Aims. Rotator cuff disease (RCD) can considerably decrease quality of life. Here, we investigated whether health-related quality of life (HRQoL) influences the need for surgery in patients with RCD. Methods. We performed an analysis of 417 patients with symptomatic RCD who were recruited from two hospitals between June 2008 and December 2014 to be randomized to receive non-surgical or surgical treatment. After a three-month rehabilitation period, 36-Item Short-Form Health Survey questionnaire (SF-36), shoulder pain (visual analogue scale (VAS)), and shoulder function (Constant-Murley score) data were available from 191 still-symptomatic patients who were eligible for surgery. A control group was formed from 87 excluded patients who were no longer eligible for surgery due to relief of symptoms. Results. Mean pain on the VAS was 51.3 (SD 20.1) in the patients eligible for surgery and 41.7 (SD 21.2) in the control group. The following domains of the SF-36 were associated with being eligible for surgery in univariate analyses: bodily pain, general health, vitality, social functioning, and emotional wellbeing. In multivariate analysis, only bodily pain was associated with pursuing surgical treatment. The RCD population’s values for physical role, bodily pain, and physical functioning were poorer compared to the values of the general population. Conclusion. Lower HRQoL, as indicated by the lower bodily pain score on the SF-36, was associated with the decision to undergo surgical treatment in patients with RCD. Therefore, HRQoL should be considered when determining treatment options for RCD. Cite this article: Bone Jt Open 2024;5(9):793–799

The function of the upper extremity is highly dependent on correlated motion of the shoulder. The shoulder can be affected by several diseases. The most common are: rotator cuff tear (RCT), shoulder instability, shoulder osteoarthritis and fractures. Rotator cuff disease is a common disorder. It has a high prevalence rate, causing high direct and indirect costs. The appropriate treatment for RCT is debated. The American Academy Orthopaedic Surgeons guidelines state that surgical repair is an option for patients with chronic, symptomatic full-thickness RCT, but the quality of evidence is unconvincing. Thus, the AAOS recommendations are inconclusive. We are performing a randomized controlled trial to compare surgical and conservative treatment of RCT, in term of functional outcomes, rotator cuff integrity, muscle atrophy and fatty degeneration. Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. Shoulder instabilities have been classified according to the etiology, the direction of instability, or on combinations thereof. The Thomas and Matsen classification, which is currently the most commonly utilized classification, divides shoulder instability events into the traumatic, unidirectional, Bankart lesion, and surgery (TUBS) and the atraumatic, multidirectional, bilateral, rehabilitation, and capsular shift (AMBRI) categories. The acquired instability overstress surgery (AIOS) category was then added. Surgical procedures for shoulder instability includes arthroscopic capsuloplasty, remplissage, bone block procedure or Latarjet procedure. Reverse total shoulder arthroplasty (RTSA) represents a good solution for the management of patients with osteoarthritis or fracture of the proximal humerus, with associated severe osteoporosis and RC dysfunction

Rotator cuff disease encompasses a spectrum from partial to full thickness tears. Despite being 2–3 times more common than full–thickness tears, effective non-operative treatment for partial thickness tears has remained elusive. Platelet enriched plasma (PRP) has been proposed to enhance rotator cuff healing by enhancing the natural healing cascade. However, its utility in rotator cuff disease remains controversial. The purpose of this study was to compare the patient reported outcomes between PRP and corticosteroid injection in patients with symptomatic partial thickness tears. This double blind randomized controlled trial enrolled patients with symptomatic, partial thickness rotator cuff tears or rotator cuff tendinopathy proven on ultrasound or MRI. Patients were randomized to either corticosteroid or PRP ultrasound-guided injection of the affected shoulder. Patients completed patient reported outcomes at 6 weeks and 12 weeks. The primary outcome was Visual Analog Scale (VAS) pain scores. Secondary outcomes included the Western Ontario Rotator Cuff (WORC) index, American Shoulder and Elbow Surgeons (ASES) score, and failure of non-operative management as determined by consent for surgery or progression to operative intervention. Ninety-nine patients were enrolled in the study with equal demographics between the two groups. Taking into account pre-injection scores, patients with PRP injections demonstrated a statistically significant improvement in VAS scores compared to patients receiving corticosteroid injections at 12 weeks (p=0.045) but not at 6 weeks (p=0.704). There was no difference in other outcome measures or progression of the two groups to surgical intervention. The use of PRP in the management of partial thickness rotator cuff tears demonstrates significant improvement of pain scores at 12 week follow up compared to corticosteroid injections. However, this did not affect the rate of progression to surgical intervention. Continued study is required to determine the utility of PRP in this patient population

Rotator cuff injuries represent a significant burden to the health care system, affecting more than 30% of the population over the age of sixty. Despite the advanced surgical techniques that are available, poor results are sometimes seen in a subset of patients receiving surgical treatment for their rotator cuff disease. The reasons for this failure of treatment remain unclear, particularly if the surgery was ‘technically’ successful. An increasing body of evidence has demonstrated a strong correlation between pre-operative psychological factors and functional outcome following several orthopaedic procedures. This association, however, has not been fully demonstrated or effectively investigated in the context of rotator cuff treatment. The main objective for this study was to conduct a systematic review to determine the impact of psychosocial factors on the outcome of treatment in patients with rotator cuff disease.

A systematic search was conducted of Medline, CINAHL, and PsychInfo databases for articles published from database inception until September 2018. The titles and abstracts were screened for all of the studies obtained from the initial search. Inclusion and exclusion criteria were applied, and a full text review was conducted on those studies meeting the eligibility criteria.

A total of 1252 studies were identified. Following removal of duplicates and application of the inclusion and exclusion criteria, 46 studies underwent a full-text review. Ten studies were included in the final analysis. A total of 1,206 patients, with a mean follow-up of 13 months, were included. Three studies examined patient expectations prior to treatment. All three found that higher expectations prior to treatment led to a significantly improved outcome following both operative and non-operative treatment.

Three studies assessed the association between pre-operative general psychological measures and post-operative pain and function. All three studies found patients with worse pre-operative general psychological scores demonstrated increased post-operative pain. Two of the studies also found a negative association with post-operative function, while one of the studies found no association with post-operative function. Three studies assessed the impact of pre-operative anxiety and depression on outcomes following surgical treatment of rotator cuff disease. Only one of the studies found a negative association with post-operative pain and function. The remaining two studies found no association between anxiety or depression and any outcomes following surgery. Finally, one study examined the impact of general distress on outcomes following the surgical treatment of rotator cuff disease and found no association with post-operative levels of pain or function.

The results of this systematic review indicate that there is somewhat conflicting and contradictory evidence within the literature. Overall, however, there does appear to be an association between pre-operative psychological factors and post-operative function and pain, in that higher levels of pre-operative psychological dysfunction are predictive of poorer function and increased pain following the treatment of rotator cuff disease.

Aims

Few risk factors for rotator cuff disease (RCD) and corresponding treatment have been firmly established. The aim of this study was to evaluate the relationship between numerous risk factors and the incidence of surgery for RCD in a large cohort.

Background. Rotator cuff disease (RCD) is the most common cause of shoulder pain and limitation of activities in sports and in repetitive work. The aetiology of RCD is not well established. A number of gene pathways are altered in RCD. Polymorphisms in Col1A1, Col5A1 (encoding collagen) and GDF5 (TGF-beta superfamily) can be associated with RCD susceptibility. Materials and Methods. Single-nucleotide polymorphisms (SNPs) in Col1A1, GDF5 and Col5A1 were genotyped in a case-control study with 103 RCD patients and 104 controls in Caucasian and African populations who suffered from injuries in any other anatomical location. All patients provided signed informed consent. Sampling was carried out with a puncture of the pad of a finger using a sterile, single-use lancet. NSPs were determined by real-time polymerase chain reaction (PCR) using specific, unique probes with the analysis of the melting temperature of hybrids. The X2 test compared genotypes between groups. Multivariate logistic regression analysed the significance of many covariates and the incidence of RCD. Results. We found significant differences in subjects who were exposed to heavy physical exertion involving the upper limbs (p=0.002). There was a significant difference in the distribution of the three polymorphisms in the GDF5 gene between the two races that were studied, with a higher frequency of TC heterozygotes in Caucasians and TT homozygotes in Africans (p=0.05). There were significant differences in the CC (rs143383) polymorphism in the GDF5 gene in patients with RCD (p<0.04)

Objectives

Triamcinolone acetonide (TA) is widely used for the treatment of rotator cuff injury because of its anti-inflammatory properties. However, TA can also produce deleterious effects such as tendon degeneration or rupture. These harmful effects could be prevented by the addition of platelet-rich plasma (PRP), however, the anti-inflammatory and anti-degenerative effects of the combined use of TA and PRP have not yet been made clear. The objective of this study was to determine how the combination of TA and PRP might influence the inflammation and degeneration of the rotator cuff by examining rotator cuff-derived cells induced by interleukin (IL)-1ß.

We hypothesised that a large acromial cover with an upwardly tilted glenoid fossa would be associated with degenerative rotator cuff tears (RCTs), and conversely, that a short acromion with an inferiorly inclined glenoid would be associated with glenohumeral osteoarthritis (OA). This hypothesis was tested using a new radiological parameter, the critical shoulder angle (CSA), which combines the measurements of inclination of the glenoid and the lateral extension of the acromion (the acromion index).

The CSA was measured on standardised radiographs of three groups: 1) a control group of 94 asymptomatic shoulders with normal rotator cuffs and no OA; 2) a group of 102 shoulders with MRI-documented full-thickness RCTs without OA; and 3) a group of 102 shoulders with primary OA and no RCTs noted during total shoulder replacement. The mean CSA was 33.1° (26.8° to 38.6°) in the control group, 38.0° (29.5° to 43.5°) in the RCT group and 28.1° (18.6° to 35.8°) in the OA group. Of patients with a CSA > 35°, 84% were in the RCT group and of those with a CSA < 30°, 93% were in the OA group.

We therefore concluded that primary glenohumeral OA is associated with significantly smaller degenerative RCTs with significantly larger CSAs than asymptomatic shoulders without these pathologies. These findings suggest that individual quantitative anatomy may imply biomechanics that are likely to induce specific types of degenerative joint disorders.

Cite this article: Bone Joint J 2013;95-B:935–41.

Introduction

The pathogenesis of rotator cuff disease (RCD) is complex and not fully understood. This systematic review set out to summarise the histological and molecular changes that occur throughout the spectrum of RCD.

Our objective was to examine the rate of revision and its predictive factors in patients undergoing total shoulder arthroplasty (TSA). We used prospectively collected data from the Mayo Clinic Total Joint Registry to examine five-, ten- and 20-year revision-free survival following TSA and the predictive factors. We examined patient characteristics (age, gender, body mass index, comorbidity), implant fixation (cemented versus uncemented), American Society of Anesthesiologists class and underlying diagnosis. Univariate and multivariable adjusted hazard rates were calculated using Cox regression analysis. A total of 2207 patients underwent 2588 TSAs. Their mean age was 65.0 years (19 to 91) and 1163 (53%) were women; osteoarthritis was the underlying diagnosis in 1640 shoulders (63%). In all, 212 TSAs (8.2%) were revised during the follow-up period. At five, ten and 20 years, survival rates were 94.2% (95% confidence interval (CI) 93.2 to 95.3), 90.2% (95% CI 88.7 to 91.7) and 81.4% (95% CI 78.4 to 84.5), respectively. In multivariable analyses men had a higher hazard ratio of revision of 1.72 (95% CI 1.28 to 2.31) (p < 0.01) compared with women, and those with rotator cuff disease had a hazard ratio of 4.71 (95% CI 2.09 to 10.59) (p < 0.001) compared with patients with rheumatoid arthritis. We concluded that male gender and rotator cuff disease are independent risk factors for revision after TSA. Future studies are needed to understand the biological rationale for these differences.

The purpose of this diagnostic, cross-sectional study, was to determine the predictive value of clinical examination versus ultrasonographic evaluation in rheumatoid arthritis patients, suspected of having rotator cuff disease.

The left and right shoulders of fifty consecutive patients from the rheumatoid clinic were subjected to clinical examination by a senior registrar in the department. Impingement was evaluated using the Neer, Hawkins and posterior impingement tests. The supra-spinatus tendon insertion (Jobe test), infraspinatusteres minor tendon insertions (resisted external rotation) and subscapularis tendon insertion (Gerber lift-off and push-off tests) into the rotator cuff were evaluated for a possible tear. A Professional Sport Sonographer, located in a separate examination room then performed an ultrasonographic evaluation on all of the patients. The clinical results were compared to the ultrasound results, hoping to find a method that will improve our current screening of rheumatoid patients for rotator cuff disease and planning of possible surgical treatment.

A significant difference was found between the clinical and sonographic evaluation of the rotator cuffs. Impingement tests showed a false positive result of 85–89%, while the tests for cuff tears had a false negative value of 87–91% compared to ultrasound evaluation. A total disagreement of 45.8–60% and total agreement of 39.5–54.1% could be explained by the fact the synovitis is the hallmark of rheumatoid disease, which could cause pain without tears or impingement.

The authors conclude that clinical examination of the rotator cuff in patients with rheumatoid disease is unreliable, and that ultrasound examination should form a routine part of the evaluation of all rheumatoid shoulders.

Aims: The purpose of this study is to examine the relationship between synovitis and shoulder pain in rotator cuff disease. Methods: Thirty-nine patients with rotator cuff disease were candidates. Subacromial synovium around the greater tuberosity and glnohu-meral synovium around the rotator interval were harvested for specimens during operation. The expression levels of inflammatory cytokine mRNA of interleukin-1β and its naturally occurring antagonists (secreted and intracellular interleukin-1 receptor antagonists) were measured by reverse transcription plolymerase chain reaction (RT-PCR). The cytokine-mRNAs producing cells were identified by RT- in situPCR. For control specimens, subacromial bursae were obtained from 10 patients with anterior instability of the shoulder that exhibited no signs of subacromial impingement. All specimens were obtained with patient’s informed consent. The level of shoulder pain was evaluated in each patients before the operation with a visual analogue scale: 0 as no pain, 5 as moderate, and 10 as severe. Results:The expression levels of the cytokine-mRNAs in the subacromial bursa well correlated to the level of shoulder pain, but not those in the glenohumeral joint. A variety of the cells (synovial and inflamatory cells) produced the cytokines at the protein and gene level in both subacromial and glenohuemeral synovium. Conclusions: Subacromial bursa is the site associated the shoulder pain caused by rotator cuff disease, and targeting the subacromial bursa for treatment leads to successful pain relief in patients with the disease.

Introduction: Little comparative information is available regarding asymptomatic and symptomatic rotator cuff tears. This data may lend insight to Natural History. The purpose of this study was to compare the morphology and incidence of cuff disease in people with unilateral painful shoulders.

Methods: 588 consecutive shoulder ultrasounds were reviewed in patients presenting with unilateral pain. Ultrasound has been validated in our institution as highly accurate. There were 212 pt/bilat intact cuffs, 191pt/unilateral tears, and 185pt/bilateral tears. Data for age, cuff thickness, tear size, and symptoms were tested for associations.

Results: Cuff disease increased with average age, (no tear/48.7yo,unilateral tear/58.7yo,bilateral tears/67.8yo). Logistic regression showed a 50% likelihood of bilateral tears after age 66(p< .01). Overall, a pt. with a full tear on the symptomatic side had a 35.5% incidence of an asymptomatic tear. In contrast, a symptomatic nl. or partial tears had only a 0.5% or 4.3% incidence of contralateral tear. In patients with bilateral tears, the symptomatic side was larger (p< .01). 65% of painful tears were on the dominant side(p< .01). For intact cuffs, avg thickness equaled 4.7 mm and was not affected by age, gender, or symptoms.

SUMMARY: The high incidence of asymptomatic and bilateral tears with age suggests that for some, cuff disease is intrinsic; however, the association with symptoms of hand dominance and increased tear size indicate that extrinsic factors may be important in the development of pain.

Aim: We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease.

Methods: Fifty patients with history of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy.

Results: The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons: 100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears.

Conclusion: The Neer’s and Hawkins’ signs were the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear.

We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease. Fifty patients with history suggestive of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of commonly used clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs of impingement syndrome we evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy.

The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons:100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears.

Our findings echoed the conclusions of other papers in that the Neer’s and Hawkins’ signs are the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear.