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PubMed1996

Proteoglycans of human rotator cuff tendons.

Rotator cuff and biceps tendons that appeared grossly normal were procured from adult cadavers without a history of shoulder problems. These tendons were analyzed for the amount and type of glycosaminoglycan, type of proteoglycan, and histology. When compared with the distal/tensional region of biceps tendon, the glycosaminoglycan content of supraspinatus, infraspinatus, and subscapularis tendons was 2.5-fold higher and the glycosaminoglycan content of the proximal/compressed region of biceps tendon was 3-fold higher. The ratio of hyaluronic acid to chondroitin sulfate/dermatan sulfate in all three cuff tendons was approximately 1. Rotator cuff tendons contained large proteoglycan similar to aggrecan, as demonstrated by sodium dodecyl sulfate-polyacrylamide gel migration elution from Sepharose CL-4B, and content of both chondroitin sulfate and keratan sulfate chains. Both decorin and biglycan were also present, as demonstrated by migration in sodium dodecyl sulfate-polyacrylamide gels and core protein immunoreactivity. In contrast decorin was the only proteoglycan prominent in distal/tensional regions of biceps tendon. Histological analysis showed layers of loosely organized alcian blue-stained material running between the longitudinal collagen fiber bundles. The proteoglycan content of rotator cuff tendons was similar to fibrocartilage in tendons that have been subjected to compressive loads in situ. This suggests that cells of normal adult rotator cuff tendons have adapted to loads distinct from pure tension. However, the histological organization did not resemble mature fibrocartilage. The increased amount of proteoglycan in rotator cuff tendons may serve to separate and lubricate collagen bundles as they move relative to each other during normal shoulder motion.

Adult↗
PubMed1997

Significance of granulation tissue in torn supraspinatus insertions: an immunohistochemical study with antibodies against interleukin-1 beta, cathepsin D, and matrix metalloprotease-1.

The pathophysiology of rotator cuff tears can be elucidated by examining the tendinous insertion of the supraspinatus muscle. As seen by light microscopy, the granulation tissue around the insertion of a torn supraspinatus tendon appears to induce osteochondral destruction by means of multinucleated giant cells and chemical mediators. The purpose of this study was to examine the contribution of certain chemical mediators to osteochondral destruction using immunohistochemical analysis of interleukin-beta, cathepsin D, and matrix metalloprotease-1. Sixteen supraspinatus insertions with portions of the greater tuberosity, including eight complete-thickness tears and eight incomplete-thickness tears, were obtained during surgery. Six fresh cadaveric supraspinatus tendons without grossly evident tears served as normal controls. Strong immunoreactivity was found in all 16 torn supraspinatus insertions but not in the six insertions of apparently intact tendons. Macrophages and multinucleated giant cells, which showed immunoreactivity for all three chemical mediators, were often found at the interface between the osteochondral margin of the enthesis and the granulation tissue, suggesting that they may be involved in osteochondral destruction. We therefore concluded that, in addition to repetitive subacromial impingement, this granulation tissue may contribute to the development of rotator cuff tears by weakening the insertion.

Adult↗
PubMed1998

Increased substance P in subacromial bursa and shoulder pain in rotator cuff diseases.

The subacromial bursa is recognized as a site associated with the shoulder pain caused by rotator cuff disease in the middle-aged and elderly. Substance P is contained in primary afferent nerves, and its quantity increases during chronic pain. The amount of substance P in the subacromial bursa of patients with rotator cuff disease was examined. Radioimmunoassay and immunohistochemistry were employed to quantify and localize substance P. The preoperative pain level was measured with a visual analogue scale with 0 as no pain, 5 as moderate, and 10 as severe. Thirty-seven patients that had undergone operation were divided into two groups: one composed of 19 patients with subacromial bursitis and a partial-thickness tear of the rotator cuff (nonperforated cuff) and the other composed of 18 patients with a full-thickness tear (perforated cuff). Subacromial bursae obtained from seven fresh cadavers with no shoulder pain before death were used as controls. The visual analogue scale showed significantly greater pain in the group with the nonperforated rotator cuff than in the group with the perforated cuff. Consistent with these results, the amount of substance P in the subacromial bursa was significantly greater in the former group than in the latter. Nerve fibers immunoreactive to substance P were localized around the vessels, with a larger number of fibers in the group with the nonperforated rotator cuff. Therefore, an increased amount of substance P in the subacromial bursa appears to correlate with the pain caused by rotator cuff disease.

Adult↗
PubMed2000

Tendon-Defect and muscle-unloaded models for relating a rotator cuff tear to glenohumeral stability.

Rotator cuff tear and glenohumeral instability are closely related. Any tear may disturb muscle force generation due to pain inhibition. In addition, a full-thickness tear may foster instability by removing a structural element constraining the joint. It was hypothesized that the loss of both dynamic force and static constraint with a rotator cuff tear will affect glenohumeral stability. In a tendon-defect model, dynamic and static elements of the joint were sacrificed. In a muscle-unloaded model, only the dynamic element was removed. The location and size of the defect were also investigated. The effect on instability of a small tendon defect was less than that of muscle unloading, implying that a patient with a small tear would have less instability than a patient with weak or nonfunctioning supraspinatus and infraspinatus muscles. On the other hand, with a larger tear the defect had a greater effect than muscle-unloading because sectioning of the glenohumeral and coracohumeral ligaments was included in the model. Clinically, such a defect in the front is critical for anterior stability because it might insult the important anterior capsule ligamentous complex. Orthopaedic surgeons should pay attention, therefore, to the effect of possible associated lesions of static constraints based on the size and location of the tear in addition to the dynamic stabilizer.

Aged↗
PubMed2006

Variation in external rotation moment arms among subregions of supraspinatus, infraspinatus, and teres minor muscles.

A rotator cuff tear causes morphologic changes in rotator cuff muscles and tendons and reduced shoulder strength. The mechanisms by which these changes affect joint strength are not understood. This study's purpose was to empirically determine rotation moment arms for subregions of supraspinatus, infraspinatus, and for teres minor, and to test the hypothesis that subregions of the cuff tendons increase their effective moment arms through connections to other subregions. Tendon excursions were measured for full ranges of rotation on 10 independent glenohumeral specimens with the humerus abducted in the scapular plane at 10 and 60 degrees . Supraspinatus and infraspinatus tendons were divided into equal width subregions. Two conditions were tested: tendon divided to the musculotendinous junction, and tendon divided to the insertion on the humerus. Moment arms were determined from tendon excursion via the principle of virtual work. Moment arms for the infraspinatus (p < 0.001) and supraspinatus (p < 0.001) were significantly greater when the tendon was only divided to the musculotendinous junction versus division to the humeral head. Moment arms across subregions of infraspinatus (p < 0.001) and supraspinatus (p < 0.001) were significantly different. A difference in teres minor moment arm was not found for the two cuff tendon conditions. Moment arm differences between muscle subregions and for tendon division conditions have clinical implications. Interaction between cuff regions could explain why some subjects retain strength after a small cuff tear. This finding helps explain why a partial cuff repair may be beneficial when a complete repair is not possible. Data presented here can help differentiate between cuff tear cases that would benefit from cuff repair and cases for which cuff repair might not be as favorable.

Biomechanical Phenomena↗
PubMed2007

In vitro study comparing two collageneous membranes in view of their clinical application for rotator cuff tendon regeneration.

Tenocytes were isolated from the rotator cuff tendons of healthy (HT) and glucocorticoid (GC)-treated rats (GCT) and were cultured on polystyrene wells (TCP) as control, and on 2 de-cellularized collagen matrices: porcine small intestinal submucosa (SIS), and human dermal matrix (Graftjacket, GJ). At 3 and 7 days cell proliferation and synthesis were evaluated. Proliferation of HT tenocytes increased between experimental times for both tested membranes, but already at 3 days, HT tenocytes cultured on GJ showed the highest WST-1 value. The collagen-I (CICP) synthesis on GJ membrane did not change between experimental times and was significantly higher than TCP and SIS at 7 days. Proteoglycans (PG), and fibronectin (FBN) synthesis increased when HT were cultured on GJ, between experimental times, and both PG and FBN synthesis on GJ membrane were higher than TCP and SIS at 7 days. GC determined decreases in cell proliferation, CICP and PG syntheses at 3 days of culture on TCP when compared to HT tenocytes while a decrease in WST-1 was maintained at 7 days. CICP, PG and FBN (only at 3 days) syntheses were significantly higher in GCT tenocytes cultured on GJ. The negative effects on GC on GCT tenocytes cultured on membrane were particularly evident on SIS for CICP (-18%) and FBN (-67%) synthesis. The obtained results support the conclusion that GJ is more suitable than SIS as a scaffold for in situ tissue engineering and for the in vitro bioengineering of tendons to heal massive tears of the rotator cuff tendon.

Animals↗
PubMed2006

Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears.

BACKGROUND: Massive rotator cuff tears provide a challenge for effective rehabilitation. Work has been ongoing at Torbay Hospital, Devon since 2000 to develop an exercise programme for the management of this patient group. This programme has been evaluated in a pilot study and a further randomised controlled trial is currently taking place which will enable us to estimate the treatment effect. This paper discusses the background to the development of the rehabilitation programme, the programme itself and the results of the pilot study. The pilot study was an evaluation of the rehabilitation programme. OBJECTIVES: This study examined the effectiveness of a physiotherapy regime for the treatment of patients with massive rotator cuff tears. METHODS: Patients identified through primary and secondary care referrals to physiotherapy with a clinical diagnosis of a massive rotator cuff tear underwent an ultrasound scan to confirm the diagnosis. A massive cuff tear was one where the leading edge of the tear had retracted past the glenoid margin. The clinical diagnosis was based on the presence of some or all of the following signs: positive humeral thrust on elevation, gross weakness and wasting of supraspinatus and infraspinatus, infraspinatus lag and rupture of the long head of biceps. Eligible patients were invited to take part in the study and informed consent was obtained. The baseline assessment was carried out and then the patient undertook the treatment programme. Outcome measures were reassessed 12 weeks from the baseline assessment. DESIGN: A cohort study of 10 patients evaluating the change from baseline to twelve weeks in the shoulder function of patients undergoing a programme of anterior deltoid strengthening and functional rehabilitation. The outcome measures used were the Oxford Shoulder Disability Questionnaire (OSDQ) and SF36. The OSDQ is validated for use with the UK population and has 12 questions with 5 point responses. The lowest (best) score is 12 and the highest (worse) score is 60. RESULTS: Scores on the OSDQ improved with all patients. The mean improvement was 9 (range 3 to 16, standard deviation 10.3). The SF36 showed an improvement in the pain scores for all patients (mean 22 points) and an overall improvement of 10 points for the sections on role limitation due to physical health. There was an overall decline in perceived general health (9 points) and in role limitation due to emotional health (23 points). CONCLUSIONS: As all 10 patients showed improved scores on the OSDQ, in spite of the long-standing nature of many of their shoulder problems, this rehabilitation programme was shown to improve shoulder function in this group of patients. The variation shown in the quality of life scores reflects the age group of this cohort who had a mean age of 75.5 years. All patients deemed their pain and function to have improved over the three-month period.

Aged↗
PubMed1992

Rotator cuff tears in anterior dislocation of the shoulder.

We diagnosed 16 rotator cuff tears in 109 shoulders in 104 patients with a traumatic anterior dislocation. Twelve of these were followed up for an average of 32 months. A surgical repair of the cuff was carried out in eleven and the results were satisfactory in eight (73%) regardless of a Bankart lesion. The repair of a torn cuff seems to be sufficient to stabilise the shoulder in elderly patients, even when a Bankart lesion is present and is not repaired.

Aged↗
PubMed1991

Arthroscopy for the diagnosis of shoulder pain.

Arthroscopy under anaesthesia was used to investigate 123 patients with painful shoulders. The clinical diagnosis was compared with the arthroscopic findings. Four types of rotator cuff lesions were found in which there were significant differences between sex and age. Instability detected under anaesthesia was an important cause of pain. These examinations proved valuable in the diagnosis of shoulder pain, particularly when the clinical diagnosis was uncertain.

Adult↗
PubMed1992

Shoulder impingement syndrome: impingement view and arthrography study based on 100 cases.

A prospective evaluation combining the shoulder impingement view and arthrography was made in patients presenting with chronic shoulder pain. Five hundred and twenty-three patients with chronic shoulder pain were X-rayed using conventional views and impingement views. One hundred of these patients (mean age 62 years) had subacromial bony spurs on the impingement view; these underwent arthrography. They were divided into two groups according to the degree of spur formation--whether or not the size of the spur exceeded one half of the acromial width as measured from the outer margin to the acromioclavicular joint. Of the 100 subacromial spurs demonstrated on the impingement view, only 18 were visible on the conventional view as assessed by an independent radiologist. Arthrography showed 35 cases of rotator cuff tear. The size of the bony spur was strongly associated with the incidence of rotator cuff tear (P < 0.02).

Acromion↗
PubMed1991

Bicipital groove dysplasia and medial dislocation of the biceps brachii tendon.

The purpose of this study was to investigate the plain film finding of dysplasia of the lesser tubercle of the humerus and its relationship to medial dislocation of the tendon of the long head of the biceps brachii muscle as diagnosed by shoulder arthrography. Of 55 patients referred for arthrography of the shoulder because of undiagnosed shoulder pain, 12 demonstrated flattening of the medial wall of the bicipital tendon groove. Of these, 58% had medial dislocation of the biceps tendon, and 43% of patients with dislocation of the biceps tendon were also shown to have a tear of the rotator cuff. Since biceps tendon pathology has long been implicated in shoulder pain and weakness, assessment of the bicipital groove may provide important information in evaluating patients with potential abnormality of the biceps tendon.

Female↗
PubMed1993

Case report 815: Tear of the rotator interval.

Rotator interval tears are an uncommon, but clinically important subtype of rotator cuff tear. As MRI assumes an ever increasing role in the imaging evaluation of the painful shoulder, radiologists must be aware of this entity and appreciate the difficulty in diagnosing these tears with MRI. Differentiation of a true rotator interval tear from normal synovium and capsule in this space is most likely not possible with MRI, and symptoms may be referred and misleading. It is therefore important to correlate the MR findings with the clinical history and physical examination.

Aged↗
PubMed1995

Effect of field of view on MR diagnosis of rotator cuff tears.

PURPOSE: To determine the effect of decreasing the field of view (FOV) on the accuracy of MR for diagnosing rotator cuff tears. MATERIAL AND METHODS: One hundred shoulder MR scans with surgical correlation were evaluated for the presence or absence of a cuff tear. The sensitivity and specificity of MR relative to the surgical results were determined for the 59 patients scanned with a 24-cm FOV, and the 41 patients scanned with an 18-cm FOV. All other imaging parameters including acquisition time were identical. The sensitivity and specificity of the two groups were compared using a t-test. RESULTS: The specificity of MR for diagnosing a rotator cuff tear improved from 0.65 for the 24-cm FOV group to 0.89 for the 18-cm FOV group (P = 0.04). The sensitivity changed from 0.91 to 0.96 (P = 0.25). CONCLUSION: Reducing the FOV from 24 cm to 18 cm results in a statistically significant improvement in specificity of MR for diagnosing rotator cuff tears.

Adult↗
PubMed1993

Coexistence of calcific tendinitis and rotator cuff tear: an arthrographic study.

A prospective evaluation of the coexistence of calcific tendinitis and tear of the rotator cuff demonstrated by arthrography was made in patients presenting with shoulder pain. Patients were X-rayed using conventional views and impingement views. Eighty-one patients (mean age 61.2 years) with calcific tendinitis underwent arthrography. Arthrography showed 22 partial or complete tears of the rotator cuff. A small rather than a large amount of calcification was more likely to be associated with a rotator cuff tear (p = 0.005). The coexistence of calcific tendinitis with rotator cuff tear is not uncommon, especially in older age groups.

Calcinosis↗
PubMed1994

Diagnosis of partial and complete rotator cuff tears using combined gradient echo and spin echo imaging.

Most magnetic resonance (MR) studies evaluating the rotator cuff for tears have used T2-weighted imaging in the coronal oblique and sagittal oblique planes. T2*-weighted gradient echo imaging, however, has advantages over spin echo imaging, including contiguous slices without cross-talk, high contrast around the cuff, and intrinsically shorter imaging times which can be used to increase the number of signals averaged and thus improve the signal-to-noise ratio. We reviewed the shoulder MR scans of 87 consecutive patients who underwent both a MR scan and a shoulder arthroscopy during which the size of tears, if present, was graded. The reviewers were blinded as to the history and arthroscopic results. The MR scans included oblique coronal T2*-weighted gradient echo and oblique sagittal T2-weighted spin echo images. MR cuff grades were correlated with arthroscopic findings. For complete tears, the sensitivity of MR was 0.91 and the specificity 0.95. For partial tears, the sensitivity was 0.74 and the specificity 0.87. This accuracy is similar to two-plane T2-weighted imaging as previously reported in the literature. There was a statistically significant correlation (p < 0.0005) between the cuff grade as determined by MR and the arthroscopic findings.

Adult↗
PubMed1993

The influence of variations of the coracoacromial arch on the development of rotator cuff tears.

In order to define the geometry of the coracoacromial arch in both its bony and soft parts and to bring it into relationship with rotator cuff tears, 54 cadaver shoulders (from subjects aged 47-90 years) were dissected and X-rayed (anteroposterior projection and supraspinatus outlet view). Partial rotator cuff tears were assessed additionally by transillumination and polarized microscopy. After transfixation of the coracoacromial arch with a polyurethane mould, sections were made along the coracoacromial ligament. The morphology of the acromion was described following the classification of Bigliani et al. [5]. Amongst other parameters, measurements were taken between the long axis of the scapula, the spina, and the acromion. In 19 of 22 cases, a traction osteophyte was associated with rotator cuff tears. In incomplete tears, spurs were completely encased within the ligament and did not impair the subacromial space. The number of rotator cuff tears was significantly increased in shoulders with "curved" acromia, flat acromial slope, and increased angle between the scapular plane and the spina (intact, mean 58 degrees; tears, mean 47 degrees). The morphology of the subacromial space was secondarily determined by this angle. In contrast to Bigliani et al. we were unable to find a "hooked" acromion. These results indicate that the combination of a flat and curved acromion or a position of the acromioclavicular joint above the cranial pole of the glenoid must be regarded as considerable risks for the development of rotator cuff tears. The concept of anterior acromioplasty is supported by our results.

Acromioclavicular Joint↗