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The incidence of primary and secondary bicipital tendinitis remains unknown. In our prospective study, 200 consecutive shoulders underwent arthroscopic subacromial decompression for impingement syndrome. A biceps tenodesis was performed in 80 shoulders (40%) featuring macroscopic degeneration of the long head of the biceps; rotator cuff tears were apparent in 91% of these shoulders, the mean patient age being 55 years. In each of 120 shoulders (60%), an extraarticular tenosynovectomy was performed, and histopathologic studies revealed chronic inflammation in 63% and fibrotic degeneration in 13% of the specimens; rotator cuff tears were evident in 70% (23% full thickness) of these cases, the mean patient age being 47 years. In addition, when glenohumeral arthritis was present, it was uniformly associated with pathologic biceps tenosynovium. In summary, the high incidence of chronic inflammation of the long head of the biceps in shoulders with benign-appearing intraarticular portions viewed arthroscopically is significant, and long head of the biceps disease should also be considered in patients with painful rotator cuff disease and arthritic shoulder conditions.

Twelve patients who had recurrent instability of the shoulder with onset after age 40 were reviewed. Eleven had anterior instability, and one had a posterior dislocation. The average age of the patients was 62.7 years. Symptoms began soon after initial injury. All patients with anterior instability had ruptured the subscapularis and anterior capsule from the lesser tuberosity, whereas the posterior dislocator had torn the infraspinatus and upper teres minor with the posterior capsule from the greater tuberosity. No patient had a Bankart lesion. Stability was restored in all cases by reattaching the ruptured tendons and capsule to the tuberosities. Follow-up was from 2 to 13 years. One patient required a reoperation. All patients now have a stable shoulder. Recurrent instability of the shoulder after age 40 can be caused by rotator cuff and capsular rupture from the tuberosities without additional significant injury to the ligamentolabral complex. In such cases, repairing the torn structures is sufficient to restore stability.

The size and location of intratendinous and joint side rotator cuff tears can be diagnosed by a technique known as positional arthrography. The site and extent of the tears diagnosed preoperatively by this technique correlated well with intraoperative findings in a study group of 200 patients who underwent a combined arthroscopic and open procedure to localize, identify, and repair incomplete rotator cuff tears.

Thirty-seven patients older than 40 years of age were seen after sustaining primary anterior dislocations of the shoulder. An associated rupture of the rotator cuff in each patient had been missed, often being mistaken for an axillary neuropathy. Eleven of these patients developed recurrent anterior instability that was due to rupture of the subscapularis and anterior capsule from the lesser tuberosity. In no patient was there a Bankart lesion. Repair of the capsule and subscapularis restored stability in all of the patients with recurrence.

Recurrent anterior unidirectional instability of the shoulder is not always associated with a classic Bankart lesion, which is an avulsion of the anterior labroligamentous structures from the anterior glenoid rim. Because the anterior scapular periosteum ruptures, the labrum and the attached ligaments are found to float out anterior to the glenoid rim when viewed arthroscopically. The anterior labroligamentous periosteal sleeve avulsion (ALPSA) of the supporting anterior inferior ligamentous and labral structures of the shoulder joint was found in four of eight acute primary anterior shoulder dislocations. This lesion differs from the Bankart lesion because the anterior scapular periosteum does not rupture, thereby allowing the labroligamentous structures to displace medially and rotate inferiorly on the scapular neck. These lesions eventually heal, and lead to recurrent anterior dislocations because of the subsequent incompetence of the anterior inferior glenohumeral ligament. An arthroscopic technique that converts the ALPSA lesion to a Bankart lesion and subsequently reconstructs the supporting anterior inferior structures of the shoulder has been successful in 26 cases (4 acute and 22 chronic) which were followed for > or = 2 years. Only one dislocation occurred, and it was the result of severe trauma.

A GLAD (glenolabral articular disruption) lesion is caused by a forced adduction injury to the shoulder from an abducted and external rotated position; patients with GLAD lesions present with anterior shoulder pain as their chief complaint. No signs of anterior instability are found on physical examination or at surgery. All cases are relieved of anterior shoulder pain by lidocaine injection intraarticularly during the arthrographic examination, but arthrographic examinations are normal. At surgery, a superficial anterior inferior labral tear has been identified in all cases associated with an anterior inferior glenoid articular cartilage injury. Arthroscopic debridement of the labral tear with glenoid articular chondroplasty or abrasion arthroplasty is the treatment of choice. All symptoms were eliminated within 3 months after the surgical debridement in all cases.

Fifty patients who underwent reoperation for failure of previous repair of rotator cuff rupture were evaluated 24 to 84 months after final repair (mean 30 months). Forty-eight of these patients had undergone all previous attempts at repair elsewhere. Most patients had had one or two earlier attempts, but four patients had had three, and three patients had had four. Forty-six (92%) patients reported pain improvement, and four were unchanged. Twenty-six patients showed an average increase in elevation of 50° (range 10° to 130°). Twenty-two retained their preoperative motion, and two lost motion (mean 45°) but still had more than 90°. Overall mean elevation increased from 92° to 137°. Compared with 17 patients before surgery, only six had less than 90° motion after surgery-and all six had deltoid abnormalities. The size of the rupture, the number of previous operations, and dysfunction of the biceps did not affect the result. The following factors were associated with success: adequate decompression, closure of all defects with tendon-to-bone junctures (by direct repair, interpositional grafting, or local tendon transfers), avoiding use of weights or resistive exercises during the early (first 3 months) postoperative rehabilitation period, and an intact, functioning deltoid., (Copyright © 1993 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

The weight lifter's desire to achieve higher limits of performance coupled with the rotator cuff's unfavorable position during lifting often leads to shoulder injury. Proper lifting techniques and training habits could reduce the risk of injury. When chronic symptoms occur, however, arthroscopy can help diagnose the injury, and arthroscopic procedures for injuries such as rotator cuff chronic tendinitis and incomplete tears, and biceps tenosynovitis can be performed.

The combined interaction of four elements produces lesions of the rotator cuff, commonly known as impingement. The elements are: vascular, degenerative, traumatic, and mechanical or anatomic factors. The elements are interrelated, and each affects the tendons in a manner that contributes to tendon weakening. It is unlikely that any one element is solely responsible for cuff lesions; the nature of each lesion is determined by the factors that predominate in that individual case. The net result is degeneration of the tendons.

The painful arc syndrome of the shoulder is a manifestation of rotator cuff tendinitis associated with tenosynovitis of the long head of the biceps under and just distal to the transverse humeral ligament. Eighty-nine patients with clinical signs of the painful arc syndrome were proven to have an associated biceps tenosynovitis by arthrography and at surgical treatment. The four-in-one arthroplasty consists of: (1) excision of the coracoacromial ligament; (2) acromioclavicular arthroplasty; (3) excision of the anterior inferior area of the acromion process; and (4) transfer and tenodesis of the long head of the biceps. The operation decompresses the acromial arch and also eliminates the biceps tenosynovitis by tenodesis. Almost invariably, there was relief of pain within four to five months of postoperative rehabilitation, and at an average follow-up of two to eight years.

Arthrography of the shoulder is a most effective diagnostic tool in evaluating the shoulder joint. The technique is easily mastered with practice. A knowledge of shoulder anatomy is imperative in order to fully understand the normal as well as abnormal shoulder arthrogram.

Thirty-one patients who were unable to abduct the involved arm after reduction of a primary anterior dislocation of the glenohumeral joint were found to have a ruptured rotator cuff. All of the patients were more than thirty-five years old. Twenty-nine of them were initially presumed to have had an injury to the axillary nerve, although this injury was confirmed in only four of the twenty patients who had electrodiagnostic studies. In eight patients, the subscapularis tendon and anterior part of the capsule had ruptured from the lesser tuberosity. Recurrent instability developed in all eight patients, and repair of these structures alone was successful in restoring stability. The association between primary anterior dislocation of the glenohumeral joint and rupture of the rotator cuff in the older patient who cannot abduct the arm after reduction is poorly appreciated, as it is often missed. In our series of such patients, the incidence of injury to the axillary nerve was 7.8 per cent, as compared with 100 per cent for rupture of the rotator cuff. However, the comparative rates of occurrence of these two entities in older patients who have an anterior dislocation have not been determined.

The procedure for diagnostic shoulder arthroscopy and proper positioning of operative portals are discussed. The superior medial portal approach to the shoulder is described. Conditions visualized by arthroscopy include the following: glenoid labrum tears, synovitis, loose bodies, instabilities, adhesive capsulitis, rotator cuff lesions, and extra-articular decompressions.

The signs and symptoms of adhesive capsulitis are reviewed. It is clear that this is a specific disease process distinct from those cases of "frozen shoulder." Four specific stages of the disease have been visualized at arthroscopy prior to manipulation. Stage 1 of adhesive capsulitis mimics the impingement syndrome of the shoulder.

A simple, effective technique for internal fixation of the clavicle with Knowles threaded pins is described in 11 patients with 1 to 21 year results. The method is applicable to fresh fractures of non-union and provides secure compression-fixation. The threads prevent migration of the pin, reduce the period of external immobilization, and obviate the need for removal of the pin.

In sixteen patients with massive tears of the rotator cuff of the shoulder, bridging of the defect with a freeze-dried graft of a rotator cuff from a cadaver produced a satisfactory repair in all cases. A good or excellent functional result was obtained in all but two patients, with a definite decrease or absence of nocturnal pain in all sixteen. The operative technique includes avoidance of a complete acromionectomy and an adequate suture of the deltoid muscle to the acromion after an acromioplasty.

Intra-articular disease processes of the shoulder are uncommon. Of all the processes, adhesive capsulitis is by far the most prevalent. Stage 1 of adhesive capsulitis mimics the impingement syndrome and must be ruled out by arthroscopy before decompression is performed. Other rare conditions of the shoulder joint, such as pigmented villonodular synovitis and synovial chondromatosis, can be treated with the same surgical techniques.

The differentiation between the stiff and painful shoulder without any joint capsule involvement and with capsule involvement (true adhesive capsulitis) must be established before a rational treatment can be prescribed. Arthrography establishes the correct diagnosis of adhesive capsulitis. Treatment of the stiff and painful shoulder is through prevention and exercise. The treatment of adhesive capsulitis includes prevention, exercises, manipulation, and capsulotomy. Each treatment method is determined by specific criteria. Arthroscopy is not useful for either diagnosis or treatment of adhesive capsulitis but may be useful for recognition of the four stages of the disease.

The role of the biceps tendon in the impingement syndrome is discussed. The anterior superior approach to the shoulder is presented and encouraged to be used in order to obtain excellent visualization of the entire rotator cuff and biceps tendon without postoperative deltoid detachment.