Shoulder complaints constitute a significant portion of primary care visits each year in the US, costing $7 billion in annual medical treatment. Shoulder complaints arise from some type of trauma caused by muscle imbalances, proprioception, overuse, anatomical or a combination of these factors. More than two thirds of complaints involve the rotator cuff. Literature regarding shoulder mechanics and proprioception is mixed and with contradictory results. This may be the reason for the high incidence and low success rate in treating shoulder complaints. Here the contributions of the supraspinatus muscle to humeral elevation, and shoulder proprioception are investigated. The results of this dissertation are applicable to developing shoulder injury treatment and preventative strategies, computational shoulder models, and understanding proprioception at the shoulder. This dissertation includes previously published and unpublished co-authored material.

FundaÃÃo Cearense de Apoio ao Desenvolvimento Cientifico e TecnolÃgico / Este trabalho teve como objetivo estudar a qualidade de bife bovino processado em escala industrial atravÃs de tecnologia sous vide durante as etapas sequenciais do processo. Foram realizadas anÃlises fÃsico-quÃmicas e microbiolÃgicas em bife de MÃsculo bovino Supraspinatus in natura, temperado e processado por tecnologia sous vide (80ÂC/5horas) e armazenados a 3ÂC durante 0, 15, 30, 45 e 60 dias, para estudo da estabilidade. Foi ainda realizada avaliaÃÃo sensorial dos bifes durante armazenamento a 0 e 30 dias a 3ÂC para verificaÃÃo da aceitaÃÃo quanto a cor, aroma, sabor, suculÃncia, textura, impressÃo global e atitude de compra. O estudo da estabilidade dos bifes bovinos sous vide permitiu observar poucas alteraÃÃes para os parÃmetros de cinzas, proteÃna, a*, b*, Chroma, Hue e nenhuma alteraÃÃo para os parÃmetros L*, umidade e gordura no decorrer do tempo de armazenamento por 60 dias a 3ÂC. NÃo houve diferenÃa significativa (p<0,05) entre as amostras para caracterÃsticas de sabor, suculÃncia, textura e impressÃo global, contudo houve diferenÃa significativa (p>0,05) dos parÃmetros de cor e aroma. As respostas para a intenÃÃo de compra mostraram que os consumidores classificaram as amostras prÃximo ao termo hedÃnico (4) correspondente a âprovavelmente comprariaâ, nÃo havendo diferenÃa significativa (p>0,05%) entre as amostras. Foram encontradas contagens de aerÃbios mesÃfilos, coliformes fecais e coliformes totais no bife bovino in natura, bife bovino temperado e presenÃa de Listeria monocytogenes em uma das cinco coletas de bife in natura, contudo estes micro-organismos nÃo foram encontrados em nenhuma das amostras submetidas à tecnologia sous vide e durante estudo de estabilidade. Foram detectados esporos de aerÃbios e anaerÃbios nos bifes sous vide durante armazenamento. Desta forma, o tratamento (80ÂC/5 horas) nÃo à suficiente para tornar o alimento isento de micro-organismos capazes de se reproduzir no produto em condiÃÃes de estocagem nÃo refrigerada. O cozimento sous vide proporcionou um produto final com uma maior retenÃÃo de nutrientes (proteÃna, gordura). O armazenamento por 30 dias a 3ÂC parece nÃo ter contribuÃdo para a alteraÃÃo das caracterÃsticas sensoriais das amostras. Isto indica que os bifes sous vide podem ser armazenado com sucesso atà a 30 dias a 3ÂC e ser de qualidade sensorial aceitÃvel para os consumidores. Os resultados deste estudo confirmam o potencial tecnolÃgico do mÃsculo Supraspinatus para a elaboraÃÃo de bife sous vide, e sua viabilidade de produÃÃo e comercializaÃÃo para consumo humano. De uma forma geral, o bife sous vide manteve suas propriedades ao longo do armazenamento, sendo uma excelente fonte de nutrientes, principalmente no que se refere ao teor de proteÃna. A tecnologia sous vide apresenta-se como uma excelente alternativa para o mercado de carne, por agregar valor ao produto e conservar suas caracterÃsticas de qualidade. / The aim of this study was to verify the quality of steak cattle processed in industrial scale using sous vide technology during the sequential steps of the process. Physico-chemical and microbiological analysis were performed with the bovine muscle steaks Supraspinatus in natura, Steaks were spicy and processed by sous vide technology (80ÂC/5 hours) and stored at 3ÂC for 0, 15, 30, 45 and 60 days for stability studies. It was also performed sensory evaluation of steaks during storage at 0 and 30 days at 3  C to verify the acceptance and the color, aroma, flavor, juiciness, texture, overall impression and attitude of purchase. The stability of sous vide bovine steak allowed to observe a few changes in parameters such as ash, protein, a *, b *, Chroma, Hue, and no changes in L *, moisture and fat during the storage time for 60 days at 3ÂC. There was no significant difference (p <0.05) between the characteristics of samples for flavor, juiciness, texture and overall impression, however significant difference (p> 0.05) was achieved for color and aroma. The responses for purchase intent showed that consumers rated the samples near the hedonic term (4) corresponding to "I would probably buy", with no significant difference (p> 0.05%) between samples. There were counts of aerobic mesophilic, coliform and fecal coliforms in natura steak, steak seasoned and Listeria monocytogenes in one of five collections of in natura steak, but these microorganisms were not found in any sample submitted to sous vide technology and for stability studies. Spores were detected in aerobic and anaerobic sous vide steak during storage. Thus, treatment (80 ÂC/5 hours) is not sufficient to make the food free of microorganisms capable of reproduction in the product in non-refrigerated storage conditions. Cooking sous vide a final product provided with a greater retention of nutrients (proteins, fat). The storage for 30 days at 3ÂC seems to have contributed to the change of the sensory characteristics of the samples. This indicates that the sous vide steaks may be stored successfully for 30 days at 3ÂC and sensory quality can be acceptable to consumers. The results of this study confirm the technological potential of the Supraspinatus muscle for the preparation of steak sous vide, and the viability of its production and marketing for human consumption. In general, the steak sous vide kept its properties during the storage, being an excellent source of nutrition, especially in regard to protein content. The sous vide technology presents itself as an excellent alternative to the meat market by adding value to the product and maintain their quality characteristics

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.

Rotator cuff injury is a debilitating condition and when injury cannot be managed through non-operative procedures, surgery is required. To determine explanations for the failure of surgery to restore joint function, human muscle biopsies of supraspinatus were studied compared to deltoid. Histology showed atrophy and a tendency toward fibrosis/fatty infiltration in injured supraspinatus. Findings from AChR-subunit western blot and Sema3A localization around satellite cells suggest supraspinatus denervation. Nucleotide incorporation to quantify satellite cell activation in culture showed a significant increase in BrdU+(active) satellite cells in supraspinatus treated with a nitric oxide-donor drug, but not deltoid muscle. The application of principal component analysis to these data extracted components that suggest variables assaying muscle atrophy, satellite cell activity, and fibrosis contribute strongly to the observed variability. The results suggest supraspinatus muscle of the injured rotator cuff is atrophic, denervated, possibly subject to fibro-fatty infiltration, and support the idea that treatment could promote growth in atrophic supraspinatus to improve functional outcomes. / October 2015

Cette thèse s’est d’abord voulue pratique. La chirurgie de l’épaule est en pleine expansion avec le vieillissement croissant de la population et la pratique de plus en plus généralisée du sport. L’épaule est une articulation complexe. Paradoxalement les progrès techniques en chirurgie sont sans cesse grandissants et renouvelés tandis que l’on tientpour acquis des données anatomiques démontrées il y a longtemps et rapportées jusqu’à nos jours. Nous avons voulu confronter l’anatomie avec les techniques diagnostiques actuelles et voir si cela pouvait avoir un impact sur les pratiques chirurgicales. Nous avons également voulu voir si certaines complications chirurgicales pouvaient s’expliquer par des données anatomiques. Ce qui a orienté nos recherches sont les principaux problèmes actuels en pathologie de l’épaule c’est-à-dire la coiffe des rotateurs et le syndrome sous-acromial. Les observations lors des nombreuses dissections de l’épaule nous ont conduit à ces réflexions : comment la glène est-elle vascularisée?, pourquoi est-elle si fragile?, que se passe-t- il dans l’espace sous acromial?, quelle est l’utilité du ligament coraco-acromial?, quels sont ses rapports avec lesuprapinatus?, pourquoi l’insertion du supraspinatus est-elle fragile et difficile à reconstituer ?, la qualité osseuse de la tête humérale a-t-elle un impact sur la géographie des fractures, les échecs des ostéosynthèses, les descellements prothétiques?, qu’est ce que la chape delto-trapézoidienne? Autant de questions que nous nous sommes posées endisséquant cette articulation très complexe qui est l’épaule. Par ailleurs, l’anatomie classique peut maintenant secompléter non seulement de l’histologie, mais aussi de techniques radiologiques modernes comme l’IRM l, le microCT, le synchrotron, la reconstruction 3D, la modélisation en éléments finis. / I would like to make a practical thesis. Shoulder surgery is growing and growing as the population is ageing and people is doing more and more sports activities. A lot of technical progress were done but there are still a lot of surgical complications. On the other way some very old anatomical ideas are still alive. I want to see with the actual knowledge, if some surgical complications could be explained by anatomy. Subacromial pathology and bone quality remain the two mainproblems of shoulder surgery and pathology. That’s what had suggested to me this study about the shoulder. I was supposed to analyze glenoid bone first .The aim was to know more about arterial supply of glenoid. That was my firststudy (article 1). Then, I was interested in glenoid bone quality. And the second study had appeared. (article 2). During the shoulder dissection, I was looking for the fascia delto-trapezoidal which I didn’t found as described in books. It was my third study. (article 3). Going on I found the coraco-acromial ligament and I was surprised to see the constant portion under the acromial process. And that gave me the idea for the fourth study. (article 4).As I had discovered the very interesting technique of micro-Ct densitometry, I would like to apply it to the humeral head bone. There was the fifth study. (article 5)But, I want to know more and more about bone quality and I went on with the greater tuberosity and especially the area ofsupraspinatus insertion. The insertion and the sub-chondral bone were analyzed. There’s the last but not least study!(article 6). I was really interested in supraspinatus muscle and tendon and I want to follow the course of the muscle as the zone of conflict. I was the subject of study in life as I went through RMI . The muscle was reconstructed as finite element. Then it was possible to describe the zone of conflict with the supraspinatus. Here’s the seventh article. (article 7)

SILVA, Ivilane Lima da. Estudo da qualidade de bife bovino submetido à tecnologia sous vide em escala de produção industrial. 2012. 95 f. : Dissertação (mestrado) - Universidade Federal do Ceará, Centro de Ciências Agrárias, Departamento de Tecnologia de Alimentos, Fortaleza-CE, 2012 / Submitted by Nádja Goes (nmoraissoares@gmail.com) on 2016-06-10T14:52:27Z No. of bitstreams: 1 2012_dis_ilsilva.pdf: 989056 bytes, checksum: 0745e26a9deb3df7e91de941b1eae9ba (MD5) / Approved for entry into archive by Nádja Goes (nmoraissoares@gmail.com) on 2016-06-10T14:52:39Z (GMT) No. of bitstreams: 1 2012_dis_ilsilva.pdf: 989056 bytes, checksum: 0745e26a9deb3df7e91de941b1eae9ba (MD5) / Made available in DSpace on 2016-06-10T14:52:39Z (GMT). No. of bitstreams: 1 2012_dis_ilsilva.pdf: 989056 bytes, checksum: 0745e26a9deb3df7e91de941b1eae9ba (MD5) Previous issue date: 2012 / The aim of this study was to verify the quality of steak cattle processed in industrial scale using sous vide technology during the sequential steps of the process. Physico-chemical and microbiological analysis were performed with the bovine muscle steaks Supraspinatus in natura, Steaks were spicy and processed by sous vide technology (80°C/5 hours) and stored at 3°C for 0, 15, 30, 45 and 60 days for stability studies. It was also performed sensory evaluation of steaks during storage at 0 and 30 days at 3 ° C to verify the acceptance and the color, aroma, flavor, juiciness, texture, overall impression and attitude of purchase. The stability of sous vide bovine steak allowed to observe a few changes in parameters such as ash, protein, a *, b *, Chroma, Hue, and no changes in L *, moisture and fat during the storage time for 60 days at 3°C. There was no significant difference (p <0.05) between the characteristics of samples for flavor, juiciness, texture and overall impression, however significant difference (p> 0.05) was achieved for color and aroma. The responses for purchase intent showed that consumers rated the samples near the hedonic term (4) corresponding to "I would probably buy", with no significant difference (p> 0.05%) between samples. There were counts of aerobic mesophilic, coliform and fecal coliforms in natura steak, steak seasoned and Listeria monocytogenes in one of five collections of in natura steak, but these microorganisms were not found in any sample submitted to sous vide technology and for stability studies. Spores were detected in aerobic and anaerobic sous vide steak during storage. Thus, treatment (80 °C/5 hours) is not sufficient to make the food free of microorganisms capable of reproduction in the product in non-refrigerated storage conditions. Cooking sous vide a final product provided with a greater retention of nutrients (proteins, fat). The storage for 30 days at 3°C seems to have contributed to the change of the sensory characteristics of the samples. This indicates that the sous vide steaks may be stored successfully for 30 days at 3°C and sensory quality can be acceptable to consumers. The results of this study confirm the technological potential of the Supraspinatus muscle for the preparation of steak sous vide, and the viability of its production and marketing for human consumption. In general, the steak sous vide kept its properties during the storage, being an excellent source of nutrition, especially in regard to protein content. The sous vide technology presents itself as an excellent alternative to the meat market by adding value to the product and maintain their quality characteristics / Este trabalho teve como objetivo estudar a qualidade de bife bovino processado em escala industrial através de tecnologia sous vide durante as etapas sequenciais do processo. Foram realizadas análises físico-químicas e microbiológicas em bife de Músculo bovino Supraspinatus in natura, temperado e processado por tecnologia sous vide (80°C/5horas) e armazenados a 3°C durante 0, 15, 30, 45 e 60 dias, para estudo da estabilidade. Foi ainda realizada avaliação sensorial dos bifes durante armazenamento a 0 e 30 dias a 3°C para verificação da aceitação quanto a cor, aroma, sabor, suculência, textura, impressão global e atitude de compra. O estudo da estabilidade dos bifes bovinos sous vide permitiu observar poucas alterações para os parâmetros de cinzas, proteína, a*, b*, Chroma, Hue e nenhuma alteração para os parâmetros L*, umidade e gordura no decorrer do tempo de armazenamento por 60 dias a 3°C. Não houve diferença significativa (p<0,05) entre as amostras para características de sabor, suculência, textura e impressão global, contudo houve diferença significativa (p>0,05) dos parâmetros de cor e aroma. As respostas para a intenção de compra mostraram que os consumidores classificaram as amostras próximo ao termo hedônico (4) correspondente a “provavelmente compraria”, não havendo diferença significativa (p>0,05%) entre as amostras. Foram encontradas contagens de aeróbios mesófilos, coliformes fecais e coliformes totais no bife bovino in natura, bife bovino temperado e presença de Listeria monocytogenes em uma das cinco coletas de bife in natura, contudo estes micro-organismos não foram encontrados em nenhuma das amostras submetidas à tecnologia sous vide e durante estudo de estabilidade. Foram detectados esporos de aeróbios e anaeróbios nos bifes sous vide durante armazenamento. Desta forma, o tratamento (80°C/5 horas) não é suficiente para tornar o alimento isento de micro-organismos capazes de se reproduzir no produto em condições de estocagem não refrigerada. O cozimento sous vide proporcionou um produto final com uma maior retenção de nutrientes (proteína, gordura). O armazenamento por 30 dias a 3°C parece não ter contribuído para a alteração das características sensoriais das amostras. Isto indica que os bifes sous vide podem ser armazenado com sucesso até a 30 dias a 3°C e ser de qualidade sensorial aceitável para os consumidores. Os resultados deste estudo confirmam o potencial tecnológico do músculo Supraspinatus para a elaboração de bife sous vide, e sua viabilidade de produção e comercialização para consumo humano. De uma forma geral, o bife sous vide manteve suas propriedades ao longo do armazenamento, sendo uma excelente fonte de nutrientes, principalmente no que se refere ao teor de proteína. A tecnologia sous vide apresenta-se como uma excelente alternativa para o mercado de carne, por agregar valor ao produto e conservar suas características de qualidade.

The purpose of the study was to investigate the static and dynamic architecture of supraspinatus throughout its volume in the normal and pathological state. The architecture was first investigated in cadaveric specimens free of any tendon pathology. Using a serial dissection and digitization method tailored for supraspinatus, the musculotendinous architecture was modeled in situ. The 3D model reconstructed in Autodesk MayaTM allowed for visualization and quantification of the fiber bundle architecture i.e. fiber bundle length (FBL), pennation angle (PA), muscle volume (MV) and tendon dimensions. Based on attachment sites and architectural parameters, the supraspinatus was found to have two architecturally distinct regions, anterior and posterior, each with three subdivisions. The findings from the cadaveric investigation served as a map and platform for the development of an ultrasound (US) protocol that allowed for the dynamic fiber bundle architecture to be quantified in vivo in normal subjects and subjects with a full-thickness supraspinatus tendon tear. The architecture was studied in the relaxed state and in three contracted states (60º abduction with either neutral rotation, 80º external rotation, or 80º internal rotation). The dynamic changes in the architecture within the distinct regions of the muscle were not uniform and varied as a function of joint position. Mean FBL in the anterior region shortened significantly with contraction (p<0.05) but not in the posterior. In the anterior region, mean PA was significantly smaller in the middle part compared to the deep (p<0.05). Comparison of the normal and pathological muscle found large differences in the percentage change of FBL and PA with contraction. The architectural parameter that showed the largest changes with tendon pathology was PA. In sum, the results showed that the static and dynamic fiber bundle architecture of supraspinatus is heterogeneous throughout the muscle volume and may influence tendon stresses. The architectural data collected in this study and the 3D muscle model can be used to develop future contractile models. The US protocol may serve as an assessment tool to predict the functional outcome of rehabilitative exercises and surgery.

Les tendinopathies sont la première cause de maladie professionnelle en France. Elles sont devenues une préoccupation majeure de santé publique. Cependant, leurs mécanismes physiopathologiques restent encore mal définis. Au cours de cette thèse, nous nous sommes intéressés aux phases précoces de la tendinopathie engendrées par une sur-utilisation du tendon supra-épineux (tSE) de la coiffe de rotateurs de l’épaule chez le rat. Nous avons tenté de comprendre les mécanismes à l’origine de cette pathologie afin de pouvoir agir et la traiter en amont de l’apparition des symptômes.Nous montrons que le profil d’évolution moléculaire des collagènes, des protéoglycanes et des glycosaminoglycanes (GAGs) associé aux phases précoces de la sur-utilisation, témoigne d’un profond remaniement matriciel et d’une différenciation chondroïde des fibroblastes tendineux. Nous avons identifié les métalloprotéinases (MMPs) majeures et leurs inhibiteurs (TIMPs) susceptibles d’être impliqués dans ce remaniement. Nos résultats suggèrent que le mécanisme lésionnel initial et les changements matriciels observés sont dus à un processus induit par des médiateurs locaux libérés par les ténocytes et non à une réaction inflammatoire. Enfin, nous avons cherché à établir une corrélation entre les changements moléculaires observés et le degré de sévérité d’une tendinopathie diagnostiquée chez l’Homme. Nous avons montré, sur des échantillons de tendon patellaire humain une relation entre la quantité des GAGs et le score (VISA score) reflétant le degré pathologique du tendon.Cette étude nous a donc permis d’améliorer nos connaissances des phases précoces du processus d’altération du tSE. Cependant, d’importants efforts restent néanmoins à accomplir dans la caractérisation de la pathogenèse précoce notamment pour préciser le contexte biomécanique qui la génère. / Tendinopathies are the first cause of professional diseases in France. They are a major public health concern. However, their physiopathological mechanisms remain poorly understood. This project aimed at investigating the early stages of supraspinatus tendinopathy caused by overuse. Using a rat animal model, we attempted to understand the mechanisms behind this disease in order to act and treat the symptoms upstream of their onset.We have shown that the molecular changes of collagens, proteoglycans and glycosaminoglycans (GAGs) associated with the early events of overuse attest a major matrix remodeling and chondrogenic differentiation of tendon cells. We identified the main metalloproteinases (MMPs) and their inhibitors (TIMPs) that may be involved in this remodeling. Our results further suggest that the initial mechanisms linked to the observed matrix changes are due to local mediators release by tenocytes rather than an inflammatory process. Finally, we attempted to correlate molecular changes observed during overuse with the severity of the tendinopathy diagnosed in humans. We have shown a relationship between the amount of GAGs and the pathological score (VISA score) on human patellar tendons.This study improved our knowledge of the early pathological events of the supraspinatus tendon. However, more remains to be done for characterizing the early stages of tendinopathy especially to clarify the biomechanical context up-stream.

The supraspinatus tendon is an important structure of the rotator cuff. Subacromial impingement is a common reason for shoulder pain. Despite extensive scientific work in this field, the cause of impingement syndrome is still not fully understood. The general aim of the present thesis was to generate new knowledge with respect to pathogenesis and treatment of impingement syndrome. A combination of animal and clinical studies were performed. Different methods were used such as histology, immunohistochemistry, development and assessment of a novel measuring device and clinical and radiological assessment. Thirty rats were injected with triamcinolone or saline into the subacromial bursa. After five corticosteroid injections, we found focal inflammation, degradation and fragmentation of collagen bundles in the supraspinatus tendon, whereas the control specimens were normal (p=0.035). Subacromial bursitis was induced by injections of carrageenan into the subacromial space (n=28). Fibrocartilaginous metaplasia and bony metaplasia were found in the supraspinatus tendon. Even in specimens with no histologic changes of the collagen bundles the staining for fibronectin was significantly increased. The distance between the anterolateral acromion and the supraspinatus tendon was measured in patients with impingement syndrome intraoperatively (n=30) and in controls (instability, n=15). The mean value of the subacromial distance in controls was 16 mm, the 95% mean confidence limits between 14 and 18 mm. The mean value in the group of patients with impingement syndrome was 8 mm before and 16 mm after the decompression. Fifty patients were reviewed after arthroscopic subacromial decompression. Twenty-five showed calcific deposits in the rotator cuff on radiographs preoperatively. In 13 patients the calcific deposits totally disappeared postoperatively. In another six patients the calcifications had decreased in size. Four patients still showed calcifications, which were 5 mm or greater in size. The postoperative results measured by the Constant score were almost identical in the calcific and the non-calcific groups. Tillander 010916 8 Human surgical supraspinatus tendon specimens were studied from patients with impingement (n=16), ruptured supraspinatus tendons (n=7) and controls (n=10). Degradation of tendinous tissue and fibrin were found only in some specimens from ruptures. The difference in fibronectin staining was significant between controls and patients with a rupture (p=0.002). Fibrosis and thinning of fascicles seemed to be a more non-specific finding, appearing in control, impingement and rupture specimens. In conclusion, subacromial corticosteroid injections may cause rupture of the supraspinatus tendon. Metaplasia of the supraspinatus tendon may play a role in the pathogenesis of impingement and rupture of the supraspinatus tendon. The subacromial distance can be measured intraoperatively and was shown to be lower in patients with impingement than in patients with instability. Calcifications disappear or decrease in size after arthroscopic subacromial decompression and do not seem to influence the postoperative outcome in patients with impingement. Degradation of tendon tissue, fibrin and fibronectin appear to be signs of tendon degeneration, whereas fibrosis and thinning of fascicles were found also in controls.

Chronic painful tendinopathies are common, not only in sports and recreationally active people, but also among people with a sedentary lifestyle. Both the lower and upper limbs are affected. There is lack of knowledge about the etiology and pathogenesis to tendinopathy, and many different treatments options have been presented. Unfortunately, most treatments have not been tested in scientific studies. Conservative (non-surgical) treatment has since long shown unsatisfactory results and surgical treatment is known to give unpredictable results. The aim of this thesis was to evaluate new models of painful eccentric training for the conservative treatment of different chronic tendinopathies. After promising results in a pilot study, using painful eccentric calf muscle training in patients with chronic mid-portion Achilles tendinopathy, we investigated if these results could be reproduced in a larger group of patients with both mid-portion and insertional Achilles tendinopathy (study I). After 12 weeks, 89% of the patients with pain from the mid-portion were satisfied and back in previous activities. In the group with insertional Achilles tendinopathy the results were poor. A new model for eccentric training was designed for patients with insertional Achilles tendinopathy. The eccentric calf muscle training was done from tip-toe to floor level (study II). With this new regimen 67% of the patients were satisfied and back in previous activities. The next step was to investigate the effects of painful eccentric quadriceps training on patients with jumper´s knee/patellar tendinopathy (study III). Two different training protocols were used. Eccentric training performed on a 250 decline board showed promising results with reduced pain and a return to previous activities, while eccentric training without the decline board had poor results. In a following prospective study, patients with jumper´s knee/patellar tendinopathy were randomised to either concentric or eccentric painful quadriceps training on a 250 decline board (study IV). After 12 weeks of training, there were significantly better results in the group that did eccentric training. In a pilot study (study V), we investigated painful eccentric deltoideus and supraspinatus muscle training on a small group of patients on the waiting list for surgical treatment of subacromial impingement syndrome. After 12 weeks of training, 5 out of 9 patients were satisfied with the results of treatment and withdrew from the waiting list for surgery. In conclusion, the present studies showed good clinical results with low risks of side effects and low costs. Thus, we suggest that painful eccentric training should be tried in patients with Achilles and patellar tendinopathy before intratendinous injections and surgery are considered. For patients with chronic painful impingement syndrome, the results of our small pilot study are interesting, and stimulates to randomised studies on larger materials.