INTRODUCTION. This study describes the prevalence of pain, functional loss and rotator cuff tears (RCTs) in a general population cohort. It is the first multidisciplinary assessment in such a cohort. METHODS. The Chingford cohort is a 19-year old longitudinal population study comprising 1003 women aged between 44 and 67 at baseline. To date 183 consecutive subjects (366) shoulders have been interviewed about their shoulders. Myometric strength assessment and high-definition ultrasound examination (US) have been performed on all shoulders. Additionally pain thresholds and perceptions of pain have been tested using quantitative sensory testing (QST) and a number of validated questionnaires, including the illness attitudes scale and the pain detect score. RESULTS. The population prevalence of at least one full-thickness RCT was 24%, with 19% being unilateral and 5% bilateral. Of the 366 shoulders: 56% had no tendon abnormality on ultrasound: Of which, 68% were asymptomatic, 23% had pain, and 24% had functional loss. 20% had abnormalities of the tendon-bone attachment: Of which, 56% were asymptomatic, 35.6% had pain and 36.1% had functional loss. 9% had a partial-thickness RCT: Of which, 53% were asymptomatic, 29% had pain and 38% had functional loss. 7% had a full-thickness RCT (less than 2cm): Of which, 58% were asymptomatic, 29% had pain and 29% had loss of function. 8% had a full-thickness RCT (greater than 2cm): Of which, 38% were asymptomatic, 55% had pain and 48% had functional loss. The pain and functional loss was significantly greater in the abnormal tendon-bone attachment group, and the full-thickness RCT (greater than 2cm) group, compared to those with no abnormality on high-definition ultrasound examination. Strength testing showed progressive weakness through all disease stages. Pain thresholds from the QST data will be presented. DISCUSSION. In a unique normal population-cohort study 44% of patients were found to have some form of degenerative tendon abnormality on high-definition ultrasound. Of these significant pain and/or loss of function was found in 48% of shoulders. High-definition US has allowed us to identify a group of tendons with an abnormality at the tendon bone interface. The pain and functional loss increases at this early stage and then only further increases once a tear is greater than 2cm. However over 50% remain asymptomatic

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.