In symptomatic subjects, the reliability of tests for shoulder joint range of motion has yet to be determined. For this reason, inter-rater and intra-rater agreement trials were undertaken to ascertain the reliability of visual estimation, goniometry, still photography, "stand and reach" and hand behind back reach for six different shoulder movements. Intra-class correlation coefficients (Rho) were derived by using a random effects model. For flexion, abduction and external rotation fair to good reliability was demonstrated for both trials using visual estimation (Inter-rater Rho = 0.57-0.70; Intra-rater Rho = 0.59-0.67), goniometry (Inter-rater Rho = 0.64-0.69; Intra-rater Rho = 0.53-0.65) and still photography (Inter-rater Rho = 0.62-0.73; Intra-rater Rho = 0.56-0.61). The tests had standard errors of measurement of between 14 and 25 degrees (inter-rater trial) and 11 and 23 degrees (intra-rater trial).

No abstract

Lead aspartate is a new en bloc stain for electron microscopy. Its predictable staining depends on chelation that results from the interaction of the two stain components, lead nitrate and aspartic acid, which must be present in a specific ratio. Lead aspartate stain is 0.02 M in lead nitrate and 0.03 M in aspartic acid, adjusted to pH 5.5. Cells or tissues are stained at 60#{176}C for 30 to 60 mm. Cells stained en bloc with lead aspartate closely resemble cells stained on grids by lead citrate, except that the former seldom have contamination. En bloc staining with lead aspartate bypasses the grid-staining step so that samples can be viewed and photographed immediately after they are thin-sectioned. The lower pH of the lead aspartate solution allows counterstaining of enzyme reaction products that dissolve in the highly alkaline .8 Walton, unpublished results. LITERATURE CITED 2. Goldfischer S: The cytochemical demonstration of lysosomal aryl sulfatase activity by light and electron microscopy.

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Background: This prospective study was performed to determine which clinical and imaging tests were most helpful for diagnosing acromioclavicular joint pain. Methods: Of 1037 patients with shoulder pain, 113 who mapped pain within an area bounded by the midpart of the clavicle and the deltoid insertion were eligible for inclusion in the study. Forty-two subjects agreed to participate, and four of them were lost to follow-up. Twenty clinical tests, radiography, bone-scanning, magnetic resonance imaging, and an acromioclavicular joint injection test were performed on all patients. The patients were divided into two groups according to whether they had a ≥50% decrease in pain following the acromioclavicular joint injection. Statistical analysis, including multivariate regression analysis, was performed in order to evaluate the diagnostic effectiveness of the various tests. Results: Acromioclavicular joint pain was confirmed in twenty-eight of the thirty-eight patients. The most sensitive tests were examination for acromioclavicular tenderness (96% sensitivity), the Paxinos test (79%), magnetic resonance imaging (85%), and bone-scanning (82%), but these studies had low specificity. In the stepwise regression model, with the response to the injection used as the dependent variable, bone-scanning and the Paxinos test were the only independent variables retained. Patients with a positive Paxinos test as well as a positive bone scan had high post-test odds (55:1) and a 99% post-test probability of having pain due to pathological changes in the acromioclavicular joint. The likelihood ratio for patients with one negative test and one positive test was indeterminate (0.4:1). Patients with both a negative Paxinos test and a negative bone scan had a likelihood ratio of 0.03:1 for having acromioclavicular joint pain, which basically rules out the disorder. Conclusions: The highly sensitive tests had low specificity, and the highly specific tests had low sensitivity. However, the combination of a positive Paxinos test and a positive bone scan predicted damage to the acromioclavicular joint as the cause of shoulder pain with a high degree of confidence. Level of Evidence: Diagnostic study, Level I-1 (testing of previously developed diagnostic criteria in series of consecutive patients [with universally applied reference "gold" standard]). See Instructions to Authors for a complete description of levels of evidence.

No abstract

Shoulder dislocation and subluxation occurs frequently in athletes with peaks in the second and sixth decades. The majority (98%) of traumatic dislocations are in the anterior direction. The most frequent complication of shoulder dislocation is recurrence, a complication that occurs much more frequently in the adolescent population. The static (predominantly capsuloligamentous and labral) and dynamic (neuromuscular) restraints to shoulder instability are now well defined. Rehabilitation aims to enhance the dynamic muscular and proprioceptive restraints to shoulder instability. This paper reviews the nonoperative treatment and the postoperative management of patients with various classifications of shoulder instability.

The optimal form of rehabilitation after rotator cuff repair has yet to be determined. A randomised clinical trial was undertaken to compare outcomes for two forms of rehabilitation for this condition: individualised supervised physiotherapy treatment, and a standardised unsupervised home exercise regime. Fifty-eight volunteers with all sizes of operatively repaired rotator cuff tears were allocated randomly to one of the two treatment groups. All subjects received a standardised home exercise regime. Subjects who were randomised to the physiotherapy group received additional individualised treatment. Independent, blinded assessments of range of motion, muscle force and functional outcome measures were performed pre-operatively, and at six, 12 and 24 weeks postoperation. At six, 12 and 24 weeks post-operation, comparable outcomes were demonstrated for both rehabilitation groups. By 24 weeks post-operation, most subjects demonstrated outcomes that were consistent with a favourable recovery, regardless of rehabilitation mode. On the basis of these results, outcomes for subjects allocated to individualised physiotherapy treatment after rotator cuff repair are no better than for subjects allocated to a standardised home exercise regime.