Rotator cuff injuries and treatment

Comparison of ultrasound-guided subacromial corticosteroid and ozone (O2-O3) injections in the treatment of chronic rotator cuff tendinopathy: a randomized clinical trial

Background

: The authors aimed to compare the effects of a one-time ultrasound (US)-guided subacromial corticosteroid injection and three-time ozone (O₂-O₃) injection in patients with chronic supraspinatus tendinopathy.

Methods

: Participants were randomly assigned to the corticosteroid group (n = 22) or ozone group (n = 22). Injections in both groups were administered into subacromial bursa with an US-guided in-plane posterolateral approach. Primary outcome measure was the change in the Western Ontario Rotator Cuff Index (WORC) score between baseline and 12-weeks post-injection. Secondary outcome measures included visual analog scale and Shoulder Pain and Disability Index scores. Assessments were recorded at baseline, and 4-weeks and 12-weeks post-injection.

Results

: Forty participants completed this study. Based on repeated measurement analysis of variance, a significant effect of time was found for all outcome measures in both groups. Both the groups showed clinically significant improvements in shoulder pain, quality of life, and function. Baseline, 4-week post-injection, and 12-week post-injection WORC scores (mean ± standard deviation) were 57.91 ± 18.97, 39.10 ± 20.50 and 37.22 ± 27.31 in the corticosteroid group, respectively and 69.03 ± 15.89, 39.11 ± 24.36, and 32.26 ± 24.58 in the ozone group, respectively. However, no significant group × time interaction was identified regarding all outcome measures.

Conclusions

: Three-time ozone injection was not superior to a one-time corticosteroid injection in patients with chronic supraspinatus tendinopathy. It might be as effective as corticosteroid injection at 4-weeks and 12-weeks post-injection in terms of relieving pain and improving quality of life and function.

Rotator Cuff Repair in the Pediatric Population Displays Favorable Outcomes: A Systematic Review

Purpose

To systematically review the literature to determine the injury mechanisms, presentation, and timing of diagnosis for pediatric patients with intratendinous rotator cuff tears and to determine the efficacy of surgical intervention for affected patients.

Methods

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus were searched. Studies were included if they involved only pediatric patients, soft-tissue rotator cuff injuries managed surgically, and reported outcomes. Patient characteristics, injury mechanisms, physical examination and imaging findings, time to diagnosis, surgical technique, and treatment outcomes were extracted. Findings were descriptively analyzed with weighted means and proportions.

Results

Twenty-one studies comprising 78 patients were included. The age range was 8 to 17 years and 57 were male. The supraspinatus (n = 56) was the most injured tendon. American football was the most reported sport played at the time of injury. Most patients were diagnosed within 6 months of injury via magnetic resonance imaging. Arthroscopic management was undertaken in 68 patients. Forty-six of 51 patients for whom data were available returned to sports at a range of 2.5 to 12 months postoperatively. Repair failure occurred in three patients.

Conclusions

The extant literature regarding rotator cuff tears in pediatric patients is limited to reports of low methodological quality. Qualitative synthesis of this low-level literature reveals that rotator cuff tears are mostly reported in male collision sport athletes but may also occur in female athletes and/or throwing athletes. These injuries are often successfully managed via arthroscopic repair, and patients and their families can be reassured that the majority of patients return to sports following surgery.

Level of Evidence

Level IV, systematic review of level IV studies.

Early Clinical and Functional Outcome of Rotator Cuff Tendinopathy of the Shoulder Treated with Platelet Rich Plasma Injection

Introduction:

Rotator cuff tendinitis has been treated using various methods including physiotherapy, steroid injections and recently platelet rich plasma (PRP). Most of these methods aim at giving symptomatic relief rather than addressing the pathology. There is no clear consensus over the benefit of using PRP for tendinitis. We decided to do a prospective clinical study to demonstrate the efficacy of PRP and study the functional outcome in the treatment of rotator cuff tendinopathy.

Material and Methods:

Patients with shoulder pain for more than three months not responding to NSAIDs or physiotherapy with a diagnosis of rotator cuff tendinitis, confirmed by MRI, were included in the study. Patients with rotator cuff tear or any other shoulder pathology were excluded. We included a total of 30 patients who received 5ml of landmark guided PRP injection in the subacromial space followed by a six-week exercise program. Patients were followed-up at 3, 6 and 12 weeks. and were assessed clinically using the VAS, SPADI and Constant and Murley Score.

Results:

VAS score of patients improved from a pre injection score of 7.4 to a score of 1.9 in the 12th week. The mean SPADI score and Constant score improved from a pre injection score of 73.33 and 39.57 to a post injection score of 18.1 and 86.47, respectively.

Conclusion:

Platelet Rich Plasma injections showed good to excellent early results, in patients with rotator cuff tendinopathy with improvement in VAS, SPADI and Constant scores.

Prospective Clinical Research of the Efficacy of Platelet-rich Plasma in the Outpatient-based Treatment of Rotator Cuff Tendinopathy

Background

The purpose of this study is to compare the clinical outcomes of the control group and platelet-rich plasma (PRP) group among the patients who failed to respond to conservative treatment as outpatient-based therapy for rotator cuff tendinopathy, and to compare the clinical results of leukocyte-poor (LP) PRP and leukocyte-rich (LR) PRP.

Methods

Inclusion criteria are (1) over 18-year-old, (2) patients with rotator cuff tendinopathy, no rotator cuff tear by radiologic diagnosis (ultrasonography or magnetic resonance imaging) within the last 3 months, and (3) not effective to conservative treatment for more than 1 month. Of the final 60 subjects, 33 patients in the exercise treatment group and 27 patients in the PRP injection group (LP-PRP, 13; LR-PRP, 14) were included. Clinical evaluation was carried out by assessing the outcomes of treatment using the Numeric Rating Scale pain score, the American Shoulder and Elbow Society (ASES) score, and the Constant score at baseline and at 3 and 6 months after the procedure.

Results

There was a statistically significant difference in ΔASES_3months (ASES_3months-ASES_first) score between the control and PRP groups (p=0.006). However, there was no statistical significance between LP-PRP and LR-PRP groups (p>0.05).

Conclusions

This study showed that PRP injection was more effective than exercise therapy for the first 3 months. However, there was no difference between the LP-PRP group and the LR-PRP group. Regardless of the type of PRP, clinical application of PRP injection in patients with rotator cuff tendinopathy seems to be effective in early treatment.

Contribution of Dry Needling to Individualized Physical Therapy Treatment of Shoulder Pain: A Randomized Clinical Trial

Study Design Multicenter, parallel randomized clinical trial. Background Myofascial trigger points (MTrPs) are implicated in shoulder pain and functional limitations. An intervention intended to treat MTrPs is dry needling. Objectives To investigate the effectiveness of dry needling in addition to evidence-based personalized physical therapy treatment in the treatment of shoulder pain. Methods One hundred twenty patients with nonspecific shoulder pain were randomly allocated into 2 parallel groups: (1) personalized, evidencebased physical therapy treatment; and (2) trigger point dry needling in addition to personalized, evidence-based physical therapy treatment. Patients were assessed at baseline, posttreatment, and 3-month follow-up. The primary outcome measure was pain assessed by a visual analog scale at 3 months, and secondary variables were joint range-of-motion limitations, Constant-Murley score for pain and function, and number of active MTrPs. Clinical efficacy was assessed using intention-to-treat analysis. Results Of the 120 enrolled patients, 63 were randomly assigned to the control group and 57 to the intervention group. There were no significant differences in outcome between the 2 treatment groups. Both groups showed improvement over time. Conclusion Dry needling did not offer benefits in addition to personalized, evidencebased physical therapy treatment for patients with nonspecific shoulder pain. Level of Evidence Therapy, level 1b. Registered February 11, 2009 at www.isrctn.com (ISRCTN30907460). J Orthop Sports Phys Ther 2017;47(1):11-20. Epub 9 Dec 2016. doi:10.2519/jospt.2017.6698.

Arthroscopic Rotator Cuff Repair Using the Undersurface Technique: A 2-Year Comparative Study in 257 Patients

Background:

Arthroscopic rotator cuff repair has traditionally been performed in the subacromial space from the bursal side of the tendon. The undersurface rotator cuff repair technique involves the arthroscope remaining in the glenohumeral joint, thus viewing the tendon from its undersurface during repair without a bursectomy or acromioplasty.

Purpose:

To compare the clinical and structural outcomes of undersurface rotator cuff repair with bursal-side repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective analysis of prospectively collected data was conducted on 2 cohorts of patients who had undergone arthroscopic rotator cuff repair with knotless suture anchors configured in a single-row formation using inverted mattress–style sutures from either the bursal side (n = 100) or undersurface (n = 165) of the supraspinatus tendon. Data were collected preoperatively, intraoperatively, and at 1 week, 6 weeks, 3 months, 6 months, and 2 years postoperatively. At each time point, patients completed a modified L’Insalata questionnaire to assess patient-ranked pain scores and were clinically examined using standardized tests. Ultrasound examination was performed at 6 months and 2 years to assess the integrity of the repair.

Results:

At 2 years postoperatively, patients in both cohorts had significantly less pain and less difficulty with overhead activities compared with preoperative levels (P < .001). The type of repair performed (bursal or undersurface) did not affect the ability to perform overhead activities at 2 years. At 2 years, both groups also had similar retear rates (21% for bursal side, 23% for undersurface). The mean operative time for the arthroscopic rotator cuff repair was 32 minutes when performed from the bursal side and 20 minutes when performed from the undersurface (P < .001).

Conclusion:

Arthroscopic rotator cuff repair, whether performed from the subacromial space or glenohumeral joint, resulted in decreased levels of pain and difficulty with overhead activities at 2 years. The major difference between the 2 techniques was operative time, with the undersurface technique being performed significantly faster than the bursal-side repair technique.

Platelet-rich plasma injections in the treatment of chronic rotator cuff tendinopathy: a randomized controlled trial with 1-year follow-up

BACKGROUND

Rotator cuff tendinopathy (RCT) is a significant source of disability and loss of work. Platelet-rich plasma (PRP) has been suggested to be beneficial in the treatment of RCT.

PURPOSE

To investigate the effect of PRP injections on pain and shoulder functions in patients with chronic RCT.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 40 patients, 18 to 70 years of age, with (1) a history of shoulder pain for >3 months during overhead-throwing activities, (2) MRI findings of RCT or partial tendon ruptures, and (3) a minimum 50% reduction in shoulder pain with subacromial injections of an anesthetic were included in this placebo-controlled, double-blind randomized clinical trial. Patients were randomized into a PRP group (n = 20) or placebo group (n = 20). Patients received an ultrasound-guided injection into the subacromial space that contained either 5 mL of PRP prepared from autologous venous blood or 5 mL of saline solution. All patients underwent a 6-week standard exercise program. Outcome measures (Western Ontario Rotator Cuff Index [WORC], Shoulder Pain and Disability Index [SPADI], 100-mm visual analog scale [VAS] of shoulder pain with the Neer test, and shoulder range of motion) were assessed at baseline and at 3, 6, 12, and 24 weeks and 1 year after injection.

RESULTS

Comparison of the patients revealed no significant difference between the groups in WORC, SPADI, and VAS scores at 1-year follow-up (P = .174, P = .314, and P = .904, respectively). Similar results were found at other assessment points. Within each group, the WORC, SPADI, and VAS scores showed significant improvements compared with baseline at all time points (P < .001). In the range of motion measures, there were no significant group × time interactions.

CONCLUSION

At 1-year follow-up, a PRP injection was found to be no more effective in improving quality of life, pain, disability, and shoulder range of motion than placebo in patients with chronic RCT who were treated with an exercise program.

Contributions of myofascial pain in diagnosis and treatment of shoulder pain. A randomized control trial

BACKGROUND

Rotator cuff tendinopathy and subacromial impingement syndrome present complex patomechanical situations, frequent difficulties in clinical diagnosis and lack of effectiveness in treatment. Based on clinical experience, we have therefore considered the existence of another pathological entity as the possible origin of pain and dysfunction. The hypothesis of this study is to relate subacromial impingement syndrome (SIS) with myofascial pain syndrome (MPS), since myofascial trigger points (MTrPs) cause pain, functional limitation, lack of coordination and alterations in quality of movement, even prior to a tendinopathy. MTrPs can coexist with any degenerative subacromial condition. If they are not taken into consideration, they could perpetuate and aggravate the problem, hindering diagnosis and making the applied treatments ineffective.The aims and methods of this study are related with providing evidence of the relationship that may exist between this condition and MPS in the diagnosis and treatment of rotator cuff tendonitis and/or SIS.

METHOD/DESIGN

A descriptive transversal study will be made to find the correlation between the diagnosis of SIS and rotator cuff tendonitis, positive provocation test responses, the existence of active MTrPs and the results obtained with ultrasonography (US) and Magnetic Renonance Imaging (MRI). A randomized double blinded clinical trial will be carried out in experimental conditions: A Protocolized treatment based on active and passive joint repositioning, stabilization exercises, stretching of the periarticular shoulder muscles and postural reeducation. B. The previously described protocolized treatment, with the addition of dry needling applied to active MTrPs with the purpose of isolating the efficacy of dry needling in treatment.

DISCUSSION

This study aims to provide a new vision of shoulder pain, from the perspective of MPS. This syndrome can, by itself, account for shoulder pain and dysfunction, although it can coexist with real conditions involving the tendons.

TRIAL REGISTRATION

ISRCTN Number: 30907460.

Post-operative rehabilitation after surgical repair of the rotator cuff

Today advances in techniques and materials for rotator cuff surgery allow the repair of a large variety of types or extensions of cuff lesions in patients from a wide range of age groups who have different kinds of jobs and participate in different kinds of sports, and who have widely different expectations in terms of recovery of functions and pain relief. A large number of factors must be taken into account before implementing a rehabilitation protocol after rotator cuff surgery. These mainly include the technique (materials and procedure) used by the surgeon. Moreover, tissue quality, retraction, fatty infiltration and time from rupture are important biological factors while the patient's work or sport or daily activities after surgery and expectations of recovery must also be assessed. A rehabilitation protocol should also take into account the timing of biological healing of bone to tendon or tendon to tendon interface, depending on the type of rupture and repair. This timing should direct the therapist's choice of correct passive or assisted exercise and mobilisation manoeuvres and the teaching of correct active mobilisation movements the patient has to do. Following accepted knowledge about the time of biological tissue healing, surgical technique and focused rehabilitation exercise, a conceptual protocol in four phases could be applied, tailoring the protocol for each patient. It starts with sling rest with passive small self-assisted arm motion in phase one, to prevent post-op stiffness. In phase two passive mobilisation by the patient dry or in water, integrated with scapular mobilisation and stabiliser reinforcement, are done. Phase three consists of progressive active arm mobilisation dry or in water integrated with proprioceptive exercise and "core" stabilisation. In phase four full strength recovery integrated with the recovery of work or sports movements will complete the protocol. Because of the multi-factorial aspects of the problem, the best results can be obtained through a full transfer of information from the surgeon to the therapist to optimise timing and sizing of the individual rehabilitation protocol for each patient.

Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol

A systematic review of the literature was performed to evaluate the role of exercise in treating rotator cuff impingement and to synthesize a standard evidence-based rehabilitation protocol. Eleven randomized, controlled trials (level 1 and 2) evaluating the effect of exercise in the treatment of impingement were identified. Data regarding demographics, methodology, and outcomes of pain, range of motion, strength, and function were recorded. Individual components of each rehabilitation program were catalogued. Effectiveness was determined by statistical and clinical significance. Although many articles had methodologic concerns, the data demonstrate that exercise has statistically and clinically significant effects on pain reduction and improving function, but not on range of motion or strength. Manual therapy augments the effects of exercise, yet supervised exercise was not different than home exercise programs. Information regarding specific components of the exercise programs was synthesized into a gold standard rehabilitation protocol for future studies on the nonoperative treatment of rotator cuff impingement.

3D kinematics of the glenohumeral joint during abduction motion: an ex vivo study

The clinical tolerance of rotator cuff tears is extremely variable, so the question is, what is the role of the deltoid in the shoulder stability? First of all, ex vivo experiments are necessary to analyse its effect. The aims of this study were: (1) to propose a testing protocol to measure the glenohumeral joint kinematics during the abduction motion by pulling on the deltoid without constraining the humerus and (2) to evaluate the repeatability of the 3D measurements. Six fresh-frozen anatomic specimens were tested. The kinematics follow-up of the osseous parts was carried out using an optoelectronic system (Polaris((R)), NDI, Canada). The abduction motion is realized by the pulling on anterior and medium fibers of the deltoid. For a 25 mm displacement, the range of motion: for the abduction was 24 degrees to 30.5 degrees , for the flexion was 1.5 degrees to -30.5 degrees (extension), for the medio-lateral rotation was 12 degrees (lateral rotation) to -5 degrees (medial rotation). For a displacement of the whole acromion-clavicle between 0 and 25 mm, the three humeral head translations were less than 5 mm. The three rotations and three translations were (with SD 95%): abduction: 0.5 degrees , flexion: 1 degrees , medio-lateral rotation: 1.5 degrees , three translations: 0.5 mm. The results showed a very high repeatability of the values. Results suggest that the deltoid alone can realize a motion of lateral elevation with a good stability in the glenohumeral joint as shown by the slight translation motion of the head and the value reproducibility. The protocol can be used to validate a finite element model of the glenohumeral joint.

Biomechanics of the deltoideus

The objective of this study was to determine the direction of the migration engendered by the middle deltoideus on the upper end of the humerus. Eleven patients suffering from shoulder pathology underwent an MRI examination (3 mm thick slices). From these MRI slices, 3D reconstructions were obtained for each patient by using a manual data capture system (SliceOmatic((R))). From this geometry, a mechanical model of the deltoideus was produced, taking into account the contacts between the latter and the following anatomical parts: supraspinatus, infraspinatus and humeral head. For the 11 shoulders, we have obtained a deltoideus showing a global resultant oriented upwards. There was, however, a component oriented downwards (at the level of the humeral head), its intensity being 40-80% less than the component oriented upwards (at the level of the deltoideus V). It is important to note that this study is valid only in the initial degrees of lateral elevation. The deltoideus is an elevator muscle of the humeral head in the glenoid, presenting nevertheless a component oriented downwards. The deltoideus would, therefore, intervene to recenter the shoulder during an abduction movement.