Rotator Cuff Research Articles

Bone Marrow Aspirate Concentrate Combined With an Appropriate Carrier Effectively Promotes Bone-Tendon Interface Healing in a Rabbit Model of Chronic Rotator Cuff Tear.

The efficacy of bone marrow aspirate concentrate (BMAC) in promoting bone-tendon interface (BTI) healing without any carriers remains a subject of debate. To evaluate BMAC effects with different carriers on tendon regeneration in a rabbit model of chronic rotator cuff tear. Controlled laboratory study. In vitro, the amount of growth factor and the differentiation potential of BMAC with different carriers (polydeoxyribonucleotide [PDRN] and atelocollagen [ATC]) were assessed. In vivo, 64 rabbits were randomly allocated into 4 groups. Different materials were injected into the repair site according to the allocated group: control, saline; BMAC, BMAC and saline; BMAC-PDRN, BMAC with PDRN; BMAC-ATC, BMAC with ATC (n = 16 in each). Genetic and histologic analyses were conducted at 4 and 12 weeks after repair, while biomechanical evaluations were performed at 12 weeks after repair. In vitro, the degree of multilineage differentiation was much stronger using BMAC with ATC as compared with administration of BMAC alone or BMAC with PDRN (P < .001). In vivo, the BMAC-ATC group had the highest levels of aggrecan expression, bone morphogenetic protein 2, and collagen type I alpha 1 among all groups (all P < .001) at 4 weeks after repair. Furthermore, the BMAC-ATC group showed collagen fiber continuity, denser collagen fibers, and more mature BTI as compared with the other groups (all P < .001) at 12 weeks after repair. Concurrently, the BMAC-ATC group also demonstrated significantly higher load-to-failure versus the remaining groups (all P < .001) at 12 weeks after repair. Local application of BMAC without appropriate carriers could not enhance BTI healing. However, BMAC with 2 different carriers effectively accelerated BTI healing, particularly in the ATC environment. Therefore, the combination of BMAC and ATC may act as a powerful biological agent to promote healing after rotator cuff repair in a chronic rotator cuff tear model using rabbits. Local application of BMAC without appropriate carriers could not enhance BTI healing. However, the combination of BMAC and ATC may synergistically promote rotator cuff tendon healing.

Efficacy of an Autologous Dermal Fibroblast Injection in Reducing the Retear Rate After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Trial.

Interest in biological augmentation for improving bone-tendon interface (BTI) healing after arthroscopic rotator cuff repair (ARCR) is growing. Dermal fibroblasts, known for collagen synthesis similar to tenocytes, have shown effectiveness in BTI healing in chronic rotator cuff tear (RCT) models in rabbits. However, no human clinical trials have been conducted. To evaluate the clinical efficacy of autologous dermal fibroblasts (ADFs) for BTI healing after ARCR in patients with full-thickness RCTs >2 cm. Randomized controlled trial; Level of evidence, 2. A total of 86 patients were prospectively enrolled and randomized into 2 groups: an additional ADF injection between the bone and tendon during ARCR (ADF group) or ARCR alone (control group). A skin biopsy from the buttock was performed to obtain ADFs, which were cultured for approximately 4 weeks before surgery. ARCR was standardized to the double-row suture bridge technique to reduce the heterogeneity in different repair methods. The primary variable for evaluating ADF efficacy was the retear rate using magnetic resonance imaging at 6 months postoperatively. Secondary variables included range of motion, the American Shoulder and Elbow Surgeons score, the Constant score, and the Simple Shoulder Test score at baseline and at 6 and 12 months postoperatively. Overall, 13 patients dropped out because of a subscapularis tendon tear, loss to follow-up, or the withdrawal of consent (7 in the ADF group and 6 in the control group). The retear rate was significantly lower in the ADF group (5.6% [2/36]) than in the control group (24.3% [9/37]) (P = .025). The American Shoulder and Elbow Surgeons, Constant, and Simple Shoulder Test scores showed significant improvement after surgery in both groups (all P values <.001). Functional scores and range of motion did not significantly differ between the 2 groups at 6 and 12 months (all P values >.05). ADF application into the BTI during ARCR significantly decreased the retear rate in patients with full-thickness RCTs >2 cm. Therefore, an ADF injection could be a promising biological supplement to enhance BTI healing in these patients. However, clinical outcomes showed no significant difference between the 2 groups at 6 months and 1 year postoperatively.

An Aligned-to-Random PLGA/Col1-PLGA/nHA Bilayer Electrospun Nanofiber Membrane Enhances Tendon-to-Bone Healing in a Murine Model.

The challenge of achieving effective tendon-to-bone healing remains a significant concern in sports medicine, necessitating further exploration. Biomimetic electrospun nanomaterials present promising avenues for improving this critical healing process. To investigate the biological efficacy of a novel aligned-to-random PLGA/Col1-PLGA/nHA bilayer electrospun nanofiber membrane in facilitating tendon-to-bone healing. Controlled laboratory study. The bilayer membrane's composition, combining PLGA/Col1 for tendon attachment and PLGA/nHA for bone integration, was examined using scanning electron microscopy, Fourier transform infrared spectroscopy, and mechanical testing. Positioned between the Achilles tendon and bone, its design aimed for harmonious integration with both types of tissue. In vitro, biocompatibility, cell adhesion, and proliferation of the biomaterial were evaluated using live/dead staining and the CCK-8 assay. Collagen secretion and mineralization were measured for 2 cell types. In vivo, tendon-to-bone insertion samples harvested from mice were analyzed: micro-computed tomography assessed bone formation; histological staining evaluated chondrogenesis, tendinogenesis, and the 4-layer structure of the insertion; and biomechanical testing measured insertion strength. Real-time polymerase chain reaction identified genes involved in tendon-to-bone healing, and transcriptome analysis elucidated the underlying cellular and molecular mechanisms. The optimal composition was determined as 10% 3:1 for aligned PLGA/Col1 and 9% 5:1 for PLGA/nHA. Coculture showed minimal cell death, firm cell adherence, and steady proliferation, with PLGA/Col1 enhancing collagen secretion. In vivo, the material promoted bone and cartilage formation and improved tendon-to-bone interface strength. Transcriptome analysis indicated links to TNF and NF-κB pathways and to genes IL-1β, ADAM8, and EGR2. The novel aligned-to-random PLGA/Col1-PLGA/nHA bilayer nanofiber membrane outperformed other materials in both in vitro and in vivo evaluations, significantly enhancing tendon-to-bone healing. It notably improved cartilage and bone formation, tendon maturation, and biomechanical strength at the surgical interface. These effects may be associated with the TNF and NF-κB pathways and with the genes IL-1β, ADAM8, and EGR2. This study introduces a biomimetic nanofiber membrane enhancing tendon-to-bone healing, which is crucial for sports medicine. Its efficacy in improving healing outcomes, including bone and cartilage formation and biomechanical strength, could significantly lower failure rates in surgical procedures such as rotator cuff repair and anterior cruciate ligament reconstruction. This advancement offers promising implications for patient recovery and the effectiveness of surgical interventions in tendon-to-bone injuries.

Relationship between humeral head translation, spur formations, and the locations of tendon tears in massive rotator cuff tears

ObjectiveThis study aimed to clarify the relationship between the directions of humeral head translation, the presence of acromial or coracoid spurs, and the locations of tendon tears in massive rotator cuff tears. Thirty shoulders from thirty patients with massive rotator cuff tears who underwent reverse shoulder arthroplasty were included. Preoperative 3DCT classified humeral head translation into three groups: minimal type, posterosuperior type, and anterosuperior type. The presence of acromial or coracoid spurs was also assessed. Preoperative MRI and intraoperative findings determined the torn tendons in each rotator cuff, along with ruptures of the anterior fascia covering the subscapularis or the long head of the biceps tendon (LHB). Relationships between humeral head translations, spur formations, and tendon tear locations were analyzed using chi-square tests and adjusted standardized residuals.ResultsAcromial spurs were more frequent in the posterosuperior type, while coracoid spurs, subscapularis tears, anterior fascia ruptures, and LHB ruptures were significantly associated with the anterosuperior type. Anterior fascia ruptures were significantly less frequent in the minimal type. Anterosuperior humeral head translation and coracoid spurs indicate subscapularis tears, anterior fascia ruptures, and LHB ruptures.

Assessment of Reference Values for Shoulder Ultrasonography and Effects of Position Change on Shoulder Hemodynamics

ABSTRACTPurposeThis study aimed to examine the reference values for shoulder ultrasonography and the effects of positional changes on anterior humeral circumflex artery (AHCA) hemodynamics.MethodsIn this study, shoulder ultrasound was examined in 92 healthy participants (women: 48; men: 44; age 37.8 ± 13.6 years). The thickness of the rotator cuff and the cross‐sectional area of the long head of the biceps tendon (LHB) were determined using ultrasonography. After gray‐scale evaluations, the pulse Doppler mode was used to measure the peak systolic velocity (PSV) of the AHCA in four shoulder positions: neutral, internal rotation, external rotation, and backward extension.ResultsThe mean thickness of the supraspinatus tendon and cross‐sectional area of the LHB were significantly different between sexes and ages (p &lt; 0.05). Compared to the neutral position, the PSV of the AHCA significantly decreased during internal rotation (p &lt; 0.001).ConclusionThe findings of our study may be useful in daily shoulder practice.

Understanding Scapulohumeral Periarthritis: A Comprehensive Systematic Review

Background: This systematic review examines the clinical presentations and prevalence of scapulohumeral periarthritis (SP) by synthesizing the relevant literature from open-access articles from international databases (Medline, Pedro, and EBSCO). Methods: Keywords guiding the review included ‘scapulohumeral periarthritis’, ‘clinical forms’, ‘incidence’, ‘impingement syndrome, ‘calcifying tendinitis’, ‘bicipital tendonitis’, ‘shoulder bursitis’, ‘adhesive capsulitis or frozen shoulder’, ‘rotator cuff tears’, ‘functional assessment’, and ‘clinical trials’. Eligible studies included randomized controlled trials, nonrandomized controlled trials, cross-sectional studies, and review articles published between 1972 and 2024. Results: Our screening identified 2481 initial articles, of which 621 were further reviewed for eligibility resulting in 107 articles that met the relevance criteria. The findings highlight six distinct clinical forms of SP, such as partial rotator cuff tears and calcific tendinitis, each characterized by specific pathological features and prevalence patterns. Key factors contributing to SP include injuries, scapular instability, acromion deformities, and degenerative rotator cuff changes. Functional assessments, including the Neer, Hawkins, Pain Arc, and Yocum tests, demonstrated diagnostic value in distinguishing SP from other shoulder conditions. Conclusions: By comprehensively analyzing the clinical forms, functional assessment methods, and prevalent lesions of SP, functional testing can improve early diagnosis and guide personalized physiotherapy protocols for optimal rehabilitation in the physiotherapist’s practice.

3D-Printed PCL Scaffolds Loaded with bFGF and BMSCs Enhance Tendon-Bone Healing in Rat Rotator Cuff Tears by Immunomodulation and Osteogenesis Promotion.

Rotator cuff tears are the most common conditions in sports medicine and attract increasing attention. Scar tissue healing at the tendon-bone interface results in a high rate of retears, making it a major challenge to enhance the healing of the rotator cuff tendon-bone interface. Biomaterials currently employed for tendon-bone healing in rotator cuff tears still exhibit limited efficacy. As a promising technology, 3D printing enables the customization of scaffold shapes and properties. Bone marrow mesenchymal stem cells (BMSCs) have multidifferentiation potential and valuable immunomodulatory effects. The basic fibroblast growth factor (bFGF), known for its role in proliferation, has been reported to promote osteogenesis. These properties make them applicable in tissue engineering. In this study, we developed a 3D-printed polycaprolactone (PCL) scaffold loaded with bFGF and BMSCs (PCLMF) to restore the tendon-bone interface and regulate the local inflammatory microenvironment. The PCLMF scaffolds significantly improved the biomechanical strength, histological score, and local bone mineral density at regenerated entheses at 2 weeks postsurgery and achieved optimal performance at 8 weeks. Furthermore, PCLMF scaffolds facilitated BMSC osteogenic differentiation and suppressed adipogenic differentiation both in vivo and in vitro. In addition, RNA-seq showed that PCLMF scaffolds could regulate macrophage polarization and inflammation through the MAPK pathway. The implanted scaffold demonstrated excellent biocompatibility and biosafety. Therefore, this study proposes a promising and practical strategy for enhancing tendon-bone healing in rotator cuff tears.

Application of an Externally Developed Algorithm to Identify Research Cases and Controls from Electronic Health Record Data: Failures and Successes.

The use of Electronic Health Records (EHRs) in research demands robust, interoperable systems. By linking biorepositories to EHR algorithms, researchers can efficiently identify cases and controls for large observational studies (e.g., Genome-Wide Association Studies (GWAS)). This is critical for ensuring efficient and cost-effective research. However, the lack of standardized metadata and algorithms across different EHRs complicates their sharing and application. Our study presents an example of a successful implementation and validation process. To implement and validate a rule-based algorithm from a tertiary medical center in Tennessee to classify cases and controls from a research study on rotator cuff tear nested within a tertiary medical center in North Texas and to assess the algorithm's performance. We applied a phenotypic algorithm (designed and validated in a tertiary medical center in Tennessee) using EHR data from 492 patients enrolled in case-control study recruited from a tertiary medical center in North Texas. The algorithm leveraged ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes to identify case and control status for degenerative rotator cuff tears. A manual review was conducted to compare the algorithm's classification with a previously recorded gold standard documented by clinical researchers. Initially the algorithm identified 398 (80.9%) patients correctly as cases or controls. After fine-tunning and corrections of errors in our gold standard dataset, we calculated a sensitivity of 0.94 and specificity of 0.76. The implementation of the algorithm presented challenges due to the variability in coding practices between medical centers. To enhance performance, we refined the algorithm's data dictionary by incorporating additional codes. The process highlighted the need for meticulous code verification and standardization in multi-center studies. Sharing case-control algorithms boosts EHR research. Our rule-based algorithm improved multi-site patient identification and revealed 12 data entry errors, helping validate our results.

The Prevalence of Tear Patterns and Their Effects on Tendon Healing After Arthroscopic Surgery in Patients With Full-Thickness Rotator Cuff Tears.

To achieve successful anatomic rotator cuff repair with minimal tension, both the tear pattern and tear size should be considered. However, little information is available concerning the frequency of tear patterns and their effects on tendon healing. To evaluate the distribution of tear patterns in full-thickness rotator cuff tears and whether these patterns affect tendon healing after arthroscopic repair. Case-control study; Level of evidence, 3. Between 2014 and 2021, patients who underwent arthroscopic surgery for symptomatic full-thickness rotator cuff tears with a minimum 2-year follow-up with postoperative magnetic resonance imaging or ultrasound were retrospectively reviewed. After the debridement of degenerative tendon tissue during arthroscopic surgery, the tear pattern was classified as crescent, U, or anterior or posterior L shaped. Intergroup differences in clinical and radiological characteristics were analyzed. In the subgroup analysis, patients were divided into 2 subgroups: small-to-medium or large-to-massive tears. Among the 1037 patients with a full-thickness rotator cuff tear, the most common tear pattern was crescent shaped (39.6%), followed by posterior L, U, and anterior L shaped (26.0%, 21.4%, and 12.9%, respectively). In the subgroup analysis, 713 patients (68.8%) had small-to-medium tears, while 324 (31.2%) had large-to-massive tears. The proportion of large-to-massive tears was significantly higher for the anterior L-shaped tear pattern than for the other tear patterns (24.8%, 28.8%, 52.2%, and 32.6% for crescent, U, and anterior and posterior L shaped, respectively; P < .001). The anterior L-shaped tear pattern had a significantly higher retear rate than the other tear patterns in small-to-medium tears (7.8%, 13.0%, 28.0%, and 10.6% for crescent, U, and anterior and posterior L shaped, respectively; P < .001). The rate of revision surgery because of a symptomatic retear within 2 years after primary surgery was significantly higher for the anterior L-shaped tear pattern than for the other tear patterns (3.8%, 7.5%, 21.6%, and 0.0% for crescent, U, and anterior and posterior L shaped, respectively; P = .002). The prevalence of tear patterns varied depending on the tear size. In small-to-medium tears, the anterior L-shaped tear pattern had the lowest incidence among the tear patterns; however, it had a significantly higher retear rate. Furthermore, the anterior L-shaped tear pattern had a higher incidence of retears requiring early revision surgery than the other tear patterns.

A feasibility study of a randomised controlled trial to assess the effect of cryotherapy vs standard treatment following arthroscopic rotator cuff repair (RCR)

Background It has yet to be established whether cryotherapy is beneficial in reducing pain following rotator cuff repairs. This study aimed to investigate the feasibility of a RCT investigating whether cryotherapy reduces pain following arthroscopic RCR. Method Randomisation into standard care (n = 18) or standard care plus cryotherapy (n = 20) occurred in theatre following arthroscopic RCR. The cryotherapy group used an ICEBAND® device in addition to standard care. VAS scores were self-completed daily for 2 weeks, at 4 and 6 weeks, plus compliance with the ICEBAND® and any issues. Results 40 out of 62 eligible patients were recruited. 3 patients withdrew. 81% (n = 30) diaries were returned. There were some missing values in 17 questionnaires. During the first 2 days all cryotherapy patients (n = 17) wore the ICEBAND® at least 6 times, with 65% (n = 11) applying it at least 12 times. There were no major complications regarding band use though some patients reported requiring help to apply it. Conclusion Overall, the study design is feasible, but some improvements need to be made in methodology especially with respect to data collection. Compliance with the cryotherapy device was good, but a future study needs to ensure there is sufficient support on the ward to teach self-application as able.

Anatomic and Reverse Total Shoulder Arthroplasty for Osteoarthritis: Outcomes in Patients 80 Years Old and Older.

There has been an increase in both primary anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) over the last decade, with rates peaking for patients aged 75 years and older. Despite aTSA being the mainstay of treatment for patients with glenohumeral arthritis in the absence of rotator cuff insufficiency, there has been an upward trend of rTSA utilization in the elderly due to concerns about rotator cuff integrity, regardless of deformity. The purpose of this study is to evaluate outcomes including pain, function, range of motion, satisfaction, and complications in patients 80 years or older following primary anatomic and reverse total shoulder arthroplasty for osteoarthritis without full thickness rotator cuff tears. A retrospective query of our institution's shoulder and elbow surgery repository identified patients treated with aTSA or rTSA between 11/2006 and 2/2022. Patients > 80 years old with minimum 2-year follow-up who underwent surgery for a primary indication of osteoarthritis without a full thickness rotator cuff tear were included. Patient-reported outcome measures (PROMs; American Shoulder and Elbow Surgeons [ASES], Simple Shoulder Test [SST], Single Assessment Numeric Evaluation [SANE], Visual Analog Score [VAS] Function and VAS Pain scores), range of motion, and strength were evaluated at the visit immediately before surgery and at most recent follow-up. Patient satisfaction was also evaluated at most recent follow-up. Complications and revisions were reported. A total of 130 patients (77 aTSA and 53 rTSA) met inclusion criteria. There were no significant differences in demographics between cohorts. At most recent follow-up, there were no significant differences in PROMs between cohorts. aTSA patients achieved greater postoperative motion in external rotation (50o vs. 40o; p=.003) and internal rotation (8 vs. 5; p=.001), with no difference in forward elevation. There were six complications amongst aTSA patients (7.8%): four with subscapularis insufficiency, one humeral shaft periprosthetic fracture treated with open reduction and internal fixation, and one with prosthetic joint infection revised to a functional composite spacer. Three rTSA patients (5.6%) sustained complications - all acromion/scapular spine fractures (2 Type 2; 1 Type 3) which were treated non-operatively. There was no significant difference in the rate of complications or revisions between groups. Both anatomic and reverse shoulder arthroplasty for osteoarthritis yield similarly high patient satisfaction, good functional outcomes and low complication rates in patients over the age of 80 years.

Effectiveness of high intensity laser treatment in partial supraspinatus tendon tears: a randomised controlled trial.

The most common cause of rotator cuff injury is supraspinatus tendon tears (STTs). High-intensity laser therapy (HILT) has recently emerged as an important conservative treatment option. This study was designed as a randomised controlled trial in patients with partial STTs to compare the effects of HILT with those of ultrasound (US) therapy. Fifty patients between the ages of 18-75, who were diagnosed with partial STT were randomised into two groups using the closed envelope method. They were blinded to group assignment. Group-1 received 3-week HILT program. Group-2 received 3-week US therapy program. HILT and US therapy were carried out by the same physiotherapist. The primary outcome measure was VAS. Secondary outcome measures were Shoulder Pain and Disability Index (SPADI) and supraspinatus tendon thickness (SP) by ultrasonography. Nine patients dropped out of the study leaving 41 (Group-1, n = 20; Group-2, n = 21) patients for analysis. There was no significant difference between the groups before treatment in terms of age, body mass index values, gender, affected side, smoking, comorbidities, STT, VAS and SPADI values. VAS and SPADI values ​​decreased significantly in both groups at the 4th and 12th weeks. However, VAS and SPADI values ​​at the 4th and 12th weeks were significantly lower in the HILT group than in the US group. Cohen's d analysis revealed large effect sizes at the 4th and 12th weeks favoring the HILT group. There was no significant change in SP within and between groups at any time points. The findings show that HILT is superior to US treatment in reducing pain and improving function and quality of life in the long term. Both treatment methods did not affect SP. Clinical Trials ID: NCT06637410.

Opioid Consumption Following Isolated and Recurrent Shoulder Dislocation and Reduction.

Recurrent shoulder dislocations often lead to multiple encounters for reduction and eventual surgical stabilization, both of which involve exposure to opioids and potentially increase the risk of chronic opioid exposure. The purpose of our study was to characterize shoulder instability and compare pre- and post-reduction opioid usage in singular dislocators (SD) and recurrent dislocators (RD). This retrospective study was performed at a single academic institution using a prospective database. Patients were included if they were 1) age 18 or older and 2) sustained a shoulder dislocation evaluated within our institution. Electronic medical records were reviewed for patient demographics, emergency department management, and opioid exposure (number and mean morphine equivalent [MME] of opioid prescriptions) both pre- and post-reduction. Cohorts were compared using Wilcoxon rank sum tests for continuous variables and chi-squared or Fischer's exact tests for categorical variables with statistical significance set at p<0.05. 222 patients were included with mean follow-up 4.4 months (range: 0-70.1 months). 53 (23.8%) patients sustained recurrent dislocations. RDs were significantly younger (median age 26.7 years, IQR: 21.6-44.9) than SDs (55.3 years, IQR: 32.8-70.4; p<0.001) and more likely to have sustained a prior shoulder fracture (n=11 [21.2%] vs. n=3 [1.8%], p<0.001). There were no differences in sex, laterality, or follow-up duration. 18 (34.0%) RDs and 18 (10.7%) SDs underwent surgery including shoulder stabilization procedures, rotator cuff repairs, and fracture fixation (p<0.001). RDs used significantly more opioids at the first follow-up in both the prescribed number of opioids (mean 0.23± 0.5 prescriptions vs. 0.10 ± 0.3, p=0.038) and MME (mean 38.3 ± 96.2 MME vs. 10.7 ± 66.4 MME, p=0.013). This difference is not appreciated from the 30-day postoperative visit onwards. Emergency Room opioid MME prescription and consumption was similar between cohorts. Patients who sustain recurrent shoulder dislocations exhibit a higher likelihood of consuming significantly greater amounts of opioids following shoulder reduction and ultimately undergoing surgical intervention. The proportion of opioid tolerance and pre-reduction total MME up to 90-days prior to reduction in the recurrent dislocator cohort trended towards significance, but there were no differences observed between rates of opioid usage during ED encounters or at the 30-, 60-, and 90-day timepoints. Patients with chronic shoulder instability should be counseled regarding the increased risk of opioid prescription patterns in the immediate post-reduction period however this risk may decrease over time.

Using a Hypotheticodeductive Reasoning Approach to Identify Coronary Artery Stenosis and Myocardial Ischemia in a Patient with Upper Arm, Scapular, and Wrist Pain

BACKGROUND: A 58-year-old male with left upper extremity pain presented for second opinion via video teleconferencing secondary to his physician’s recommendation for potential rotator cuff surgery. CASE PRESENTATION: He reported subacute variable left upper extremity pain. He denied questioning targeting the cardiopulmonary symptoms but also denied movement-based aggravating factors of the cervical spine and shoulder. OUTCOME: A movement-based exam targeting potential cervical and shoulder differential diagnoses failed to elicit symptoms. The physical therapist advocated for referral by the primary care provider to a cardiologist to rule out an underlying cardiac etiology. Per-recommendation stress EKG testing reproduced his symptoms and caused abnormal EKG behavior, leading to angiography and stenting. FOLLOW-UP: At follow-up forty-eight hours, one week, and four weeks after stent placement, the patient reported complete resolution of symptoms. DISCUSSION: This case underscores the importance of ruling out competing differential diagnoses, the role the physical therapist can have in entry-point care, and the value that telehealth-based services can have in patient triage.

The Statistical Fragility of Functional Outcomes for Arthroscopic Rotator Cuff Repair With and Without Acromioplasty: A Systematic Review and Meta-analysis.

Views surrounding acromioplasty at the time of arthroscopic rotator cuff repair (RCR) have shifted dramatically over time. In recent years, various studies have argued against acromioplasty, citing equivocal functional outcomes after arthroscopic RCR with or without acromioplasty. To assess the statistical fragility of functional outcomes after arthroscopic RCR with and without acromioplasty using the reverse continuous fragility index (RCFI). Systematic review and meta-analysis; Level of evidence, 3. A systematic review and meta-analysis was performed including all randomized controlled trials through February 5, 2024 investigating arthroscopic RCR with and without acromioplasty. The RCFI, defined as the number of qualifying data points required to be moved from the lower mean group to the higher mean group to alter the significance, was calculated for the Welch t test, Student t test, and Wilcoxon rank-sum test under various data assumptions. The reverse continuous fragility quotient (RCFQ) was determined by dividing the RCFI by the sample size. A total of 6 clinical trials consisting of 609 patients with functional outcome scores were analyzed. Using the Welch t test, the median RCFI across all study outcomes was 20 (interquartile range [IQR], 17-24). For the Student t test, the median RCFI across all study outcomes was 14 (IQR, 13-19), with a median RCFQ of 0.18 (IQR, 0.15-0.20). For the Wilcoxon rank-sum test, the median RCFI was 14 (IQR, 13-17), with a median RCFQ of 0.17 (IQR, 0.13-0.19). While using the Welch t test, 64% of study outcomes had an RCFI greater than the loss to follow-up (LTFU). When using the other tests, 32% of study outcomes had an RCFI greater than the LTFU. The fragility of these studies was largely dependent on the statistical test used to analyze the results. The Wilcoxon rank-sum test and Student t test appeared to be most appropriate to find differences in treatment arms. When using these tests, we found the results to be fragile. This, in combination with a small number of studies and the LTFU close to or exceeding 20%, indicates an overall lack of strong evidence to support previously accepted conclusions.

Effectiveness of Additional or Standalone Corticosteroid Injections Compared to Physical Therapist Interventions in Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Rotator cuff tendinopathy represents the most prevalent cause of shoulder pain, the third most common musculoskeletal disorder after low back pain and knee pain. The objective of this study was to determine the effectiveness of corticosteroid injection(s), alone or in combination with anesthetic injection or any other physical therapist interventions, compared to physical therapist interventions alone in adults with rotator cuff tendinopathy. This study was a systematic review and meta-analysis of randomized controlled trials. PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Web of Science, and Physiotherapy Evidence Database (PEDro) were searched from inception to March 2023. Meta-analysis using a random-effects model was performed. Risk of bias and certainty of the evidence for the primary outcomes were assessed using the Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, respectively. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021240882). Participants were adults with rotator cuff tendinopathy. Corticosteroid injection(s), alone or in combination with anesthetic injection or with any other physical therapist interventions, was compared to physical therapist interventions alone. Pain, function, quality of life, patient-rated overall improvement, and adverse events were the main outcomes. Fifteen randomized controlled trials (1785 participants) met the inclusion criteria. At short term, corticosteroid injection coupled with physical therapist interventions and compared to the same interventions alone might have resulted in some small to moderate improvements in pain and function. Conversely, corticosteroid injection alone seemed not to be more effective than physical therapist interventions in improving pain and function in most of the studies included. At mid- and long-term follow-up assessments corticosteroid injection seemed not to be more effective than any physical therapist interventions. This study highlights the potential effectiveness of corticosteroid injection(s) in rotator cuff tendinopathy for pain and function at short term at best, especially in combination with physical therapist interventions. However, the evidence is of moderate to mostly very low certainty. Additional high-quality research considering core outcomes is therefore needed. Corticosteroid injection(s) seems not to be superior to physical therapist interventions, other than resulting in some transient improvements at short term if provided together with other physical therapist interventions, in adults with rotator cuff tendinopathy. Furthermore, considering the potential adverse events associated with the injections, physical therapist interventions may be an important stand-alone treatment option.

Dynamic ultrasound evaluation and treatment of subcoracoid bursitis after HPV vaccination: a case of shoulder injury related to vaccine administration (SIRVA).

Shoulder Injury Related to Vaccine Administration (SIRVA) is a complication caused by improperly administered vaccinations. It triggers an inflammatory cascade that damages shoulder structures, resulting in prolonged shoulder pain and restricted range of motion. Common diagnoses in SIRVA patients include shoulder bursitis (all classified as subacromial bursitis), adhesive capsulitis, and rotator cuff injuries such as tears or tendinopathy. Less frequent diagnoses include biceps tenosynovitis, shoulder synovitis, intramuscular hematoma, and polymyalgia rheumatica or polymyalgia rheumatica-like syndrome. We present a case of SIRVA with prominent subcoracoid bursitis, confirmed via ultrasound. Ultrasound plays a critical role in static and dynamic assessments, providing accurate diagnoses and valuable guidance for identifying associated pathologies and managing SIRVA.

Hedgehog signaling directs cell differentiation and plays a critical role in tendon enthesis healing

A high prevalence of rotator cuff tears presents a major clinical challenge. A better understanding of the molecular mechanisms underlying enthesis development and healing is needed for developing treatments. We recently identified hedgehog (Hh)-lineage cells critical for enthesis development and repair. This study revealed cell-cell communication within the Hh-lineage cell population. To further characterize the role of Hh signaling, we used mouse models to activate and inactivate the Hh pathway in enthesis progenitors. Activation of Hh target genes during enthesis development increased its mineralization and mechanical properties. Activation of Hh signaling at the injured mature enthesis promoted fibrocartilage formation, enhanced mineralization, and increased expression of chondrogenic and osteogenic markers, which implies that Hh signaling drives cell differentiation to regenerate the damaged enthesis. Conversely, deletion of Hh target genes impaired enthesis healing. In summary, this study revealed a new strategy for enthesis repair via activation of Hh signaling in endogenous cells.

Comparison of high-volume versus conventional image-guided injection for rotator cuff tendinopathy: a randomized pilot study

Comparison of high-volume versus conventional image-guided injection for rotator cuff tendinopathy: a randomized pilot study

Three-dimensional scapular kinematics during commonly used rehabilitation exercises in patients 12 weeks after Reversed Shoulder Arthroplasty.

Reversed shoulder arthroplasty (rTSA) is often used to restore functionality in patients with joint arthropathy and dysfunctional rotator cuff. As rTSA changes the biomechanical properties of the shoulder, an altered movement pattern of arm and scapula is to be expected. Previous studies focused on changes of the scapulohumeral rhythm during functional elevation tasks. To our knowledge, no study exists examining scapular kinematics during rehabilitation exercises in a patient population with rTSA. Therefore, this study aimed to analyze 3-dimensional scapular kinematics during 3 commonly used rehabilitation exercises, 12 weeks after rTSA surgery. It was hypothesized that scapular kinematics would be different between the horizontal and the vertical plane. Secondly, differences in scapular kinematics in the vertical plane, between the open and closed chain were hypothesized. In this cross-sectional study, 48 patients (55 shoulders) aged 69 ± 7.4 years participated. Scapular kinematics in terms of anterior/posterior tilt, external/internal rotation and upward/downward rotation were registered during 3 rehabilitation exercises. Exercises varied based on the plane (horizontal or vertical) and the modality (closed or open chain). Data were analyzed using Statistical Parametric Mapping (SPM). Post-hoc pairwise analysis within SPM (SPM(t)) revealed no significant differences among the exercises regarding posterior tilt. During vertical plane exercises (Standing Wall Slide 120° (WS), Standing reach 120° (REACH)), the scapula was more upwardly rotated for most of the time (14.93% - 74.63%, p<0.001) than during the exercise in the horizontal plane (Seated Bench Slide (BS)). No statistically significant differences were found between the vertical open chain (REACH) and the vertical closed chain exercise (WS). For the internal /external rotation, significant differences were found between the horizontal (BS) and the vertical plane (WS, REACH) (0% - 100%, p<0.001), and between the open (REACH) and closed chain (WS) vertical exercises (3.0% - 91.5%, p<0.001), with more external rotation when performing the movement in the vertical plane, and in the closed chain compared to respectively the horizontal plane and the open chain. Scapular kinematics during rehabilitation exercises after rTSA differ, depending on the plane and modality of the exercise. Insight into the impact of changing the plane (horizontal /vertical), and training in open versus closed chain, may assist physical therapists in the choice of exercises.