Effect of intraarticular pressure on glenohumeral kinematics during a simulated abduction motion: a cadaveric study.

BACKGROUND: The current understanding of glenohumeral joint stability is defined by active restrictions and passive stabilizers including naturally-occurring negative intraarticular pressure. Cadaveric specimens have been used to evaluate the role of intraarticular pressure on joint stability, although, while the shoulder's negative intraarticular pressure is universally acknowledged, it has been inconsistently accounted for. HYPOTHESIS: During continuous, passive humeral abduction, releasing the native intraarticular pressure increases joint translation, and restoring this pressure decreases joint translations. STUDY DESIGN: Descriptive Laboratory Study. METHODS: A validated shoulder testing system was used to passively abduct the humerus in the scapular plane and measure joint translations for seven (n = 7) cadaveric specimens. The pressure within the glenohumeral joint was measured via a 25-gauge needle during passive abduction of the arm, which was released and subsequently restored. During motion, the rotator cuff muscles were loaded using stepper motors in a force feedback loop and electromagnetic sensors were used to continuously measure the position of the humerus and scapula. Joint translation was defined according to the instant center of rotation of the glenohumeral head according to the recommendations by the International Society of Biomechanics. RESULTS: Area under the translation versus abduction angle curve suggests that releasing the pressure within the capsule results in significantly less posterior translation of the glenohumeral head as compared to intact (85-90˚, p < 0.05). Posterior and superior translations were reduced after 70˚ of abduction when the pressure within the joint was restored. CONCLUSION: With our testing system employing a smooth continuous passive motion, we were able to show that releasing intraarticular pressure does not have a major effect on the path of humeral head motion during glenohumeral abduction. However, both violating the capsule and restoring intraarticular pressure after releasing alter glenohumeral translations. Future studies should study the effect of simultaneous external rotation and abduction on the relationship between joint motion and IAP, especially in higher degrees of abduction. CLINICAL RELEVANCE: Thoroughly simulating the glenohumeral joint environment in the cadaveric setting may strengthen the conclusions that can be translated from this setting to the clinic.

Recommended Musculoskeletal and Sports Ultrasound Terminology: A Delphi-Based Consensus Statement.

OBJECTIVES: The current lack of agreement regarding standardized terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice, and research. This consensus was developed to provide a reference to improve clarity and consistency in communication. METHODS: A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus which was defined as group level agreement >80%. RESULTS: Content was organized into seven general topics including: 1) General Definitions, 2) Equipment and Transducer Manipulation, 3) Anatomic and Descriptive Terminology, 4) Pathology, 5) Procedural Terminology, 6) Image Labeling, and 7) Documentation. Terms and definitions which reached consensus agreement are presented herein. CONCLUSIONS: The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients, and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

Lateral release associated with MPFL reconstruction in patients with acute patellar dislocation.

OBJECTIVE: Medial patellofemoral ligament (MPFL) injury occurs in the majority of the cases of acute patellar dislocation. The role of concomitant lateral retinaculum release with MPFL reconstruction is not clearly understood. Even though the lateral retinaculum plays a role in both medial and lateral patellofemoral joint stability in MPFL intact knees, studies have shown mixed clinical outcomes following its release during MPFL reconstruction surgery. Better understanding of the biomechanical effects of the release of the lateral retinaculum during MPFL reconstruction is warranted. We hypothesize that performing a lateral release concurrent with MPFL reconstruction will disrupt the patellofemoral joint biomechanics and result in lateral patellar instability. METHODS: A previously developed and validated finite element (FE) model of the patellofemoral joint was used to understand the effect of lateral retinaculum release following MPFL reconstruction. Contact pressure (CP), contact area (CA) and lateral patellar displacement were recorded. abstract. RESULTS: FE modeling and analysis demonstrated that lateral retinacular release following MPFL reconstruction with tibial tuberosity-tibial groove distance (TT-TG) of 12 mm resulted in a 39% decrease in CP, 44% decrease in CA and a 20% increase in lateral patellar displacement when compared to a knee with an intact MPFL. In addition, there was a 45% decrease in CP, 44% decrease in CA and a 21% increase in lateral displacement when compared to a knee that only had an MPFL reconstruction. CONCLUSION: This FE-based analysis exhibits that concomitant lateral retinaculum release with MPFL reconstruction results in decreased PF CA, CP and increased lateral patellar displacement with increased knee flexion, which may increase the risk of patellar instability.

Recommended musculoskeletal and sports ultrasound terminology: a Delphi-based consensus statement.

The current lack of agreement regarding standardised terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice and research. This consensus was developed to provide a reference to improve clarity and consistency in communication. A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus, which was defined as group level agreement of >80%. Content was organised into seven general topics including: (1) general definitions, (2) equipment and transducer manipulation, (3) anatomical and descriptive terminology, (4) pathology, (5) procedural terminology, (6) image labelling and (7) documentation. Terms and definitions which reached consensus agreement are presented herein. The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

Lateral Release With Tibial Tuberosity Transfer Alters Patellofemoral Biomechanics Promoting Multidirectional Patellar Instability.

PURPOSE: The purpose of this study was to develop and validate a finite element (FE) model of the patellofemoral (PF) joint to characterize patellofemoral instability, and to highlight the effect of lateral retinacular release in combination with tibial tuberosity transfer with respect to contact pressures (CP), contact area (CA), and kinematics during knee flexion. METHODS: A comprehensive, dynamic FE model of the knee joint was developed and validated through parametric comparison of PF kinematics, CP, and CA between FE simulations and in vitro, cadaveric experiments. Using this FE model, we characterized the effect of patellar instability, lateral retinacular release (LR), and tibial tuberosity transfer (TTT) in the setting of medial patellofemoral ligament injury during knee flexion. RESULTS: There was a high level of agreement in CP, CA, lateral patellar displacement, anterior patellar displacement, and superior patellar displacement between the FE model and the in vitro data (P values 0.19, 0.16, 0.81, 0.10, and 0.36, respectively). Instability conditions demonstrated the greatest CP compared to all of the other conditions. During all degrees of flexion, TTT and concomitant lateral release (TTT + LR) decreased CP significantly. TTT alone shows a consistently lower CA compared to nonrelease conditions with subsequent lateral release further decreasing CA. CONCLUSIONS: The results of this study demonstrate that the FE model described reliably simulates PF kinematics and CP within 1 SD in uncomplicated cadaveric specimens. The FE model is able to show that tibial tubercle transfer in combination with lateral retinacular release markedly decreases patellofemoral CP and CA and increases lateral patellar displacement that may decrease bony stabilization of the patella within the trochlear groove and promote lateral patellar instability. CLINICAL RELEVANCE: The goal of surgical correction for patellar instability focuses on reestablishing normal PF kinematics. By developing an FE model that can demonstrate patient PF kinematics and the results of different surgical approaches, surgeons may tailor their treatment to the best possible outcome. Of the surgical approaches that have been described, the biomechanical effects of the combination of TTT with lateral retinacular release have not been studied. Thus, the FE analysis will help shed light on the effect of the combination of TTT with lateral retinacular release on PF kinematics.

Evolution of knowledge on meniscal biomechanics: a 40 year perspective.

BACKGROUND: Knowledge regarding the biomechanics of the meniscus has grown exponentially throughout the last four decades. Numerous studies have helped develop this knowledge, but these studies have varied widely in their approach to analyzing the meniscus. As one of the subcategories of mechanical phenomena Medical Subject Headings (MeSH) terms, mechanical stress was introduced in 1973. This study aims to provide an up-to-date chronological overview and highlights the evolutionary comprehension and understanding of meniscus biomechanics over the past forty years. METHODS: A literature review was conducted in April 2021 through PubMed. As a result, fifty-seven papers were chosen for this narrative review and divided into categories; Cadaveric, Finite element (FE) modeling, and Kinematic studies. RESULTS: Investigations in the 1970s and 1980s focused primarily on cadaveric biomechanics. These studies have generated the fundamental knowledge basis for the emergence of FE model studies in the 1990s. As FE model studies started to show comparable results to the gold standard cadaveric models in the 2000s, the need for understanding changes in tissue stress during various movements triggered the start of cadaveric and FE model studies on kinematics. CONCLUSION: This study focuses on a chronological examination of studies on meniscus biomechanics in order to introduce concepts, theories, methods, and developments achieved over the past 40 years and also to identify the likely direction for future research. The biomechanics of intact meniscus and various types of meniscal tears has been broadly studied. Nevertheless, the biomechanics of meniscal tears, meniscectomy, or repairs in the knee with other concurrent problems such as torn cruciate ligaments or genu-valgum or genu-varum have not been extensively studied.

Changes in Contact Area in Meniscus Horizontal Cleavage Tears Subjected to Repair and Resection.

PURPOSE: To assess the changes in tibiofemoral contact pressure and contact area in human knees with a horizontal cleavage tear before and after treatment. METHODS: Ten human cadaveric knees were tested. Pressure sensors were placed under the medial meniscus and the knees were loaded at twice the body weight for 20 cycles at 0°, 10°, and 20° of flexion. Contact area and pressure were recorded for the intact meniscus, the meniscus with a horizontal cleavage tear, after meniscal repair, after partial meniscectomy (single leaflet), and after subtotal meniscectomy (double leaflet). RESULTS: The presence of a horizontal cleavage tear significantly increased average peak contact pressure and reduced effective average tibiofemoral contact area at all flexion angles tested compared with the intact state (P < .03). There was approximately a 70% increase in contact pressure after creation of the horizontal cleavage tear. Repairing the horizontal cleavage tear restored peak contact pressures and areas to within 15% of baseline, statistically similar to the intact state at all angles tested (P < .05). Partial meniscectomy and subtotal meniscectomy significantly increased average peak contact pressure and reduced average contact area at all degrees of flexion compared with the intact state (P < .05). CONCLUSIONS: The presence of a horizontal cleavage tear in the medial meniscus causes a significant reduction in contact area and a significant elevation in contact pressure. These changes may accelerate joint degeneration. A suture-based repair of these horizontal cleavage tears returns the contact area and contact pressure to nearly normal, whereas both partial and subtotal meniscectomy lead to significant reductions in contact area and significant elevations in contact pressure within the knee. Repairing horizontal cleavage tears may lead to improved clinical outcomes by preserving meniscal tissue and the meniscal function. CLINICAL RELEVANCE: Understanding contact area and peak contact pressure resulting from differing strategies for treating horizontal cleavage tears will allow the surgeon to evaluate the best strategy for treating his or her patients who present with this meniscal pathology.

Corticosteroid Injections for Adhesive Capsulitis: A Review.

OBJECTIVE: Adhesive capsulitis is a self-limiting condition in a majority of patients and is often treated nonoperatively. However, symptoms may take 2 to 3 years to resolve fully. A small, but significant, portion of patients require surgical intervention. The purpose of this systematic review is to evaluate the efficacy of corticosteroid injections for the treatment of adhesive capsulitis (AC). DATA SOURCES: A review of articles indexed by the United States National Library of Medicine was conducted by querying the PubMed database for studies involving participants with AC, frozen shoulder, stiff shoulder, or painful shoulder. Articles that included corticosteroids, glucocorticoids, steroids, and injections were included. MAIN RESULTS: Corticosteroid injections provide significant symptom relief for 2 to 24 weeks. Injections can be performed intra-articularly or into the subacromial space. Evidence suggests that a 20 mg dose of triamcinolone may be as effective as a 40 mg injection. It remains unclear whether image-guided injections produce a clinically significant difference in outcomes when compared with landmark-guided (blind) injections. Corticosteroids may be less beneficial for diabetic patients. Patients using protease inhibitors (antiretroviral therapy) should not receive triamcinolone because the drug-drug interaction may result in iatrogenic Cushing syndrome. CONCLUSIONS: Corticosteroid injections for AC demonstrate short-term efficacy, but may not provide a long-term benefit. More high quality, prospective studies are needed to determine whether corticosteroid injections using ultrasound guidance significantly improve outcomes.

Magnetic resonance imaging is comparable to computed tomography for determination of glenoid version but does not accurately distinguish between Walch B2 and C classifications.

BACKGROUND: Computed tomography (CT) scan is the standard for the preoperative assessment of glenoid version and morphology before total shoulder arthroplasty. However, the capacity of magnetic resonance imaging (MRI) to visualize bone morphology has improved with advancing technology. The purpose of this study was to compare the accuracy of MRI to CT for assessment of glenoid version and Walch classification. METHODS: Three fellowship-trained shoulder surgeons assessed glenoid version and Walch classification of 30 patients with primary shoulder osteoarthritis who received both CT and MRI scans before total shoulder arthroplasty. Version measurements, Walch classification, and observer agreement were compared. RESULTS: Mean glenoid version was -15.5° and -18.6° by CT and MRI, respectively (P = .17). Interobserver reliability coefficients were good for both imaging modalities (CT, 0.73; MRI, 0.62). Intraobserver coefficients were good to excellent for CT (range, 0.76-0.87) and good for MRI (range, 0.75-0.79). For Walch classification, interobserver reliability for both modalities was merely fair, whereas intraobserver reliability was moderate to good. Although identification of type A1, A2, and B1 was nearly identical between CT and MRI, there was observer disagreement on type B2 (P = .001) and C glenoids (P = .03). Specifically, MRI underidentified type B2 and overidentified type C compared with CT. CONCLUSIONS: MRI is largely comparable to CT scan for evaluation of the glenoid, with similar measurements of version and identification of less extreme Walch glenoids. However, MRI is less accurate at distinguishing between type B2 and C glenoids.

Evaluating Nonoperative Treatments for Adhesive Capsulitis.

Patients commonly present with shoulder complaints to the primary care and orthopaedic setting. The differential includes rotator cuff tears, subacromial impingement, osteoarthritis, and adhesive capsulitis, also known as frozen shoulder. Despite the prevalence of adhesive capsulitis, it is commonly misdiagnosed and management remains unclear. This article reviews the presentation of adhesive capsulitis, presents an overview of the pathophysiology of this poorly understood disease, and evaluates nonoperative treatment options for adhesive capsulitis. (Journal of Surgical Orthopaedic Advances 26(4):193-199, 2017).

Influence of disruption of the acromioclavicular and coracoclavicular ligaments on glenohumeral motion: a kinematic evaluation.

BACKGROUND: Changes to the integrity of the acromioclavicular (AC) joint impact scapulothoracic and clavicular kinematics. AC ligaments provide anterior-posterior stability, while the coracoclavicular (CC) ligaments provide superior-inferior stability and a restraint to scapular internal rotation. The purpose of this cadaveric study was to describe the effect of sequential AC and CC sectioning on glenohumeral (GH) kinematics during abduction (ABD) of the arm. We hypothesized that complete AC ligament insult would result in altered GH translation in the anterior-posterior plane during abduction, while subsequent sectioning of both CC ligaments would result in an increasing inferior shift in GH translation. METHODS: Six cadaveric shoulders were studied to evaluate the impact of sequential sectioning of AC and CC ligaments on GH kinematics throughout an abduction motion in the coronal plane. Following an examination of the baseline, uninjured kinematics, the AC ligaments were then sectioned sequentially: (1) Anterior, (2) Inferior, (3) Posterior, and (4) Superior. Continued sectioning of CC ligamentous structures followed: the (5) trapezoid and then the (6) conoid ligaments. For each group, the GH translation and the area under the curve (AUC) were measured during abduction using an intact cadaveric shoulder. Total translation was calculated for each condition between ABD 30° and ABD 150° using the distance formula, and a univariate analysis was used to compare total translation for each axis during the different conditions. RESULTS: GH kinematics were not altered following sequential resection of the AC ligaments. Disruption of the trapezoid resulted in significant anterior and lateral displacement of the center of GH rotation. Sectioning the conoid ligament further increased the inferior shift in GH displacement. CONCLUSION: A combined injury of the AC and CC ligaments significantly alters GH kinematics during abduction. Type III AC separations, result in a significant change in the shoulder's motion and may warrant surgical reconstruction to restore normal function.

The effect of the rotator interval on glenohumeral kinematics during abduction.

BACKGROUND: The rotator interval (RI) has been exploited as a potentially benign point of entry into the glenohumeral (GH) joint. Bounded by the supraspinatus, subscapularis and coracoid process of the scapula, the RI is believed to be important in the shoulder's soft tissue balancing and function. However, the role of the RI in shoulder kinematics is not fully understood. The purpose of this study is to describe the effect of the RI on GH motion during abduction of the arm. METHODS: Six shoulders from three cadaveric torsos were studied to assess the impact of changes in the RI during abduction under four conditions: Intact (Baseline), Opened, Repaired (repaired with side-to-side tissue approximation, no overlap) and Tightened (repaired with 1 cm overlap). For each group, the GH translation and area under the Curve (AUC) were measured during abduction using an intact cadaveric shoulder (intact torso). RESULTS: GH kinematics varied in response to each intervention and throughout the entire abduction arc. Opening the RI caused a significant change in GH translation. The Repair and Tightened groups behaved similarly along all axes of GH motion. CONCLUSIONS: The RI is central to normal GH kinematics. Any insult to the tissue's integrity alters the shoulder's motion throughout abduction. In this model, closing the RI side-to-side has the same effect as tightening the RI. Since suture closure may offer the same benefit as tightening the RI, clinicians should consider this effect when treating patients with shoulder laxity. This investigation provides an improved perspective on the role of the RI on GH kinematics during abduction. When managing shoulder pathology, surgeons should consider how these different methods of RI closure affect the joint's motion. In different circumstances, the surgical approach to the RI can be tailored to address each patient's specific needs.

Analysis of a new all-inside versus inside-out technique for repairing radial meniscal tears.

PURPOSE: The purpose of this study was to compare gap formation, strength, and stiffness of repaired radial tears of the meniscus treated using a new all-inside technique versus a traditional inside-out suture technique. METHODS: Radial tears were created in 36 fresh-frozen porcine menisci. Repairs were performed using a novel all-inside suture-based meniscal repair device or an inside-out technique. The repairs were tested for cyclic loading and load to failure. The displacement, response to cyclic loading (100, 300, and 500 cycles), and mode of failure were recorded, and the construct's stiffness was calculated. RESULTS: The all-inside repairs using the novel device resulted in a significantly lower displacement (gap formation) after 100, 300, and 500 cycles (P = .002, P = .001, and P = .001, respectively). The ultimate load to failure was significantly greater for the all-inside repairs (111.61 N v 95.01 N; P = .03). The all-inside repairs showed greater stiffness (14.53 N/mm v 11.19 N/mm; P = .02). The all-inside repairs failed most often by suture breakage (suture failure). The inside-out repairs failed most commonly when the suture pulled through the tissue (tissue failure) (P < .001). CONCLUSIONS: For repair of radial tears of the meniscus, the vertical suture configuration created by the all-inside technique resulted in lower displacement, higher load to failure, and greater stiffness compared with the horizontal inside-out technique. CLINICAL RELEVANCE: In a porcine specimen meniscus repair model, the biomechanical properties of a vertical all-inside technique were superior to that of a horizontal inside-out technique. Future studies of biomechanical and clinical outcomes in human meniscal repairs with this device are warranted to explore whether this repair method is valuable to clinical practice and patient outcomes.

Biomechanical evaluation of an all-inside suture-based device for repairing longitudinal meniscal tears.

PURPOSE: A device for all-inside suture-based meniscal repairs has been introduced (NovoStitch; Ceterix, Menlo Park, CA) that passes the suture vertically through the meniscus, thereby encircling the tear, and does not require an additional incision or extra-capsular anchors. Our aim was to compare this all-inside suture-based repair with an inside-out suture repair and an all-inside anchor-based repair (FasT-Fix 360°; Smith & Nephew, Andover, MA). METHODS: Longitudinal tears were created in 36 fresh-frozen porcine menisci. Repairs were performed using an all-inside suture-based meniscal repair device, an all-inside anchor-based repair, and an inside-out suture repair. They were tested with cyclic loading and load-to-failure testing. The displacement, response to cyclic loading (100, 300, and 500 cycles), and mode of failure were recorded. The stiffness of the constructs was calculated as well. RESULTS: The all-inside suture-based repairs and the inside-out repairs showed significantly higher loads to failure than the all-inside anchor-based repairs. The stiffness values for the 3 repairs were not different. There were no differences in initial displacement. After 100, 300, and 500 cycles, the inside-out repair had higher gap formation (displacement) than the other 2 groups. Suture failure was the predominant mode of failure across all repair techniques. CONCLUSIONS: The all-inside suture-based repairs and inside-out repairs did not exhibit different load-to-failure values. In addition, the all-inside suture-based repairs and the all-inside anchor-based repairs did not exhibit different displacement values during cyclic loading. CLINICAL RELEVANCE: When addressing a longitudinal meniscal tear, surgeons should consider biomechanical data of various repair devices and techniques in their decision-making process to maximize the mechanical strength and healing probability of the repair.

Biomechanical characterization of unicortical button fixation: a novel technique for proximal subpectoral biceps tenodesis.

PURPOSE: Proximal biceps tenodesis is one method for treating biceps-related pain. Tenodesis protects the length-tension relationship of the biceps muscle, maintains strength, and provides a better cosmetic appearance than tenotomy. The purpose of this investigation was to compare the mechanical properties of a unicortical metal button and an interference screw in proximal biceps tenodesis. METHODS: Six pairs of fresh-frozen shoulders were dissected, leaving the proximal biceps tendon as a free graft. On each pair of shoulders, a biceps tenodesis was performed using an interference screw or a unicortical metal button. The specimens were mounted and a cyclic load (10-60 N) was applied at 1 Hz for 200 cycles, followed by an axial load to failure. The displacement, ultimate load to failure, and mode of failure were recorded. RESULTS: Displacement in response to cyclic loading was 3.7 ± 2.2 mm for the interference screw and 1.9 ± 1.0 mm for the cortical button (P = 0.03). Load at failure for the interference screw was 191 ± 64 N (stiffness: 24 ± 11 N/mm) and 183 ± 61 N (stiffness: 24 ± 7. N/mm) for the unicortical button (P = n.s. for both cases). CONCLUSIONS: As a novel technique for subpectoral biceps tenodesis, a unicortical button demonstrated significantly less displacement in response to cyclic loading than the interference screw. The ultimate load to failure and stiffness for the two methods were not different. In this way, a unicortical button may provide a reliable alternative method of fixation with a potentially lower risk of post-operative humeral fracture and a construct that permits early mobilization following biceps tenodesis.

Effect of Tear Size and Location on Supraspinatus Tendon Strain During Activities of Daily Living and Physiotherapy.

The supraspinatus tendon plays a crucial role in shoulder abduction, making it one of the common structures affected by injury. Clinically, crescent-shaped tears are the most commonly seen tear shape. By developing six specimen-specific, three-dimensional, supraspinatus-infraspinatus finite element model with heterogeneous material properties, this study aimed to examine the changes in tissue deformation (maximum principal strain) of the supraspinatus tendon due to specimen-specific material properties and rotator cuff tear size. FE models with small- and medium-sized full-thickness crescent-shaped tears were subjected to loads seen during activities of daily living and physiotherapy. Six fresh-frozen cadaveric shoulders were dissected to mechanically test the supraspinatus tendon and develop and validate FE models that can be used to assess changes in strain due to small (< 1 cm, equivalent to 20-30% of the tendon width) and medium-sized (1-3 cm, equivalent to 40-50% of the tendon width) tears that are located in the middle and posterior regions of the supraspinatus tendon. FE predictions of maximum principal strain at the tear tips were examined to determine whether failure strain was reached during activities of daily living (drinking and brushing teeth) and physiotherapy exercises (prone abduction and external rotation at 90° abduction). No significant differences were observed between the middle and posterior tear failure loads for small- and medium-sized tears. For prone abduction, there was a potential risk for tear progression (exceeded failure strain) for medium-sized tears in the supraspinatus tendon's middle and posterior regions. For external rotation at 90° abduction, one model with a middle tear and two with posterior tears experienced failure. For all daily activity loads, the strain never exceeded the failure strain. Our three-dimensional supraspinatus-infraspinatus FE model shows that small tears appear unlikely to progress based on the regional strain response; however, medium-sized tears are at higher risk during more strenuous physiotherapy exercises. Furthermore, differences in patient-specific tendon material properties are important in determining whether the tear will progress. Therefore, patient-specific management plans based on tear size may be beneficial to improve clinical outcomes.

Successive tendon injury in an in vivo rat overload model induces early damage and acute healing responses.

Introduction: Tendinopathy is a degenerative condition resulting from tendons experiencing abnormal levels of multi-scale damage over time, impairing their ability to repair. However, the damage markers associated with the initiation of tendinopathy are poorly understood, as the disease is largely characterized by end-stage clinical phenotypes. Thus, this study aimed to evaluate the acute tendon responses to successive fatigue bouts of tendon overload using an in vivo passive ankle dorsiflexion system. Methods: Sprague Dawley female rats underwent fatigue overloading to their Achilles tendons for 1, 2, or 3 loading bouts, with two days of rest in between each bout. Mechanical, structural, and biological assays were performed on tendon samples to evaluate the innate acute healing response to overload injuries. Results: Here, we show that fatigue overloading significantly reduces in vivo functional and mechanical properties, with reductions in hysteresis, peak stress, and loading and unloading moduli. Multi-scale structural damage on cellular, fibril, and fiber levels demonstrated accumulated micro-damage that may have induced a reparative response to successive loading bouts. The acute healing response resulted in alterations in matrix turnover and early inflammatory upregulations associated with matrix remodeling and acute responses to injuries. Discussion: This work demonstrates accumulated damage and acute changes to the tendon healing response caused by successive bouts of in vivo fatigue overloads. These results provide the avenue for future investigations of long-term evaluations of tendon overload in the context of tendinopathy.

A Passive Ankle Dorsiflexion Testing System for an In Vivo Model of Overuse-induced Tendinopathy.

Tendinopathy is a chronic tendon condition that results in pain and loss of function and is caused by repeated overload of the tendon and limited recovery time. This protocol describes a testing system that cyclically applies mechanical loads via passive dorsiflexion to the rat Achilles tendon. The custom-written code consists of pre- and post-cyclic loading measurements to assess the effects of the loading protocol along with the feedback control-based cyclic fatigue loading regimen. We used 25 Sprague-Dawley rats for this study, with 5 rats per group receiving either 500, 1,000, 2,000, 3,600, or 7,200 cycles of fatigue loads. The percentage differences between the pre- and post-cyclic loading measurements of the hysteresis, peak stress, and loading and unloading moduli were calculated. The results demonstrate that the system can induce varying degrees of damage to the Achilles tendon based on the number of loads applied. This system offers an innovative approach to apply quantified and physiological varying degrees of cyclic loads to the Achilles tendon for an in vivo model of fatigue-induced overuse tendon injury.

The effect of simulated scapular winging on glenohumeral joint translations.

HYPOTHESIS: In this study, we aim to test whether scapular winging results in a significant change in glenohumeral translation in the initial phase of the throwing motion. METHODS: Six shoulders underwent an abbreviated throwing motion (ATM) from late cocking to the end of acceleration by use of a validated robotic system. The intact specimens were tested to establish a baseline. The position of the scapula was then affected to simulate scapular winging by placing a cylindrical wedge under the inferior angle of the scapula, and the ATM was performed again. For both conditions, the average glenohumeral translations and scapular rotations were plotted over time to calculate the area under the curve, as a representative of the overall glenohumeral translations and scapular rotations observed during the ATM. RESULTS: Throughout the motion, the winged scapulae showed, on average, 7.7° more upward rotation, 1.6° more internal rotation, and 5.3° more anterior tipping as compared with the baseline. The scapular position relative to the hanging arm was significantly different between the baseline and scapular winging conditions in all arm positions, except for maximal external rotation and the neutral position. Comparing the area under the curve at baseline and with scapular winging indicated that scapular winging significantly increased anterior translation of the glenohumeral joint whereas translation in the superior/inferior and medial/lateral directions did not result in a change in translation. DISCUSSION: These results may suggest a more important role of abnormalities in scapular position in predisposing throwing athletes to shoulder injuries of the anterior capsulolabral structures and consecutive glenohumeral instability.

A Validated Three-Dimensional, Heterogenous Finite Element Model of the Rotator Cuff and The Effects of Collagen Orientation.

Continuum mechanics-based finite element models of the shoulder aim to quantify the mechanical environment of the joint to aid in clinical decision-making for rotator cuff injury and disease. These models allow for the evaluation of the internal loading of the shoulder, which cannot be measured in-vivo. This study uses human cadaveric rotator cuff samples with surface tendon strain estimates, to validate a heterogeneous finite element model of the supraspinatus-infraspinatus complex during various load configurations. The computational model was considered validated when the absolute difference in average maximum principal strain for the articular and bursal sides for each load condition estimated by the model was no greater than 3% compared to that measured in the biomechanical study. The model can predict the strains for varying infraspinatus loads allowing for the study of load sharing between these two tightly coordinated tendons. The future goal is to use the modularity of this validated model to study the initiation and propagation of rotator cuff tear and other rotator cuff pathologies to ultimately improve care for rotator cuff tear patients.