Week 7 Discussion

Review article

Obere Extremität 2018 · 13:89–97 https://doi.org/10.1007/s11678-018-0449-1 Received: 30 November 2017 Accepted: 29 January 2018 Published online: 19 February 2018 © The Author(s) 2018. This article is an open access publication.

Jonas Pogorzelski1,2 · Erik M. Fritz1 · Jonathan A. Godin1,3 · Andreas B. Imhoff2 · Peter J. Millett1,3 1 Steadman Philippon Research Institute, Vail, USA 2 Department of Orthopedic Sports Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany

3 The Steadman Clinic, Vail, USA

Nonoperative treatment of five common shoulder injuries A critical analysis

Introduction

Shoulderpainisoneofthemostcommon musculoskeletal complaints accounting for at least 4.5 million patient visits an- nually in the United States [43, 55] and occurring in as many as 51% of indi- viduals in a lifetime [64]. Moreover, the economic burden of shoulder pathology is vast with annual direct costs for treat- ment of shoulder dysfunction totaling at least $7 billion in the United States, mostly due to operative treatment [47]. InGermanythepercentageofaffectedpa- tients and associated costs are expected to be similar. Moreover, with an aging and increasingly active patient popula- tion in the Western world, the absolute number of shoulder pathologies is likely to grow, further increasing costs.

These economic implications high- light the critical need for appropriate diagnosisandtreatmentofvariousshoul- der pathologies, as under-diagnosis and under-treatment can result in increased costs to society with disability and lost production. On the other hand, aggres- sive over-treatment can further inflate already burgeoning health-care costs and potentially harm the patient.

Therefore, the purpose of this review is to distinguish the indications between operative and nonoperative management for five common shoulder pathologies,

ResearchperformedattheSteadmanPhilippon ResearchInstitute,Vail,CO,USAandtheDepart- ment of Orthopedic Sports Medicine,Technical UniversityofMunich,Munich,Germany.

including rotator cuff tears, anterior shoulder instability, biceps tendinitis, lesions to the acromioclavicular (AC) joint, and proximal humeral fractures. Moreover, we aim to provide a short overview of the nonoperative manage- ment of each of these pathologies.

Rotator cuff tears

Indications for nonoperative treatment of symptomatic full- thickness rotator cuff tears

Although symptomatic rotator cuff tears are common and affect between 4% and 32% of the general population, the most appropriate therapy is still debatable [59, 75]. While there is agreement that traumatic rotator cuff tears should be treated operatively, the treatment choice for atraumatic rotator cuff tears remains unclear [38, 39]. This is mainly due to the fact that the radiological failure rate following rotator cuff repair surgery can be as high as 70% depending on the patient cohort, thus leading to the assumption that nonoperative treatment may be equivalent [5, 8, 24, 41]. This conjecture is further strengthened by the fact that pain relief and improvement of symptoms do not necessarily go hand in hand with structural healing of the tendon [59].

However, when taking a closer look at published outcomes in the literature, nonsurgical treatment appears to have limitations. While multiple studies with short-term follow-up of nonsurgical

treatment show promising results with good clinical outcomes, studies with mid-term follow-up are more disillu- sioning [10, 22, 38, 39, 50]. This could be explained by the fact that smaller tears may not affect the force couples in the shoulder, thus a reasonable degree of shoulder function may be maintained [42]. As there is strong evidence that the natural history of nonoperatively treated rotator cuff tears leads to tear progression over time, nonoperative outcomes studies with longer follow-up may include more patients whose tears have progressed to the point of destroyed force couples [80].

Kukkonen et al. [38, 39] published a randomized controlled trial for the treatment of supraspinatus tendon tears in patients older than 55 years. A total of 180 shoulders with supraspinatus tendon tears were randomly allocated into one of three treatment groups: 1. Isolated physiotherapy 2. Acromioplasty and physiotherapy 3. Rotator cuff repair with acromio-

plasty and physiotherapy

After 1 year of follow-up, no statistically significant differences in outcomes were detected, thus leading to the conclusion that surgical therapy is not superior in these patients [38]. Later, with an addi- tional year of follow-up, the groups still did not differ significantly in outcomes; however, tear progression measured with magnetic resonance imaging (MRI) sug- gested thatonlypatients withlowerphys- ical demands should be treated nonoper-

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Review article

Fig. 1 8 Axial T2-weightedmagnetic res- onance imaging sequence of a 36-year-old patient aftera first-timeshoulderdislocation. Givenhisageandtheabsenceofanyrotatorcuff tearorotherconcomitant pathology,he was deemedlow risk forre-dislocation.Therefore, nonoperative treatment was pursued,which was successful withno recurrent subluxation or dislocation

atively and patient counseling is critical [39].

In another randomized controlled trial of 103 patients, which compared rotator cuff repair with nonoperative physiotherapy for tears not exceeding 3cm, Moosmayer et al. [50] found sev- eral additional factors that may influence the outcome. With a minimum follow- up of 5 years, the results for the group of patients who had immediate tendon repair were generally superior to those of patients who underwent physiotherapy as primary treatment and decided later to progress with surgery. Furthermore, treatment failed in almost 24% of the patients who received physiotherapy as primary therapy, and they underwent subsequent rotator cuff repair. In 37% of patients who did not undergo surgery, the tear size increased more than 5mm over 5 years with associated inferior outcomes [50].

SimilarresultswerereportedbySafran et al. [68], who followed up 51 patients younger than 60 years with full-thick- ness rotator cuff tears in a longitudinal study. In this particularly young patient cohort, almost half of the tears increased after a mean follow-up of 29 months. Moreover, the authors found a signifi- cant association between the size of the rotator cuff tear and pain, which led to theconclusionthatyoungpatientsinpar- ticular benefit from surgery [68].

Treatment

While multiple rehabilitation protocols for the postoperative treatment follow- ing rotator cuff repair have been pro- posed, there are only a few published studies focusing on treatment protocols for primary nonoperative management of rotator cuff tears [37, 48, 59, 75]. In general, conservative treatment options include 3–6 months of activity modifica- tion, physical therapy such as strength- ening and stretching ofthe muscles ofthe shouldergirdle, andinjectionororalanti- inflammatory and pain-relieving medi- cation [37, 48, 59].

A prospective multicenter study pub- lished in 2013 by the MOON shoulder group of 452 patients treated with a stan- dardized physical therapy program for atraumatic full-thickness rotator cuff tears revealed a 75% satisfaction rate in patients after 2 years of follow-up. Phys- ical therapy included daily postural and stretching exercising as well as strength- ening of the rotator cuff three times a week. If needed, patients were seen by aphysicaltherapist, especiallyformanual mobilization of the glenohumeral joint. Although less than a quarter of patients underwent surgery in the short-term follow-up period, the lack of imaging follow-up raises doubts about the long- term success.

In summary, careful patient selection is necessary when nonoperative treat- ment for full-thickness rotator cuff tears is chosen. The best possible outcomes are generally achieved in patients pre- senting with pain as the primary symp- tom, those having largely intact coronal and axial force couples, and patients who are willing to trade functional deficits of their shoulder to avoid surgical risks. However, as there is no evidence that the torn tendon actually heals without surgi- cal re-fixation, patient counseling about tear size progression is indicated. This includes the progression from an initially reparable tear to an irreparable tear, as wellasinferiorpostoperativeoutcomesof chronictearscomparedwithacutelyfixed tears. If treated nonoperatively, a combi- nation of activity modification, stretch- ing and strengthening of the periscapular muscles and the deltoid should be per-

formed. MRI of a known rotator cuff tear can be performed on patients who want to progress with surgical refixation of the tear and those who wish to monitor tear progression to consider surgery at some future time point.

Anterior shoulder instability

Indications for nonoperative treatment of anterior shoulder instability

There is consensus in the literature that a detailed analysis of individual risk fac- tors for recurrent instability should be madeforeachpatientpresentingwithan- terior instability to determine the most appropriate treatment [3, 61]. In gen- eral, knownfactorsassociatedwithahigh risk of recurrent instability when treated nonoperatively are young age, an active lifestyle, bone loss of more than 20% of the glenoid surface, and engaging or off- track Hill–Sachs lesions[3, 9, 11, 44, 61, 65, 73].

In patients younger than 30 years of age, the risk of re-dislocation when treated nonoperatively is between 70 and 90% compared with up to 25% when treated operatively [9, 30, 71].

When nonoperative treatment is ap- plied to overhead athletes and active patients, the re-dislocation rate is even higher [3, 61]. However, with increasing age, the re-dislocation rate in patients treated nonoperatively decreases sub- stantially making nonoperative treat- ment an option [12].

In general, patients without structural lesions of the glenohumeral joint can be treated nonoperatively, especially when older than 35 years (. Fig. 1). However, the treating physician must ensure that concomitant injuries such as rotator cuff tears, Hill–Sachs lesions of more than 25% of the humeral surface, or glenoid bone loss are excluded as those would need surgical intervention [3, 11, 44, 66]. The “critical” amount of glenoid bone loss is typically defined as a loss of more than 20% of the glenoid surface [11, 44]. Another risk factor for recurrent insta- bility is engaging or off-track Hill–Sachs lesions, as reported in recent literature

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recommending operative treatment [57, 73].

Furthermore, the injury pattern should be taken into account. High- energy trauma often results in a locked dislocation or displaced fracture of the glenoid or the humeral head and is generally best approached with surgical treatment. Finally, patients who have the ability to voluntarily dislocate their shoulder without discomfort should be treated nonsurgically in most cases, as these patients likely suffer not from structural instability but rather from functional instability, which can be due to a pathological functional activation pattern [27, 33] and may respond better to functional conservative treatments [70] or even electrical muscle stimu- lation in some therapy-resistant cases [51].

Treatment

In order to manage shoulder instability without surgical intervention, a combi- nation of immobilization and physical therapy is often used before the patient can return to activity [12, 35, 36, 54]. Physicaltherapyprotocolsmayeitherfol- low a period of immobilization of about 3 weeks in internal or external rotation of the shoulder or be initiated immedi- ately. The overall goal of physical ther- apy is to progress through glenohumeral strengthening and stabilization, thus re- ducing the probability of recurrent in- stability. Return to full activity is mostly allowedwhenthereissymmetricalshoul- der strength of the scapulothoracic and glenohumeral joints, as well as functional shoulder range of motion [12, 57].

More recently, several studies have fo- cused on the position of the arm during immobilization after a traumatic anterior shoulder dislocation. In an MRI study by Itoi et al. [31], immobilization with the arm in external rotation resulted in reductionoftheBankartlesionaftertrau- maticshoulderdislocation, thussupport- ing the hypothesis thatimmobilizationin external rotation may be superior to im- mobilization in internal rotation. How- ever, published clinical trials have not been able to demonstrate similar efficacy of external rotation immobilization for

Abstract · Zusammenfassung

Obere Extremität 2018 · 13:89–97 https://doi.org/10.1007/s11678-018-0449-1 © The Author(s) 2018. This article is an open access publication.

J. Pogorzelski · E. M. Fritz · J. A. Godin · A. B. Imhoff · P. J. Millett

Nonoperative treatment of five common shoulder injuries. A critical analysis

Abstract Economic pressure highlights the critical need for appropriate diagnosis and treatment of various shoulder pathologies since under- diagnosis and under-treatment can result in increased costs to society in the form of disability and lost production. On the other hand, aggressive over-treatment can further inflate already burgeoning health-care costs and potentially harm the patient. Therefore, it is crucial to distinguish the indications between operative and nonoperative management, especially in common shoulder pathologies such as rotator cuff tears, anterior shoulder instability, biceps tendinitis, lesions

to the acromioclavicular joint, and proximal humeral fractures. As a result, a detailed analysis of individual risk factors for potential failures should be performed and treatment should be based on individualized care with consideration given to each patient’s particular injury pattern, functional demands, and long-term goals.

Keywords Rotator cuff tears · Shoulder injuries · Tendinitis · Acromioclavicular joint · Humeral fractures, proximal

Konservative Therapie von 5 häufigen Schulterläsionen. Eine kritische Analyse

Zusammenfassung Der zunehmende Kostendruck in der Medizin verstärkt die Notwendigkeit einer rasch zielführenden Diagnose und Therapie verschiedener pathologischer Veränderungen im Bereich der Schulter. Unterversorgte Patienten erhöhen die Kosten für die Gemeinschaft durch längere Ausfallzeiten und damit erniedrigte Produktion, während überzogene Therapien die bereits ausufern- den Kosten in der medizinischen Versorgung weiter erhöhen und den Patienten sogar potenziell schädigen können. Deshalb ist es unabdingbar, die Indikationen für operative und konservative Therapien zu kennen und anzuwenden, besonders im Hinblick auf häufige pathologische Veränderungen wie Rotatorenmanschettenläsionen, vordere

Schulterinstabilität,Bizepssehnentendinitis, Akromioklavikular Gelenkluxationen und pro- ximale Humerusfrakturen. Grundsätzlich ist es dabei wichtig, individuelle Risikofaktoren für ein Therapieversagen zu erkennen, den Erwartungshorizont des Patienten bezüglich funktionaler Ansprüche und Langzeitziele abzuklären und auch das Verletzungsmuster zu analysieren, um so letztendlich die Therapie individuell an den jeweiligen Patienten anpassen zu können.

Schlüsselwörter Rotatorenmanschettenläsionen · Schulterverletzungen · Tendinitis · Akromioklavikulargelenk · Proximale Humerusfrakturen

preventing recurrent shoulder instability [20, 78], including a recent randomized controlled multicenter trial published in 2014 [78]. Additionally, the conclusion that “immobilization in internal or exter- nal rotation does not change recurrence rates after traumatic anterior shoulder dislocation” was confirmed in a 2014 sys- tematic review of the literature [76] and a 2016 meta-analysis of randomized con- trolled trials [77]. Of note, immobiliza- tion in external rotation is reported to be veryuncomfortable and, therefore, could reduce patient compliance.

Overall, careful consideration of the injury mechanism, patient demands, and concomitant injuries associated with anterior shoulder instability are crucial when deciding on nonopera- tive vs. operative intervention. Patients younger than 35 years of age should rarely be treated nonoperatively as the recurrence rate is unacceptably high. If treated nonoperatively, immobilization in internal rotation seems to be more comfortable and shows equal outcomes to immobilization in external rotation

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Fig. 2 8 Images of a 46-year-oldman with right-sidedbicepstendonitis,diagnosedvia history,phys- icalexamination,andaT2-weightedmagneticresonanceimagingwithaclearhalosign(yellow circle) aroundthe long headof the biceps tendon indicating inflammation.The patient was treatedconser- vatively with physical therapyandNSAIDs butcontinuedto experiencesymptoms 6months later.He thusunderwentoperativemanagementasseeninbwiththelongheadofthebicepstendon(BT)and biceps reflection pulley visualizedthrough the standardposteriorviewing portal.HH humeral head

and thus should be preferred, according to current literature findings.

Biceps tendinitis

Indications for nonoperative treatment of long head biceps tendinitis

Inflammation of the long head biceps tendon (LHBT) can lead to damage and weakening of surrounding supporting structures, thereby causing LHBT in- stability. In turn, instability can place increased stresses on the LHBT, which subsequently increase inflammation. This cycle can predispose the LHBT to rupture.

Given the potential success of non- operative management for most LHBT tendinopathies, a management strategy involving medications and physical ther- apy should be the first step in treating these conditions. After progressing a pa- tient through physical therapy, a course of nonsteroidal anti-inflammatory drugs (NSAIDs) and/or injections, it is impor- tanttore-evaluatethepatientforprogres- sion of pain, weakness, and mechanical symptoms. At that time, continuation of a home exercise program vs. consider- ation of additional interventions will be discussed based on symptom progres- sion.

Ifapatientprogressesthroughallnon- operative treatment options and notes no improvement of pain or weakness, he or she should progress to surgical evalua- tion (. Fig. 2). This is also the case for

patients suffering from biceps reflection pulley lesions because these lesions do nothealandsymptomsworsenovertime. In general, patients suitable for surgical evaluation include the following: young, highly motivated patients with instabil- ity or complete LHBT rupture; man- ual laborers with significant instability or complete LHBT rupture; elite-level ath- letes with instability or complete LHBT rupture; any individual with a complete LHBT rupture who is not agreeable to a potential loss of elbow flexion or fore- arm supination strength and long-stand- ing “Popeye” deformity; and any individ- ual whohas progressed throughall stages of nonoperative treatment and continues to have symptoms of pain and/or weak- ness that affects their quality of life.

Treatment

After identification of the underlying pathologic condition of the LHBT, treat- ment generally begins with activity modification, NSAIDs, and/or cortico- steroid injections [1, 53]. NSAIDs can provide short-term benefit for swelling and pain control. However, there is little evidence that they are efficacious in treating chronic tendon injuries [13].

Useofcorticosteroidinjectionsshould follow a similar treatment protocol to NSAIDs. Multiple case reports discuss the risk of tendon rupture with steroid injections, and caution should be exer- cised when injecting steroid around the LHBT [2, 13]. Corticosteroid injections alone will likely provide short-term anti-

inflammatory effects for most LHBT dis- orders. However, they should be used for short-term pain relief and as an adjunct for the patient to initiate and tolerate a physical therapy program, rather than as a long-term treatment option. Be- cause these injections have the potential toreachtheglenohumeraljoint, theanes- theticofchoice, usedincombinationwith corticosteroid, should be ropivacaine, as it is found to be less chondrotoxic than bupivacaine [62].

Theinitiationofa3–6-monthphysical therapy program allows for progressive increase in muscle strength while pro- viding protection against further LHBT and associated structure injury during rehabilitation [1, 4, 19, 53, 67].

Other evolving nonoperative treat- mentoptionsforLHBTdisordersinclude prolotherapy (dextrose solution, sodium morrhuate), platelet-rich plasma (dif- fering concentrations of platelets, white blood cells, red blood cells, and activated and inactivated platelets), and stem cells (circulating stem cells, adipose-derived, bone marrow aspirate, bone marrow aspirate concentrate, amniotic mem- brane-derived). The choice to utilize one of these treatment options varies from patienttopatientand conditiontocondi- tion, and current research is beginning to thoroughly evaluate these interventions and to standardize treatment protocols [21, 23, 45, 46, 49]. Indications for these injections include pain impairing athletic performance, connective tissue laxity impairing athletic performance, and pain impairing rest and quality of life [49]. Future research is needed to de- termine which LHBT disorders respond best to, and what patient populations are the most suitable candidates for, such procedures.

Acromioclavicular joint injuries

Indications for nonoperative treatment of acromioclavicular joint injury

Injuryclassificationisthesinglemostim- portant factor in determining the most appropriate treatment of acromioclavic- ular (AC) joint injuries. In 1989, Rock- wood and colleagues developed the clas-

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Fig. 3 8 Radiographs of a 26-year-oldmale patientafteradirectfallonto his rightshoulder.a Panoramic view after in- jury showing a probable Rockwoodtype II injury.b However,the Alexanderview demonstratestheclavicleoverriding the acromion, thus indicating horizontal instabilityanddefining thisasa RockwoodtypeIVinjury.Accordingly,the patient un- derwentoperativetherapywithtwodog-bonesinsteadofoneinordertobetteraddressthehorizontalinstability,aspictured in c, the postoperative panoramicradiograph.d Postoperatively, the horizontal instability wasresolvedasdemonstratedon the Alexanderview 6 weeks aftersurgery

sification system that is most widely used for AC joint injuries today [79]. No- tably, this system, which is based on the work of Tossy et al. [74], recognizes the importance of the coracoclavicular (CC) ligaments in joint stability [79].

Rockwood type I injuries are charac- terized by a sprain without rupture of the AC ligaments with no anatomic dis- location and intact trapezius and deltoid fascia. Type II injuries involve rupture of the AC joint ligaments but are otherwise similar to type I. Type III injuries are characterized by rupture of both the AC andCCligamentswithsuperiordisplace- ment of the clavicle of 25–100% com- pared with the contralateral shoulder; notably, the trapezius and deltoid fascia are disrupted with this injury. Type IV injuries generally present with additional horizontal instability (. Fig. 3). Type V injuries are similar to type-III injuries, but the clavicle is superiorly displaced more than 100% compared with the con- tralateral side. Type-VI injuries, which are rarely seen, involve rupture of both AC and CC ligaments with inferior dis- placement of the distal clavicle under- neath the acromion; the trapezius and deltoid fascia are disrupted [74, 79].

Although high-level studies are rare inthe orthopedic literature todefinitively guide optimal treatment, there is a com- mon consensus regarding the most ap- propriatetreatmentsbasedonRockwood type [6].

It is generally agreed that type I and II injuries should undergo initial nonop- erative treatment while types IV–VI re- quire surgery [6]. Optimal management of type III injuries has been controver- sial. In the highest-level study to date, the Canadian Orthopedic Trauma Soci- ety [16] recently completed a prospective randomized trial of 83 patients compar- ing nonoperative treatment of grade III, IV, or V AC joint injuries with operative intervention using a hook plate. Out- come scores at short-term follow-up as far as 2 years demonstrated no signifi- cant difference between the groups with the exception of superior radiographic results in the operative group [16].

Moreover, Petri and colleagues re- viewed 41 patients with Rockwood grade III AC joint injuries who were initially treated nonoperatively [60]. Nonoperative management consisted of formalphysicaltherapytwotothreetimes per week for at least 6 weeks using a pha- sic approach with progression dictated

by patient tolerance and evidence of improved scapulohumeral kinematics. Nonoperative treatment failed in 12 pa- tients, who ultimately required surgery. Reasons cited for nonoperative failure included unremitting pain, weakness, instability, and dysfunction in spite of physical therapy. At a mean follow-up of 3.3 years, patient-reported outcome scores—including the American Shoul- der and Elbow Surgeons score (ASES), Quick Disabilities of the Arm, Shoul- der, and Hand score (QuickDASH), Single Assessment Numeric Evalua- tion score (SANE), and Short Form 12 Physical Component Summary (SF- 12 PCS)—did not significantly differ be- tween those who successfully completed nonoperative therapy and those who required eventual surgery [60].

In general, there is consensus that the horizontal stability of the clavicle is considered a potential key factor for a successful postoperative outcome. It is hypothesized that an unstable clavi- cle causes pain and functional deficits. Therefore, the ISAKOS shoulder com- mittee [7] recently proposed a modifica- tion to the classic Rockwood classifica- tion in which type III injuries may be fur- ther subdivided into types IIIA and IIIB;

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type IIIA injuries are horizontally stable and may respond well to conservative management, but type IIIB injuries are unstable and should therefore be treated surgically [7].

Treatment

Typical nonoperative treatment consists of primary immobilization and subse- quent active rehabilitation [15]. How- ever, evidence to support the efficacy of specificrehabilitationprotocolsislimited [15].

Gladstoneetal. [25]publishedaphys- icaltherapyregimenforthenonoperative treatment of AC joint injuries types I, II, andIIIinathletes. Phase1lasts3–10days and focuses on elimination of pain and sling immobilization to protect the AC joint. Range-of-motion exercises begin in phase 2 with gradual progression of isotonic exercise for strengthening. Phase 3 involves advanced strengthen- ing, and phase 4 involves sports-specific training before full returntoactivity[25]. The total length of rehabilitation can last 3–6 months. Moreover, it is important to check on the scapula movement since a significant number of patients suffering from AC joint injuries also present with scapula dyskinesis.

Overall, the general consensus re- garding management of AC joint in- juries is fairly straightforward: initial nonoperative treatment for Rockwood grades I–II, and operative intervention for grades IV–VI. For patients with grade III lesions, a closer look con- cerning the stability of the clavicle is necessary.

Proximal humeral fracture

Indications for nonoperative treatment of proximal humeral fractures

The number of bone parts and concomi- tant displacement mainly influences the treatment strategy of proximal humeral fractures. Nonoperative treatment of two-part fractures with early rehabil- itation has been found to be at least as efficacious as surgical treatment in injuries with minimal displacement [29].

Betteroutcomesmaybeachievedwith surgical fixation in cases with signifi- cant displacement, a bony avulsion of the supraspinatus tendon, a block to range of motion, andinvolvementoftheanatomic neck. However, well-designed compar- ative studies of operative vs. nonoper- ative management of two-part fractures are lacking [26].

Some authors have found that greater tuberosity fractures with >5mm of dis- placement may benefit from surgical fix- ation to reduce the risk of subacromial impingement [58, 63]. Lesser tuberosity fractures with internal rotation impinge- ment may also benefit from surgery if nonoperative management fails [52]. In contrast to other parts of the proximal humerus, the anatomic neck is devoid of soft-tissue attachments and has a tenu- ous blood supply, which may result in an increased risk of osteonecrosis.

Court-Brown et al. recommend 2 weeks of sling immobilization followed byphysical therapyforpatients with two- part surgical neck fractures and valgus- impacted fractures [17, 18]. Two-part proximal humeral fractures with >66% translation were treated with either sling immobilization or with internal fixation with flexible intramedullary nailing and tension-band wires [17, 18]. No statis- tical difference was reported between the groups with regard to Neer score, return to activities of daily living, and union rates [17, 18]. The data demon- strate that the Constant score diminishes with advancing age and degree of dis- placement. However, when calculated based on age-adjusted Constant score, the older patients actually had better scores than the younger patients [14, 17, 18, 34]. Therefore, sling immobilization is an appropriate treatment option for patients older than age 60 years with valgus-impacted, two-part surgical neck or two-part tuberosity fractures.

Although three-part and four-part fractures often require surgical fixation, nonoperative management can be con- sidered for patients with poor baseline function and/or an inability to toler- ate surgery. In select three-part and four-part fractures, particularly valgus- impacted fractures with <1cm of dis- placement of the tuberosities in relation

to the head fragment, nonsurgical treat- ment may yield good-to-excellent results [17].

Although surgical treatment of com- plex fracture patterns is generally advo- cated, theefficacyofoperativevs. nonop- erativemanagementremainstobeclearly delineated. In a study of 60 elderly pa- tients with a displaced three-part frac- ture of the proximal humerus, Olerud et al. found that surgical management with a locking plate resulted in better functional outcomes and health-related quality of life than did nonsurgical treat- ment, butatacostofadditionalsurgeryin 30% of patients [56]. By contrast, a meta- analysis of randomized controlled trials did not find improved functional out- comes with open reduction and internal fixation (ORIF) compared with nonsur- gical treatment in elderly patients with displaced three-part or four-part prox- imal humeral fractures [40]. The study concluded that these results must be con- sidered in the context of variable patient demographics.

A systematic review supported the use of nonsurgical treatment of proximal humeral fractures and noted a 2% rate of osteonecrosis mainly associated with three-part and four-part fractures, high rates of radiographic union, and modest complication rates [32]. Ultimately, the patient’s baseline physiology and func- tion may help to quantify the potential advantages of nonsurgical management, even in the setting of complex fracture patterns.

Treatment

A number of proximal humeral fractures may be treated nonoperatively. However, patients must understand the expecta- tions with this treatment approach and comply with the accompanying restric- tions. In general, excellent results have been achieved with short-term immobi- lization (<2 weeks) in a sling and early physical therapy [28, 63, 72]. While the literature supports early mobilization, it is important to ensure that further frac- ture displacement does not occur. Sling immobilization with or without closed reduction also has a role in the man-

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agement of displaced proximal humeral fractures [69].

Practical conclusion

4 For rotator cuff tears, the best pos- sible outcomes with nonoperative therapyaregenerallyachievedforpa- tients presenting pain as the primary symptom of an atraumatic rotator cuff tear, largely intact coronal and axial force couples, and a willingness to trade functional deficits to avoid surgical risks.

4 In patients suffering from anterior shoulder instability, careful consid- eration of the injury mechanism, patient demands, and concomitant injuries associated with anterior shoulder instability are crucial when deciding on nonoperative vs. opera- tive intervention. Patients <35 years should rarely be treated nonopera- tively.

4 For tendinitis of the LHBT, treatment generally begins with a nonoperative treatment protocol including activity modification and NSAIDs. In patients with structural instability of the biceps tendon complex, or in any individual who continues to have symptoms of pain after nonoperative treatment, surgery is favored.

4 The general consensus regarding management of AC joint injuries sug- gests initial nonoperative treatment for Rockwood types I–II, and oper- ative intervention for types IV–VI. For patients with type III lesions, a pathologic instability of the clav- icle potentially requiring surgical stabilization should be considered.

4 Tuberosity fractures with >5mm of displacement may benefit from surgical fixation to reduce the risk of subacromial impingement as well as displaced multifragment fractures in young and active patients.

Corresponding address

P. J. Millett, M.D., M.Sc. The Steadman Clinic 181 West Meadow Drive suite 400, 81657 Vail, CO, USA drmillett@ thesteadmanclinic.com

Compliance with ethical guidelines

Conflict of interest. A.B. Imhoffservesasaboardor committeememberforAGA,servesontheeditorial boardofArchives of Orthopaedic and Trauma Surgery, isapaidconsultantandreceivesroyaltiesandresearch supportfromArthrex, Inc.,servesontheeditorial boardofArthroskopie, isapaidconsultantandreceives royaltiesfromArthrosurface,servesasaboardor committeememberforDGOOC,servesasaboardor committeememberforDGOU,servesasaboardor committeememberforISAKOS,servesontheeditorial boardofKSSTA, isapaidconsultantformedi-bayreuth, servesontheeditorialboardofOOTR,andreceives royaltiesandfinancialsupportfromSpringerand Thieme. P.J.Millett isapaidconsultantforArthrex, Inc., receivesroyaltiesfromArthrex, Inc.,Medbridge, andSpringerPublishing,ownsstockorstockoptions inGameReadyandVuMedi,andreceivesresearch supportfromArthrex, Inc.,Ossur,Siemens,andSmith andNephew. J.Pogorzelski,E.M.Fritz,andJ.A.Godin declarethattheyhavenocompetinginterests.

Thisarticledoesnotcontainanystudieswithhuman participantsoranimalsperformedbyanyoftheau- thors.

OpenAccess. Thisarticleisdistributedundertheterms oftheCreativeCommonsAttribution4.0International License(http://creativecommons.org/licenses/by/ 4.0/),whichpermitsunrestricteduse,distribution, andreproductioninanymedium,providedyougive appropriatecredittotheoriginalauthor(s)andthe source,providealinktotheCreativeCommonslicense, andindicateifchangesweremade.

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