Author: Anna Reiterová Title: Early rehabilitation in comparison with the traditional approach after arthroscopic surgery of the rotator cuff - literature research Aim: To process a literature search concerning the reconstruction of the rotator cuff with regard to early physiotherapy, its safety and effectiveness.To map the approach to the issue from the point of view of surgeons in the form of a non-standardized questionnaire survey. To compile a systematic review of studies comparing early and delayed physiotherapy in the form of passive movements. Backgroung: The primary goals in the postoperative period after rotator cuff repair are to minimize pain, protect the repaired muscle and tendon, and finally restore shoulder function. At a time when the gold standard was open access, surgeons recommended an early passive range of motion after repairing the rotator cuff in an effort to reduce the likelihood of the formation of adhesions leading to stiffness of the operated arm. Although early passive movement may minimize the chance of a stiff arm, it may not be optimal for the early stages of rotator cuff healing. Metoda: thesis is processed in the form of literary research. Literary sources of the work were searched in the databases PubMed, MEDLINE, PEDro, Web of Science, EBSCOhost and Scopus. The...

BACKGROUND: There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP). OBJECTIVE: To identify the most relevant clinical descriptors for diagnosing RCRSP. METHODS: A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus. RESULTS: Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus. CONCLUSION: In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2015. / Background: The most common shoulder complaint seen by physicians is shoulder impingement syndrome. There has been limited success with the current conservative treatment that has been provided for this condition. Thoracic spine and rib manipulation is purported to aid in the treatment of this condition; however there is a paucity of controlled investigations. The purpose of this study was to determine the short term efficacy of thoracic and prone rib manipulation on shoulder impingement syndrome. Methods: A randomised, placebo controlled pre-test post-test experimental design was used. Informed consent was obtained and 30 participants were recruited according to inclusion criteria and allocated to either a placebo or intervention group. Intervention consisted of thoracic spinal and rib manipulation. Data was collected, pre and post the first treatment and at a 48 hours follow up. SPSS was used to analyse the data with a p value of 0.05. Results: No statistically significant differences were seen between the groups for pain rating, range of motion of the glenohumeral joint, lateral scapula slide test or scapula isometric pinch test. The shoulder pain and disability index (SPADI) showed significant (p = 0.04) differences between the groups in terms of disability scores, with the intervention group having a great improvement in disability. No clinically significant differences were observed between the groups. Conclusion: Thoracic spine and rib manipulation appears to improve the disability associated with shoulder impingement syndrome, however further research is required with a larger sample size.

Degenerative disorders of the rotator cuff tendons account for nearly 75% of all shoulder pain, causing considerable pain and morbidity. Given the strong correlation between age and tendinopathy, and unprecedented population aging, these disorders will become increasingly prevalent. Improved understanding of tendon degeneration will guide the development of future diagnostic and treatments, and is therefore urgently needed. However, the aetiology and pathology of rotator cuff tendinopathy remain unclear. The complicated mechanical environment of the rotator cuff is hypothesised to influence the susceptibility of the tendons to degeneration and tearing. Studies have reported biological adaptations in torn cuff tendons indicative of increased compressive loading within the tendon. The material adaptations of healthy and degenerative cuff tendons are largely unreported but will provide further insight into the role of the mechanical environment in rotator cuff aetiology and pathology. This thesis examined the material adaptations of healthy and diseased tendons to explore the role of mechanical loading in rotator cuff pathology. The material adaptations of healthy animal tendons, and healthy and delaminated human cadaveric rotator cuff tendons, in response to different loading environments were characterised. The effects of age, tears, steroid injection and subacromial decompression surgery on the structural adaptations of human cuff tendons were also studied, as was the effect of tendon cell proliferation on the mechanical properties and degradation behaviour of collagen scaffolds. Loading environment significantly affected the structural adaptations of healthy tendons. Regions exposed to compressive and shear strains exhibited thinner fibres, shorter crimp lengths and thinner, less aligned fibrils compared with regions exposed to tensile strains alone. In healthy rotator cuff tendons, the inhomogeneous loading environment produced topographically inhomogeneous structural adaptations. The tendons of a delaminated rotator cuff exhibited less topographical variation in properties and thinner, less aligned fibrils compared with healthy cuff tendons. Torn cuff tendons exhibited thinner fibrils and shorter crimp lengths compared with control samples. These adaptations were identifiable early in the disease progression, and neither steroid injection nor subacromial decompression surgery significantly influenced these adaptations at seven weeks post‐treatment. Significant correlations between decreasing dimensions and increasing tear size were found when age was included as a confounding factor, reflecting the importance of age and tear size in determining the material properties of tendons. Tendon cell proliferation influenced the mechanical properties and degradation behaviour of the collagen scaffolds, emphasising the integral role of cells in the functional adaptation of biological materials. These results demonstrate the effect of mechanical environment on the material adaptations of tendons. They also indicate the importance of the complicated mechanical environment experienced by the rotator cuff tendons in predisposing the tendons to degeneration and tearing. The observed material adaptations of degenerative and torn tendons suggest that rotator cuff pathology is associated with increased levels of compressive and/or shear strains within the tendon. These changes begin early in the disease progression and neither steroid injection nor sub‐acromial decompression surgery are capable of reversing the changes in the timeframe investigated. These findings highlight the urgent clinical need for pre‐rupture diagnostic techniques for the detection of early pathological changes in the rotator cuff. They also emphasize the requirement for new intervention strategies that restore the healthy mechanical environment and reverse early pathological adaptations in order to prevent catastrophic failure of the tendons.

Chondroplasia, the development of cartilage-like characteristics in tendinous tissue, is a form of degeneration found in tendons including those of the rotator cuff. The molecular mechanism of its development is currently unknown. An examination of the features of the torn rotator cuff and the cartilage literature led to the identification of several potential drivers of chondroplasia including cell shape change/actin cytoskeleton and hypoxia. Lovastatin caused actin cytoskeleton disruption and promoted cartilage matrix deposition in the ATDC5 model. It was the most effective member of a panel of cytoskeletal inhibitors, increasing expression of the chondrocytic markers Sox5 and Sox9 and decreasing expression of COL1A1 and COL3A1 in primary human tenocytes. Its effects were dose dependent, reversible by mevalonate addition and long term treatment induced de novo expression of collagen II. Short term hypoxia upregulated VEGF-A and chondrocytic marker gene DEC1 expression but not other chondrocyte markers. Combination treatment with hypoxia did not enhance the effects of lovastatin. These data suggest that modulation of pathways that regulate the actin cytoskeleton and cell shape may alter tenocyte phenotype.

Title The most often problems in shoulder girdle of women basketball players and options of physiotherapeutic affect. Objectives The main goal of the thesis is in theoretical part to summarize potentional problems in shoulder girdle of basketball players, options and solutions of these problems. There is complex examination of shoulder girdle of dominant upper limb of women basketball players in an experimental part and figure out where is the main problem in this part. Methods There are two parts of the thesis, the first one is the theoretical background for second experimental part where complex functional physiotherapeutic examination of shoulder girdle with using of aspection, palpation and special tests for shoulder girdle were made. The most often problems in shoulder girdle of women basketball player has been determined by using the results of testing process. Results Testing of shoulder girdle of women basketball players showed how often blockage of ribs is. Blockage of fifth rib was present in 90% of the probands, frequent was also decentred position of shoulder and shoulder blade, hypertone of upper fixators of shoulder blade and pectoral muscles. Most of probands had restriction of passive motion to segment in thoracic spine and hypermobility of shoulder. Often was present weakness of...

Universidade de São Paulo, Faculdade de Medicina; 2015. Introdução: Diante de uma rotura traumática do manguito rotador, não há evidência direta que comprove que os reparos realizados precocemente são mais eficazes que aqueles realizados tardiamente. Para abordar essa questão, ensaios biomecânicos e de morfometria óssea foram realizados após roturas extensas do manguito rotador realizadas precocemente (lesões agudas) e tardiamente (lesões crônicas), mediante a utilização de um modelo experimental em ratos. Método: 30 ratos adultos da raça Wistar foram aleatoriamente divididos em três grupos (I, II e III) e submetidos à secção completa dos tendões do supraespinal e infraespinal nos ombros esquerdos. Após oito semanas, nos animais dos grupos I e II, os tendões rotos pertencentes aos ombros esquerdos foram cirurgicamente reparados, e os tendões equivalentes nos ombros direitos foram seccionados e imediatamente reparados. Quatro semanas após os reparos (para os ratos do grupo II) ou oito semanas após os reparos (para os ratos do grupo I), os animais foram submetidos à eutanásia. Os ratos do grupo III foram submetidos à eutanásia oito semanas após a cirurgia de secção tendínea sem que houvesse ocorrido o reparo dos tendões rotos. Os ombros direitos dos animais do grupo III permaneceram intactos e serviram como controles. Após a eutanásia, todos os ratos tiveram seus ombros dissecados e os espécimes foram encaminhados para a realização de testes biomecânicos e de microtomografia computadorizada. Resultados: Para todos os parâmetros biomecânicos analisados, foram encontradas interações significantes referentes aos fatores tempo de cicatrização e reparo, considerando os reparos precoces e tardios. Com relação ao tendão supraespinal para o período de oito semanas de cicatrização, a força máxima até a falha foi significantemente maior nos reparos precoces em comparação aos reparos tardios (31,81 ± 3,86N vs 19,36 ± 6,14N; p < 0,001), bem como a rigidez (17,22 ± 4,35N/mm vs 10,85 ± 4,25N/mm; p=0,034), a tensão máxima até a falha (4,49 ± 2,02N/mm2 vs 1,97 ± 0,61N/mm2; p < 0,001) e o módulo de elasticidade (13,72 ± 5,29N/mm2 vs 6,47 ± 2,42 N/mm2; p=0,033). Com relação ao tendão infraespinal com oito semanas de cicatrização, a força máxima até a falha foi significantemente maior nos reparos precoces em comparação aos reparos tardios (21,26 ± 3,94N vs 12,74 ± 2,87N; p=0,005), assim como a rigidez (12,86 ± 2,65N/mm vs 7,21 ± 3,30N/mm; p=0,014). O grupo com reparo tardio com oito semanas de cicatrização obteve resultados nos testes biomecânicos semelhantes aqueles obtidos nos testes do grupo com lesão sem reparo com oito semanas de cicatrização. A avaliação microtomográfica não apresentou diferenças significantes na microarquitetura óssea entre os reparos realizados precocemente e tardiamente. Conclusões: Os resultados desse estudo demonstram que as roturas extensas do manguito rotador reparadas precocemente produzem um tecido cicatricial na junção ósteo-tendínea com melhores propriedades biomecânicas que as roturas reparadas tardiamente. Porém, ao analisar a morfometria óssea da porção proximal do úmero, verificou-se que os efeitos são equivalentes, tanto para os reparos realizados tardiamente quanto para os reparos realizados precocemente / Introduction: In the event of a traumatic rotator cuff tear, there is no direct evidence that supports early over late surgical repair. To address this knowledge gap, biomechanical and bone morphometry outcomes were assessed following early (acute) and late (chronic) massive rotator cuff tear repairs in an experimental rat model. Methods: 30 adult Wistar rats were randomly divided into three groups (I, II and III), then subjected to combined supraspinatus and infraspinatus tendon tears of the left shoulder. Eight weeks following the injury, animals from groups I and II had the tendons of the injured shoulder surgically repaired. In addition, these animals were subjected to the same injury on the contralateral shoulder, which was immediately repaired. The rats were euthanized four weeks (group II) or eight weeks (group I) following the repairs. Group III was euthanized eight weeks following the injury, without surgical repair of the left shoulder, and the intact right shoulders of this group were used as controls. Tissues from all groups were harvested and subjected to biomechanical testing and bone morphometry analysis. Results: In all biomechanical parameters analyzed, a significant interaction was observed between healing and repair timing. For the supraspinatus tendon with eight weeks healing time, biomechanical properties were significant increased in the early repair group compared to the late repair group, including maximum load to failure (31,81 ± 3,86N vs 19,36 ± 6,14N; p < 0,001), stiffness (17,22 ± 4,35N/mm vs 10,85 ± 4,25N/mm; p=0,034), maximum stress to failure (4,49 ± 2,02N/mm2 vs 1,97 ± 0,61N/mm2; p < 0,001) and modulus of elasticity (13,72 ± 5,29N/mm2 vs 6,47 ± 2,42 N/mm2; p=0,033). For the infraspinatus tendon with eight weeks healing time, biomechanical properties were also significantly increased in the early repair group, including maximum load to failure (21,26 ± 3,94N vs 12,74 ± 2,87N; p=0,005) and stiffness (12,86 ± 2,65N/mm vs 7,21 ± 3,30N/mm; p=0,014). There were no significant differences between the late repair with eight weeks of healing time and the group without surgical repair for supraspinatus and infraspinatus tendons. Concerning bone morphometry of the humeral head, no significant differences were observed when comparing early and late repair groups. Conclusions: The results from this study indicate that early surgical repair of a massive rotator cuff tear leads to increased biomechanical properties of the tissue after healing. However, proximal humerus bone morphometry was unaffected by surgical repair timing

Zur Zeit gibt es keinen optimalen Sehnentransfer zur Behandlung von irreparablen Ruptur der Subscapularissehne. Obwohl der Pectoralis major Transfer als Therapie der Wahl gilt, bleibt der Kraftvektor der verlagerten Sehne-Muskeleinheit sehr unterschiedlich zum Kraftvektor des Subscapularismuskels. Das Ziel dieser Arbeit war, ein neues Konzept zur Behandlung von irreparablen Subscapularisrupturen zu definieren, bei dem die Subscapulariseinheit selektiv mittels Teres major(TM) und Pectoralis major (PM) wiederhergestellt wird. In den Kadaverstudien dieser Arbeit konnte gezeigt werden, dass sich der M. Teres major anatomisch-chirurgisch als Sehnentransfer zur Rekonstruktion der unteren Hälfte des M. Subscapularis eignet. Darüberhinaus wurde in einer dreidimensionalen Vektoranalyse gezeigt, dass der Kraftvektoren vom verlagerten Teres major sich nicht signifikant vom Kraftvektoir des unteren Anteils des Musculus subscapularis unterscheidet. Es wurde weiterhin gezeigt, dass Modifikationen des Pectoralis major transfer durch Reroutingmassnahmen zu einer deutlichen Verbesserung seines Kraftvektors im Vergleich zum oberen Amteil des Musculussubscapularis führt. Basierend auf den neuen anatomischen und biomechanischen Erkenntnissen wurde im letzten Teil dieser Schrift das neue Konzept klinisch angewandt. Dabei wurde bei 7 Patienten mit einer irreparablen Subscapularisruptur nach multiplen Voreingriffen eine selektive Rekonstruktion mittels kombinierten TM-PM Transfer durchgeführt. Es traten keine Komplikationen auf und alle Patienten hatten eine deutliche Linderung Ihrer Schmerzen und eine Verbesserung der Funktion. Somit erscheint diese neue Transferoperation eine sichere und effiziente Option zur Behandlung irreparabler Subscapularisrupturen darzustellen. / Currently there is no optimal tendon transfer procedure for the management of irreparable subscapularis lesions. Although the pectoralis major transfer is considered as the gold standard in the treatment of irreparable subscapularis tears, the force vector orientation of this transfer may not be optimal in comparision to the situation at the subscapularis muscle. Objective of this monograph was to establish the anatomical and biomechanical basis for a new concept of selective subscapularis reconstruction combining a teres major transfer to the pectoralis major transfer. In the cadaveric part of this work, it could be demonstrated that the teres major is a safe and biomechanically logical transfer for reconstruction of the lower part of the subscapularis. The analysis was carried on to define the optimal transfer for reconstruction of the upper part of the subscapularis. It was possible to determine the biomechanical effect of rerouting procedures of the pectoralis major transfer. Passing the tendon underneath the conjoined tendon appeared to be the most effective way to improve the direction of the pectoralis major transfer for subscapularis reconstruction. However this technique is demanding when the plane underneath the conjoined tendon is scarred and the pectoralis major is bulky. In such cases there is a risk to injure the musculocutaneous nerve. Therefore, rerouting the sternal part of the pectoralis major underneath its clavicular part (sPM tansfer) may be a safer option. Finally, based on the acquired anatomical and biomechanical data, early clinical experience in a series of 7 patients was reported. Although the clinical series was small, the combined TM-sPM transfer appeared to be a valuable and a safe alternative to treat irreparable subscapularis tears. An interesting observation in this study was that the transfer was able to recenter the statically subluxed humeral head in two cases. This could be attributed to the dynamic hammock built by the transferred teres major. The early promising subjective and objective results presented here encourage for further investigation.

No description available.

Correct muscular activation of the body segments during an overhand throw is achieved when movement originates in the larger and more proximal legs and trunk and moves sequentially to the smaller, distal segments of the shoulder and arm. This sequence permits angular velocity to transfer progressively through the throw as part of an open kinetic chain. The athlete can summate angular velocity and segmental forces only if he is able to create a separation between the body segments during the movement pattern, and this separation is thus essential to effective segmental sequencing for activation of the trunk muscles to occur separately from distal segment motion. Limited mobility of the shoulder and scapula during the kinematic sequence will limit the ability of that segment to receive and contribute to the angular velocity of its proximal neighbors and to apply its own muscle torque to the throwing implement. This may result in compensatory motion of the proximal muscle groups to meet the demands placed on the body. To establish a link between compensatory activation of the trunk muscles and mobility in the rotator cuff and to apply this relationship to the pattern of the overhand throw, activity in the latissimus dorsi and external oblique/quadratus lumborum muscles was measured using surface electromyography in 40 college-age participants during arm flexion and lateral shoulder rotation. Muscle activation was recorded both before and after mobilization of relevant throwing muscles through targeted functional exercise. Results showed no significant change but suggested a general decrease in the level of peak muscle activation after participants engaged shoulder exercises. This is indicative of a downward trend in compensatory trunk activation during the initiation of shoulder motion. An increase in overall trunk muscle activity was also observed after exercise, which may imply a simultaneous engagement of the proximal throwing muscles in response to shoulder motion.