Historically, many causes have been proposed for rotator cuff conditions. The most prevalent theory is that the rotator cuff tendons, especially the supraspinatus, make contact with the acromion and coracoacromial ligament, resulting in pain and eventual tearing of the tendon. However, more recent evidence suggests that this concept does not explain the changes in rotator cuff tendons with age. The role of acromioplasty and coracoacromial ligament release in the treatment of rotator cuff disease has become questioned. Evidence now suggests that tendinopathy associated with aging may be a predominant factor in the development of rotator cuff degeneration. We propose that the overwhelming evidence favors factors other than "impingement" as the major cause of rotator cuff disease and that a paradigm shift in the way the development of rotator cuff pathology is conceptualized allows for a more comprehensive approach to the care of the patient with rotator cuff disease.

Background For hip and knee arthroplasties, an Ameri-

In the evaluation of the painful shoulder, especially in the overhead athlete, diagnosing superior labrum anterior and posterior (SLAP) lesions continues to challenge the clinician because of 1) the lack of specificity of examination tests for SLAP; 2) a paucity of well-controlled studies of those tests; and 3) the presence of coexisting confounding abnormalities. Some evidence indicates that multiple positive tests increase the likelihood that a SLAP lesion is present, but no one physical examination finding conclusively makes that diagnosis. The goals of this article were to review the physical examination techniques for making the diagnosis of SLAP lesions, to evaluate the clinical usefulness of those examinations, and to review the role of magnetic resonance imaging in making the diagnosis.

The shoulder is one of the most complex joints in the human body and, as such, presents an evaluation and diagnostic challenge. The first steps in its evaluation are obtaining an accurate history and physical examination and evaluating conventional radiography. The use of other imaging modalities (eg, ultrasound, magnetic resonance imaging and computed tomography) should be based on the type of additional information needed. The goals of this study were to review the current limitations of evidence-based medicine with regard to shoulder examination and to assess the rationale for and against the use of diagnostic physical examination tests.

A 14-year-old right-hand dominant female lacrosse player presented with a complaint of right shoulder and upper posterior thorax pain of 8 days’ duration. She had been playing lacrosse at the attack wing and midfielder positions and experienced insidious pain after a game. She had no history of trauma to that shoulder during that game and had not experienced an injury in the past. Six days after the pain developed, she woke up one night with a sudden increase in the pain, which brought her to tears and caused slight difficulty with breathing. The pain was located anteriorly just lateral to the right sternoclavicular joint and posteriorly in the paraspinal muscles in the upper thoracic region. Physical examination suggested a first-rib stress fracture, which was subsequently confirmed by chest and shoulder radiographs.