, immobilization, medication, and physical therapy exercises and modalities, only 10% of patients, or fewer, should require surgical intervention.

The clinical records were reviewed of 142 men and 7 women (average age 26.8 years; range, 15 to 58 years) who had surgical reconstruction for anteromedial rotatory instability of the knee. All were treated consecutively at the same clinic during a 15- year period (1960 to 1975). Preoperative and postoperative symptoms were rated both subjectively and objectively by de vised scales and analyzed by a computer program. Comparison of the three major surgical procedures show that the subjective success rate was 87% for the pes anserinus transfer, 70% for the posterior oblique ligament reconstruction, and 72% for the combination procedure. Of the 149 patients, 130 had been injured in sportive activities and 110 were able to return to some degree of athletics. Accurate and detailed recording of clinical data allowed construction of subjective and objective rating systems for computer analysis in review of a large series over a period of years. This approach enhanced our ability to obtain correlation and objective evaluation of the data. Com mercial equipment for evaluating the quadriceps and ham- strings is beneficial in determining that a patient has achieved complete rehabilitation or if there will be a permanent decrease in function after surgical intervention.

Ankles are sprained when supported on an unstable foundation, while too rididly fixed to the playing surface, or when forced into unnatural positions by extrinsic muscle tightness. The unstable foundation may be the shoe itself, a chuck-hole, or another player's foot. Undue fixation may be by 1-inch mud cleats, baseball spikes, or a modern wrestling mat. When these circumstances occur, heel cord tightness may alter the ankle's response. Thus, prevention of ankle sprains may be by modification of any of these factors.

How to classify knee ligament instabilities continues to present problems when clinicians try to interpret literature on this subject.1,2 Personal communications with a number of associates (Hughston, Andrews, Norwood, Walsh, 1980) help confirm this finding. It is difficult for the surgeon to explain his clinical or surgical findings or for the physical therapist to design a proper rehabilitation program for a specific diagnosis unless they use the same standards and terminology in classifying the injury or reporting the surgical procedures. Anatomical terminology, especially for functional anatomy, deserves special consideration when discussing the knee. This article presents a system for classifying knee ligament instability, as developed by the Hughston Orthopaedic Clinic in Columbus, Georgia. The basic consideration in this classification is the status of the posterior cruciate ligament after injury.1 If the posterior cruciate ligament is intact, the patient may have anteromedial, anterolateral, posterolateral, or combined rotatory instability.…

Five baseball pitchers, three college and two profes sional, with an average age of 24 years, exhibited pain between the acceleration phase and follow- through phase of the pitching motion. This caused the players to be unable to continue at the level of com petition necessary to play. A significant osteophyte on the posteromedial aspect of the olecranon process was identified in all pitchers. This caused impingement with the articular wall of the olecranon fossa and often created an area of chondromalacia. The more com monly identified posterior osteophyte was present in all cases. However, if just this posterior osteophyte is removed, the described lesion will be missed, with resultant persistent disability. Surgical excision of the posteromedial osteophyte through a relatively atraumatic posterolateral ap proach allowed early return of function without mor bidity. With an average follow up of 1 year, all of the pitchers returned for one full season at maximum effectiveness.