Rotator cuff rehabilitation: current theories and practice

Pain Neuroscience Education Following Arthroscopic Rotator Cuff Repair for Patients With Rotator Cuff Tears: A Double-Blind Randomized Controlled Clinical Trial

OBJECTIVE

This trial examines the efficacy of the pain neuroscience education on clinical outcomes in patients with arthroscopic rotator cuff repair.

DESIGN

A total of 36 participants undergoing arthroscopic rotator cuff repair were assigned to either the experimental group ( n = 18) or control group ( n = 18) in this randomized study. A 6-wk-long conventional physiotherapy program was administered for both groups. In addition, a pain neuroscience education protocol was administered for the experimental group for a whole period of 6 wks (1 session/week, 15-60 mins per session). The primary outcomes were to compare pretreatment and posttreatment scores of the experimental versus control groups on the pain and disability. Our secondary outcomes included the comparisons of scores on the catastrophizing, anxiety, depression, kinesiophobia, and quality of life. The participants were assessed both at baseline and posttreatment.

RESULTS

The improvement in pain catastrophizing, anxiety, depression, and kinesiophobia was greater in the experimental group ( P < 0.05). The improvement was similar in both groups in terms of the rest of outcome measures.

CONCLUSIONS

This study showed that the pain neuroscience education improved only psychological aspects of the chronic pain in arthroscopic rotator cuff repair. Therefore, adding pain neuroscience education to the conventional program might be useful to improve pain catastrophizing, anxiety, depression, and kinesiophobia in patients with arthroscopic rotator cuff repair.

Efficacy of manual therapy on shoulder pain and function in patients with rotator cuff injury: A systematic review and meta‑analysis

To critically evaluate the effects of manual therapy (MT) on pain and functional improvement in patients with rotator cuff injury (RCI), a systematic review of all randomized controlled trials (RCTs) on MT for RCI was conducted in the following databases: PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Physiotherapy Evidence Database, Chinese National Knowledge Infrastructure, Wan-fang Data, Chinese Scientific Journal Database, and Chinese Biomedical Literature database from inception to March 28, 2023. A total of 1,110 participants from 24 eligible RCTs were included in the analysis. Compared with placebo, MT could not effectively relieve pain [standardized mean difference (SMD)=-0.25; 95% CI: -0.51 to 0.01; P=0.06], although its impact on functional improvement appears limited (SMD=0.20; 95% CI: -0.09 to 0.49; P=0.18). Combining MT with exercise had significant advantages over exercise alone, as combined therapy contributed to both pain reduction (SMD=0.36; 95% CI: 0.08 to 0.64; P=0.01) and functional enhancement (SMD=0.32; 95% CI: 0.11 to 0.52; P=0.002). Furthermore, MT combined with multimodal physiotherapy showed additional benefits in pain reduction (mean difference=1.57; 95% CI: 0.18 to 2.96; P=0.03) and functional improvement (SMD=0.77; 95% CI: 0.43 to 1.12; P<0.0001) compared with multimodal physiotherapy alone. These findings highlight the superior pain alleviation and functional improvement provided by MT when combined with exercise or physiotherapy. Consequently, MT has emerged as a pivotal component of therapeutic intervention for RCI.

Biocomposite Anchors Have Greater Yield Load and Energy Compared With All-Suture Anchors in an In Vitro Ovine Infraspinatus Tendon Repair Model

Purpose

To compare tensile fatigue and strength measures of biocomposite and all-suture anchors in an ovine humerus-infraspinatus tendon model of rotator cuff repair.

Methods

Infraspinatus tendons on adult ovine humeri were sharply transected at the insertion. One of each pair was assigned randomly for fixation with 2 biocomposite or all-suture anchors. Constructs were tested with 200 cycles of 20 to 70 N tensile load, and gap formation was measured at the incised tendon end every 50 cycles. They were subsequently tested to failure. Outcome measures including fatigue stiffness, hysteresis, creep, and gap formation and tensile stiffness, and yield and failure displacement, load, and energy were compared between anchors.

Results

Biocomposite anchors had greater yield load (134.1 ± 6.5 N, P < .01) and energy (228.6 ± 85.7 J, P < .03) than all-suture anchors (104.7 ± 6.5 N, 169.8 ± 85.7 J). Fatigue properties were not different between anchors, but stiffness and gap formation increased and hysteresis and creep decreased significantly with increasing cycle number.

Conclusions

Although the yield displacement of both anchors was within the range of clinical failure, the tensile yield load and energy of ovine infraspinatus tendons secured to the humerus with 2 single-loaded all-suture anchors in a single row were significantly lower than those secured with 2 biocomposite anchors in the same configuration.

Clinical Relevance

It is important to understand the biomechanical properties for selecting anchors for rotator cuff repair. A direct comparison of fatigue testing followed by failure strength of infraspinatus tendon fixation with all-suture and biocomposite anchors could help guide anchor selection and postoperative mobility recommendations.

Effect of tetrahedral framework nucleic acids on the reconstruction of tendon-to-bone injuries after rotator cuff tears

Clinicians and researchers have always faced challenges in performing surgery for rotator cuff tears (RCT) due to the intricate nature of the tendon-bone gradient and the limited long-term effectiveness. At the same time, the occurrence of an inflammatory microenvironment further aggravates tissue damage, which has a negative impact on the regeneration process of mesenchymal stem cells (MSCs) and eventually leads to the production of scar tissue. Tetrahedral framework nucleic acids (tFNAs), novel nanomaterials, have shown great potential in biomedicine due to their strong biocompatibility, excellent cellular internalisation ability, and unparalleled programmability. The objective of this research was to examine if tFNAs have a positive effect on regeneration after RCTs. Experiments conducted in a controlled environment demonstrated that tFNAs hindered the assembly of inflammasomes in macrophages, resulting in a decrease in the release of inflammatory factors. Next, tFNAs were shown to exert a protective effect on the osteogenic and chondrogenic differentiation of bone marrow MSCs under inflammatory conditions. The in vitro results also demonstrated the regulatory effect of tFNAs on tendon-related protein expression levels in tenocytes after inflammatory stimulation. Finally, intra-articular injection of tFNAs into a rat RCT model showed that tFNAs improved tendon-to-bone healing, suggesting that tFNAs may be promising tendon-to-bone protective agents for the treatment of RCTs.

The effect of rehabilitation time on functional recovery after arthroscopic rotator cuff repair: a systematic review and meta-analysis

Objective

We compared the effects of early and delayed rehabilitation on the function of patients after rotator cuff repair by meta-analysis to find effective interventions to promote the recovery of shoulder function.

Methods

This meta-analysis was registered in PROSPERO (CRD42023466122). We manually searched the randomized controlled trials (RCTs) in the Cochrane Library, Pubmed, Cochrane Library, EMBASE, the China National Knowledge Infrastructure (CNKI), the China VIP Database (VIP), and the Wanfang Database to evaluate the effect of early and delayed rehabilitation after arthroscopic shoulder cuff surgery on the recovery of shoulder joint function. Review Manager 5.3 software was used to analyze the extracted data. Then, the PEDro scale was employed to appraise the methodological quality of the included research.

Results

This research comprised nine RCTs and 830 patients with rotator cuff injuries. According to the findings of the meta-analysis, there was no discernible difference between the early rehabilitation group and the delayed rehabilitation group at six and twelve months after the surgery in terms of the VAS score, SST score, follow-up rotator cuff healing rate, and the rotator cuff retear rate at the final follow-up. There was no difference in the ASES score between the early and delayed rehabilitation groups six months after the operation. However, although the ASES score in the early rehabilitation group differed significantly from that in the delayed rehabilitation group twelve months after the operation, according to the analysis of the minimal clinically important difference (MCID), the results have no clinical significance.

Conclusions

The improvement in shoulder function following arthroscopic rotator cuff surgery does not differ clinically between early and delayed rehabilitation. When implementing rehabilitation following rotator cuff repair, it is essential to consider the paradoxes surrounding shoulder range of motion and tendon anatomic healing. A program that allows for flexible progression based on the patient's ability to meet predetermined clinical goals or criteria may be a better option.

Tackling Kinesiophobia in Chronic Shoulder Pain: A Case Report on the Combined Effect of Pain Education and Whole-Body Cryostimulation

BACKGROUND

Chronic shoulder pain may cause significant functional disability and reduced psychosocial well-being. Detailed Case Description: In this case, we propose the use of pain neuroscience education and whole-body cryostimulation (WBC) to treat a 64-year-old woman with severe functional limitations and chronic right shoulder pain. The aim was to overcome kinesiophobia and improve her motor function, autonomy, and quality of life. Functional and clinical assessments were conducted at admission, discharge, and at a one-month follow-up via phone call. The patient's global health, shoulder function, and quality of life showed improvement during hospitalisation and were maintained after one month.

DISCUSSION

Pain education is crucial in managing chronic shoulder pain, especially in addressing kinesiophobia and promoting positive patient outcomes. In this context, WBC was used as a supplementary treatment to traditional pain relief and exercise tolerance therapies. This can help individuals to participate more actively in their rehabilitation process, ultimately promoting functional recovery and an improved quality of life.

CONCLUSION

The combination of cryostimulation, tailored physical exercises, pain education, manual therapy, and psychological support created a synergistic effect that addressed both the physical and psychological aspects of pain and kinesiophobia.

Structural and Functional Changes in Supraspinatus Tendinopathy through Percutaneous Electrolysis, Percutaneous Peripheral Nerve Stimulation and Eccentric Exercise Combined Therapy: A Single-Blinded Randomized Clinical Trial

Shoulder tendinopathies produce pain and reduce functionality. The aim of this randomized clinical trial was to analyze the effects of Percutaneous electrolysis (PE), Percutaneous peripheral Nerve Stimulation (PNS) and eccentric exercise (EE) on pain (NPRS), strength, electromyographic activity, ultrasound characteristics of the tendon (echogenicity, thickness and hypervascularization) and functionality (DASH and SPADI) in individuals with supraspinatus tendinopathy. Participants (n = 50) were divided into two groups; they received 4 treatment sessions, 1 per week, of PE and PNS (n = 25) or 10 treatment sessions of TENS and US (n = 25). Both groups performed the EE program consisting of 3 sets of 10 repetitions of each of the 3 exercises, twice a day, during the 4 weeks. Follow-up was carried out at 4, 12 and 24 weeks after the start of the intervention. There are statistically significant differences in the analysis between groups (p < 0.001) in the post-treatment and follow-up measurements favorable to the PE+PNS+EE treatment on pain (NPRS), strength, supraspinatus electromyographic amplitude, ultrasound characteristics of the tendon (echogenicity, thickness and hypervascularization) and DASH and SPADI questionnaires. The combined treatment with PE, PNS and EE is an effective option in the clinical management of tendinopathies, with positive results in the short and long term on the variables studied.

The influence of rotator cuff tear type and weight bearing on shoulder biomechanics in an ex vivo simulator experiment

Glenohumeral biomechanics after rotator cuff (RC) tears have not been fully elucidated. This study aimed to investigate the muscle compensatory mechanism in weight-bearing shoulders with RC tears and asses the induced pathomechanics (i.e., glenohumeral translation, joint instability, center of force (CoF), joint reaction force). An experimental, glenohumeral simulator with muscle-mimicking cable system was used to simulate 30° scaption motion. Eight fresh-frozen shoulders were prepared and mounted in the simulator. Specimen-specific scapular anthropometry was used to test six RC tear types, with intact RC serving as the control, and three weight-bearing loads, with the non-weight-bearing condition serving as the control. Glenohumeral translation was calculated using instantaneous helical axis. CoF, muscle forces, and joint reaction forces were measured using force sensors integrated into the simulator. Linear mixed effects models (RC tear type and weight-bearing) with random effects (specimen and sex) were used to assess differences in glenohumeral biomechanics. RC tears did not change the glenohumeral translation (p > 0.05) but shifted the CoF superiorly (p ≤ 0.005). Glenohumeral translation and joint reaction forces increased with increasing weight bearing (p < 0.001). RC and deltoid muscle forces increased with the presence of RC tears (p ≤ 0.046) and increased weight bearing (p ≤ 0.042). The synergistic muscles compensated for the torn RC tendons, and the glenohumeral translation remained comparable to that for the intact RC tendons. However, in RC tears, the more superior CoF was close to where glenoid erosion occurs in RC tear patients with secondary osteoarthritis. These findings underscore the importance of early detection and precise management of RC tears.

The Rehabilitation Journey of a Cricket Player With Partial Rotator Cuff Tear: A Case Report of Pre and Postoperative Physiotherapy

In adults, partial rotator cuff injuries can frequently be the root cause of pain in the shoulder. One recurrent pathology that may significantly impact a broad spectrum of individuals, including athletes, laborers, and sedentary people, is partial rotator cuff tears (RCTs). Physical therapy, anti-inflammatories, painkillers, rest or activity modifications, and corticosteroid injections are a few nonoperative treatment options for partial RCTs. We report a case of a 27-year-old male who sustained a rotator cuff injury of the right shoulder. The patient presented with pain and restriction of the right shoulder joint following the injury, which had occurred while throwing a ball forcefully with his right hand. The rehabilitation program emphasized pain management, restoring range of motion (ROM), increasing strength of muscles, and functional activities to optimize the patient's recovery. Concurrently, isometrics, ROM, and strengthening exercises were integrated into the rehabilitation program to enhance muscle strength, prevent tightness, and maintain ROM. The patient's progress was monitored by using the Disabilities of Arm, Shoulder, and Hand (DASH) score and the Upper Extremity Functional Scale (UEFS) at specific intervals during rehabilitation. The treatment and healing of a patient with an RCT who underwent both pre and postoperative physiotherapy are explored in this case report.

Performance Evaluation of an Immersive Virtual Reality Application for Rehabilitation after Arthroscopic Rotator Cuff Repair

Few studies have evaluated the effectiveness of shoulder rehabilitation in virtual environments. The objective of this study was to investigate the performance of a custom virtual reality application (VR app) with a stereophotogrammetric system considered the gold standard. A custom VR app was designed considering the recommended rehabilitation exercises following arthroscopic rotator cuff repair. Following the setting of the play space, the user's arm length, and height, five healthy volunteers performed four levels of rehabilitative exercises. Results for the first and second rounds of flexion and abduction displayed low total mean absolute error values and low numbers of unmet conditions. In internal and external rotation, the number of times conditions were not met was slightly higher; this was attributed to a lack of isolated shoulder movement. Data is promising, and volunteers were able to reach goal conditions more often than not. Despite positive results, more literature comparing VR applications with gold-standard clinical parameters is necessary. Nevertheless, results contribute to a body of literature that continues to encourage the application of VR to shoulder rehabilitation programs.

Factors influencing physical therapy utilization after shoulder surgery: a retrospective review

Background

Postoperative physical therapy (PT) is a cornerstone to achieve optimal patient outcomes. Access to postoperative PT can be limited by insurance type, coverage, and cost. With copayments (CP) for PT as high as $75 per visit, PT can be costprohibitive for patients. The purpose of this study was to evaluate factors affecting PT utilization among patients that underwent shoulder surgery.

Methods

A retrospective analysis was performed of 80 shoulder surgery patients with postoperative PT sessions attended at a single institution from 2017 to 2019. Patients were divided based on insurance type: private insurance (PI), and Medicare with or without supplemental insurance (MI), and CP or no copayment. Demographics, CP, total, and postoperative number of PT sessions utilized was collected and analyzed.

Results

The cohort had 53 females and an average age of 62. There was no significant difference between PI and MI at baseline other than surgery performed (P = .03), older MI group (69 years vs. 56 years: P < .01), and more females in PI group (76% vs. 55%; P = .05). There was no significant difference in the number of PT sessions between groups. The PI group was more likely to have a CP (P < .01). The CP group more often had PI and significantly more total PT visits (P = .05), while the no copayment group more often had Medicare (P < .01). CP was not independently associated with a change in the number of PT visits or total PT visits.

Conclusions

The utilization of PT after shoulder surgery was found to not be influenced by insurance type or CP as determined by the number of PT sessions attended. Further investigations are necessary to better understand the relationship between CP and different insurance types and develop effective strategies to increase access to PT for postoperative shoulder patients.

Pressure pain sensitivity, thermographic changes, function, life and sleep quality in patients with unilateral rotator cuff injury: A case-control study

INTRODUCTION-AIM

This study aimed to assess pressure pain sensitivity, thermographic changes, functional status, quality of life, and sleep in individuals with unilateral shoulder pain due to rotator cuff tear and compare these parameters with the unaffected side and asymptomatic individuals.

MATERIAL-METHOD

Thirty-two patients with unilateral rotator cuff injury and 32 volunteers without shoulder problems were included. Pain was evaluated using a visual analogue scale, pressure pain sensitivity with a digital algometer, thermographic changes with a thermal camera, upper extremity function through the Disabilities of the Arm, Shoulder, and Hand Disability Questionnaire, sleep quality using the Pittsburgh Sleep Quality Index, and quality of life using SF-36.

RESULTS

Pressure pain sensitivity of the deltoideus, supraspinatus, and subscapularis muscles in the affected limb was lower than in the unaffected limb (p = 0.027, p = 0.005, p < 0.001). Conversely, pressure sensitivity of the deltoideus, biceps brachii, and subscapularis muscles was higher in the patient group (p = 0.008, p = 0.042, p < 0.001). Furthermore, a decrease in temperature was observed in all patients, except for the trapezius muscles of the affected side (p < 0.05).

CONCLUSION

This study sheds light on altered pressure pain sensitivity and thermographic changes in individuals with unilateral shoulder pain due to rotator cuff tear. Additionally, the study highlights impairments in functional status, quality of life, and sleep in these individuals, emphasizing the broader impact of such injuries. Targeted interventions based on these findings have the potential to enhance overall well-being and functional outcomes for affected individuals.

LEVEL OF EVIDENCE

Level III, Case-control study, prognosis study.

Preoperative factors affecting the quality of life after arthroscopic rotator cuff repair: a prospective study

Background

Rotator cuff tears are well known to cause significant pain and disability, having a marked impact on an individual's quality of life. This prospective study aimed to analyze the various patient factors and their impact on health-related quality of life (HrQoL) post arthroscopic rotator cuff repair (RCR).

Material and Methods

We prospectively analyzed 95 patients at one year and 81 patients at two years, with complete rotator cuff tear, who underwent arthroscopic repair of the same. The 36-Item Short Form Survey (physical and mental component score), visual analog scale (pain, function), and QuickDASH questionnaires were administered to all the patients preoperatively and at one- and two-year follow-ups. Relationships between various patient factors (age, gender, side, duration of symptoms, pseudoparalysis, diabetes mellitus [DM], type, and size of tear) and outcome measures were analyzed.

Results

All outcome parameters showed significant improvement at one- and two-year follow-ups. Patient factors, such as gender, tear type (traumatic vs degenerative), and DM, affected all outcome parameters and were significant even in the regression analysis model at a 2-year follow-up. Factors such as age and symptoms duration were significant only at 1-year follow-up, with older age and patients with symptoms > 6 weeks showing more disability. Side (dominant or nondominant), tear size, and pseudoparalysis do not affect outcomes.

Conclusions

This study showed that arthroscopic RCR significantly improved HrQoL post arthroscopic RCRs. Factors independently affecting HrQoL were noted as gender, tear type, and DM. On the other hand, age, side involved, duration of symptoms, pseudoparalysis, and tear size had no independent effect on HrQoL at a two-year follow-up.

A network meta-analysis of arthroscopic rotator cuff repair

OBJECTIVE

Rotator cuff tear is a common shoulder injury that often leads to serious limitations in daily life. Herein, a network Meta-analysis using frequency theory was performed to evaluate the clinical outcomes of five rotator cuff repair techniques, including single-row repair, double-row repair, suture bridge repair, platelet-rich plasma therapy, and bone marrow stimulation, thus guiding clinical decision-making on rotator cuff repair.

METHODS

PubMed, EMbase, The Cochrane Library, and Web of Science were searched for randomized controlled trials and cohort studies comparing rotator cuff repair techniques published from inception to May 2022. Combined analysis and quality assessment were performed using software STATA15.1 and Review Manager5.3.

RESULTS

A total of 51 articles were finally included, including 27 randomized controlled trials and 24 cohort studies. Results from the network Meta-analysis showed that: (1) In terms of the American Shoulder and Elbow Surgeons score, platelet-rich plasma therapy, double-row repair, bone marrow stimulation, and single-row repair were significantly better than suture bridge repair. (2) In terms of Constant score, bone marrow stimulation was significantly better than double-row repair, single-row repair, and suture bridge repair. (3) In terms of visual analog scale score, platelet-rich plasma therapy was significantly better than double-row repair and suture bridge repair. (4) In terms of the Shoulder Rating Scale of the University of California at Los Angeles score, platelet-rich plasma therapy and double-row repair were relatively better but not significantly different from the other treatments. (5) In terms of the risk of re-tear, the re-tear rate of platelet-rich plasma therapy and double-row repair was significantly lower than that of single-row repair and suture bridge repair.

CONCLUSION

Based on the results of network Meta-analysis and surface under the cumulative ranking, platelet-rich plasma therapy, bone marrow stimulation, and double-row repair have good overall rehabilitation effects. It is recommended to choose appropriate repair techniques as per the actual clinical situation.

Effectiveness of Glenohumeral Joint Mobilization on Range of Motion and Pain in Patients With Rotator Cuff Disorders: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to determine the effectiveness of glenohumeral joint mobilization (JM) on range of motion and pain intensity in patients with rotator cuff (RC) disorders.

METHODS

An electronic search was performed in the MEDLINE, CENTRAL, Embase, PEDro, LILACS, CINAHL, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that investigated the effect of glenohumeral JM techniques with or without other therapeutic interventions on range of motion, pain intensity, and shoulder function in patients older than 18 years with RC disorders. Two authors independently performed the search, study selection, and data extraction, and assessed risk of bias. Grades of Recommendation Assessment, Development and Evaluation ratings were used to evaluate the quality of evidence in this study.

RESULTS

Twenty-four trials met the eligibility criteria, and 15 studies were included in the quantitative synthesis. At 4 to 6 weeks, for glenohumeral JM with other manual therapy techniques vs other treatments, the mean difference (MD) for shoulder flexion was -3.42° (P = .006), abduction 1.54° (P = .76), external rotation 0.65° (P = .85), and Shoulder and Pain Disability Index score 5.19 points (P = .5), and standard MD for pain intensity was 0.16 (P = .5). At 4 to 5 weeks, for the addition of glenohumeral JM to an exercise program vs exercise program alone, the MD for the visual analog scale was 0.13 cm (P = .51) and the Shoulder and Pain Disability Index score was -4.04 points (P = .01).

CONCLUSION

Compared with other treatments or an exercise program alone, the addition of glenohumeral JM with or without other manual therapy techniques does not provide significant clinical benefit with respect to shoulder function, range of motion, or pain intensity in patients with RC disorders. The quality of evidence was very low to high according to Grades of Recommendation Assessment, Development and Evaluation ratings.

Bibliometric and visualized analysis of scientific publications on rehabilitation of rotator cuff injury based on web of science

Background

Since the discovery of rehabilitation as an intervention for rotator cuff injury, its impact on the recovery of rotator cuff injury has attracted crucial attention, and the number of related studies is increasing worldwide. There were no bibliometric and visualized analysis studies in this field. This study aimed to investigate the research hotpots and trends in the rehabilitation of rotator cuff injury via bibliometric and visualized analysis and to identify the future development of clinical practice.

Method

The publications regarding rehabilitation of rotator cuff injury from inception to December 2021 were obtained from the Web of Science Core Collection database. The trends of publications, co-authorship and co-occurrence analysis and visualized analysis were carried out using Citespace, VOSviewer, Scimago Graphica software, and R Project.

Results

A total of 795 publications were included in this study. The number of publications significantly increased yearly. The United States published the highest number of related papers and the papers published by the United States had the highest citations. The University of Laval, the University of Montreal and Keele University were the top 3 most contributive institutions. Additionally, the Journal of Shoulder and Elbow Surgery was the journal with the highest number of publications. The most common keywords were "rotator cuff", "rehabilitation", "physical therapy", "management", and "telerehabilitation".

Conclusion

The total number of publications has shown a steady upward trend. The cooperation between countries globally was still relatively lacking, and therefore it is necessary to strengthen cooperation between different countries and regions to provide conditions for multi-center, large sample, and high-quality research. In addition to the relatively mature rehabilitation of rotator cuff injury such as passive motion or exercise therapy, telerehabilitation has also attracted much attention with the progress of science.

Arthroscopic therapy of rotator cuff diseases: A bibliometric study of the past 2 decades (2002–2021)

Purpose

Rotator cuff diseases, as a common cause of shoulder pain and disability, have seriously affected the patients' daily life. Rotator cuff repair techniques have been a hot topic in the arthroscopic therapy field. Our study was to use bibliometrics analysis to clarify the current status and research trends in the field of arthroscopic therapy of rotator cuff diseases.

Methods

The publications relating to arthroscopic therapy of rotator cuff diseases published from 2001 to 2021 were obtained from the Web of Science Core Collection (WoSCC) database. The R software and VOSviewer software were used for the cross-sectional bibliometric and scientometric analysis.

Results

A total of 4,567 publications about arthroscopic therapy of rotator cuff diseases published between 2002 and 2021 retrieved from the WoSCC database were analyzed in our study. The results showed that the United States made the largest contribution to this field. The most relevant institutions were Seoul National University, Rush University, and Hospital for Special Surgery. Stephen S Burkhart was the most relevant researcher in this field with the largest number of publications, as well as the highest H-index and G-index. The journal ARTHROSCOPY contributed the largest number of publications in the past 2 decades. Considering the H-index and G-index, ARTHROSCOPY was also the journal with the largest impact in this field.

Conclusions

Arthroscopic Therapy of Rotator Cuff Diseases Related research presented a rising trend in the past 2 decades. The United States can be regarded as the leader because of its huge contributions to this field. The journal ARTHROSCOPY published the largest number of publications in this field. It can be predicted that research about advanced arthroscopic techniques and postoperative pain management of patients with rotator cuff diseases will be the next research hotspots in the following years.

Functional biomaterials for tendon/ligament repair and regeneration

With an increase in life expectancy and the popularity of high-intensity exercise, the frequency of tendon and ligament injuries has also increased. Owing to the specificity of its tissue, the rapid restoration of injured tendons and ligaments is challenging for treatment. This review summarizes the latest progress in cells, biomaterials, active molecules and construction technology in treating tendon/ligament injuries. The characteristics of supports made of different materials and the development and application of different manufacturing methods are discussed. The development of natural polymers, synthetic polymers and composite materials has boosted the use of scaffolds. In addition, the development of electrospinning and hydrogel technology has diversified the production and treatment of materials. First, this article briefly introduces the structure, function and biological characteristics of tendons/ligaments. Then, it summarizes the advantages and disadvantages of different materials, such as natural polymer scaffolds, synthetic polymer scaffolds, composite scaffolds and extracellular matrix (ECM)-derived biological scaffolds, in the application of tendon/ligament regeneration. We then discuss the latest applications of electrospun fiber scaffolds and hydrogels in regeneration engineering. Finally, we discuss the current problems and future directions in the development of biomaterials for restoring damaged tendons and ligaments.

The effect of watching shoulder ROM changes on functional outcome and quality of life following arthroscopic rotator cuff repair

PurposeThis study aimed to evaluate the effectiveness of watching video records of their shoulder motion changes on functional outcomes and quality of life after arthroscopic rotator cuff repair (ARCR). Methods The patients were divided into two groups. In Group 1, video records of pre- and postoperative shoulder motions were recorded and showed. In Group 2, no video was showed to the patients. In Group 1, the first postoperative evaluation was done before video watching, and the second evaluation was done just after watching video records. In Group 2, the first and second postoperative measurements were performed with 10-20 days interval. The Constant Murley score (CS), the American Shoulder and Elbow Surgeons score (ASES), the Short-Form 36 (SF-36) score, and active shoulder range of motion (ROM) values were used as an outcome tool. Results A total of 196 patients (Group 1; 76 patients and Group 2; 120 patients) with a mean age of 62.06 ± 7.17 years were included. There was a significant improvement in postoperative scores of SF-36 subscales (except emotional well-being and energy/fatigue), ASES, CM scores, and joint ROM values when compared to preoperative values for both groups (p < .001). The first postoperative outcomes were similar between groups (p > .05). In the second postoperative evaluation, emotional role functioning, energy/fatigue, emotional well-being, health change subscales of SF-36, and ASES scores were significantly higher in Group 1 compared with Group 2 (p < .05). Conclusion When patients watch the pre- and postoperative video records of their shoulder ROM after ARCR, patients' satisfaction and well-being perception increase in the short-term despite unchanged shoulder ROM.

Effectiveness of supervised physiotherapy versus home exercise in subjects with rotator cuff disorders treated surgically: A systematic review and meta-analysis

OBJECTIVE

The aim is to determine the effectiveness of supervised Physiotherapy (PT) versus a home exercise program for functional outcomes in patients with rotator cuff (RC) disorders treated surgically. TYPE: Systematic review and meta-analysis of randomized clinical trials.

METHODOLOGY

An electronic search was performed in the MEDLINE, CENTRAL, EMBASE, PEDro, LILACS, CINAHL, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that compared supervised PT versus home exercises in functional outcomes, such as shoulder or upper limb function, pain intensity, and range of motion, in subjects older than 18 years with RC disorders treated surgically.

SYNTHESIS

Six trials met the eligibility criteria, and for the quantitative synthesis, five studies were included. At 3 months, the mean difference (MD) for the Constant-Murley questionnaire (0-100 points) was -0.76 points (95% confidence interval (CI) = -15.64 to 14.12, p = 0.92), while the MD for the visual analog scale (0-10 cm) was -0.87 cm (95% CI = -2.8 to 1.06, p = 0.38). These differences were neither clinically nor statistically significant.

CONCLUSION

There was very low quality of evidence towards no better benefits in shoulder pain and function of supervised PT over home exercises programs in patients older than 18 years with RC disorders treated surgically.

PROSPERO REGISTRATION

CRD42020185805.

Non-Operative Shoulder Dysfunction in the United States Military

INTRODUCTION

Recent epidemiological evidence shows that shoulder and upper-arm complaints impose a substantial burden on the armed forces of the United States and create significant challenges for all components of the physical fitness domain of total force fitness. Clinicians, epidemiologists, and health-services researchers interested in shoulder and upper-arm injuries and their functional limitations rarely have objective, validated criteria for rigorously evaluating diagnostic practices, prescribed treatments, or the outcomes of alternative approaches. We sought to establish and quantify patient volume, types of care, and costs within the Military Health System (MHS) in assessing and managing active duty members with nonoperative shoulder and upper-arm dysfunction.

MATERIALS AND METHODS

We performed a retrospective cohort study using data from the MHS Data Repository and MHS MART (M2) from fiscal year 2014 to identify active duty individuals with a diagnosis of shoulder and upper-arm injury or impairment defined by one of the International Classification of Disease Ninth Edition diagnosis codes that were selected to reflect nonoperative conditions such as fractures or infections. Statistical analyses include descriptive statistics on patient demographics and clinical visits, such as the range and frequency of diagnoses, number and types of appointments, and clinical procedure information following the diagnosis. We also examined treatment costs related to shoulder dysfunction and calculated the total cost to include medications, radiological, procedural, and laboratory test costs for all shoulder dysfunction visits in 2014 and the average cost for each visit. We further examined the category of each medication prescribed.

RESULTS

A total of 55,643 individuals met study criteria and accrued 193,455 shoulder-dysfunction-related clinical visits in fiscal year 2014. This cohort represents approximately 4.8% of the 1,155,183 active duty service members assigned to the United States and its territories during FY 2014. Most patients were male (85.32%), younger (85.25% were under 40 years old), and Caucasian/White (71.12%). The most common diagnosis code was 719.41 (pain in joint, shoulder region; 42.48%). The majority of the patients 42,750 (76.8%) had four or fewer medical visits during the study period and 12,893 (23.2%) had more than four visits. A total of 4,733 patients (8.5%) underwent arthrocentesis aspiration or injection. The total cost for all visits was $65,066,767.89. The average and median cost for each visit were $336.34 (standard deviation was $1,493.87) and $163.11 (range was from 0 to $84,183.88), respectively. Three out of four patients (75.3%) underwent radiological examinations, and 74.2% of these individuals had more than one radiological examination. Medications were prescribed to 50,610 (91.0%) patients with the three most common being IBUPROFEN (12.21%), NAPROXEN (8.51%), and OXYCODONE-ACETAMINOPHEN (5.04%), respectively.

CONCLUSIONS

Nearly 1 in 20 active duty military service members presented for nonoperative care of shoulder and/or upper-arm dysfunction during FY2014. Further examinations of the etiology and potential impact of shoulder/upper-arm dysfunction on force readiness are clearly warranted, as are additional studies directed at identifying best practices for preventing injury-related dysfunction and determining best practices for the treatment of shoulder dysfunction to optimize service member fitness and force readiness.

The role of scapular dyskinesis on rotator cuff tears: a narrative review of the current knowledge

Scapular dyskinesis can be present in healthy individuals as in patients with shoulder pathology.Altered patterns of scapular kinematics can cause or exacerbate rotator cuff tear pathology. However, more research is needed.Regardless of the cause or the consequence of rotator cuff tear, scapular dyskinesis impairs shoulder function, worsens the symptoms, and compromises the success of clinical intervention.The available literature suggests physical therapy as the first treatment for degenerative cuff tears, and scapular dyskinesis should be addressed if present. Non-responsive cases or traumatic tears may require surgery.Postsurgical physical therapy protocols after rotator cuff repair must consider scapular dyskinesia to improve the outcomes. Cite this article: EFORT Open Rev 2021;6:932-940. DOI: 10.1302/2058-5241.6.210043.

Conservative versus accelerated rehabilitation after rotator cuff repair: a systematic review and meta-analysis

Background

The purpose of this systematic review and meta-analysis is to compare the conservative and accelerated rehabilitation protocols in patients who underwent arthroscopic rotator cuff repair in terms of clinical outcomes and range of motions at 3, 6, 12, and 24-month follow-up.

Methods

According to PRISMA guidelines, a systematic review of the literature was performed. For each included article, the following data has been extracted: authors, year, study design, level of evidence, demographic characteristics, follow-up, clinical outcomes, range of motions, and retear events. A meta-analysis was performed to compare accelerated versus conservative rehabilitation protocols after arthroscopic rotator cuff repair. The retear rate, postoperative Constant-Murley score and range of motions at 3, 6, 12, and 24 months of follow-up were the outcomes measured.

Results

The search strategy yielded 16 level I-II clinical studies. A total of 1424 patients, with 732 patients and 692 in the accelerated and conservative group, were included. The average age (mean ± standard deviation) was 56.1 ± 8.7 and 56.6 ± 9 in the accelerated and conservative group. The mean follow-up was 12.5 months, ranging from 2 to 24 months. The meta-analysis showed no statistically significant differences in terms of retear rate between the groups (P = 0.29). The superiority of the accelerated group was demonstrated in terms of external rotation (P < 0.05) at 3-month follow-up; in terms of forward elevation, external rotation, abduction (P < 0.05), but not in terms of Constant-Murley score at 6-month follow-up; in terms of forward elevation (P < 0.05) at 12-month follow-up. No significant differences between the two group were highlighted at 24-month follow-up.

Conclusions

No statistically significant differences in the retear rate among the accelerated and conservative group have been demonstrated. On the other hand, statistically and clinically significant differences were found in terms of external rotation at 3 and 6 months of follow-up in favour of the accelerated group. However, no differences between the two groups were detected at 24 months follow-up.

Analysis of Functional Recovery and Subjective Well-Being after Arthroscopic Rotator Cuff Repair

Background: Rotator cuff tears are common causes of functional shoulder instability and often lead to arthroscopic rotator cuff repair. A well-programmed rehabilitation leads to successful tendon healing, positive functional recovery and subjective well-being (SWB). Objective: To evaluate the changes in shoulder functioning and SWB pre-, post-outpatient rehabilitation and after one-month follow-up. Materials and Methods: A total of 44 patients were assessed three times: at the beginning (six weeks’ post-surgery), at the end of outpatient rehabilitation (2–3 weeks) and one month after rehabilitation. The outcome measures were the Disabilities of the Arm, Shoulder and Hand score (DASH), active range of motion (ROM), manual muscle testing (MMT), hand dynamometry (HD) and pain level by a Visual Analogue Scale (VAS). SWB was assessed by Rosenberg self-esteem scale (RSES), Positive and Negative Affect Schedule (PANAS) and the Lithuanian Psychological Well-Being Scale (LPWBS). Results are presented as a difference between periods. Results: Affected shoulder motor function (MMT, HD and ROM) significantly improved in three periods (p < 0.05); however, major recovery was observed in the follow-up period. VAS scores meaningfully decreased over all stages and negatively correlated with motor function recovery (p < 0.05). DASH rates exhibited significant retrieval in all phases, especially in follow-up. SWB results demonstrated the larger effects of self-evaluation in follow-up, improved daily functions and psychological wellness, then negative emotions significantly decreased (p < 0.05). Conclusions: The experienced pain and psychosocial factors significantly influence functional recovery of the shoulder during rehabilitation. The improvement in motor function, ability and pain relief during rehabilitation increases level of SWB, psychological wellness and positive emotional affect in long-term context.

The effectiveness of high-intensity laser therapy in the treatment of post-stroke patients with hemiplegic shoulder pain: a prospective randomized controlled study

To evaluate clinical and ultrasonographic efficacy of high-intensity laser therapy (HILT) in patients with hemiplegic shoulder pain (HSP) accompanied by partial thickness rotator cuff tear (PTRCT). The study was designed as a prospective, randomized, controlled trial. Patients with HSP accompanied by PTRCT (n = 44) were randomly assigned to HILT and control groups. Both groups were treated with a multidisciplinary stroke rehabilitation and a therapeutic exercise program to the affected shoulder supervised by physiotherapists. In addition, HILT group received 3 sessions of the intervention per week for 3 weeks. Primary outcome measure was visual analogue scale (VAS) for pain. Secondary outcome measures were range of motion (ROM) of the shoulder joint, Shoulder Pain and Disability Index (SPADI), Brunnstrom Recovery Stage (BRS), Modified Ashworth Scale (MAS), Nottingham Health Profile (NHP), Functional Independence Measure (FIM), and ultrasonographic PTRCT size. Participants were assessed at pre- and post-treatment. A total of 41 patients completed the study. A statistically significant improvement was observed in VAS, ROM, FIM, SPADI, NHP, and PTRCT parameters in HILT group at post-treatment compared to pre-treatment (all P < 0.05). However, control group indicated significant improvement only in VAS, ROM, and SPADI parameters (all P < 0.05). When differences in clinical parameters at pre- and post-treatment assessment were compared between two groups, change in VAS, FIM, BRS, SPADI, NHP, and PTRCT in HILT group was significantly better than control group (all P < 0.05). HILT combined with therapeutic exercise seems to be clinically and ultrasonographically more effective in the treatment of patients with HSP accompanied by PTRCT than therapeutic exercise alone in the short term. Further studies are needed with long-term follow-up. CinicalTrials.gov Identifier: NCT04669405.

The effect of physiotherapy in rotator cuff injury patients with platelet-rich plasma: study protocol of a non-randomized controlled trial

Background

The study aims to identify whether Platelet-rich plasma (PRP) combined with early physiotherapy has an advantage over PRP alone for rotator cuff injury patients, regarding pain release, function score, tear size, and quality of life improvement.

Methods

This is a single-center prospective non-randomized study implemented in July 2019 at the Affiliated Hospital of Southwest Medical University in Sichuan. Three hundred-forteen patients with rotator cuff injury aged over 18 years were recruited. Participants were assigned to the experiment group (PRP plus physiotherapy) or control group (PRP) by their desire. We used the Constant-Murley score to assess the shoulder function, the Visual Analogue Scale to evaluate shoulder pain, and the MOS Item Short-form Health Survey (SF-12) to measure the quality of life. MRI was applied to measure tear size, and the follow-up duration is 12 months.

Discussion

Our findings will give information on the effects of PRP and physiotherapy on rotator cuff injuries. Physiotherapy might be added to improve the effects of PRP in patients with rotator cuff injuries.

Trial registration

This study was registered in the Chinese clinical trial registry on September 1st, 2019 (ChiCTR1900025563).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04171-2.

A Review of Online Rehabilitation Protocols Designated for Rotator Cuff Repairs

Purpose

To compare publicly available rehabilitation protocols designated for rotator cuff (RTC) repairs published online by academic residency programs and private practice institutions.

Methods

A systematic electronic search using the Fellowship and Residency Electronic Interactive Database Access System (FREIDA) was performed for RTC repair rehabilitation protocols. Private practice programs with published rehabilitation protocols that were discovered during the Google search were also included for review, but no comprehensive search for private practice protocols was performed. The main exclusion criteria consisted of non–English-language protocols and protocols without any of the time-based components in question. Included protocols were assessed independently based on the specified RTC tear size (small [≤1 cm], medium [1-4 cm], large or massive [≥5 cm], or no mention of size). Protocols were compared based on the inclusion, exclusion, and timing of certain rehabilitation components.

Results

A total of 96 rehabilitation protocols were included for review, from 39 academic institutions and 28 private practice programs. Specific instructions for concomitant biceps tenodesis were included in 26 protocols (27.1%). Of the 96 protocols, 88 (91.7%) did not place restrictions on early postoperative passive range of motion (PROM) of the shoulder. Isolated PROM with restrictions on active range of motion was most commonly recommended for the first 4 or 6 weeks postoperatively (80.2%). Use of a sling or immobilizer was most frequently recommended for the first 4 or 6 weeks postoperatively (78.1%). Wide variation was noted in recommendations for returning to resistance strengthening, with the highest incidence being 27 protocols recommending returning at 12 weeks (28.1%); this further varied based on the size of the tear. A total of 21 protocols (21.9%) recommended the use of cryotherapy postoperatively.

Conclusions

Although certain rehabilitation components were common, such as duration of PROM and sling or immobilizer use, a large degree of variation remains among published rehabilitation protocols after RTC repair, and this variability is still seen even when subdividing by the size or severity of the RTC tear.

Clinical Relevance

Rehabilitation after RTC repair is crucial to patient outcomes. This study summarizes the variability among online rehabilitation protocols for RTC repair in the United States and emphasizes the importance of appropriate rehabilitation after RTC surgery.

Tendon Healing Progression Evaluated With Magnetic Resonance Imaging Signal Intensity and Its Correlation With Clinical Outcomes Within 1 Year After Rotator Cuff Repair With the Suture-Bridge Technique

BACKGROUND

After a rotator cuff (RC) is repaired, its signal intensity (SI) on magnetic resonance imaging (MRI) gradually changes to normal and could reflect the degree of RC healing. Nevertheless, it remains unclear how long it takes for SI to recover to normal and whether the SI progression correlates with clinical outcomes after RC repair (RCR).

PURPOSE

To serially evaluate the SIs of the repaired RC tendon on MRI and the postoperative clinical outcomes and then analyze the correlation between them.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study prospectively included 25 patients who underwent arthroscopic RCR with the suture-bridge technique between June 2016 and July 2017. Twenty-three patients accepted full follow-ups at 1, 3, 6, 9, and 12 months. Before surgery and at each follow-up, visual analog scale (VAS) for pain and 4 functional scores were evaluated: Constant-Murley score, American Shoulder and Elbow Surgeons shoulder evaluation form, modified University of California at Los Angeles score, and Fudan University shoulder score. The patients underwent MRI examinations at every follow-up. The values of the signal/noise quotient at the distal (SNQd) and proximal (SNQp) areas were calculated to evaluate the SI of the repaired tendon. The correlations of clinical outcomes with SNQd and SNQp values were analyzed, and subgroup analyses were performed.

RESULTS

Overall, the mean postoperative VAS score significantly decreased at postoperative 1 month (P < .001), and the functional scores were all significantly higher than the preoperative values at 6 months (all P < .001). SNQd and SNQp values were both significantly higher than normal at 1 and 3 months (all P < .001) and reduced to normal after 9 and 6 months, respectively. Correlation analyses showed that the SNQp value significantly correlated with VAS score (positive) and all functional scores (negative) at 1 and 3 months postoperatively. Further comparison indicated that the patients with VAS score >3 had higher SNQp values than patients with VAS score ≤3 at 1 and 3 months postoperatively (both P = .01).

CONCLUSION

After RCR with the suture-bridge technique, it took longer for SI to become relatively normal than it did to have a significant clinical improvement. Early after surgery (1-3 months), worse clinical outcome correlated with higher SI on proximal cuff tendon.

Comparison of MRI and MRA for the diagnosis of rotator cuff tears: A meta-analysis

BACKGROUND

Numerous quantitatively based studies measuring the accuracy of MRI and MRA for the diagnosis of rotator cuff tears remain inconclusive. In order to compare the accuracy of MRI with MRA in detection of rotator cuff tears a meta-analysis was performed systematically.

METHODS

PubMed/Medline and Embase were utilized to retrieve articles comparing the diagnostic performance of MRI and MRA for use in detecting rotator cuff tears. After screening and diluting out the articles that met inclusion criteria to be used for statistical analysis the pooled evaluation indexes including sensitivity and specificity as well as hierarchical summary receiver operating characteristic (HSROC) curves with 95% confidence interval (CI) were calculated.

RESULTS

Screening determined that 12 studies involving a total of 1030 patients and 1032 shoulders were deemed viable for inclusion in the meta-analysis. The results of the analysis showed that MRA has a higher sensitivity and specificity than MRI for the detection of any tear; similar results were observed in the detection of full-thickness tears. However, for the detection of partial-thickness tear, MRI has similar performance with MRA.

CONCLUSION

MRI is recommended to be a first-choice imaging modality for the detection of rotator cuff tears. Although MRA have a higher sensitivity and specificity, it cannot replace MRI after the comprehensive consideration of accuracy and practicality.

Evaluating strategies and outcomes following rotator cuff tears

INTRODUCTION

Rotator cuff tear surgical repair techniques have significantly progressed. However, tendon retear following primary repair persistently occurs at high rates. Rehabilitation protocols, surgical fixation techniques, biologic therapy with scaffolds, platelet-rich plasma, and even stem cell applications are under study to promote adequate tendon healing.

METHODS

A nonsystematic query of the PubMed database was conducted in July 2016 utilizing the search terms "rotator cuff repair," "tear," "rehabilitation," "scaffold," "platelet-rich plasma," and "stem cell" to identify, analyze, and summarize relevant studies.

CONCLUSION

Individualized rehabilitation protocols may be the best approach for small to medium sized tears. Surgical fixation will continue to be debated as modifications to single-row technique and increases in suture number have improved tensile strength. Double-row repairs have been associated with higher costs. Transosseous equivalent technique exhibits comparable subjective and objective outcomes to single- and double-row repair at two-year follow-up. Biocompatible scaffold augmentation has showed inconsistent short-term results. Platelet-rich plasma has lacked uniformity in treatment preparation, administration, and outcome measurement with mixed results. Few human studies have suggested decreased retear rates and improved repair maintenance following bone marrow-derived mesenchymal stem cell augmentation. This review reiterated the necessity of additional high-quality, large-sample studies to develop any final verdict regarding efficacy.

Involvement of synovial matrix degradation and angiogenesis in oxidative stress-exposed degenerative rotator cuff tears with osteoarthritis

BACKGROUND

Shoulder osteoarthritis is a gradual wearing of the articular cartilage concomitant with degenerative rotator cuff tears (RCTs). This pathologic disorder is related to inflammation, oxidative stress, and angiogenesis. Degenerative alterations may prompt production of cytokines and angiogenesis-related proteins, evoking rotator cuff diseases. This study tested the hypothesis that oxidative stress-responsive mediators can influence joint inflammation of patients with RCT.

METHODS

Twelve healthy RCT patients not suffering shoulder osteoarthritis were categorized as the control group, and 24 patients were allocated to 2 RCT groups (RCTP1 and RCTP2), according to severity of RCT and glenohumeral arthritis. Cytokines, growth factors, and angiogenic biomarkers in synovial fluids, blood, platelet-rich plasma (PRP), and tendon tissues were analyzed with enzyme-linked immunosorbent assay, immunoblotting, and collagen zymography.

RESULTS

Induction of interleukin 8, tumor necrosis factor α, and interleukin 1β was considerably elevated in synovial fluids of RCTP groups (P = .0398, P = .0428, P = .0828, respectively). The joint inflammation highly enhanced insulin-like growth factor 1 and transforming growth factor β1 (TGF-β1) in the synovial fluids and serum. Angiogenesis-related angiopoietin (Ang) 1 and 2, Tie-2, and hypoxia-inducible factor 1α were upregulated in reactive oxygen species-exposed RCTP synovium (P < .05). The production of matrix metalloproteinase 1 markedly increased in synovial fluids of the RCTP group (P = .043), whereas tissue collagen type I expression diminished with reduction of connective tissue growth factor expression (P = .032). Although the secretion of platelet-derived growth factor AB and vascular endothelial growth factor was marginal in the circulation (P = .714, P = .335), platelet-derived growth factor AB, TGF-β1, Ang-1, and matrix metalloproteinase 1 were enriched in PRP of the RCTP group (P < .001, P = .002, P = .0389, respectively).

CONCLUSIONS

Synovial matrix degradation and oxidative stress-triggered angiogenesis may be involved in inducing RCT with joint inflammation. TGF-β1, Ang-1, and Ang-2 are the major components to repair RCT and to alleviate joint inflammation in PRP therapy.

Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis

OBJECTIVE

To produce a best evidence synthesis of exercise prescription used when treating shoulder pathology in the overhead athlete.

DESIGN

A systematic review of exercises used in overhead athletes including case studies and clinical commentaries.

DATA SOURCES

MEDLINE, PubMed, SPORTDiscus and CINAHL from database inception through July 8, 2016.

METHODS

We examined data from randomised controlled trials and prospective cohort (level I-IV evidence) studies that addressed exercise intervention in the rehabilitation of the overhead athlete with shoulder pathology. Case studies and clinical commentaries (level V evidence) were examined to account for expert opinion-based research. Data were combined using best evidence synthesis and graded (A-F) recommendations (Centre for Evidence-Based Medicine).

RESULTS

There were 33 unique exercises in six level I-IV studies that met our inclusion criteria. Most exercises were single-plane, upper extremity exercises performed below 90^o of elevation. There were 102 unique exercises in 33 level V studies that met our inclusion criteria. These exercises emphasised plyometrics, kinetic chain and sport-specific training.

CONCLUSIONS AND RELEVANCE

Overall, evidence for exercise interventions in overhead athletes with shoulder pathology is dominated by expert opinion (grade D). There is great variability between exercise approaches suggested by experts and those investigated in research studies and the overall level of evidence is low. The strongest available evidence (level B) supports the use of single-plane, open chain upper extremity exercises performed below 90° of elevation and closed chain upper extremity exercises. Clinical expert pieces support a more advanced, global treatment approach consistent with the complex, multidimensional nature of sport.

Costs, quality of life and cost-effectiveness of arthroscopic and open repair for rotator cuff tears: an economic evaluation alongside the UKUFF trial

AIMS

A trial-based comparison of the use of resources, costs and quality of life outcomes of arthroscopic and open surgical management for rotator cuff tears in the United Kingdom NHS was performed using data from the United Kingdom Rotator Cuff Study (UKUFF) randomised controlled trial.

PATIENTS AND METHODS

Using data from 273 patients, healthcare-related use of resources, costs and quality-adjusted life years (QALYs) were estimated at 12 months and 24 months after surgery on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for arthroscopic versus open management at 24 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data.

RESULTS

There were no significant differences between the arthroscopic and open groups in terms of total mean use and cost of resources or QALYs at any time post-operatively. Open management dominated arthroscopic management in 59.8% of bootstrapped cost and effect differences. The probability that arthroscopic management was cost-effective compared with open management at a willingness-to-pay threshold of £20 000 per QALY gained was 20.9%.

CONCLUSION

There was no significant overall difference in the use or cost of resources or quality of life between arthroscopic and open management in the trial. There was uncertainty about which strategy was most cost-effective. Cite this article: Bone Joint J 2016;98-B:1648-55.