The aim of this study was to observe cellular and vascular changes in different stages of full thickness rotator cuff tear. Biopsies of the Supraspinatus tendon in 40 patients with chronic rotator cuff tears undergoing surgery were analysed using histological and contempary immunocytochemical techniques. Sections were stained with primary antibodies against PCNA (Proliferating cell nuclear antigen), CD34 (QBEnd 10), CD45 (Leucocyte Common Antigen), CD68, D2-40 (Lymphatic Endothelial Marker) and Mast Cell Tryptase. A histological analysis was performed with Mayer’s Haemotoxylin and Eosin, Congo Red and Toluidine Blue. The reparative response and inflammatory component (figure 1) of the tissue was seen to diminish as the rotator cuff tear size increased. This was evidenced by increasing degeneration and oedema, reducing fibroblast proliferation, reduced thickening of the synovial membrane and reducing vascularity. Macrophage, other leucocyte and mast cell numbers also reduced as tear size increased. Large and massive tears revealed a higher degree of chondroid metaplasia and amyloid deposition when compared to smaller sized tears. There was no association with the patient’s age or duration of symptoms. Small sized rotator cuff tears retain the greatest potential to heal and have a significant inflammatory component. Tissue from large and massive tears is of such a degenerate nature that it may never heal and this is probably a significant cause of re-rupture after surgical repair in this group. Selection of patients for reconstructive surgery should take into account the composition and healing potential of tendon tissue and its relationship to tear size in chronic tears of the rotator cuff.
This is the largest reported natural history study of frozen shoulder. 500 patients were identified from a specialist shoulder clinic register with a diagnosis of frozen shoulder based on Codman’s criteria. 273 patients with primary frozen shoulder replied to a detailed postal questionnaire regarding their condition. Mean follow up from symptom onset was 52 months (range 12–240months), with 89% of shoulders followed up for a minimum of 3 years. A positive family history was identified in 20% (n=45) of 1st degree relatives. The relative risk to siblings compared with a control population was 4:1. Patients with mild to moderate symptoms recovered more quickly than those with severe or unbearable symptoms. The mean age of onset was 53 years (range27–85yrs). The female to male ratio was 1.6:1. The condition was bilateral in 20%, with no incidence of ipsilateral recurrence. 22% of patients reported a history of minor trauma to the upper limb prior to the onset of symptoms. 16% were diabetic and 4% reported a history of Dupuytren’s contracture. Right and left arms were affected equally with no relationship to hand dominance. 61% reported slow, and 39% reported sudden onset of symptoms. Generally pain and stiffness improved with time but at 3 and 4 years after onset 13% and 9% respectively still had symptoms. Frozen shoulder affects people mainly in their 6th decade. Genetic factors play an important role in the aetiology. The natural history is for improvement with time, with the less severe symptoms at onset improving most quickly. 9% of patients were still symptomatic at 4 year follow up.
