explaining medical procedures and treatments. The main issue with the materials is that they lack simplicity. They are great for medical students or experts in the field, but a patient may have difficulty understanding the information. Illustrations for patients should be simple and highlight the most important concepts of the lesson. For example, a patient probably won’t need to know the name of every artery or vein, or every origin and insertion of each muscle. However, they do need to understand the basic anatomy and how long the recovery time will be for a procedure. Media designed to match a learner’s background will improve a patient understanding.
Arthroscopic repair of articular-sided or bursal-sided partial-thickness tears may involve completion of the tear or transtendinous repair of the tendon down to the bone with suture anchors. Advocates of the latter technique favor the ability to preserve the intact portion of the rota- tor cuff. 52 For repair of complete tears, single or double-row suture anchor fixation may be used, although there are currently insufficient data to support one technique over another. Anchors may be metallic or bioabsorbable, depending on surgeon preference, although we favor bioab- sorbable anchors. Our preference is the 5.0-mm BioCorkscrew anchor (Arthrex, Naples, Fla) loaded with No. 2 FiberWire (Arthrex). Optimally, the anchors are placed at a 45 ° angle (dead man’s angle) 9 to the direction of contractile force of the rotatorcuff muscles. Two anchors are typically used for a double-row repair of tears 1.5 cm or less in length from anterior to posterior, and 3 to 4 anchors are typically used for tears greater than 1.5 cm. Lo and Burkhart 52 have described a transtendinous repair technique for partial-thickness articular surface tears that restores the medial footprint of the cuff while preventing a length-tension mismatch that may result from removing normal cuff tissue that is then advanced too far laterally. 10 Articular-sided partial-thickness tears may be repaired by making a small perforation in the rotatorcuff to place medial anchors. The sutures from these anchors may then be used to repair the articular side of the tear and thus restore the footprint while leaving the lateral aspect of the footprint intact. Bursal-sided partial-thickness tears may be repaired by placing a lateral row of anchors and thus preserving the medial footprint. Restoration of the native footprint anatomy and length-tension relationships may be more technically difficult with this latter tech- nique.
healing, in particular the nature, timing, and incidence of “failure with continuity”, must be investigated and refined. Translational research efforts are greatly challenged by the lack of an animal model that captures the anatomy, loading, and age or disease condition of the human rotatorcuff. At the same time, prospective controlled trials in humans are expensive, time-consuming, and difficult to execute with the highest scientific rigor. The current weak correlation between PROs and structural outcomes 21–32 further suggests that cur-
Following on from this point, in an attempt to offer a potential rationale for the idea that the size of the initial rotatorcuff tear might not be a useful basis upon which to guide rehabilitation prescription, it is apparent that good patient reported outcomes can still be acheived in the presence of re tear [6,7]. Thus, it is plausible that the primary mechanism of action of the surgery is not wholly biomechanical in terms of structural repair but might be impacting in some other, currently unknown, way. So, whether the tendon re tears or not might not actually be the important factor and probably should not be the primary concern of the patient or clinician.
In contrast, six of 16 studies did not find an association between dyslipidemia and rotatorcuff diseases [12, 20, 25, 28, 30, 31]. The study by Longo et al.  indicated no statistically significant difference in serum TG and TC concentration. Abate et al.  compared the prevalence of hypercholesterolemia in subjects with bilateral and monolateral rotatorcuff tears and did not find an associ- ation of bilateral rotatorcuff tears with hypercholesterol- emia. The study by Applegate et al.  showed that hypercholesterolemia was statistically associated with gle- nohumeral joint pain, but not with rotatorcuff tendinopa- thy. Davis et al.  evaluated the serum and synovial lipid profiles in patients with and without rotatorcuff tear and found that there were no significant differences in any lipid values between patients with rotatorcuff and those without a tear. In addition, Juge et al.  performed a retrospective study and indicated that there was no signifi- cant difference in the rate of dyslipidemia between rotatorcuff-related osteoarthritis and primary shoulder osteoarth- ritis. Yamamoto et al.  explored the risk factors of symptomatic rotatorcuff tear progression and showed that hypercholesterolemia was not significantly correlated with tear progression.
Another contributing factor to unnecessary waiting times occurred for patients waiting for MRI. Patients in this study spent a mean waiting time of 103 days before undergoing an MRI in the public system; however, this is likely an underestimation as the reported wait time from the Alberta Wait Times Reporting Website cur- rently shows an average wait time of 280 days . The ideal standard of care begins with standardized shoulder x-rays . If additional investigations are warranted, an ultrasound should be obtained to assess the status of the rotatorcuff  Patients in this study spent a mean waiting time of 28 days waiting for ultrasound; an average difference of 75 days. An MRI is unwarranted in most oc- casions and should ideally be requested by a surgeon for surgical planning . Ultrasound is the cost-effective in- vestigation for defining full and partial-thickness rotatorcuff tears, and is comparable to MRI in both sensitivity and specificity . More importantly, surgical treatment of chronic, full-thickness rotatorcuff tears is not always necessary. In fact, non-operative treatment using physical therapy protocols have been previously demonstrated as an effective treatment for chronic rotatorcuff tears . It is crucial that primary care physicians and complementary allied medical providers managing patients with chronic, full-thickness rotatorcuff tears recognize that a trial of non-operative treatment should be started at the time of the initial clinical presentation, and that MRI and referral to a surgeon be reserved for ‘non-responders’ to the initial line of treatment . Surgery is an invasive procedure and is not always the best option for patients. Prescription and adherence to an early non-operative program can re- sult in successful treatment of chronic, full-thickness rota- tor cuff tears and serve as an alternative to surgery [17– 20], which can reduce utilization of healthcare resources, reduce inappropriate surgical referrals, and save costs to both the healthcare system and the patient.
Although there are many causes of shoulder pain, the most common cause is compression in lesions including bursa and tendon. The majority of the diagnoses for the shoulder compromise are rotatorkaf pathologies and subacromial impingement syndrome. Rotatorcuff injuries are associ- ated with impingement [3,4]. Although impingement is a leading cause of rotatorcuff injuries, it is not the only re- ason. Overuse and fatigue, external loading of the rotator sheath muscles, damage to the tendons are also important reasons .
results in weakening of the bone cortex . In 2001, Ro- deo et al.  reported that osteoprotegerin improves stiffness at the healing tendon-bone junction due to inhib- ition of osteoclast activity. On the other hand, application of receptor activator of nuclear factor-kappa B ligand (RANKL) impaired bone ingrowth and impeded the tendon healing process in a rabbit model. In a clinical study, Chung et al.  found that bone mineral density (BMD) is an inde- pendent risk factor for rotatorcuff healing after arthroscopic repair in a multivariate analysis. Hyperparathyroidism-related renal osteodystrophy is similar to the effect of osteoporosis on tendon healing. In addition, dialysis-related amyloidosis has a high proportion of shoulder involvement , Konishiike et al.  reporting a 48% incidence of shoulder pain in patients who have received dialysis for an average of nine years. Non-fatty infiltration in the rotator interval was identified by Kerimoglu et al. , and has a strong correl- ation with constraint of shoulder internal rotation, external rotation and abduction motion. These contributing factors to tendon rupture may play roles in the tendon healing process, and even in healed tendons in patients with hemodialysis.
The data were drawn from a database that included all patients who were to undergo arthroscopic acromioplasty for surgical management of impingement or rotatorcuff pathology of the shoulder (Table 3) in a tertiary level hos- pital in Toronto, Canada between October 2000 and July 2004. Complete data were available on 329 (196 males, 133 females) out of a total of 334 patients. All patients subsequently underwent arthroscopic acromioplasty with or without rotatorcuff repair. A number of patients had superior labral anterior and posterior (SLAP) lesions that required surgical repair.
Randelli et al. (2011) performed a double blinded randomised controlled trial and applied autologous PRP intraoperatively to arthroscopic rotatorcuff repairs. At two year follow up they found that the treated group had less pain in the immediate post operative period. They also noted that the application of the PRP resulted in better healing of grade 1 and 2 tears. Furthermore, some clinicians treat painful and inflamed rotatorcuff tendons with local steroid injections which may further damage the tendons themselves (Bhatia et al., 2009). Baboldashti et al. (2011) looked at the use of platelet-rich plasma (PRP), a rich source of growth factors, as a healing agent to accelerate tendon repair. They exposed human tenocytes were exposed to different doses of dexamethasone with and without PRP. Dexamethasone reduced viable cell number without inducing overt cell death, but the number of senescent cells increased considerably. After co-treatment with 10% PRP, viable cell number increased significantly and the dexamethasone-induced senescence was markedly reduced. These findings suggest the potential for local administration of PRP to enhance tendon healing in patients undergoing glucocorticoid treatment.
Two reviews 38,45 have been published on the rehabilitation of patients following rotatorcuff repair. Plessis et al 38 performed their review to find the effect of one of the adjunctive components (i. e., the CPM) on rotatorcuff rehabilitation program; the authors did not perform the review on any other interventions, including the core intervention of land-based exercise programs; However, the findings of our systematic review on the effect of the CPM are in agreement with the results of Plessis et al. 38 Van den Meijden et al, 45 without mentioning their research strategy, performed a narrative review to recommend an evidence-based rehabilitation protocol. The authors concluded by stating that there is little scientific evidence available to guide postsurgical rotatorcuff rehabilitation; expert opinion and clinical experience remain the basis of the available rehabilitation protocols. The result of our systematic review is in agreement with these findings; However, the results of our systematic review are more than the narrative review, 45 as in our current review two pairs of independent evaluators performed vigorous quality appraisals of all included studies using a valid and standardized tool.
The higher prevalence of neovascularity in painful rotatorcuff tendons found in the current study suggests that 65% (approximately 2 in 3) patients clinically diagnosed with rotatorcuff tendinopathy may have US signs of neovascu- larity. This is of potential relevance as pain scores have been shown to be consistently higher in tendons with neovascularity when compared with those with- out[39,63]. Additionally, the presence of neovascularity may be of relevance as Ohberg and Alfredson hypoth- esised that the pain in chronic tendinosis may originate from the new blood vessels and the nerves accompanying the vessels. Furthermore, they suggested that sclerosing the neovessels might reduce pain in chronic Achilles tend- inosis. In a study of 10 subjects with painful Achilles tend- inosis, colour Doppler ultrasound was used to guide an injection of a sclerosing agent into the tendon. Ohberg and Alfredson reported that eight patients were satis- fied with the results of treatment. There was significantly reduced pain during activity [reported on a visual ana- logue scale (VAS)] and no remaining neovascularisation after an average of two injections. Two patients were not satisfied, and the neovascularisation was reported to have remained. At the six month follow up, the same eight patients remained satisfied and could perform Achilles tendon loading activities as desired. Their mean VAS
The management of a rotatorcuff tear is multifaceted. Conservative management includes analgesia and anti- inflammatory medications, physical therapy, activity modification and subacromial injections of local anaes- thetic and/or steroid. Injection of hyaluronate is advo- cated by some authors for complete rotatorcuff tears, but a randomized control trial found it to be no more effective than a steroid injection . More recently however Chou et al. demonstrated a significant improvement in shoulder function at 6 weeks following injection with hyaluronate compare with placebo for partial tears . Operative interventions include arthro- scopic debridement of the tear or repair of the torn rota- tor cuff, with or without subacromial decompression. Most reports in the literature are procedure oriented, consisting of retrospective single surgeon series with limited numbers of patients. A Cochrane review per- formed in 2004 analysed interventions for rotatorcuff tears and concluded that there is little evidence to sup- port or refute the efficacy of commonly used treatment methods .
104 which is often used as an objective measure of shoulder function. The changes in these forces are likely present due to the induced paralysis of the scapular rotators in this model (i.e., the trapezius and serratus anterior), which are particularly important in abduction, acting in coordination with the humerus, to upwardly rotate the scapula in order to achieve proper clearance of the rotatorcuff under the acromion, preventing subacromial impingement. Additionally, vertical force has been used as an objective assessment of weight-bearing and pain. 8, 27 The altered loading profile placed on the shoulder joint in the presence of scapular dyskinesis may relate to functional deficits and associated pain and could have a significant effect on tendon properties. The changes due to scapular dyskinesis are similar to those previously described in Chapter 2. Alternatively, overuse activity did not diminish joint function. Therefore, we can conclude that the mechanical mechanism by which overuse activity alters tendon properties and by which scapular dyskinesis alters tendon properties are distinct.
Most studies on the pathophysiology, natural history, diagnosis by imaging and outcomes after operative or nonoperative treatment of ro- tator cuff tear have focused on those of full-thickness tears, resulting in limited knowledge of partial-thickness rotatorcuff tears. However, a partial-thickness tear of the rotatorcuff is a common disorder and can be the cause of persistent pain and dysfunction of the shoulder joint in the affected patients. Recent updates in the literatures shows that the partial-thickness tears are not merely mild form of full-thick- ness tears. Over the last decades, an improved knowledge of pathophysiology and surgical techniques of partial-thickness tears has led to more understanding of the significance of this tear and better outcomes. In this review, we discuss the current concept of management for partial-thickness tears in terms of the pathogenesis, natural history, nonoperative treatment, and surgical outcomes associated with the commonly used repair techniques.
A large body of research has been devoted to the development of the HRQOL scales since the 1980s . The HRQOL scales are generally used to collect the relevant data through questionnaires completed independently by patients. Doctors can understand the severity of the patients’ condition by the informa- tion obtained through these scales and to develop a more appropriate treatment option for patients . Ac- cording to their applications, these scales can be classified as generic scales and disease-specific scales. The former are developed for the evaluation of the overall status of a patient, such as the commonly used Medical Outcomes Study Short-Form 36 (SF-36), while the latter may be applicable for specific patient populations, such as the Western Ontario Shoulder Instability Index (WOSI) for shoulder instability , the Western Ontario Osteoarth- ritis of the Shoulder Index (WOOS) for shoulder osteo- arthritis , and the RotatorCuff Quality of Life Index (RC-QOL)  and the Western Ontario Cuff Index (WORC)  for RC disorders.
characterized by anterolateral catching pain or aching of the shoulder, without a history of trauma. Pain originates from the tissues within the subacromial space including the rotatorcuff (N. Hanchard, Cummins, & Jeffries, 2004; J. S. Lewis, Green, & Dekel, 2001). In people with SSI it is proposed rotatorcuff muscle weakness develops secondary to inflammation and degeneration that occurs as a result of mechanical compression from a structure external to the tendon, known as extrinsic SSI (Michener, McClure, & Karduna, 2003), or as a result of overuse and tension overload affecting the tendons intrinsically, as in tendinopathy, known as intrinsic SSI (Jeremy S Lewis, 2009).
Rotatorcuff tears (RCTs) are a common shoulder dis- order among elderly people and can cause shoulder pain, weakness, and decreased range of motion . Patients with symptomatic RCTs often choose to undergo rotatorcuff repair to relieve pain, improve function, and return to high-level activities [2, 3]. As patients ’ function and ability are directly affected by joint kinematics, there is an interest in quantifying the shoulder kinematics of patients with RCTs. Of particular importance are pre- operative shoulder mechanics during scapular plane ab- duction and axial rotation, as patients expect to perform
inclusion criteria we were able to include only 14 studies describing 13 independent cohorts. A number of variables were investigated in one cohort only. In an effort to identify a homogenous pool of literature, we included only those predictors that were analysed or followed in at least 2 or more cohorts. If a predictor was followed in only 2 cohorts, its effect as a significant predictor was considered if the effect sizes were not significantly heterogeneous to avoid a negating effect between the cohorts. Common clinical and demographic factors such as pre-operative range of motion of the affected shoulder, pre-operative rotatorcuff muscle atrophy and gender were evaluated in only a single cohort and were therefore not considered in the final analysis. The lack of consistent selection and measurement of potential prognostic variables across prognostic studies meant that only a subset of studies designed to address clinical prognosis were suitable for meta-analysis. By limiting to these, we strengthened the rigor of our analysis, but must consider that potential useful clinical information is lost when studies are excluded.