Rotator cuff tears are a common injury impacting a large and diverse group of patients and refer to a partial or full discontinuation of one or more of the muscles or tendons comprising the shoulder complex. It may occur as a result of traumatic injury, applied weight, overuse, or intrinsic degeneration over a period of years. The incidence of rotator cuff tears has been found to increase with age. Though not a life-threatening condition, rotator cuff tears adversely affect the quality of one's lifestyle causing significant pain, weakness, and limitation of motion that hinders a person from performing routine daily activities as adequately and frequently as desired. Data from cadaveric studies suggest that as many as 65% of individuals over the age of 70 have a partial-thickness rotator cuff tear. Oftentimes, rotator cuff tears are asymptomatic which can make diagnosis and early treatment challenging. The decision to pursue operative versus conservative management is often controversial. Though surgical intervention may provide more immediate pain relief and functional improvement, it portends a higher risk of morbidity than conservative measures, particularly with an older demographic of patients. Moreover, surgical repair is often followed by long recovery periods and has variable outcomes. A number of conservative treatment options are currently being utilized for the management of partial rotator cuff tears including oral medication, corticosteroid injection, and targeted physical therapy. This review seeks to assess an innovative, biologic approach to treating partial rotator cuff tears using autologous platelet-rich plasma (PRP). The use of PRP for the conservative management of both degenerative and acutely injured tissues is quickly becoming a more popular option within the clinical community. PRP treatment has received significant attention from the media and has been used by several professional athletes as a means of expediting the healing process. The appeal of PRP stems from the fact that it is produced from a patient's own blood. After a blood sample is obtained, it is placed into a centrifuge, a tool used to separate the blood into its many components. A large concentration of platelet-enriched plasma can then be collected and augmented before administration to an injured area of bone or soft tissue, such as a tendon or ligament. Platelets contain an abundance of growth factors essential for cellular recruitment, proliferation, and specialization required for the healing process. PRP is given to a patient via an injection, often under ultrasound assistance for more precise placement. This study reviewed a collection of current literature on the efficacy of PRP in rotator cuff repair. Published studies have generally illustrated a general trend towards effectiveness, suggesting PRP may improve patient outcomes and prevent the need for surgery in patients with partial rotator cuff tears. Study designs and results have proved to be inconsistent at times. However, further clinical investigation is required to validate the use of PRP as an additional non-surgical treatment option.

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic in the Faculty of Health at Technikon Natal, 2002. / Purpose . Rotator cuff tendinitis is a common problem, however, its diagnosis and management is not completely understood. The purpose of this research project was to investigate the efficacy of the chiropractic adjustment to determine whether or not it is an effective approach in the treatment of rotator cuff tendinitis. Methods This randomized controlled trial consisted of two groups. Each group consisted of thirty subjects, of any age, selected from the general population and randomly allocated to Group 1 or 2, participation in this trial was voluntary. Group 1 received chiropractic adjustment of the glenohumeral or acromioclavicular joint according to the fixations found on motion palpation and group 2 received placebo laser. Subjects in both groups had to comply with certain inclusion criteria before being allowed to participate in the study. Goniometer readings were taken to measure range of motion, algometer readings to measure pain threshold and the Numerical Pain Rating Scale was answered at the initial consultation, and on the third and sixth consultations. The Unpaired and Friedman's T- tests were used to assess the intra and intergroup information from the first, third and sixth consultations. Groups 1 and 2 were compared in terms of age, gender, race and clinical severity prior to onset. / M

Previous investigations have indicated that shoulder stiffness was related with the degree of inflammation and the number of myofibroblasts in subacromial bursa tissue of rotator cuff lesions. But the interaction mechanism between inflammatory cytokines and myofibroblasts induced shoulder stiffness has not been fully explored. The purpose of this research is to study the effect of IL-1 £] on myofibroblasts in rotator cuff lesions with shoulder stiffness. Myofibroblasts from subacromial bursa tissue of rotator cuff lesions were cultured with or without IL-1 £]. The gene and protein expression of £\-smooth muscle actin (£\-SMA) and prolyl 4-hydroxylase (PH-4) were determined. The results showed that high levels of PH-4 and low levels of £\-SMA were expressed in myofibroblasts cultured with IL-1 £]. PH-4 gene had higher expression in tissue of stiff patients than non-stiff patients, but £\-SMA gene expression had no significant difference. According to the results, myofibroblasts cultured with extra IL-1 £] showed increased PH-4 expression and decreased £\-SMA expression. This indicates myofibroblasts might transdifferentiate into fibroblasts via IL-1 £] effect.

Analysis techniques specific to the proximal upper extremity have historically been overlooked in the field of ergonomics. This research effort provides a methodology that will allow the ergonomics practitioner to analyze a job and predict whether or not that job exposes workers to increased risk of proximal upper extremity disorders. Literature from the fields of physiology, biomechanics, and epidemiology was assimilated in order to understand the theories of pathogenesis of disorders in the rotator cuff and to identify the risk factors associated with proximal upper extremity disorders. A retrospective epidemiological study was conducted to identify job task variables that may contribute to the occurrence of proximal upper extremity disorders. Two proximal upper extremity constructs were proposed: a fatigue-based model and a compressive load-based model. The constructs incorporated lessons learned from the literature and results from the epidemiological study. Validation of the models was performed using data from the epidemiological study. It was determined that the fatigue-based model was a good predictor of proximal upper extremity disorders.

The purpose of this study is to evaluate anatomical variations of the coracoacromial ligament (CAL) in relation to the etiology of subacromial impingement syndrome and rotator cuff tears. A knowledge and understanding of these variations will help to determine how such variations may influence the surrounding tissues and how the biomechanics of the shoulder works, as well as improving accurate diagnosis and subsequent treatment of shoulder impingement syndrome. The methodological approach involved the dissection of 220 cadaveric shoulders in the Centre for Anatomy and Human Identification (CAHID) with a mean age of 82 years (range 53 to 102 years). The CAL was classified according to its morphology and composed band number. The rotator cuff tendons were inspected for tears that were categorized into partial bursal and complete tears. Furthermore, the study inspected the CAL’s parameters and attachment sites: degenerative changes include acromial and coracoid spurs and attrition lesions at the undersurface of the acromion. Results: the multiple banded ligament was the most commonly observed type and was seen in 101 (46%) specimens. The attachment sites of the ligament varied as the size or number of bands of the ligament increased. An association was found between rotator cuff tears and shoulders which had three or more CAL bands (52%). In addition, shoulders with rotator cuff tears had wider attachments, thicker ligaments and larger subacromial insertions. Shoulders with rotator cuff tears also had a significant incidence and size of acromial spurs. The size of the spurs was correlated with the size of the CAL and attrition lesions on the undersurface of the acromion, and changes in morphology of the acromion. Attrition lesions at the subacromial insertion of the CAL were associated with tears in the rotator cuff tendons, and worsened as the size of the subacromial insertion increased. In conclusion, anatomical variations of the CAL showed a relationship with rotator cuff tears.

Shoulder pain is very common, affecting 14-21 % of the population at some time during their lifetime. The aims of this thesis were to improve the understanding of various aspects concerning the pathogenesis and treatment of subacromial pain and rotator cuff tears. Patients and healthy individuals were examined and compared in five studies: Study I) Seventy patients were retrospectively examined, clinically and with ultrasound, 15 years after arthroscopic subacromial decompression. All patients had an intact rotator cuff at surgery. Ultrasound showed significantly fewer rotator cuff tears compared to the prevalence of asymptomatic tears reported in the literature for the same age group. This indicates that arthroscopic subacromial decompression might protect the rotator cuff. Study II) Forty-two patients were retrospectively examined, clinically and with ultrasound, 39 months (mean) after an acute rotator cuff repair. All patients had pseudoparalysis after trauma, a full thickness tear and no previous history of shoulder symptoms. A delay in surgical treatment of three months and the number of tendons injured did not affect the outcome. Age affected outcome negatively. Study III) Plasma samples from 17 patients with cuff tears and 16 plasma samples from healthy age- and gender-matched controls were collected and analysed regarding the levels of matrix metalloproteinases and their inhibitors, TIMP1-4. Elevated levels of TIMP-1 were found in the patients with cuff tears compared to controls. Higher levels of TIMP-1, TIMP-3 and MMP-9 were found in patients with full-thickness tears compared to patients with partial-thickness tears. Study IV) Ninety-seven patients with longstanding subacromial pain, on the waiting-list for arthroscopic subacromial decompression, were prospectively randomised to specific shoulder exercises or control exercises for three months. Thereafter they were clinically examined and asked if they still wanted surgery. The specific shoulder exercises focusing on eccentric exercise for the rotator cuff and scapula stabilisers were found to be effective in reducing subacromial pain and improving shoulder function, thereby reducing the need for surgery. Study V) All patients including those operated, in Study IV were re-examined after one year using clinical assessment scores. The option of surgery was continuously available up to the one-year follow-up. Ultrasound and radiological examinations performed at inclusion were analysed in relation to the choice of surgery. The positive effects of the specific exercise programme were maintained after one year and significantly fewer patients in this group chose surgery. Surgery was significantly more often chosen by patients who had a low baseline shoulder score, and/or a full thickness rotator cuff tear.  All patients showed significant improvement in the clinical scores one year after inclusion or one year after surgery. These results support the concept that subacromial pain has a multifactorial aetiology and that the first line of treatment should be specific shoulder exercises. When conservative treatment fails, an acceptable result can be achieved with arthroscopic subacromial decompression. The rotator cuff status is important to consider when treating and studying these patients.

Rotator cuff disorders encompass a range of impairments from tendinopathy to partialor full-thickness rotator cuff tears, and represent the largest subgroup of shoulder pain. Rotator cuff tears, most of which are atraumatic, are common in adults with shoulder pain and are strongly associated with increasing age. Conservative treatment including physiotherapy is the first-line treatment, but some patients do not respond, and ultimately require surgery. Early predictions of response could allow individuals’ care pathways to be optimised, preventing unnecessary delays and suffering and benefiting patients and healthcare providers alike. My primary aim was to develop a prognostic model for the outcome of physiotherapy in adults with painful atraumatic partial-thickness tears (PTTs) of the rotator cuff. This was addressed by a prospective prognostic model study. The study was underpinned by a systematic review of prognostic models in adults undergoing physiotherapy for painful rotator cuff disorders and was further informed and complemented by the following work: the development and validation of the physiotherapy protocol for the prognostic study; the identification, selection and definition of the candidate prognostic factors for the prognostic study; the estimation of the Minimal Important Difference (MID) of the study’s primary outcome measure (the Western Ontario Rotator Cuff Index, WORC); and an exploratory responder analysis of the WORC outcome scores. The prognostic systematic review, prognostic study, MID analysis and responder analysis are original contributions to knowledge. The prognostic systematic review revealed important methodological deficiencies in the five included studies, and no clinically usable model. No study addressed a distinct PTT population. The process of identifying factors for my own prognostic model study revealed a lack of knowledge about the prognostic relevance of factors. All of the candidate models I explored in my prognostic study (n sample = 65, n analysed = 61) had low performance and precision. The estimated MID of the WORC was -300. The responder analysis resulted in different proportions of responders to treatment depending on the responder definition. My results highlight the difficulties involved in predicting outcomes in the field of shoulder pain and rotator cuff disorders, and the need for methodologically sound prognosis research.

Currently, rotator cuff injuries are the most common problem for the shoulder and accounted for 4.1 million physicians visits. Partial and full thickness tears are more common in people over the age of 50. The increased prevalence of rotator cuff injuries in the United States population certainly affects the working population and often represents a significant economic burden for employers. Few studies have examined outcomes in worker compensation patients or considered biopsychosocial predictive variables for rotator cuff repairs. The current study aimed to characterize injured workers who have undergone rotator cuff repairs across a number of pre- and postprocedural variables, evaluate multidimensional functional and quality of life outcomes, and examine biopsychosocial variables predictive of success and failure in this sample. The current study examined 93 injured workers who had undergone at least one rotator cuff repair within the past five years. Participants were solicited through the Worker’s Compensation Fund of Utah (WCF) computerized database. The current study used a retrospective cohort design, patients’ medical charts were reviewed, and various preprocedural variables were coded for analysis including age at the time of the rotator cuff repair, lawyer involvement in the claim, prior shoulder surgery history, and quantity of other compensation claims. Of the total sample, 47 patients (50.5%) were contacted and completed outcome surveys that assessed patient satisfaction, shoulder functional impairment, disability status, and general physical and mental health functioning. Findings revealed that approximately one third of the patients were totally disabled (29.8%), had poor shoulder specific functioning (36.2%), and were dissatisfied with their current shoulder condition (31.7%). A multivariate regression model was utilized in predicting patient outcomes. Specifically, the number of WCF claims of the patient was a robust predictor of multidimensional outcomes, while age and gender were less predictive of outcomes, and the presence of a prior shoulder surgery reflected no predictive power. Results of descriptive, correlational, and regression analyses are compared to existing data for rotator cuff repair patients when available or to other surgical procedures with similar populations. The study limitations are discussed, such as small sample size, the retrospective design, and lack of matched controls.

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