Aims. Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data. Methods. In the UK, the National Institute for Health and Care Excellence (NICE) advises that prompt early management of frozen shoulder is initiated in primary care settings with analgesia, physiotherapy, and joint injections; most people can be managed without an operation. Currently, there is variation in the type of joint injection: 1) CSI, thought to reduce the inflammation of the capsule reducing pain; and 2) HD, where a small volume of fluid is injected into the shoulder joint along with the steroid, aiming to stretch the capsule of the shoulder to improve pain, but also allowing greater movement. The creation of musculoskeletal hubs nationwide provides infrastructure for the early and effective management of frozen shoulder. This potentially reduces costs to individuals and the wider NHS perhaps negating the need for a secondary care referral. Results. We will conduct a multicentre RCT comparing CSI and HD in combination with CSI alone. Patients aged 18 years and over with a clinical diagnosis of frozen shoulder will be randomized and blinded to receive either CSI and HD in combination, or CSI alone. Feasibility outcomes include the rate of randomization as a proportion of eligible patients and the ability to use routinely collected data for outcome evaluation. This study has involved patients and the public in the trial design, dissemination methods, and how to include groups who are underserved by research. Conclusion. We will disseminate findings among musculoskeletal clinicians via the British Orthopaedic Association, the Chartered Society of Physiotherapy, the Royal College of Radiologists, and the Royal College of General Practitioners. To ensure wide reach we will communicate findings through our established network of charities and organizations, in addition to preparing dissemination findings in Bangla and Urdu (commonly spoken languages in northeast London). If a full trial is shown to be feasible, we will seek additional National Institute for Health and Care Research funding for a definitive RCT. This definitive study will inform NICE guidelines for the management of frozen shoulder. Cite this article: Bone Jt Open 2024;5(3):162–173

Introduction. There are conflicting reports about the efficacy of injection to the thumb carpometacarpal joint (CMCJ) for osteoarthritis (OA). The accuracy of joint injection without radiological control is unclear. We investigated the accuracy of blind injection and recorded their immediate and short term efficacy. Materials/Methods. We injected 25 consecutive patients between March 2010-January 2011. The CMCJ was palpated, manually distracted and a 23 gauze needle introduced blindly. Image intensifier was then used to visualize and redirect needle if necessary. Radio-opaque dye was injected to confirm intra-articular placement. We recorded patient demographics, number of attempts required for correct needle placement, pre and 10 minutes post-injection visual analogue scale (VAS) pain score, and Nelson Score (NS)before and six weeks after injection. NS is a validated thumb CMCJ specific patient administered questionnaire. Results. Mean age was 60 (range 46–90). M:F ratio was 23:2. CMC J OA ranged from grade 2–4.1. st. attempt was successful in 6 cases. Mean attempts required for accurate injection was 3 (range 0–4). Mean pain pre- injection VAS was 7 (range 4–10), 10 minutes following injection 0.5 (range 0–4) and at 6 weeks 5 (range 3–10). Mean pre-operative NS was 29.6 (range 14–65) and at 6 weeks 32.4 (range 14–55). The difference was not statistically significant (paired t test, p=0.24). Conclusion. Our results suggest that blind injection of thumb CMCJ may not be accurate. Accuracy can be improved by X-ray guided injection. The procedure afforded excellent immediate pain relief but was not effective over six weeks follow up

Background: Diagnostic injection plays an increasing role in the diagnosis of foot and ankle pathology. Joint communications have been reported in several studies, and it has been suggested they may impact on clinical management. Method: We analysed the findings of 389 arthrograms of the foot and ankle, identifying any joint communications noted on imaging. A case note review was then undertaken on a subset of 153 of these patients with the aim of establishing the effect of injection findings on clinical management. All injections were performed and reported by a single consultant radiologist. Results: Joint communications were seen in 24% of patients with an equal distribution amongst males and females. Rates of individual joint communications were consistent with those previously published. Injection studies had an impact on subsequent management in 88% of cases. Symptoms resolved with injection alone in 28% of patients with no communication versus 8% in those with a communication. Surgical plans were changed in over 20% of cases if a joint communication was found. There were no major complications reported (Joint sepsis or contrast allergy). Conclusion: This study confirms the presence of multiple joint communications within the foot and ankle, and highlights the importance of arthrography in the diagnosis of pathology. We would recommend joint injection be considered in all patients, especially if joint fusion is being considered. Contrast should be used in all cases to demonstrate any potential communications, which should be taken into consideration when surgical management plans are formulated. A significant number of patients will experience resolution of symptoms from injection alone, with no further intervention needed

Estimated to affect 2–5% of the population, adhesive capsulitis is a common cause of shoulder pain and dysfunction. The objective of this study is to determine if arthrographic injection of the shoulder joint with steroid, local anesthetic and contrast is an effective treatment modality for adhesive capsulitis and whether it is superior to arthrographic injection with local anesthetic and contrast alone.

This is a double-blinded RCT of patients with a diagnosis of adhesive capsulitis who were randomly assigned to receive an image guided arthrographic glenohumeral injection with either triamcinalone (steroid), lidocaine (local anesthetic) and contrast or lidocaine and contrast alone. Outcome measures included active and passive shoulder range of motion (ROM) and functional outcomes assessed using the Shoulder Pain and Disability Index (SPADI), the Constant Score and a Visual Analog Scale for pain. Post-operative evaluation occurred at 3 weeks, 6 weeks and 12 weeks. Descriptive statistics were utilised to summarise patient demographics and other study parameters. One-way ANOVAs compared the VAS, Constant and SPADI scores across the different time points for both study groups. The post hoc Bonferroni correction was used to adjust for multiple comparisons.

There were 37 shoulders injected with follow-up visits at 12 weeks. Twenty shoulders were randomised to receive local plus steroid and 17 shoulders received local anesthetic only. There were 21 females and 14 males with an average age of 54 years (range, 42–70). VAS scores for both patient groups were significantly improved (p<0.05) at all follow-up times. Goniometric testing demonstrated significant improvements in forward flexion and internal rotation at 90 degrees in the local group and only abduction in the local plus steroid group. There were no significant changes in the Constant scores for the local group (p=0.08), however, the Constant scores showed significant improvement for the local plus steroid group (p=0.003) at all follow-up time points. The local group showed significant improvement in their SPADI pain scores at the 12 week follow-up only (p=0.01). There were no significant differences in their SPADI disability scores (p=0.09). The local plus steroid group had significant improvement in SPADI pain and disability scores at all follow-up time points (p=0.001).

The optimal treatment for adhesive capsulitis remains unclear. Our study demonstrated that patients receiving an arthrographic injection of either steroid and local anesthetic or local anesthetic alone had significantly improved post-injection pain scores. However, only the steroid and local anesthetic group demonstrated improved SPADI disability and Constant scores. Thus, we believe that either treatment may be a good option for patients with adhesive capsulitis and can reliably relieve pain, but we would recommend the steroid with local anesthetic over the local anesthetic alone as it may provide improved function.

Aim: To determine the effectiveness of therapeutic lumbar facet joint injections in patients with chronic low back pain.

Methods: Eighty-six patients with refractory chronic low back pain were randomly assigned to receive facet joint injection using local anaesthetic and corticosteroid suspension under fluoroscopic guidance after clinical and radiological assessment. The main parameter for the success or failure of this treatment was the relief of the pain. Pain intensity was assessed with a visual analog scale (VAS) and changes in function and quality of life were assessed by the revised Oswestry Disability Questionnaire (ODQ) at baseline and during follow-up after injection.

Results: Patients reported lasting pain relief, better function, and improved quality of life following injection. Cumulative significant relief following injection was 91.9% up to 1 to 3 months, 81% for 4 to 6 months, 34% for 7 to 12 months, and 10% after 12 months, with a mean relief of 6.5 +/− 0.76 months. There was significant improvement noted in overall health status with improvement not only in pain relief, but also with physical, functional, and psychological status, as well as return-to-work status. No complications were noted following injection.

Conclusion: The results of this study demonstrate that intra-articular facet joint injection appear to have a beneficial medium-term effect in patients with chronic lower back pain and may therefore be a reasonable adjunct to non-operative treatment.

Aim: This study aims to quantify pain relief and quality-of-life benefit from a diagnostic SIJ injection.

Methods: 50 consecutive patients were retrospectively recruited with unilateral low back pain, pain mapping compatible with a sacroiliac origin, tenderness over the SIJ, and no obvious source of pain in the lumbar spine. These were selected for a diagnostic SIJ injection. A structured questionnaire was completed both pre- and post-injection. Median patient age was 63. All patients were injected under fluoroscopic imaging with Triamcinolone 40mgs and 3mls Ropivacaine hydrochloride.

Results: Onset of lower back pain symptoms ranged from 1962 to 2007. 38 patients (76%) had some form of previous non-operative treatment. No patients had previous injection or surgery. 8 patients (16%) were smokers. 17 patients (34%) had a desk based job, 22 patients (44%) had a manual job, 7 patients (14%) had heavy manual jobs. 18 patients (36%) had sustained previous back injury. A visual assessment score was carried out for low back pain and pain in both legs, both pre- and post-injection. Overall, 16 patients (32%) reported no change in their symptoms, 7 (14%) reported worsening, but in 27 (54%) improvement was recorded. When considering the Oswestry Disability Index score, 18% reported no symptom change, 24% worsened and 58% improved.

Conclusion: History and physical examination can enter SIJ syndrome into the differential diagnosis, but cannot make a definitive diagnosis. Fluoroscopically guided diagnostic SIJ injection is the gold standard test for making the diagnosis whilst also conferring substantial pain relieve and quality-of-life benefit.

Conflicts of Interest: None

Source of Funding: None

Aims. Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients’ symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB. Methods. The Therapeutic Injections For Frozen Shoulder (TIFFS) study is a single centre, parallel, two-arm, randomized clinical trial. Participants will be allocated on a 1:1 basis to either a GHJ corticosteroid injection or SSNB. Participants in both trial arms will then receive physiotherapy as normal for frozen shoulder. The primary analysis will compare the Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include OSS at six and 12 months, range of shoulder movement at three months, and Numeric Pain Rating Scale, abbreviated Disabilities of Arm, Shoulder and Hand score, and EuroQol five-level five-dimension health index at three months, six months, and one year after injection. A minimum of 40 patients will be recruited to obtain 80% power to detect a minimally important difference of ten points on the OSS between the groups at three months after injection. The study is registered under ClinicalTrials.gov with the identifier NCT04965376. Conclusion. The results of this trial will demonstrate if there is a difference in shoulder pain and function after GHJ injection or SSNB in patients with frozen shoulder. This will help provide effective treatment to patients with frozen shoulder. Cite this article: Bone Jt Open 2023;4(3):205–209

Introduction. Ankle fractures represent approximately 10% of the fracture workload and are projected to increase due to ageing population. We present our 5 years outcome review post-surgical management of ankle fractures in a large UK Trauma unit. Methods. A total of 111 consecutive patients treated for an unstable ankle fracture were entered into a database and prospectively followed up. Baseline patient characteristics, complications, further intervention including additional surgery, functional status were recorded during five-year follow-up. Pre-injury and post-fixation functional outcome measures at 2-years were assessed using Olerud-Molander Ankle Scores (OMAS) and Lower Extremity Functional Scales (LEFS). A p value < 0.05 was considered significant. Results. The mean age was 46 with a male:female ratio of 1:1.1. The distribution of comorbidities was BMI >30 (25%), diabetes (5%), alcohol consumption >20U/week (15%) and smoking (26%). Higher BMI was predictive of worse post-op LEFS score (p = 0.02). Between pre-injury and post fixation functional scores at 2 years, there was a mean reduction of 26.8 (OMAS) and 20.5(LEFS). Using very strict radiological criteria, 31 (28%) had less than anatomical reduction of fracture fragments intra-operatively. This was, however, not predictive of patients' functional outcome in this cohort. Within 5-year period, 22 (20%) patients had removal of metalwork from their ankle, with majority 13 (59%) requiring syndesmotic screw removal. Further interventions included: joint injection (3), deltoid reconstruction (1), arthroscopic debridement (1), superficial sinus excision (2), and conversion to hindfoot nail due to failure of fixation (1). Reduction in OMAS was predictive of patients' ongoing symptoms (p=0.01). Conclusion. There is a significant reduction in functional outcome after ankle fracture fixation and patients should be counselled appropriately. Need for removal of metalwork is higher in patients who require syndesmosis stabilisation with screw(s)

Aims. Osteoarthritis (OA) is a prevalent joint disorder with inflammatory response and cartilage deterioration as its main features. Dihydrocaffeic acid (DHCA), a bioactive component extracted from natural plant (gynura bicolor), has demonstrated anti-inflammatory properties in various diseases. We aimed to explore the chondroprotective effect of DHCA on OA and its potential mechanism. Methods. In vitro, interleukin-1 beta (IL-1β) was used to establish the mice OA chondrocytes. Cell counting kit-8 evaluated chondrocyte viability. Western blotting analyzed the expression levels of collagen II, aggrecan, SOX9, inducible nitric oxide synthase (iNOS), IL-6, matrix metalloproteinases (MMPs: MMP1, MMP3, and MMP13), and signalling molecules associated with nuclear factor-kappa B (NF-κB) and mitogen-activated protein kinase (MAPK) pathways. Immunofluorescence analysis assessed the expression of aggrecan, collagen II, MMP13, and p-P65. In vivo, a destabilized medial meniscus (DMM) surgery was used to induce mice OA knee joints. After injection of DHCA or a vehicle into the injured joints, histological staining gauged the severity of cartilage damage. Results. DHCA prevented iNOS and IL-6 from being upregulated by IL-1β. Moreover, the IL-1β-induced upregulation of MMPs could be inhibited by DHCA. Additionally, the administration of DHCA counteracted IL-1β-induced downregulation of aggrecan, collagen II, and SOX9. DHCA protected articular cartilage by blocking the NF-κB and MAPK pathways. Furthermore, DHCA mitigated the destruction of articular cartilage in vivo. Conclusion. We present evidence that DHCA alleviates inflammation and cartilage degradation in OA chondrocytes via suppressing the NF-κB and MAPK pathways, indicating that DHCA may be a potential agent for OA treatment. Cite this article: Bone Joint Res 2023;12(4):259–273

Aim: To investigate the magnitude of revenue lost by the Department of Trauma and Orthopaedics at Ports-mouth Hospitals NHS Trust in 2007 as a result of providing outpatient viscosupplementation joint injections. Methods: Data was collated on all outpatient intra-articular hyaluronic acid viscosupplementation performed by our department in 2007. Information on existing HRG tariffs for orthopaedic outpatient attendances as well as clinical coding of joint injections by our department was also gathered. Results: The 2007/2008 tariffs for orthopaedic outpatient first and follow-up appointments were £147 and £73 respectively for adults, and £157 and £85 respectively for children (under 17 years of age). No additional mandatory tariff currently exists for joint injections performed in the outpatient setting. During our study period, the cost of a dose of viscosuplementation (Hyaluronic acid 60mg/ 3 ml) varied between £213 and £248. A total of 812 doses of viscosupplementation were administered to outpatients by our department resulting in pharmaceutical costs of £175,126. Only 751 cases of outpatient appointment with joint injection (all types) were recorded and coded by the department. Conclusions:. As long as no mandatory DoH tariff exists for out-patient joint injections, outpatient viscosupplementation remains an expensive service for trusts to provide and may warrant rationalisation. Under Payment by Results it is imperative that the quality of data capture and clinical coding improve, if trusts are to maximise financial gains. Clinicians need to be made more aware of the processes and implications of Payment by Results. In order for trusts to receive fair remuneration it is essential that reasonable national tariffs be set for all types of procedure or service delivered

Musculoskeletal ultrasound (MSK-US) can have many uses for orthopaedic surgeons, such as assisting in clinical diagnosis for muscle, tendon and ligament injuries, providing direct guidance for joint injections, or assessing the adequacy of a reduction in the emergency department. However, proficiency in sonography is not a requirement for Royal College certification, and orthopaedic trainees are rarely exposed to this modality. The purpose of this project was to assess the usefulness in clinical education of a newly implemented MSK-US course in an orthopaedic surgery program. A MSK-US course for orthopaedic surgery residents was developed by an interdisciplinary team involving a paediatric orthopaedic surgeon, an emergency physician with a fellowship in point-of-care ultrasonography, and an orthopaedic surgery resident. Online videos were created to be viewed by residents prior to a half-day long practical course. The online portion covered the basics of ultrasonography, as well as the normal and abnormal appearance of musculoskeletal structures, while the practical portion applied those principles to the examination, injection, and aspiration of joints, and ultrasound-guided fracture reduction. An online survey covering the level of training of the resident and their previous use of ultrasound (total hours) was filled by the participants prior to the course. Resident's knowledge acquisition was measured with a written pre-course, same-day post-course and six-month follow-up tests. Residents were also scored on a practical shoulder examination immediately after the course and at six-month follow-up. An online survey was also sent to evaluate residents' satisfaction with different aspects of the course (NAS). Change in test scores were calculated using an ANOVA and a Wilcoxon signed-rank test. Ten orthopaedic surgery residents underwent the MSK-US curriculum. Pre-course interest to MSK-US was moderate (65%) and prior exposure was low (1.5 hours mean total experience). MSK-US has been previously mostly observed in the emergency department and sports orthopaedic clinic. Satisfaction with the online curriculum, hands-on practice session and general quality of the course were high (8.78, 8.70 and 8.60/10 respectively). Written test scores improved significantly from 50.7 ± 17% to 84 ± 10.7% immediately after the course (p < 0 .001) and suffered no significant drop at six months (score 75 ± 8.7%, p=0.303). Average post-course practical exam score was 78.8 ± 3.1% and decreased to 66.2 ± 11.3% at six months (p=0.012). Residents significantly improved their subjective comfort level with all aspects of ultrasound use at six months (p=0.007–0.018) but did not significantly increase clinical usage frequency. A MSK-US curriculum was successfully developed and implemented using an interdisciplinary approach. The course was rated high quality and succeeded in improving the residents' knowledge, skills, and comfort with MSK-US. This improvement was maintained at six months on the written test, but did not result in higher frequency of use by the residents

Background. NICE guidance suggests that caudal epidural injections of steroid and local anaesthetic may be considered for acute and severe sciatica, however studies have demonstrated limited long-term benefit and impact on future surgery. This study aimed to investigate the use of caudal epidural injections in a district general hospital setting and the rate of subsequent operation. Methods. All patients undergoing caudal epidural injection between 1. st. January and 30. th. June 2015 were included. Records were reviewed to obtain diagnosis, pre- and post-epidural clinical findings, prior interventions, and subsequent operations. Results. A total of 141 patients underwent a caudal epidural, with a median age of 63 (18 – 90). 37 patients went on to surgical intervention within 3 years, resulting in a conversion rate of 26.1%. Amongst those not requiring surgery, 59 (56.19%) had disc herniation, 42 (40%) stenosis, 4 spondylolisthesis, and 1 a facet cyst. Pre-operatively 63.81% reported back pain and 93.33% sciatica. 39.05% of patients had sensorimotor changes. Post-operatively, 27.62% reported an improvement in their back pain, compared to 62.86% reporting improved leg pain. 36.59% of those with sensorimotor changes reported improvement. 32 later had a further caudal epidural or foraminal block, and 25 had facet and sacroiliac joint injections. Amongst those requiring surgery, 21 (56.76%) had disc herniation, 15 (40.54%) stenosis, and 1 spondylolisthesis (2.7%). Conclusion. In our series, approximately three quarters of patients undergoing caudal epidural injection did not subsequently require surgery. Lumbosacral radicular symptoms improved in two thirds, however the epidural was less effective at treating back pain. No conflicts of interest. No funding obtained

Aims

Pigment epithelium-derived factor (PEDF) is known to induce several types of tissue regeneration by activating tissue-specific stem cells. Here, we investigated the therapeutic potential of PEDF 29-mer peptide in the damaged articular cartilage (AC) in rat osteoarthritis (OA).

Arthrosis of the hip joint can be a significant source of pain and dysfunction. While hip replacement surgery has emerged as the gold standard for the treatment of end stage coxarthrosis, there are several non-arthroplasty management options that can help patients with mild and moderate hip arthritis. Therefore, the purpose of this paper is to review early prophylactic interventions that may help defer or avoid hip arthroplasty. Nonoperative management for the symptomatic hip involves minimizing joint inflammation and maximizing joint mobility through intra-articular joint injections and exercise therapy. While weight loss, activity modifications, and low impact exercises is generally recommended for patients with arthritis, the effects of these modalities on joint strength and mobility are highly variable. Intra-articular steroid injections tended to offer reliable short-term pain relief (3–4 weeks) but provided unreliable long-term efficacy. Additionally, injections of hyaluronic acid do not appear to provide improved pain relief compared to other modalities. Finally, platelet rich plasma injections do not perform better than HA injections for patients with moderate hip joint arthrosis. Primary hip joint arthrosis is rare, and therefore treatment such as peri-acetabular osteotomies, surgical dislocations, and hip arthroscopy and related procedures are aimed to minimise symptoms but potentially aim to alter the natural history of hip diseases. The state of the articular cartilage at the time of surgery is critical to the success or failure of any joint preservation procedures. Lech et al. reported in a series of dysplastic patients undergoing periacetabular osteotomies that one third of hips survived 30 years without progression of arthritis or conversion to THA. Similarly, surgical dislocation of the hip, while effective for treatment of femoroacetabular impingement, carries a high re-operation rate at 7 years follow up. Finally, as the prevalence of hip arthroscopic procedures continues to rise, it is important to recognise that failure to address the underlying structural pathologies can lead to failure and rapid joint destruction. In summary, several treatment modalities are available for the management of hip pain and dysfunction in patients with a preserved joint space. While joint preservation procedures can help improve pain and function, they rarely alter the natural history of hip disease. The status of the articular cartilage at the time of surgery is the most important predictor of treatment success or failure

The June 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Reverse versus anatomical total shoulder replacement for osteoarthritis? A UK national picture; Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomized controlled trial; acid for rotator cuff repair: a systematic review and meta-analysis of randomized controlled trials; Metal or ceramic humeral head total shoulder arthroplasty: an analysis of data from the National Joint Registry; Platelet-rich plasma has better results for long-term functional improvement and pain relief for lateral epicondylitis: a systematic review and meta-analysis of randomized controlled trials; Quantitative fatty infiltration and 3D muscle volume after nonoperative treatment of symptomatic rotator cuff tears: a prospective MRI study of 79 patients; Locking plates for non-osteoporotic proximal humeral fractures in the long term; A systematic review of the treatment of primary acromioclavicular joint osteoarthritis.

Aims

Intra-articular (IA) injection may be used when treating hip osteoarthritis (OA). Common injections include steroids, hyaluronic acid (HA), local anaesthetic, and platelet-rich plasma (PRP). Network meta-analysis allows for comparisons between two or more treatment groups and uses direct and indirect comparisons between interventions. This network meta-analysis aims to compare the efficacy of various IA injections used in the management of hip OA with a follow-up of up to six months.

Aims

Staphylococcus aureus is a major cause of septic arthritis, and in vitro studies suggest α haemolysin (Hla) is responsible for chondrocyte death. We used an in vivo murine joint model to compare inoculation with wild type S. aureus 8325-4 with a Hla-deficient strain DU1090 on chondrocyte viability, tissue histology, and joint biomechanics. The aim was to compare the actions of S. aureus Hla alone with those of the animal’s immune response to infection.

Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

The April 2013 Shoulder & Elbow Roundup. 360 . looks at: biceps, pressure and instability; chronic acromio-clavicular joint instability; depression and shoulder pain; shoulder replacement and transfusion; cuff integrity and function; iatropathic plexus injury; the accuracy of acromio-clavicular joint injection; and tennis as a risk factor for tennis elbow