Rotator cuff tendinopathy accounts for the majority of cases of shoulder pain, however, the aetiology and pathophysiology of the condition is poorly understood and treatment interventions for the condition have been introduced on an empirical basis, guided only by unproven theories of biological and structural changes in and around the affected tissue. This thesis explores changes in the provision of surgical interventions for rotator cuff tendinopathy, showing a rapid, sustained increase over the last decade. Investigation into the use of ultrasound as a clinical and research tool led to the development of an independent learning method for surgeons using the modality for shoulder imaging and highlighted the technological limitations of contrast enhanced ultrasound in assessing the microvascularity of the supraspinatus tendon. Development of a novel biopsy method for sampling the supraspinatus tendon permitted collection of tissue samples from several cohorts of individuals with rotator cuff tendinopathy. These studies, for the first time, described tissue changes across the whole spectrum of pathology suggesting the possibility of an early inflammatory phase of the condition followed by tissue senescence and reduced viability as pathology progressed. Paired samples taken before and after treatment identified reduced tissue activity in response to glucocorticoid therapy and a potential healing response from the supraspinatus tendon following surgical repair. Significant deterioration in tissue activity and viability was shown as age increased in a large cohort of individuals, highlighting the major impact of ageing as a factor in the onset and progression of rotator cuff tendinopathy. The techniques introduced provide standardised, reproducible methods for further evaluation of rotator cuff tendinopathy and the development of novel therapeutic interventions.

Thesis questions: • Is the glutaminergic system altered in rotator cuff tendinopathy? • Is the glutaminergic system altered by common treatments? • Are glutaminergic changes related to pain symptoms? • What are the effects of glutamate and glutamate receptor modulation on tendon derived cells? Summary answers: • The glutaminergic system is altered in rotator cuff tendinopathy • Changes within this system are seen after common treatments • Specific glutaminergic changes are associated with the resolution of pain following shoulder surgery but do not predict the severity of pain symptoms • Glutamate has significant effects on tendon derived cells. What is known: It is known that extracellular glutamate concentrations are increased in both Achilles and patellar tendinopathy. It has also been previously shown that the glutamate receptors NMDAR1 and mGluR5 are upregulated in patellar tendinopathy. What this thesis adds: This thesis has shown for the first time that glutamate and NMDAR1 are increased in rotator cuff tendinopathy. Increases in cell proliferation, vascularity and HIF1α are seen after surgical rotator cuff repair and these features are not seen after glucocorticoid injection. There are significant differences between painful and pain-free rotator cuff tendons in terms of glutamate receptor expression (KA1, mGluR7 and mGluR2) and inflammatory cell numbers (CD45 and CD206). Exposure to 1.875mM glutamate for 72 hours results in reduced cell viability, decreased collagen (COL1A1 and COL3A1) and increased aggrecan gene expression; NMDAR antagonism with MK-801 attenuates the deleterious effect on cell viability but had no effect on the changes in matrix gene expression. Bias, confounding and other reasons for caution: The observational histological work was limited by the control tissue. Some control tissue was not age matched, while some of the pain-free control tendons were post-surgical intervention. Confounding factors include tendon structure, length of symptoms and previous treatments. Caution must be applied when discussing the in vivo implications of the in vitro work.

Title Comparison between the effectiveness of extracorporeal shockwave therapy (ESWT) and the surgical approach in the treatment of the rotator cuff tendinopathy. Objective The main goal of this research work is comparing the effectiveness of extracorporeal shock wave therapy and the surgical intervention (arthroscopic approach) in the treatment of calcific rotator cuff tendinopathy depending on the outcome measures of the Constant-Murley Score (CMS), and the Visual Analogue Scale (VAS) from the recent scientific publications. Methodology This thesis is systemic (literature) review. The studies which recruited in this research were randomized controlled trials, prospective studies, and retrospective case series studies which written in English language form, and published between the year 2000 to the year 2018. The studies were retrieved from following databases: EMBASE, PubMed, CINAHL, Medline, SpringerLink, ProQuest using different integrations of the key words. The participants in the studies were from both genders and all ages. The type of the pathology which included in this research was chronic calcific rotator cuff tendinopathy. Regarding the intervention types both Radial, and Focused ESWT with low, medium, and high intensities and the arthroscopic interventions were the main types of...

La douleur, fréquemment rencontrée lors d’atteintes musculosquelettiques, est un phénomène complexe influencé par une combinaison multifactorielle de déterminants biopsychosociaux. Elle présente un important taux de chronicité avec près de huit millions de personnes au Canada atteintes de douleur chronique (douleur qui perdure plus de trois mois), c’est-à-dire un Canadien sur cinq. Les troubles musculosquelettiques incluent le syndrome de conflit sous-acromial (SCSA), une atteinte fréquente à l’épaule, qui a une forte tendance à se chroniciser. Un an après le début des symptômes, environ la moitié des personnes avec ce syndrome présentent de la douleur et une limitation de la fonction persistantes. Des facteurs psychosociaux seraient prédictifs de la chronicité pour le SCSA. Toutefois, dans les guides de pratique qui orientent la prise en charge de cette atteinte, les interventions ciblant ces facteurs sont limitées et parfois même manquantes. En physiothérapie, une discipline fréquemment impliquée dans la réadaptation de cette atteinte, des approches englobant les facteurs biopsychosociaux seraient à privilégier. L’enseignement au patient, une modalité faisant partie intégrante de la physiothérapie, mais pour laquelle les recommandations sont limitées pour en guider la réalisation, serait une avenue pertinente. Cette thèse vise à développer des recommandations qui soutiennent l'enseignement structuré auprès des patients ciblant l’autonomisation (implication active pour la prise de décision et la gestion de la condition) de la personne dans le suivi du SCSA en physiothérapie. Elles intègrent les données scientifiques, expérientielles et contextuelles et les composantes de la Classification internationale du fonctionnement, du handicap et de la santé. La première phase de cette thèse contient une revue systématique de la portée qui visait à répertorier l’étendue de la littérature sur les interventions d’enseignement au patient lors de la prise charge du SCSA. Cette revue a permis d’identifier des cibles initiales d’enseignement au patient issues de la littérature, utilisées pour orienter la phase suivante du projet. La deuxième phase a utilisé une consultation d’experts par des groupes de discussion focalisée intégrant des professionnels de la réadaptation et des patients-partenaires pour explorer les cibles et décrire les stratégies d’enseignement (plan pour atteindre un objectif d’enseignement visé). Cette consultation a été analysée de manière qualitative en vue de faire ressortir les thématiques principales d’enseignement au patient émergeant des discussions. Cette étape a mené au développement de recommandations préliminaires. La troisième phase visait à obtenir un consensus sur la pertinence et la formulation de recommandations détaillées encadrant les interventions d’enseignement au patient en physiothérapie pour le SCSA à l’aide d’une consultation par approche Delphi. À la suite de ces trois phases, sept recommandations générales encadrant les stratégies d’enseignement au patient et six recommandations touchant des cibles d’interventions spécifiques d’enseignement ont été développées. Un outil d’aide à la décision guidant l’utilisation de ces recommandations d’enseignement structuré lors du suivi des personnes atteintes d’un SCSA a aussi été élaboré. Ces recommandations sont les premières existantes pouvant soutenir l’enseignement structuré au patient lors du suivi du SCSA. Celles-ci sont pertinentes pour guider l’enseignement prodigué basé sur la littérature et un consensus d’experts. Les cibles d’autogestion et d’engagement actif de la personne sont pertinentes pour intervenir sur les facteurs psychosociaux et ainsi potentiellement réduire la chronicité de cette atteinte. / Pain, frequently encountered in musculoskeletal injuries, is a complex phenomenon influenced by a multifactorial combination of biopsychosocial determinants. It has a high rate of chronicity with nearly eight million people in Canada suffering from chronic pain (pain lasting more than three months), i.e., one in five Canadians. Among musculoskeletal disorders, subacromial pain syndrome (SAPS), a frequently encoutered shoulder disorder, has a high propensity to become chronic. One year after the onset of symptoms, about half of individuals with SAPS have persistent pain and functional limitations. Psychosocial factors are predictive of SAPS chronicity, however, in the clinical practice guidelines that guide the management of this condition, interventions targeting these factors are limited and sometimes absent. Approaches that target biopsychosocial factors should be favoured, among others, in physiotherapy, a discipline frequently involved in the rehabilitation of this condition. Patient education, a modality that is an integral part of physiotherapy, but for which there is limited evidence and recommendations to guide its implementation, would be a relevant avenue. Therefore, this thesis aims to develop recommendations that support structured patient education. These recommendations focus on the person's empowerment and self-management during the follow-up of SAPS in physical therapy. They are based on scientific, experiential and contextual data as well as components of the International Classification of Functioning, Disability and Health. The first phase of this thesis contains a systematic scoping review that aimed to map the extent of the literature on patient education interventions in the management of SAPS. This review identified the initial patient education targets from the literature that were used to guide the next phase. The second phase used expert consultation through focus groups involving rehabilitation professionals and patient-partners to explore targets and outline strategies for structured patient education interventions in physical therapy for the follow-up of individuals with SAPS. The development of the interview guide and the analysis of these discussions were based on the initial educational targets and strategies (plan to conduct the educational intervention) extracted from the previous phase. This consultation was qualitatively analyzed to identify the main patient education themes resulting from the discussions. The main themes led to the development of preliminary recommendations. The third phase aimed to reach consensus on the relevance and formulation of detailed recommendations framing patient education interventions in physical therapy for the follow-up of individuals with SAPS using a Delphi consultation approach. As a result of these three phases, seven general recommendations framing patient teaching strategies and six recommendations for specific teaching interventions targets were developed. A decision support tool guiding the use of these structured patient education recommendations in the follow-up of people with SAPS has also been developed. These recommendations are the first that can comprehensively support structured patient education intervention during the follow-up of individuals with SAPS. They are relevant to guide patient education interventions that are based on the literature and expert consensus. The goals of self-management and active engagement of the person are relevant to intervene on psychosocial factors and thus potentially reduce the chronicity of this condition.