Immobilization in external rotation does not reduce the rate of recurrence for patients with first-time traumatic anterior shoulder dislocation.

There are few previous studies on the incidence of shoulder dislocation in the general population. The aim of the study was to report the incidence of acute shoulder dislocations in the capital of Norway (Oslo) in 2009. Patients of all ages living in Oslo, sustaining a dislocation of the glenohumeral joint, were identified using electronic diagnosis registers, patient protocols, radiological registers of the hospitals, and the Norwegian Patient Register (NPR). The overall incidence rate was 56.3 [95% confidence interval (CI) 50.2–62.4] per 100 000 person-years, with rates of 82.2 (95% CI 71.7–92.8) and 30.9 (95% CI 24.5–37.3) in men and women, respectively. The incidence of primary dislocations was 26.2 (95% CI 22.1–30.4). The overall incidence of shoulder dislocations in Oslo was higher than previously reported incidences. The incidence of primary dislocations was also higher than that in previously reported studies for the general population but it was close to the incidence reported in Malmø, Sweden.

BackgroundHaving an estimate of the measurement error of self-report questionnaires is important both for assessing follow-up results after treatment and when planning intervention studies. Specific questionnaires have been evaluated for patients with shoulder instability, but not in particular for patients with SLAP (superior labral anterior posterior) lesions or recurrent dislocations. The aim of this study was to evaluate the agreement, reliability, and validity of two commonly questionnaires developed for patients with shoulder instability and a generic questionnaire in patients with SLAP lesions or recurrent anterior shoulder dislocations.MethodsSeventy-one patients were included, 33 had recurrent anterior dislocations and 38 had a SLAP lesion. The patients filled in the questionnaires twice at the same time of the day (± 2 hours) with a one week interval between administrations. We tested the Oxford Instability Shoulder Score (OISS) (range 12 to 60), the Western Ontario Shoulder Instability Index (WOSI) (0 to 2100), and the EuroQol: EQ-5D (−0.5 to 1.0) and EQ-VAS (0 to 100). Hypotheses were defined to test validity.ResultsICC ranged from 0.89 (95% CI 0.83 to 0.93) to 0.92 (0.87 to 0.95) for OISS, WOSI, and EQ-VAS and was 0.66 (0.50 to 0.77) for EQ-5D. The limits of agreement for the scores were: -7.8 to 8.4 for OISS; -339.9 to 344.8 for WOSI; -0.4 to 0.4 for EQ-5D; and −17.2 and 16.2 for EQ-VAS. All questionnaires reflect the construct that was measured. The correlation between WOSI and OISS was 0.73 and ranged from 0.49 to 0.54 between the shoulder questionnaires and the generic questionnaires. The divergent validity was acceptable, convergent validity failed, and known group validity was acceptable only for OISS.ConclusionMeasurement errors and limitations in validity should be considered when change scores of OISS and WOSI are interpreted in patients with SLAP lesions or recurrent shoulder dislocations. EQ-5D is not recommended as a single outcome.

Background: Exercise for patellofemoral pain (PFP) is traditionally knee focused, targeting quadriceps muscles. In recent years, hip-focused exercise has gained popularity. Patient education is likely an important factor but is underresearched. Purpose: To compare 3 treatment methods for PFP, each combined with patient education: hip-focused exercise, knee-focused exercise, or free physical activity. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A single-blind randomized controlled trial was performed with 112 patients who were 16 to 40 years old (mean, 27.6 years) and had a symptom duration >3 months (mean, 39 months) with a clinical diagnosis of PFP and no radiograph or magnetic resonance evidence of other pathology. Patients were randomized to a 6-week intervention consisting of patient education combined with isolated hip-focused exercise (n = 39), traditional knee-focused exercise (n = 37), or free physical activity (n = 36). The primary outcome was Anterior Knee Pain Scale (0-100) at 3 months. Secondary outcomes were visual analog scale for pain, Tampa Scale for Kinesiophobia, Knee Self-efficacy Scale, EuroQol, step-down, and isometric strength. Results: There were no between-group differences in any primary or secondary outcomes at 3 months except for hip abduction strength and knee extension strength. Between-group differences at 3 months for Anterior Knee Pain Scale were as follows: knee versus control, 0.2 (95% CI, –5.5 to 6.0); hip versus control, 1.0 (95% CI, –4.6 to 6.6); and hip versus knee, 0.8 (95% CI, –4.8 to 6.4). The whole cohort of patients improved for all outcomes at 3 months except for knee extension strength. Conclusion: The authors found no difference in short-term effectiveness in combining patient education with knee-focused exercise, hip-focused exercise, or free training for patients with PFP. Registration: NCT02114294 (ClinicalTrials.gov identifier).

Background and purpose In January 2008, we established the Norwegian Register for Shoulder Instability Surgery. We report on the establishment, the baseline data, and the results at 1-year follow-up.Methods Primary and revision shoulder stabilization is reported by the surgeon on a 1-page paper form containing the patient's history of shoulder injury, clinical findings, and perioperative findings. The WOSI questionnaire for self-assessment of shoulder function is completed at baseline and at follow-up after 1, 2, and 5 years. To evaluate the completeness of registration, we compared our data with those in the Norwegian Patient Registry (NPR).Results The NPR reported 39 hospitals performing shoulder stabilizations. 20 of these started to report to our register during 2009, and 464 procedures (404 primary, 59 revisions) were included up to December 31, 2009, which represented 54% of the procedures reported to NPR. Of the 404 primary procedures, 83% were operations due to anterior instability, 10% were operations due to posterior instability, and 7% were operations due to multidirectional instability. Arthroscopic soft tissue techniques were used in 88% of the patients treated for primary anterior instability and open coracoid transfer was used in 10% of such patients. At 1-year follow-up of 213 patients, we found a statistically significantly improved WOSI score in all types of instability. 10% of the patients treated with arthroscopic anterior labral repair and 16% treated with arthroscopic posterior labral repair reported recurrent instability. No statistically significant difference in functional improvement or rate of recurrence was found between these groups.Interpretation The functional results are in accordance with those in previous studies. However, the incidence of recurrent instability 1 year after arthroscopic labral repair is higher than expected.

The glenohumeral ligaments are important structures for the stability of the shoulder. They are integrated parts of the capsule and are at risk to be injured in a traumatic shoulder dislocation. The aim was to examine the prevalence of capsular ligament lesions in the acute phase and at minimum 3 weeks' follow-up after first-time traumatic shoulder dislocation. Forty-two patients aged 16–40 years were included. All patients underwent computed tomography and magnetic resonance imaging (MRI) scans shortly after the injury and MR-arthrography (MRA) at follow-up. The median time from dislocation to MRI was 7 (range 2–14) days and to MRA 30 (range 21–54) days. We found capsular ligament lesions in 22 patients (52.4%) in the acute stage and in five patients (11.9%) at follow up. Nine patients (21.4%) had a humeral avulsion of the anterior glenohumeral ligament (HAGL lesion) on MRI. Three patients (7.1%) had this lesion at follow-up. The rate of HAGL lesions in the acute stage was higher than reported previously, but the prevalence at follow-up was in keeping with earlier published studies.

Objective Extended follow‐up of a randomized trial comparing hip‐focused exercise, knee‐focused exercise, and free physical activity in patellofemoral pain (PFP). Methods A single‐blind randomized controlled trial included 112 patients aged 16‐40 years (mean 27.6 years) with a clinical diagnosis of PFP ≥3 months (mean 39 months) and pain ≥3/10 on a Visual Analog Scale. Patients were randomized to a 6‐week exercise‐based intervention consisting of either isolated hip‐focused exercises (n = 39), traditional knee‐focused exercise (n = 37), or free physical activity (n = 36). All patients received the same patient education. The primary outcome measure was the Anterior Knee Pain Scale (AKPS, 0‐100). Secondary outcomes were usual and worst pain, Tampa Scale of Kinesiophobia, Knee Self‐Efficacy Score, Euro‐Qol (EQ‐5D‐5L), step‐down test, and isometric strength. Blinded observers assessed outcomes at baseline, 3, and 12 months. The study was designed to detect a difference in AKPS >10 at 12 months. Results After 1 year, there were no significant between‐group differences in any primary or secondary outcomes. Between‐group differences for AKPS were as follows: knee versus free physical activity −4.3 (95% CI −12.3 to 3.7); hip versus free physical activity −1.1 (95% CI −8.9 to 6.7); and hip versus Knee 3.2 (95% CI −4.6 to 11.0). The cohort as a whole improved significantly at 3 and 12 months compared to baseline for all measures except for knee extension strength. Conclusion After 1 year, there was no difference in effectiveness of knee exercise, hip exercise, or free physical activity, when combined with patient education in PFP.

Background and purpose Immobilization in external rotation (ER) for shoulder dislocation has been reported to improve the coaptation of Bankart lesions to the glenoid. We compared the position of the labrum in patients treated with immobilization in ER or internal rotation (IR). A secondary aim was to evaluate the rate of Bankart lesions.Patients and methods 55 patients with primary anterior shoulder dislocation, aged between 16 and 40 years, were randomized to immobilization in ER or IR. Computer tomography (CT) and magnetic resonance imaging (MRI) were performed shortly after the injury. After the immobilization, MRI arthrography was performed. We evaluated the rate of Bankart lesions and measured the separation and displacement of the labrum as well as the length of the detached part of the capsule on the glenoid neck.Results Immobilization in ER reduced the number of Bankart lesions (OR = 3.8, 95% CI: 1.1 –13; p = 0.04). Separation decreased to a larger extent in the ER group than in the IR group (mean difference 0.6 mm, 95% CI: 0.1 – 1.1, p = 0.03). Displacement of the labrum and the detached part of the capsule showed no significant differences between the groups.Interpretation Immobilization in ER results in improved coaptation of the labrum after primary traumatic shoulder dislocation.