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Unlabelled: There have been technologic advances in the methods for repairing torn rotator cuffs. We compared the clinical and structural outcomes of three different forms of rotator cuff repair with up to 24 months' followup. We wished to assess how surgical technique affected clinical outcomes and see how these correlated to repair integrity. Three cohorts of patients had repair of a symptomatic rotator cuff tear using (1) an open technique (n = 49); (2) arthroscopic knotted (n = 53); or (3) arthroscopic knotless (n = 57) by one surgeon. Standardized patient- and examiner-determined outcomes were obtained preoperatively and at 6 weeks, 3 and 6 months, and 2 years postoperatively. Ultrasound studies were performed with a validated protocol at 6 months and 2 years postsurgery. Clinical outcomes were similar with the exception that the arthroscopic groups had, on average, 20% better American Shoulder and Elbow Surgeons scores than the open group at 6 months and 2 years. Retear correlated with tear size and operation time and occurred more frequently after open repair (39%) than after arthroscopic knotted (25%) and arthroscopic knotless (16%) repair. An intact cuff on ultrasound corresponded to better results for supraspinatus strength, patient outcomes, and rotator cuff functional ability.Level Of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Tendinopathy is a common clinical problem with athletes and in many occupational settings. Tendinopathy can occur in any tendon, often near its insertion or enthesis where there is an area of stress concentration, and is directly related to the volume of repetitive load to which the tendon is exposed. Recent studies indicate tendinopathy is more likely to occur in situations that increase the "dose" of load to the tendon enthesis - including increased activity, weight, advancing age, and genetic factors. The cells in tendinopathic tendon are rounder, more numerous, and show evidence of oxidative damage and more apoptosis. These cells also produce a matrix that is thicker and weaker with more water, more immature and cartilage-like matrix proteins, and less organization. There is now evidence of a population of regenerating stem cells within tendon. These studies suggest prevention of tendinopathy should be directed at reducing the volume of repetitive loads to below that which induces oxidative-induced apoptosis and cartilage-like genes. The management strategies might involve agents or cells that induce tendon stem cell proliferation, repair and restoration of matrix integrity. [ABSTRACT FROM AUTHOR]

Unlabelled: Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.Level Of Evidence: Level II, systematic review. [ABSTRACT FROM AUTHOR]

Nitric oxide is an important messenger molecule in many physiological processes. The addition of NO via NO-flurbiprofen enhances the material properties of healing tendon, however, flurbiprofen has a detrimental effect on healing. We asked if NO delivered by a cyclooxygenase 3 inhibitor (paracetamol/acetaminophen) would enhance healing in a rat Achilles tendon healing model. Rats were injected subcutaneously daily with NO-paracetamol, paracetamol or vehicle from two days before surgery to the day of tissue harvesting. Paracetamol had no effect on tendon healing compared with vehicle alone. NO-paracetamol did not change the failure load, but did decrease the water content, enhance the collagen content, reduce the cross-sectional area and improve the ultimate stress of healing tendon compared with paracetamol and vehicle. The collagen organization of the healing tendon in the NO-paracetamol group, as determined by polarized light microscopy, was enhanced. Our data suggests NO-paracetamol increases the total collagen content and enhances organization while decreasing the cross-sectional area of healing rat Achilles tendon and is consistent with human clinical trials where NO has improved the symptoms and signs of tendinopathy. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the interobserver and intraobserver reliability of the interpretation of MRIs for supraspinatus tendinosis. METHODS: In the interobserver trial, the MRIs of 52 athletes' shoulders were observed by 3 observers on one occasion within a 2-month period. All 52 images were read by the most experienced musculoskeletal radiologist on 3 different occasions on separate days without access to the previous readings for the intraobserver trial. Supraspinatus tendinosis was graded using a modified 4-point scale from grades 0 to grade 3. RESULTS: The grading of MRI-determined supraspinatus tendinosis was reliable, having an intraclass correlation (ICC) of 0.85 when assessed by the single well-trained observer. Interobserver reliability was only fair to good (ICC = 0.55). CONCLUSIONS: Supraspinatus tendinosis can be accurately identified on MRI with little variation by a single well-trained observer. Interobserver reliability was only fair to good. Our data indicated that the reliability of the assessment was much greater in more experienced radiologists than in those with less experience. [ABSTRACT FROM AUTHOR]

Introduction: From the surgeon's perspective, a successful rotator cuff is one that remains intact. However, it is undetermined which factors contribute to an improved shoulder from the patient's perspective. The aim of this study was to determine the variables that predicted greater patient-rated benefit from presurgery to 6 months postarthroscopic rotator cuff repair., Methods: Multiple linear regression analysis was conducted on prospectively collected data of 2010 consecutive patients who underwent arthroscopic rotator cuff repair by a single surgeon to determine the predictors of greater patient-rated benefit. Patient-rated shoulder ranking was graded on a five-point Likert scale in response to "How is your shoulder overall?" preoperatively and at 6 months postoperatively. The patient-rated benefit was the difference in rankings between these time points., Results: Six months following rotator cuff repair, a self-reported benefit was observed in 84% of patients. Patients who rated their shoulder as poor preoperatively reported the greatest benefit (t = 22, P < 0.001). Other preoperative determinants of greater patient-rated benefit were lower patient-rated shoulder stiffness (t = 5, P < 0.001), an injury that was not related to work (t = 4, P < 0.001), stronger internal rotation strength (t = 4, P < 0.002), a more strenuous line of work preinjury (t = 3, P = 0.007), female sex (t = 2, P = 0.019), having a larger tear area (t = 2, P = 0.020), and weaker abduction strength (t = 2, P = 0.046)., Conclusions: Patients who were most likely to perceive a benefit from rotator cuff repair at 6 months postoperation were those who preoperatively rated their shoulder poorly, had a less stiff shoulder, an injury that was not related to work, stronger internal rotation, more strenuous line of work preinjury, were female, had larger tear area, and weaker abduction strength., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: The management of superior labrum anterior to posterior (SLAP) tears is somewhat controversial. It is unclear if the length of time between symptom onset and surgery affects SLAP repair outcomes., Methods: Sixty-one SLAP repairs were retrospectively reviewed pre-operatively and post-operatively at 1, 6, 24 weeks, and > 2 years post-surgery. Patients were allocated to an 'early repair' or 'late repair' group based on time between symptom onset and surgery., Results: Of the 61 patients, 22 patients had surgery within six months of symptom onset. Pre-operatively, 'late repair' patients played a higher level of sport than 'early repair' patients prior to injury. Post-operatively, both groups had similar outcomes up to six months, though at six months 'early repair' patients reported a higher level of work than 'late repair' patients (p = 0.01). At > 2 years after surgery, 'early repair' patients had reduced pain and difficulty with overhead activities (p = 0.002), less stiffness (p = 0.001) and were more satisfied than 'late repair' patients (p = 0.04)., Conclusions: Up to six months post-operatively, the time between symptom onset and surgery has limited effect on functional outcomes. However, at > 2 years after surgery, earlier repairs ( < 6 months) are interestingly associated with better functional outcomes. Further studies are required to determine if this is a causal relationship., Competing Interests: Declaration of Conflicting Interest: GACM is a paid consultant and has research funding (products) from Smith and Nephew; and is a financial stakeholder with the facility (Kogarah Private Hospital – formerly known as National Day Surgery – Sydney) and is also on the Editorial Board of the following publications: Journal of Shoulder and Elbow Surgery; Shoulder and Elbow; Techniques in Shoulder and Elbow Surgery., (© 2021 The British Elbow & Shoulder Society.)

Introduction: Rotator cuff tendons are typically reattached to the proximal humerus using transosseous sutures or suture anchors. Their primary mode of failure is at the tendon-bone interface., Methods: We investigated the addition of an adhesive, gelatin-resorcin-formalin (GRF) glue, to a single-row rotator cuff repair (RCR) on ex vivo sheep models. We hypothesised the addition of GRF glue would increase the repair construct strength. The study consisted of three groups of six sheep infraspinatus tendons with an inverted-mattress stitch, tension-band configuration. Group 1 was the control group where no glue was applied. Group 2 involved applying 2 × 2 cm of GRF glue to the infraspinatus footprint and a 2-min curing time. Group 3 allowed for a 15-min cure time., Results: Failure occurred at the tendon-bone-suture interface in 6/6 of the control group, and 4/6 from groups 2 and 3. Failure occurred via the suture pulling out of the anchor in 2/6 of groups 2 and 3. No significant differences were noted between all three groups in ultimate failure load, repair stiffness or total energy to failure (p > 0.05)., Discussion: The addition of GRF glue to the tendon-bone-suture interface did not enhance RCR strength in an ovine model., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2020 The British Elbow & Shoulder Society.)

Background: Traumatic anterior shoulder dislocations can cause bony defects of the anterior glenoid rim and are often associated with recurrent shoulder instability. For large glenoid defects of 20-30% without a mobile bony fragment, glenoid reconstruction with bone grafts is often recommended. This review describes two broad categories of glenoid reconstruction procedures found in literature: coracoid transfers involving the Bristow and Latarjet procedures, and free bone grafting techniques., Methods: An electronic search of MEDLINE and PubMed was conducted to find original articles that described glenoid reconstruction techniques or modifications to existing techniques., Results: Coracoid transfers involve the Bristow and Latarjet procedures. Modifications to these procedures such as arthroscopic execution, method of graft attachment and orientation have been described. Free bone grafts have been obtained from the iliac crest, distal tibia, acromion, distal clavicle and femoral condyle., Conclusion: Both coracoid transfers and free bone grafting procedures are options for reconstructing large bony defects of the anterior glenoid rim and have had similar clinical outcomes. Free bone grafts may offer greater flexibility in graft shaping and choice of graft size depending on the bone stock chosen. Novel developments tend towards minimising invasiveness using arthroscopic approaches and examining alternative non-rigid graft fixation techniques., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: GACM: Journal of Shoulder and Elbow Surgery: Editorial or governing board. Shoulder and Elbow: Editorial or governing board. Smith & Nephew: Paid consultant and research support. Techniques in Shoulder and Elbow Surgery: Editorial or governing board. All other authors: Nil., (© 2021 The British Elbow & Shoulder Society.)

Background: A number of surgical techniques for the treatment of acromioclavicular joint separations have been described; however, few have been able to create a strong intra-operative construct that provides minimal joint translation. A biomechanical study was conducted to examine joint translation in an independent acromioclavicular ligament repair., Methods: Three variations of a novel independent acromioclavicular ligament repair technique underwent testing using a Sawbones model. The technique involves threading sutures through two acromial bone tunnels in a suture-bridge configuration and anchoring them into the distal clavicle. Three groups of eight specimens underwent reconstruction; group 1 using FiberTape, group 2 using FiberWire and group 3 using FiberTape in a modified (under-over) suture-bridge configuration. Superior, anterior and posterior translation was tested at loads of 10, 20 and 30 N., Results: Group 3 repair yielded the least translation in both anterior-posterior and superior-inferior planes, with a two-fold decrease in superior translation compared to groups 1 and 2 (P < .05). Both groups 1 and 3 using FiberTape resulted in significantly less anterior and posterior translation compared to the FiberWire group (P < .05)., Discussion: The independent acromioclavicular ligament repair, without repair of the coracoclavicular ligament, demonstrated significant translational stability in the anterior-posterior and superior-inferior planes., (© 2019 The British Elbow & Shoulder Society.)

Introduction: Shear wave elastography ultrasound is a relatively new technique that evaluates the tissue elasticity by applying an acoustic radiation force impulse. It is undetermined how reliable this modality is in assessing rotator cuff tendons. The aim of this study, therefore, was to evaluate the reliability of shear wave elastography ultrasound to assess the stiffness of normal and tendinopathic supraspinatus tendons., Methods: An inter- and intra-rater reliability trial was carried out using shear wave elastography to assess the supraspinatus tendon at its distal insertion, by measuring shear wave velocity and elasticity. Twenty participants with a mean age of 37 (21-69) years old were evaluated. Ten subjects with normal supraspinatus tendon and 10 subjects with tendinopathic tendon were selected. The Virtual Touch Imaging Quantification program was used to generate the acoustic radiation force impulse and to obtain the elastography data. Three raters with different experience in conventional ultrasound were used for the inter-rater trial in normal tendons and the most experienced rater examined all subjects for the intra-rater reliability evaluation. Each rater obtained three readings in three different examinations per subject over a one-week period., Results: The mean (±SEM) shear wave velocity for the normal supraspinatus tendon was 9.96 ± 0.02 m/s (=297 kPa), while in the tendinopathic supraspinatus tendon was 8.3 ± 0.2 m/s (=207 kPa) (p < 0.001). The intra-rater trial agreement was excellent, with an intraclass correlation coefficient = 0.96. In the inter-rater testing, the mean shear wave velocity in normal tendons was 9.90 ± 0.07 m/s (=294 kPa), with intraclass correlation coefficient = 0.45., Conclusion: Shear wave elastography ultrasound was able to show that tendinopathic tendons were less stiff than normal tendons. It was a reliable imaging technique to assess the supraspinatus tendon, especially when used by a single experienced musculoskeletal sonographer., (© 2019 The British Elbow & Shoulder Society.)

Background: Rotator cuff repair often results in significant pain postoperatively, the cause of which is undetermined. Purpose/Hypothesis: The aim of this study was to evaluate the relationship between rotator cuff tear area and postoperative pain in patients who had undergone arthroscopic rotator cuff repair. We hypothesized that larger tears would be more painful because of elevated repair tension at 1 week postoperatively but that smaller tears would be more painful because of a greater healing response, especially from 6 weeks postoperatively., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 1624 patients who underwent arthroscopic rotator cuff repair were included in this study. Exclusion criteria were moderate to severe osteoarthritis, isolated subscapularis repair, calcific tendinitis, synthetic patch repair, revision surgery, and retears on ultrasound at 6 months after surgery. Rotator cuff tears were subdivided into groups based on the tear size and retear rate found for each group. A modified L'Insalata questionnaire was given before surgery and at 1 week, 6 weeks, 3 months, and 6 months after surgery. Pearson and Spearman correlation coefficient tests were performed between rotator cuff tear areas and pain scores., Results: Intraoperative rotator cuff tear areas did not correlate with pain scores preoperatively or at 1 week after surgery. A smaller tear area was associated with more frequent and severe pain with overhead activities, at rest, and during sleep as well as a poorer perceived overall shoulder condition at 6 weeks, 3 months, and 6 months after repair ( r = 0.11-0.23, P < .0001). Patients who were younger, had partial-thickness tears, and had occupational injuries experienced more pain postoperatively ( r = 0.10-0.28, P < .0001). Larger tears did not have more pain at 1 week after surgery. The retear rate was 7% in tears <2 cm 2 but reached 44% in tears >8 cm 2 ., Conclusion: There were fewer retears with smaller tears, but they were more painful than large tears postoperatively from 6 weeks to 6 months after surgery. Smaller tears may heal more vigorously, causing more pain. Patients with smaller tears experienced more pain after rotator cuff repair compared with patients with larger tears. These findings are contrary to previous ideas about tear size and postoperative pain. Healing is likely a determinant of postoperative pain.

Tendinopathy is a multifactorial spectrum of tendon disorders that affects different anatomical sites and is characterized by activity-related tendon pain. These disorders are common, account for a high proportion (∼30%) of referrals to musculoskeletal practitioners and confer a large socioeconomic burden of disease. Our incomplete understanding of the mechanisms underpinning tendon pathophysiology continues to hamper the development of targeted therapies, which have been successful in other areas of musculoskeletal medicine. Debate remains among clinicians about the role of an inflammatory process in tendinopathy owing to a lack of clinical correlation. The advent of modern molecular techniques has highlighted the presence of immune cells and inflammatory mechanisms throughout the spectrum of tendinopathy in both animal and human models of disease. Key inflammatory mediators - such as cytokines, nitric oxide, prostaglandins and lipoxins - play crucial parts in modulating changes in the extracellular matrix within tendinopathy. Understanding the links between inflammatory mechanisms, tendon homeostasis and resolution of tendon damage will be crucial in developing novel therapeutics for human tendon disease.

Background: Retear and stiffness are not uncommon outcomes of rotator cuff repair. The purpose of this study was to evaluate the relationship between rotator cuff repair healing and shoulder stiffness., Methods: A total of 1,533 consecutive shoulders had an arthroscopic rotator cuff repair by a single surgeon. Patients assessed their shoulder stiffness using a Likert scale preoperatively and at 1, 6, 12, and 24 weeks (6 months) postoperatively, and examiners evaluated passive range of motion preoperatively and at 6, 12, and 24 weeks postoperatively. Repair integrity was determined by ultrasound evaluation at 6 months., Results: After rotator cuff repair, there was an overall significant loss of patient-ranked and examiner-assessed shoulder motion at 6 weeks compared with preoperative measurements (p < 0.0001), a partial recovery at 12 weeks, and a full recovery at 24 weeks. Shoulders that were stiff before surgery were more likely to be stiff at 6, 12, and, to a lesser extent, 24 weeks after surgery (r = 0.10 to 0.31; p < 0.0001). A stiffer shoulder at 6 and 12 weeks (but not 24 weeks) postoperatively correlated with better rotator cuff integrity at 6 months postoperatively (r = 0.11 to 0.18; p < 0.001). The retear rate of patients with ≤20° of external rotation at 6 weeks postoperatively was 7%, while the retear rate of patients with >20° of external rotation at 6 weeks was 15% (p < 0.001)., Conclusions: In patients who developed stiffness after surgery, a rotator cuff repair was more likely to heal., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: This cross-sectional analytic diagnostic accuracy study was designed to compare the accuracy of ultrasound performed by general sonographers in local radiology practices with ultrasound performed by an experienced musculoskeletal sonographer for the detection of rotator cuff tears., Methods: In total, 238 patients undergoing arthroscopy who had previously had an ultrasound performed by both a general sonographer and a specialist musculoskeletal sonographer made up the study cohort. Accuracy of diagnosis was compared with the findings at arthroscopy., Results: When analyzed as all tears versus no tears, musculoskeletal sonography had an accuracy of 97%, a sensitivity of 97% and a specificity of 95%, whereas general sonography had an accuracy of 91%, a sensitivity of 91% and a specificity of 86%. When the partial tears were split with those ≥ 50% thickness in the tear group and those < 50% thickness in the no-tear group, musculoskeletal sonography had an accuracy of 97%, a sensitivity of 97% and a specificity of 100% and general sonography had an accuracy of 85%, a sensitivity of 84% and a specificity of 87%., Conclusions: Ultrasound in the hands of an experienced musculoskeletal sonographer is highly accurate for the diagnosis of rotator cuff tears. General sonography has improved subsequent to earlier studies but remains inferior to an ultrasound performed by a musculoskeletal sonographer.

Background: Little is known about the short-term temporal outcomes of an arthroscopic capsular release for adhesive capsulitis (frozen shoulder). Specifically, it is not known how immediate the improvements are and how quickly patients return to normal function after an arthroscopic release., Methods: The study included 140 shoulders in 133 patients with idiopathic adhesive capsulitis who underwent a complete arthroscopic release of the shoulder capsule, performed by a single surgeon in a day surgery setting. Patient-reported pain and shoulder function were evaluated with the use of Likert scales, and an independent examiner assessed shoulder strength and range of motion preoperatively and at 1 week, 6 weeks, 12 weeks, and 24 weeks postoperatively., Results: Arthroscopic capsular release resulted in immediate improvements in pain, functional outcomes, and range of motion (P < .0001). External rotation increased from 21° ± 17° (mean ±  standard deviation) to 76° ± 17° at 1 week. Passive range of shoulder motion improved at 1 week, deteriorated slightly at 6 weeks, and then continued to improve at 12 and 24 weeks. Before surgery, 38% of patients reported that they "always" experienced extreme pain. This proportion reduced to 30% (P < .0001) at 1 week postoperatively and 2% (P < .0001) at 24 weeks postoperatively. There were no complications., Conclusions: Patients who underwent an arthroscopic capsular release for idiopathic adhesive capsulitis experienced significant reductions in pain, improvements in range of motion, and improvements in overall shoulder function in the first postoperative week. These immediate improvements in pain and function continue to improve at 6, 12, and 24 weeks postoperatively., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Ultrasonography for the diagnosis of rotator cuff tears has been a topic of debate for years. The literature shows promising results for the diagnostic utility of ultrasonography for rotator cuff tears. This study assessed the effect of a surgeon-sonographer interaction on the ability of ultrasonography to predict the presence or absence of rotator cuff tears., Methods: This study was a temporal cohort analysis of 775 patients to detect the diagnostic accuracy of ultrasonography at predicting a rotator cuff tear. The surgeon-sonographer interaction had three components: (1) presence of an ultrasound machine and ultrasonographer within a shoulder clinic, (2) the ultrasonographer attends shoulder operations, (3) and the ultrasonographer reviews patients preoperatively and postoperatively. Comparisons of 2 variables-presence and size of a tear-were made between the preoperative ultrasonographic findings with arthroscopic findings (gold standard)., Results: The diagnostic utility for the detection of rotator cuff tears by ultrasonography at the start of the study was 93% sensitive and 68% specific, and at the end of the study was 99% sensitive and 93% specific. There was an improvement in the correlation of the ability to estimate the size of rotator cuff tears from ultrasonography to surgery in both full- and partial-thickness tears., Conclusions: The surgeon-sonographer interaction improved the diagnostic utility of an office-based ultrasonographer over time, particularly with respect to the overall accuracy of ultrasonography for the detection of rotator cuff tears and for the ability to predict the size of full- and partial-thickness rotator cuff tears., (Copyright © 2016. Published by Elsevier Inc.)

Increasingly, inflammatory mediators are considered crucial to the onset and perpetuation of tendinopathy. We sought evidence of interleukin 17A (IL-17A) expression in early human tendinopathy and thereafter, explored mechanisms whereby IL-17A mediated inflammation and tissue remodeling in human tenocytes. Torn supraspinatus tendon (established pathology) and matched intact subscapularis tendon (representing 'early pathology') along with control biopsies were collected from patients undergoing shoulder surgery. Markers of inflammation and IL-17A were quantified by RT-PCR and immunohistochemistry. Human tendon cells were derived from hamstring tendon obtained during ACL reconstruction. In vitro effects of IL-17A upon tenocytes were measured using RT-PCR, multiplex cytokine assays, apoptotic proteomic profiling, immunohistochemistry and annexin V FACS staining. Increased expression of IL-17A was detected in 'early tendinopathy' compared to both matched samples and non-matched control samples (p < 0.01) by RT-PCR and immunostaining. Double immunofluoresence staining revealed IL-17A expression in leukocyte subsets including mast cells, macrophages and T cells. IL-17A treated tenocytes exhibited increased production of proinflammatory cytokines (p < 0.001), altered matrix regulation (p < 0.01) with increased Collagen type III and increased expression of several apoptosis related factors. We propose IL-17A as an inflammatory mediator within the early tendinopathy processes thus providing novel therapeutic approaches in the management of tendon disorders.

Background: The pathophysiologic mechanisms behind proliferation of fibroblasts and deposition of dense collagen matrix in idiopathic frozen shoulder remain unclear. Accumulation of advanced glycation end products (AGEs) with cross-linking and stabilization of collagen has been hypothesized to contribute to this pathophysiologic process. This study investigated whether the immunoreactivity of AGEs is higher in patients with idiopathic frozen shoulder than in the control groups., Methods: Shoulder capsule samples were collected from 8 patients with idiopathic frozen shoulder, 6 with unstable shoulders (control 1), and 8 with rotator cuff tears (control 2). The samples were hematoxylin and eosin stained and analyzed by immunohistochemistry using antibodies against AGEs. Immunoreactivities were rated in a blinded fashion from none (0) to strong (3). Immunohistochemical distribution within the capsule was noted., Results: Frozen shoulder patients had greater frequency and severity of self-reported pain (P = .02) than rotator cuff tear patients and more restricted range of motion in all planes (P < .05) than patients of the instability and rotator cuff tear groups. Hematoxylin and eosin-stained capsular tissue from frozen shoulder showed fibroblastic proliferation, increased numbers of adipocytes, and increased subsynovial vascularity. Immunoreactivity of AGEs was stronger in frozen shoulder capsules (2.8) than in instability (0.3; P = .0001) and rotator cuff tear (1.1; P = .016) capsules., Conclusion: This study highlights a potential role for AGEs in the pathogenesis of frozen shoulder. The overexpression of AGEs may explain the fibroblastic proliferation and deposition of collagen matrix in idiopathic frozen shoulder., Level of Evidence: Basic Science Study; Histology., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: There is debate as to whether to operate or to defer surgery on patients with concomitant rotator cuff tear and shoulder stiffness. The purpose of this study was therefore to compare the outcomes in those patients who had both their rotator cuff tear and shoulder stiffness treated with the outcomes of patients who had a rotator cuff repair but no stiffness., Methods: Twenty-five patients formed the stiffness group (receiving a concomitant rotator cuff repair and manipulation under anesthesia ± arthroscopic capsular release for preoperative ipsilateral stiffness), and a chronologically matched group of 170 rotator cuff repair-only patients formed the nonstiffness group. Patients ranked their pain and function scores preoperatively and at 1 week, 6 weeks, 12 weeks, 6 months, and 2 years postoperatively; examiners recorded range of motion, strength, and presence of impingement signs. Repair integrity was determined using ultrasound., Results: Patients from both groups had significantly improved clinical outcomes at the 2-year follow-up compared with preoperative values. Range of motion was similar between groups at 2 years for forward flexion, abduction, and external rotation, whereas the nonstiffness group had a superior range of internal rotation (P = .014). Stiffness patients had 0 of 25 (0%) retears at 2 years compared with 34 of 170 (20%) in the nonstiffness group (P = .009)., Conclusions: The good outcomes of rotator cuff repair with glenohumeral capsular release disproved our hypothesis and suggest that there is no advantage in delaying repair of a rotator cuff tear to allow stiffness to resolve and that stiffness confers an advantage in terms of repair integrity., Level of Evidence: Level III; Retrospective Cohort Design; Treatment Study., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Subacromial corticosteroid injections are frequently performed for impingement syndrome of the shoulder. To improve the accuracy of injections, ultrasound can be used., Purpose: To assess the clinical outcome of ultrasound-guided subacromial injections compared with blind subacromial injections for subacromial impingement syndrome., Study Design: Randomized controlled clinical trial; Level of evidence, 1., Methods: A total of 56 shoulders with subacromial impingement syndrome were randomized into 2 groups: 28 shoulders received a subacromial corticosteroid injection with ultrasound guidance (ultrasound group), and 28 shoulders received a subacromial corticosteroid injection without ultrasound guidance (blind group). The visual analog scale (VAS) for pain with overhead activities and the American Shoulder and Elbow Surgeons (ASES) score were obtained before the injection and at 6 weeks after the injection., Results: The VAS score for pain with overhead activities decreased from 59 ± 5 mm (mean ± SEM) before the injection to 33 ± 6 mm at 6 weeks after the injection in the ultrasound group (P < .001) and from 63 ± 4 mm to 39 ± 6 mm, respectively, in the blind group (P < .001). The decrease in the VAS score was not significantly different between the groups (P > .999). The ASES score increased from 57 ± 2 before the injection to 68 ± 3 at 6 weeks after the injection in the ultrasound group (P < .01) and from 54 ± 3 before the injection to 65 ± 4 after the injection in the blind group (P < .01), with no significant difference between the groups (P = .7). Four shoulders (14%) in the ultrasound group and 6 shoulders (21%) in the blind group eventually needed surgery (P = .7)., Conclusion: No significant differences were found in the clinical outcome when comparing ultrasound-guided subacromial injections to blind subacromial injections for subacromial impingement syndrome., Clinical Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12615000562572., (© 2015 The Author(s).)

Background: Calcific tendinitis can be a substantial cause of pain and dysfunction in the shoulder, and the pathophysiology is unclear. Recent studies have shown a link among nerve ingrowth, neovascularization, and pain in tendinopathy. The aim of this study was to determine whether there is evidence of neoinnervation and/or neovascularization in calcific tendinitis lesions of the shoulder., Methods: At arthroscopy, ultrasound was used to identify calcium within the tendon. Samples were taken from the supraspinatus tendon adjacent to the calcific lesion (in the calcific tendinitis group, with ten patients), the torn supraspinatus tendon of patients undergoing rotator cuff repair (the rotator cuff tear group, with ten patients), and the subscapularis tendon of patients undergoing a stabilization surgical procedure (the control group, with ten patients). Biopsied tendon samples were evaluated immunohistochemically by quantifying the presence of macrophages (using CD68 and CD206), T cells (CD3), mast cells (mast cell tryptase), vascular endothelium (CD34), and peripheral nerve markers (PGP 9.5)., Results: There was a twofold to eightfold increase of nerve markers, neovascularization, macrophages, M2 macrophages, and mast cells in the calcific tendinitis group compared with the rotator cuff tear group (p < 0.001) and the control group (p < 0.001). Increased nerve counts positively correlated with more frequent extreme pain (r = 0.5, p < 0.01) and with increased neovascularization (r = 0.7, p < 0.01) and counts of CD68 macrophages (r = 0.8, p < 0.01), M2 macrophages (r = 0.6, p < 0.01), and mast cells (r = 0.7, p < 0.01)., Conclusions: This is the first study to show a significant increase in neovascularization and neoinnervation in calcific tendinitis lesions of the shoulder along with an eightfold increase in mast cells and macrophages. The findings are consistent with the hypothesis that, in calcific tendinitis, the calcific material is inducing a vigorous inflammatory response within the tendon with formation of new blood vessels and nerves., Clinical Relevance: This study helps to explain why calcific tendinitis is related to substantial pain in the clinical setting., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Massive irreparable rotator cuff tears are a difficult problem. Modalities such as irrigation and debridement, partial repair, tendon transfer and grafts have been utilized with high failure rates and mixed results. Synthetic interpositional patch repairs are a novel and increasingly used approach. The present study aimed to examine the biomechanical properties of common synthetic materials for interpositional repairs in contrast to native tendon., Methods: Six ovine tendons, six polytetrafluoroethylene (PTFE) felt sections and six expanded PTFE (ePTFE) patch sections were pulled-to-failure to analyze their biomechanical and material properties. Six direct tendon-to-bone surgical method repairs, six interpositional PTFE felt patch repairs and six interpositional ePTFE patch repairs were also constructed in ovine shoulders and pulled-to-failure to examine the biomechanical properties of each repair construct., Results: Ovine tendon had higher load-to-failure (591 N) and had greater stiffness (108 N/mm) than either PTFE felt (296 N, 28 N/mm) or ePTFE patch sections (323 N, 34 N/mm). Both PTFE felt and ePTFE repair techniques required greater load-to-failure (225 N and 177 N, respectively) than direct tendon-to-bone surgical repairs (147 N) in ovine models., Conclusions: Synthetic materials lacked several biomechanical properties, including strength and stiffness, compared to ovine tendon. Interpositional surgical repair models with these materials were significantly stronger than direct tendon-to-bone model repairs.

Background: Rotator cuff repair aims to reattach the torn tendon to the greater tuberosity footprint with suture anchors. The present study aimed to assess the diagnostic accuracy of ultrasound in predicting rotator cuff tear repairability and to assess which sonographic and pre-operative features are strongest in predicting repairability., Methods: The study was a retrospective analysis of measurements made prospectively in a cohort of 373 patients who had ultrasounds of their shoulder and underwent rotator cuff repair. Measurements of rotator cuff tear size and muscle atrophy were made pre-operatively by ultrasound to enable prediction of rotator cuff repairability. Tears were classified following ultrasound as repairable or irreparable, and were correlated with intra-operative repairability., Results: Ultrasound assessment of rotator cuff tear repairability has a sensitivity of 86% (p < 0.0001) and a specificity of 67% (p < 0.0001). The strongest predictors of rotator cuff repairability were tear size (p < 0.001) and age (p = 0.004). Sonographic assessments of tear size ≥4 cm(2) or anteroposterior tear length ≥25 mm indicated an irreparable rotator cuff tear., Conclusions: Ultrasound assessment is accurate in predicting rotator cuff tear repairability. Tear size or anteroposterior tear length and age were the best predictors of repairability.

Background: Patients with rotator cuff tears often recall a specific initiating event (traumatic), whereas many cannot (nontraumatic). It is unclear how important a history of trauma is to the outcomes of rotator cuff repair., Methods: This question was addressed in a study cohort of 1300 consecutive patients who completed a preoperative questionnaire regarding their shoulder injury and had a systematic evaluation of shoulder range of motion and strength, a primary arthroscopic rotator cuff repair performed by a single surgeon, an ultrasound scan, and the same subjective and objective measurements made of their shoulder 6 months after surgery. Post hoc, this cohort was separated into 2 groups: those who reported no history of trauma on presentation (n = 489) and those with a history of traumatic injury (n = 811)., Results: The retear rate in the group with no history of trauma was 12%, whereas that of the group with a history of trauma was 14% (P = .36). Those patients with a history of shoulder trauma who waited longer than 24 months had higher retear rates (20%) than those who had their surgery earlier (13%) (P = .040)., Conclusion: Recollection of a traumatic initiating event had little effect on the outcome of arthroscopic rotator cuff repair. Duration of symptoms was important in predicting retears if patients recalled a specific initiating event but not in patients who did not recall any specific initiating event. Patients with a history of trauma should be encouraged to have their rotator cuff tear repaired within 2 years., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: To our knowledge there has been no research that has compared the effectiveness of two popular cold therapy modalities applied to healthy human knees, with a surgical dressing, over a 4 h period., Hypothesis: To determine whether gel packs are more effective than ice bags at reducing skin surface temperature in humans., Study Design: This was a randomised, repeated measures crossover study, which included nine healthy participants., Level of Evidence: Level 2., Methods: Two cold therapy modalities-a gel pack (DonJoy-Orthopaedic Pty Ltd, Normanhurst, New South Wales, Australia) and an ice bag (ICE'N'EASY, Bokarina, Queensland, Australia)-were applied on top of a surgical dressing, covering the knee. Each participant randomly received two cold therapy treatments, in separate sessions, at least 4 days apart. Each session utilised the time protocol of 20 min application on the hour, for 4 h. Skin surface temperature was recorded throughout the session at 1 min intervals., Results: In the first application, the ice bag (5°C±1.7°C) was more effective at reducing skin surface temperature (p<0.04) from baseline than the gel pack (4°C±0.9°C), and had a significantly greater cooling rate (p<0.02). On the subsequent three applications, both modalities were just as effective at reducing skin surface from baseline, and had similar cooling rates., Conclusions: An ice bag initially was more effective than the gel pack at reducing skin surface temperature of healthy knees, with a surgical dressing. Over a 4 h period both gel packs and ice bags were just as effective at reducing skin surface temperature and at maintaining these lower temperatures.

Background: Rotator cuff repair is a common method to treat rotator cuff tears; however, retear rates remain high. High-frequency, low-magnitude vibration has been demonstrated to promote new bone formation in both animal models and in humans., Hypothesis: This type of mechanical stimulation applied postoperatively will enhance tendon-to-bone healing and reduce postoperative retear rates., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: A randomized, double-blinded, placebo-controlled clinical trial was conducted to investigate the effects of 5 minutes of 80-Hz vibration applied daily after arthroscopic rotator cuff repair for 6 months on postoperative rotator cuff healing. The primary outcome was ultrasound-assessed repair integrity at 6 months after repair. Recruited patients were randomized into 2 groups: one group received a vibration device that oscillated at 80 Hz, and the other group received a placebo device., Results: The postoperative retear rates of both groups were similar (9.1% [5/55] in the vibration group, and 9.3% [5/54] in the placebo group) at 6 months as determined by ultrasound imaging. Vibration did provide acute pain relief at 6 weeks after surgery (visual analog scale [VAS] score, 2.24 ± 0.29 cm) compared with placebo (VAS score, 3.67 ± 0.48 cm) (P < .003). Six months after surgery, both groups had significant reductions in pain during overhead activities, at rest, and during sleep and overall shoulder pain compared with before surgery (P < .001). Both the vibration and placebo groups had significant increases in shoulder strength with abduction in the scapular plane, adduction, liftoff, internal rotation, and external rotation 6 months after surgery. Statistical analysis showed that vibration was not a contributing factor at improving these parameters in these periods., Conclusion: High-frequency, low-magnitude vibration did provide acute pain relief on application 6 weeks after arthroscopic rotator cuff repair surgery. However, vibration did not improve tendon-to-bone healing, shoulder range of motion, shoulder strength, or shoulder pain with activities, at rest, and at night when compared with placebo., (© 2015 The Author(s).)

Background: Arthroscopic rotator cuff repair has traditionally been performed in the subacromial space from the bursal side of the tendon. The undersurface rotator cuff repair technique involves the arthroscope remaining in the glenohumeral joint, thus viewing the tendon from its undersurface during repair without a bursectomy or acromioplasty., Purpose: To compare the clinical and structural outcomes of undersurface rotator cuff repair with bursal-side repair., Study Design: Cohort study; Level of evidence, 3., Methods: A retrospective analysis of prospectively collected data was conducted on 2 cohorts of patients who had undergone arthroscopic rotator cuff repair with knotless suture anchors configured in a single-row formation using inverted mattress-style sutures from either the bursal side (n = 100) or undersurface (n = 165) of the supraspinatus tendon. Data were collected preoperatively, intraoperatively, and at 1 week, 6 weeks, 3 months, 6 months, and 2 years postoperatively. At each time point, patients completed a modified L'Insalata questionnaire to assess patient-ranked pain scores and were clinically examined using standardized tests. Ultrasound examination was performed at 6 months and 2 years to assess the integrity of the repair., Results: At 2 years postoperatively, patients in both cohorts had significantly less pain and less difficulty with overhead activities compared with preoperative levels (P < .001). The type of repair performed (bursal or undersurface) did not affect the ability to perform overhead activities at 2 years. At 2 years, both groups also had similar retear rates (21% for bursal side, 23% for undersurface). The mean operative time for the arthroscopic rotator cuff repair was 32 minutes when performed from the bursal side and 20 minutes when performed from the undersurface (P < .001)., Conclusion: Arthroscopic rotator cuff repair, whether performed from the subacromial space or glenohumeral joint, resulted in decreased levels of pain and difficulty with overhead activities at 2 years. The major difference between the 2 techniques was operative time, with the undersurface technique being performed significantly faster than the bursal-side repair technique.

Background: The present study aimed to determine how repair technique influenced structural and clinical outcomes at 5 years post-surgery., Methods: Three cohorts of patients had repair of a symptomatic rotator cuff tear using (i) an open double-row mattress repair technique (n = 25); (ii) arthroscopic single-row simple suture knotted technique (n = 25); or (iii) arthroscopic single-row inverted mattress knotless technique (n = 36) by one surgeon. Standardized patient- and examiner-determined outcomes were obtained pre-operatively and postoperatively with a validated protocol, ultrasound were also performed at the same time., Results: Retear occurred more often after open repair (48%) at 5 years than after arthroscopic knotted (33%) and arthroscopic knotless (26%) repair. Retear was associated with increasing age, pre-operative tear size and weaker pre-operative and 5 years postoperative cuff strength. Between 2 years and 5 years, the open repair group experienced an increase in the frequency of pain during activity, as well as in the difficulty experienced and the severity of pain during overhead activities (p < 0.05) and, at 5 years, also experienced more difficulty with overhead activities, compared to the arthroscopic knotless repair group., Conclusions: At 5-year follow-up, arthroscopic rotator cuff repair techniques resulted in fewer retears and better outcomes compared to an open double-row technique.

Background: Symptomatic rotator cuff tears are often treated surgically. However, there is a paucity of information regarding the outcomes of revision arthroscopic rotator cuff repairs., Purpose: To evaluate the outcome of revision arthroscopic rotator cuff surgery when compared with primary arthroscopic rotator cuff surgery in a large cohort of patients., Study Design: Cohort study; Level of evidence, 3., Method: A consecutive series of 50 revision arthroscopic rotator cuff repairs performed by a single surgeon, with minimum 2-year follow-up, were retrospectively reviewed using prospectively collected data. As a comparison, 3 primary arthroscopic rotator cuff repair cases (primary group; n = 310) were chosen immediately before each revision case, and 3 were chosen after. Standardized patient-ranked outcomes, examiner-determined assessments, and ultrasound-determined rotator cuff integrity were assessed preoperatively at 6 months and at a minimum of 2 years after surgery., Results: The revision group was older (mean age, 63 years; range, 43-80 years) compared with the primary group (mean age, 60 years; range, 18-88 years) (P < .05) and had larger tear size (mean ± SEM) (4.1 ± 0.5 cm(2)) compared with the primary group (3.0 ± 0.2 cm(2)) (P < .05). Two years after surgery, the primary group reported less pain at rest (P < .02), during sleep (P < .05), and with overhead activity (P < .01) compared with the revision group. The primary group had better passive forward flexion (+13°; P < .05), abduction (+18°; P < .01), internal rotation (+2 vertebral levels; P < .001) and also significantly greater supraspinatus strength (+15 N; P < .001), lift-off strength (+9.3 N; P < .05), and adduction strength (+20 N; P < .01) compared with the revision group at 2 years. When compared with the primary group, the revision group was more satisfied with the overall shoulder function before surgery but was less satisfied with their shoulder function than the primary group at 2 years (P < .005). The retear rate for primary rotator cuff repair was 16% at 6 months and 21% at 2 years, while the retear rate for revision rotator cuff repair was 28% at 6 months and deteriorated to 40% at 2 years (P < .05)., Conclusion: The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair. However, these results did not persist, and by 2 years patients who had revision rotator cuff repair were twice as likely to have retorn compared with those undergoing primary repair. The increase in retear rate in the revision group at 2 years was associated with increased pain, impaired overhead function, less passive motion, weaker strength, and less overall satisfaction with shoulder function., (© 2014 The Author(s).)

Background: This study investigated the biomechanical effects of expanded polytetrafluoroethylene (ePTFE) suture augmentation patches in rotator cuff repair constructs., Methods: The infraspinatus tendon in 24 cadaveric ovine shoulders was repaired using an inverted horizontal mattress suture with 2 knotless bone anchors (ArthroCare, Austin, TX, USA) in a lateral-row configuration. Four different repair groups (6 per group) were created: (1) standard repair using inverted horizontal mattress sutures, (2) repair with ePTFE suture augmentations on the bursal side of the tendon, (3) repair with ePTFE suture augmentations on the articular side, and, (4) repair with ePTFE suture augmentations on both sides of the tendon. Footprint contact pressure, stiffness, and the load to failure of the repair constructs were measured., Results: Repairs with ePTFE suture augmentations on the bursal side exerted significantly more footprint contact pressure (0.40 ± 0.01 MPa) than those on the articular side (0.34 ± 0.02 MPa, P = .04) and those on both sides (0.33 ± 0.02 MPa, P = .01). At 15 degrees of abduction, ePTFE-augmented repairs on the bursal side had higher footprint contact pressure (0.26 ± 0.03 MPa) compared with standard repairs (0.15 ± 0.02 MPa, P = .01) and with ePTFE-augmented repairs on the articular side (0.18 ± 0.02 MPa, P = .03). The ePTFE-augmented repairs on the bursal side demonstrated significantly higher failure loads (178 ± 18 N) than standard repairs (120 ± 17 N, P = .04)., Conclusions: Inverted horizontal mattress sutures augmented with ePTFE patches on the bursal side of the tendon enhanced footprint contact pressures and the ultimate load to failure of lateral-row rotator cuff repairs in an ovine model., (Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The rate of retears after rotator cuff repair varies from 11% to 94%. A retear is associated with poorer subjective and objective clinical outcomes than intact repair., Purpose: This study was designed to determine which preoperative and/or intraoperative factors held the greatest association with retears after arthroscopic rotator cuff repair., Study Design: Cohort study; Level of evidence, 3., Methods: This study retrospectively evaluated 1000 consecutive patients who had undergone a primary rotator cuff repair by a single surgeon using an arthroscopic inverted-mattress knotless technique and who had undergone an ultrasound evaluation 6 months after surgery to assess repair integrity. Exclusion criteria included previous rotator cuff repair on the same shoulder, incomplete repair, and repair using a synthetic polytetrafluoroethylene patch. All patients had completed the modified L'Insalata Questionnaire and underwent a clinical examination before surgery. Measurements of tear size, tear thickness, associated shoulder injury, tissue quality, and tendon mobility were recorded intraoperatively., Results: The overall retear rate at 6 months after surgery was 17%. Retears occurred in 27% of full-thickness tears and 5% of partial-thickness tears (P < .0001). The best independent predictors of retears were anteroposterior tear length (correlation coefficient r = 0.41, P < .0001), tear size area (r = 0.40, P < .0001), mediolateral tear length (r = 0.34, P < .0001), tear thickness (r = 0.29, P < .0001), age at surgery (r = 0.27, P < .0001), and operative time (r = 0.18, P < .0001). These factors produced a predictive model for retears: logit P = (0.039 × age at surgery in years) + (0.027 × tear thickness in %) + (1 × anteroposterior tear length in cm) + (0.76 × mediolateral tear length in cm) - (0.17 × tear size area in cm(2)) + (0.018 × operative time in minutes) -9.7. Logit P can be transformed into P, which is the chance of retears at 6 months after surgery., Conclusion: A rotator cuff retear is a multifactorial process with no single preoperative or intraoperative factor being overwhelmingly predictive of it. Nevertheless, rotator cuff tear size (tear dimensions, tear size area, and tear thickness) showed stronger associations with retears at 6 months after surgery than did measures of tissue quality and concomitant shoulder injuries.

Background: The present study aimed to determine the long-term outcome as a result of the use of synthetic patches as tendon substitutes to bridge massive irreparable rotator cuff defects., Methods: All patients who previously had a rotator cuff repair with a synthetic patch (2-mm Gore DUALMESH ePTFE patch; Gore, Flagstaff, AZ, USA; or a 2.87-mm Bard PTFE Felt pledgets; CR Bard, Warwick, RI, USA) were followed-up at a minimum of 8.5 years postoperatively. Assessment of shoulder pain, function, range of motion, strength and imaging was performed., Results: Six patients had an interpositional repair with a synthetic patch. One patient had died. In the remaining five patients, the mean tear size at repair was 27 cm(2). At 9.7 years postoperatively, all the patches remained in situ and no patient required further surgery. The repair was intact in four out of five patients. Patients had improved external rotation and abduction compared to before surgery (p < 0.02)., Conclusions: We describe the long-term outcomes of patients who had undergone synthetic patch rotator cuff repair for an irreparable rotator cuff tear. At 9.7 years postoperatively, patients reported less severe and more infrequent pain, as well as greater overall shoulder function, compared to before surgery. Patients also had increased passive external rotation and abduction. All the patches remain in situ and there have been no further operations on these shoulders.

The pathogenetic mechanisms underlying tendinopathy remain unclear, with much debate as to whether inflammation or degradation has the prominent role. Increasing evidence points toward an early inflammatory infiltrate and associated inflammatory cytokine production in human and animal models of tendon disease. The IL-21/IL-21R axis is a proinflammatory cytokine complex that has been associated with chronic inflammatory diseases including rheumatoid arthritis and inflammatory bowel disease. This project aimed to investigate the role and expression of the cytokine/receptor pair IL-21/IL-21R in human tendinopathy. We found significantly elevated expression of IL-21 receptor message and protein in human tendon samples but found no convincing evidence of the presence of IL-21 at message or protein level. The level of expression of IL-21R message/protein in human tenocytes was significantly upregulated by proinflammatory cytokines (TNFα/IL-1β) in vitro. These findings demonstrate that IL-21R is present in early human tendinopathy mainly expressed by tenocytes and macrophages. Despite a lack of IL-21 expression, these data again suggest that early tendinopathy has an inflammatory/cytokine phenotype, which may provide novel translational targets in the treatment of tendinopathy.

Biologic and synthetic scaffolds, mechanical loads, vitamin D, and diabetes can affect tendon and tendon-to-bone healing, muscle recovery, and growth in the perioperative period. Despite important advances in technical approaches to achieve surgical repair of soft tissues in a minimally invasive fashion, structural healing after tendon-to-bone repair remains a formidable challenge that is complicated by our incomplete knowledge of complex natural biologic processes and a diverse patient population with various comorbidities and deficiencies. Scientific research has led to promising strategies for promoting a structural repair that recapitulates the native anatomy of the tendon or enthesis. Augmentation with scaffolds may reinforce the initial repair biomechanically and can be coupled with growth factors to promote a favorable biologic environment for healing. Careful consideration of the implications of postoperative rehabilitation and endocrine and nutritional deficiencies on structural healing and muscle recovery are also critical to optimize patient outcomes.

Historically, many causes have been proposed for rotator cuff conditions. The most prevalent theory is that the rotator cuff tendons, especially the supraspinatus, make contact with the acromion and coracoacromial ligament, resulting in pain and eventual tearing of the tendon. However, more recent evidence suggests that this concept does not explain the changes in rotator cuff tendons with age. The role of acromioplasty and coracoacromial ligament release in the treatment of rotator cuff disease has become questioned. Evidence now suggests that tendinopathy associated with aging may be a predominant factor in the development of rotator cuff degeneration. We propose that the overwhelming evidence favors factors other than "impingement" as the major cause of rotator cuff disease and that a paradigm shift in the way the development of rotator cuff pathology is conceptualized allows for a more comprehensive approach to the care of the patient with rotator cuff disease.

Background: Little is known about the morphology of healing rotator cuffs after surgical repair. This investigation aimed to determine whether there are changes in tendon thickness, subacromial bursa, anatomical footprint, tendon vascularity, and capsular thickness after rotator cuff repair, and whether supraspinatus tendon thickness correlates with pain., Methods: Fifty-seven patients completed a validated pain questionnaire. Using a standardized protocol, their shoulders were scanned by the same ultrasonographer at 1 week, 6 weeks, 3 months, and 6 months postarthroscopic repair by a single surgeon. The contralateral shoulders, if uninjured, were also scanned., Results: Of 57 patients, 4 re-tore their tendons at 6 weeks and 4 retore at 3 months. Sixteen of the remaining 49 patients had intact contralateral supraspinatus tendons. The repaired supraspinatus tendon thickness remained unchanged throughout the 6 months. Compared to week 1, at 6 months, bursal thickness decreased from 1.9 (0.7) mm to 0.7 (0.5) mm (P < .001); anatomical footprint increased from 7.0 (2.0) mm to 9.3 (1.5) mm; tendon vascularity decreased from mild to none (P < .001); posterior capsule thickness decreased from 2.3 (0.8) mm to 1.3 (0.6) mm (P < .001). Frequency and severity of pain and shoulder stiffness decreased (P < .001). There was no correlation between tendon thickness and pain., Conclusion: After rotator cuff repair, there was an immediate increase in subacromial bursa thickness, tendon vascularity, and posterior glenohumeral capsular thickness. These normalized after 6 months. Tendon thickness was unchanged while footprint contact was comparable with the contralateral tendons. There was no correlation between tendon thickness and pain., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Tendon disorders-tendinopathies-are the primary reason for musculoskeletal consultation in primary care in the UK and account for up to 30% of rheumatological consultations. While the molecular pathophysiology of tendinopathy remains incompletely understood, recent observations concerning repetitive stress and cellular load provide important mechanistic insight implicating a role for tissue alarmins. These in turn have an emerging effector role in many disease processes across the rheumatological diseases. Intracellular alarmins, also called damage-associated molecular patterns, are rapidly released following non-programmed cell death, are key effectors of the innate immune system and critically restore homeostasis by promoting the reconstruction of the affected tissue. Recent investigations have highlighted a key role for several alarmins including hypoxia-induced elements, cytokines and heat shock proteins affecting tissue rescue mechanisms in tendon pathology. This review aims to provide an overview of the biology of alarmins in the context of inflammatory mediators and matrix regulation in tendinopathy.

Background: Rotator cuff repair has a relatively high (20%-90%) chance of retears. Patients with an intact rotator cuff 6 months after surgery have better subjective and objective outcomes at 6 months and 2 years after rotator cuff repair than those who do not have an intact repair., Purpose: The aim of this study was to determine if, and if so which, intraoperative factors predict an intact repair 6 months after rotator cuff repair., Study Design: Cohort study; Level of evidence, 3., Methods: The study consisted of a cohort of 500 consecutive patients who had an arthroscopic rotator cuff repair performed by a single surgeon and an ultrasound evaluation using standard protocols of the repair 6 months after surgery. Exclusion criteria included previous fracture or shoulder surgery, incomplete or partial rotator cuff repair, and concomitant arthroplasty. Rotator cuff tear size was measured intraoperatively and mapped. The quality of the tendon, tendon mobility, and repair quality were assessed and ranked based on predetermined scales (1-4) and recorded on a specifically designed form. Logistic regression analysis was performed, with cuff integrity at 6-month follow-up as the dependent variable and tear/repair factors as the independent variables., Results: The overall postoperative retear rate was 19% at 6 months. The best predictor of rotator cuff integrity was preoperative tear size (correlation coefficient, r = 0.33; P < .001). Patients with small (≤2 cm(2)) rotator cuff tears were least likely to have retears (retear rate, 10%). As the tear size increased, the retear rate increased in a linear fashion: ≤2 cm(2) (10%), 2 to 4 cm(2) (16%), 4 to 6 cm(2) (31%), 6 to 8 cm(2) (50%), and >8 cm(2) (57%). Other surgeon-ranked intraoperative assessments did correlate with retears, but the correlations were relatively weak: repair quality (r = -0.17; P < .001), tendon mobility (r = -0.15; P < .001), and tendon quality (r = -0.14; P < .01). Regression analysis showed that the retear rate at 6-month follow-up was best predicted from the preoperative tear size and the surgeon-ranked repair quality: chance of retear = 0.38 + (0.02 × tear size in cm(2)) - (0.08 × repair quality). Tendon quality and tendon mobility did not contribute significantly to this prediction., Conclusion: Tear size was the best intraoperative predictor of repair integrity after rotator cuff repair, with tears less than 2 cm(2) twice as likely to heal than tears greater than 6 cm(2).

Background: Our understanding of the pathogenesis of frozen shoulder and why it is so painful is undetermined. This study investigated the expression of neuronal proteins in the capsular tissue of frozen shoulder., Methods: Shoulder capsular samples were collected from 8 patients with idiopathic adhesive capsulitis and 10 patients with a rotator cuff tear but no stiffness (controls). Samples were analyzed by immunohistochemistry using antibodies against protein gene product 9.5 (PGP9.5), a general nerve marker; growth associated protein 43 (GAP43), a nerve growth marker; nerve growth factor receptor p75; and CD34, an endothelial cell marker., Results: Samples from frozen shoulders showed subsynovial hypercellularity and fibroblastic proliferation, with increased expression of nerve growth factor receptor p75 and CD34 compared with controls. Nerves positive for PGP9.5 and GAP43 were more abundant in samples of frozen shoulder (2.8 ± 0.2 and 2.4 ± 0.4 per field; P < .01) compared with controls (1.6 ± 0.3 and 1.3 ± 0.3 per field; P < .05). Expression of neuronal proteins followed that of CD34., Conclusion: Increased expression of nerve growth factor receptor and new nerve fibers were found in the shoulder capsular tissue of patients with frozen shoulder compared with those without a frozen shoulder. These data suggest that neoinnervation and neoangiogenesis in the shoulder capsule are important events in the pathogenesis of frozen shoulder and may help explain the often-severe pain of patients with frozen shoulder., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Objectives: The aim of this study was to determine whether there is any significant difference in temporal measurements of pain, function and rates of re-tear for arthroscopic rotator cuff repair (RCR) patients compared with those patients undergoing open RCR., Methods: This study compared questionnaire- and clinical examination-based outcomes over two years or longer for two series of patients who met the inclusion criteria: 200 open RCR and 200 arthroscopic RCR patients. All surgery was performed by a single surgeon., Results: Most pain measurements were similar for both groups. However, the arthroscopic RCR group reported less night pain severity at six months, less extreme pain and greater satisfaction with their overall shoulder condition than the open RCR group. The arthroscopic RCR patients also had earlier recovery of strength and range of motion, achieving near maximal recovery by six months post-operatively whereas the open RCR patients took longer to reach the same recovery level. The median operative times were 40 minutes (20 to 90) for arthroscopic RCR and 60 minutes (35 to 120) for open RCR. Arthroscopic RCR had a 29% re-tear rate compared with 52% for the open RCR group (p < 0.001)., Conclusions: Arthroscopic RCR involved less extreme pain than open RCR, earlier functional recovery, a shorter operative time and better repair integrity.

Background: One management strategy for the treatment of idiopathic adhesive capsulitis, or frozen shoulder, is arthroscopic capsular release. While there are long-term data regarding nonoperative treatment and good short-term outcomes following a release for idiopathic adhesive capsulitis, little is known about the outcomes five years or more after arthroscopic capsular release., Methods: Patients with idiopathic adhesive capsulitis treated with a circumferential arthroscopic capsular release of the glenohumeral joint by a single surgeon were assessed with use of patient-reported pain scores, shoulder functional scores with use of a Likert scale, and shoulder range of motion at the preoperative evaluation and at one, six, twelve, twenty-four, and fifty-two weeks and a mean of seven years after surgery., Results: At a mean follow-up of seven years (range, five through thirteen years), forty-three patients (forty-nine shoulders) had significant improvement with regard to pain frequency and severity, patient-reported shoulder function, stiffness, and difficulty in completing activities compared with the findings at the initial presentation (p < 0.001) and the one-year follow-up evaluation (p < 0.01 to p < 0.001). Shoulder motion also improved (p < 0.001) and was comparable with that of the contralateral shoulder. There were no complications., Conclusions: Patients with idiopathic adhesive capsulitis treated with an arthroscopic capsular release had early significant improvements in shoulder range of motion, pain frequency and severity, and function. These improvements were maintained and/or enhanced at seven years. In contrast to results reported for nonoperative treatment, shoulder range of motion at seven years was equivalent to that in the contralateral shoulder.

Background: Little is known about the outcomes after repair of partial-thickness rotator cuff tears. The aim of this study was to assess the outcome after repair of partial-thickness rotator cuff tears compared with full-thickness tears. Our hypothesis was that repair of partial-thickness tears leads to more shoulder stiffness but fewer retears compared with repair of full-thickness tears., Methods: A group of 105 consecutive patients who had a full-thickness tear measuring <3 cm2 was compared with a group of sixty-four patients who had a partial-thickness tear. All tears were repaired with use of a knotless single-row arthroscopic repair. The American Shoulder and Elbow Surgeons (ASES) score and standardized patient and examiner-determined outcomes were obtained preoperatively and at six, twelve, and twenty-four weeks and at two years after surgery. Rotator cuff integrity was determined by ultrasound examination at six months and two years after surgery., Results: Examiner-determined postoperative stiffness at six weeks was common in both groups (50% of those with a partial-thickness tear and 47% of those with a full-thickness tear) but was decreased compared with preoperative findings in both groups to 21% and 19%, respectively, at three months and to 15% and 14% at six months. The ultrasound-determined retear rate was small (5% in the partial-thickness group and 10% in the full-thickness group) at six months, but increased to 10% and 20%, respectively, at twenty-four months. The ASES score, patient-determined overall shoulder function, and all pain scores were superior to preoperative scores at six months (p < 0.001) and at twenty-four months (p < 0.001) in both groups., Conclusions: Arthroscopic repair of partial-thickness and small and medium-sized full-thickness rotator cuff tears was associated with excellent medium-term clinical outcomes with low retear rates. The data did not support our hypothesis: the differences in retear rate and postoperative shoulder stiffness rate found between the two groups did not reach significance.