Shoulder pain management strategies and early functional outcome after arthroscopic rotator cuff tear repair. A randomized controlled study.

BACKGROUND: The management of acute postoperative pain after rotator cuff surgery can be challenging. To our knowledge, there are no data available in the literature correlating satisfactory pain control with improvement in terms of function. The purposes of the present study were to evaluate: 1) pain pattern after arthroscopic rotator cuff repair in patients operated with two different techniques (transosseous vs transosseous equivalent); 2) safety/efficacy of three different pharmacological pain control strategies; 3) possible relationship between a correct shoulder pain management protocol in the early post-operative period and patients' functional improvement. METHODS: 114 patients underwent rotator cuff tear repair, either with a Transosseus or a Transosseus equivalent technique. 62 (54%) were male and 52 (46%) were female. The average age was 59 ± 9 years. They were randomly assigned into three different pain management protocols: Paracetamol as needed (max 3 tablets/day) for 1 week (Protocol A), Paracetamol + Codein 1 tablet three times per day for 7 days (Protocol B), or Paracetamol + Ibuprofen 1 tablet two times per day for 7 days (Protocol C). Immediate passive mobilization of the operated shoulder was allowed. VAS and Passive Flexion values were recorded at 7 (T1), 15 (T2) and 30 (T3) days post-surgery. DASH values were recorded at 90 days post-surgery. All patients were asked to register any kind of signs/symptoms that may appear during drug assumption according to each pain management protocols. RESULTS: All the pain management protocols administered were well tolerated by all the study population, and no adverse signs/symptoms were highlighted during drug assumption. Pain pattern: in both surgical techniques, patients within Protocol A were associated with worst results in terms of mean VAS at each time point examined when compared to Protocol B and C (p < 0,05). In patients within Protocol A, no statistically significant differences were found at each point time examined comparing the two surgical techniques, with the exception of T2, where the TO was associated with an higher VAS value than TOE (p < 0.05). No differences were highlighted in Protocol B and C when comparing the values between two surgical techniques. ROM: in both surgical techniques, patients within Protocol A were associated with worst results in terms of mean PROM at each time point examined when compared to Protocol B and C (p < 0,05). In the TO group, patients within Protocol B had better PROM values at T1 (p < 0,05) and T2 (p < 0,05) compared to Protocol C, but no differences were highlighted at T3. In the TOE group, no statistically significant differences were found between patients within Protocol B and C at each time point examined. DASH: In the TO group, no statistically significant differences were found regarding the DASH values comparing Protocol B vs Protocol C, but they were highlighted comparing the values between Protocol A and Protocol B (p < 0,05), and between Protocol A and Protocol C (p < 0,05). Similar results were recorded in the TOE group. CONCLUSION: Post-operative pain is influenced by the surgical technique used being transosseous more painful in the first 15 days after surgery. Oral anti-inflammatory drugs are a feasible strategy to appropriately control post-operative pain. An association between Paracetamol and either Codein or Ibuprofen can lead to better outcomes in terms of VAS reduction and early recovery of passive ROM.

Effects of adipose-derived cell supplementation on tendon-bone healing in a rat model of chronic rotator cuff tear with suprascapular nerve injury.

OBJECTIVE: To investigate the effect of adipose-derived cells (ADCs) on tendon-bone healing in a rat model of chronic rotator cuff tear (RCT) with suprascapular nerve (SN) injury. METHODS: Adult rats underwent right shoulder surgery whereby the supraspinatus was detached, and SN injury was induced. ADCs were cultured from the animals' abdominal fat. At 6 weeks post-surgery, the animals underwent surgical tendon repair; the ADC (+ve) group (n = 18) received an ADC injection, and the ADC (-ve) group (n = 18) received a saline injection. Shoulders were harvested at 10, 14, and 18 weeks and underwent histological, fluorescent, and biomechanical analyses. RESULTS: In the ADC (+ve) group, a firm enthesis, including dense mature fibrocartilage and well-aligned cells, were observed in the bone-tendon junction and fatty infiltration was less than in the ADC (-ve) group. Mean maximum stress and linear stiffness was greater in the ADC (+ve) compared with the ADC (-ve) group at 18 weeks. CONCLUSION: ADC supplementation showed a positive effect on tendon-bone healing in a rat model of chronic RCT with accompanying SN injury. Therefore, ADC injection may possibly accelerate recovery in massive RCT injuries.

Editorial Commentary: Postoperative Zoledronic Acid Improves Tendon Healing but Does Not Affect Outcomes in Rotator Cuff Repair Patients With Postmenopausal Osteoporosis.

Understanding the preoperative risk factors for successful rotator cuff repair (RCR) and ways to optimize these factors is an evolving area of study. The Rotator Cuff Healing Index and other proxy risk factors for failed rotator cuff healing have implicated significant fatty infiltration, muscular atrophy, advanced chronological age, tear size and retraction, and ultimately, osteoporosis. Although structural (or biological) augmentation and tendon transfer have been proposed as solutions for the alarmingly high rate of failure after primary RCR, other options may preferentially focus on the enthesis and underlying osseous footprint. Currently, bisphosphonates are frequently used in the treatment of osteoporosis and prevention of fragility fractures. However, burgeoning evidence suggests that postoperative zoledronic acid may have clinical utility after rotator cuff and other tendon repairs. In the cost-conscious world of evidence-based medicine, the added economic burden of additional medications and office visits may or may not improve patient outcomes-much less confer added value. Our advice to fellow shoulder surgeons: Wait for further information, but continue to holistically consider and optimize risk factors for poor soft-tissue healing. Although the addition of postoperative bisphosphonates may improve suture anchor fixation and promote a better foundation for healing, it will not immediately transform your RCR success rates.

A scoping review and best evidence synthesis for treatment of partial-thickness rotator cuff tears.

BACKGROUND: Rotator cuff disorders include a broad spectrum of pathological conditions including partial-thickness and full-thickness tears. Studies have shown partial-thickness rotator cuff tear (PTRCT) prevalence to be twice that of full-thickness tears. In the working population, PTRCTs are one of the most common causes of shoulder pain and often result in occupational disability due to pain, stiffness, and loss of shoulder function. Treatment of PTRCTs remains controversial. The purpose of this study was to consolidate the existing high-quality evidence on best management approaches in treating PTRCTs using both nonoperative and operative approaches. METHODS: A scoping review with best evidence synthesis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE (OVID), EMBASE (OVID), Cochrane Library (Wiley), SCOPUS, Web of Science Core Collection, CINAHL Plus with Full Text (EBSCOhost), PubMed Central, and Science Direct were searched from 2000 to March 3, 2023. Level 1 studies, and systematic reviews and meta-analyses that included level 1 and 2 studies, were included. RESULTS: The search yielded 8276 articles. A total of 3930 articles were screened after removing 4346 duplicates. Application of inclusion criteria resulted in 662 articles that were selected for full-text review. Twenty-eight level 1 studies, 1 systematic review, 4 meta-analyses, and 1 network meta-analyses were included in the best evidence synthesis. Nonoperative strategies included injections (ie, platelet-rich plasma, corticosteroid, prolotherapy, sodium hyaluronate, anesthetic, and atelocollagen), exercise therapy, and physical agents. Operative interventions consisted of débridement, shaving of the tendon and footprint, transtendon repair, and traditional suture anchor repair techniques with and without tear completion. Both nonoperative and operative strategies demonstrated effectiveness at managing pain and functional outcome for PTRCTs. The evidence supports the effectiveness of surgical intervention in treating PTRCTs regardless of arthroscopic technique. CONCLUSION: The results of this scoping review do not support superiority of operative over nonoperative management and suggest that both strategies can be effective at managing pain and functional outcome for PTRCTs. Surgery, however, is the most invasive and costly approach, with the highest risk of complications such as infection. Other variables such as patient expectation, treating practitioner bias, or preference may change which modalities are offered and in what sequence.

A multi-center, single-blinded, randomized, parallel-group, superiority study to compare the efficacy of manipulation under anesthesia versus intra-articular steroid injection in the treatment of patients with frozen shoulder and a diagnosis of rotator cuff injury or tear by MRI: study protocol for a randomized controlled trial.

BACKGROUND: Frozen shoulder (FS) is a common condition that can cause severe pain and limited range of motion in the shoulder joint. While intra-articular steroid injection has been shown to be an effective treatment for FS, manipulation under anesthesia (MUA) is an alternative treatment that has gained popularity in recent years. However, there is a lack of evidence regarding the effectiveness of MUA on FS patients with concomitant rotator cuff injury or tear. Though a few studies have shown that MUA is not associated with rotator cuff tears, and will not exacerbate the injury, more high-quality studies with bigger sample sizes are needed. Therefore, the aim of this multi-center, single-blinded, randomized, parallel-group, superiority study is to compare the efficacy of MUA versus intra-articular steroid injection in the treatment of FS patients with a diagnosis of rotator cuff injury or tear by MRI. METHODS: A parallel, single-blinded, multi-center randomized controlled trial of 320 patients will be conducted at three hospitals of China. Eligible patients with frozen shoulder and rotator cuff injury or tear diagnosed by MRI will be randomly assigned to, in equal proportions, the manipulation under anesthesia group and the intra-articular steroid injection group via a central randomization system, undergoing a corresponding operation on day one and a sequent physical exercise for 14 days. The primary outcome is the comprehensive efficacy evaluation (total effective rate) and the change of Constant-Murley Score. Outcome assessors and data analysts will be blinded, and participants will be asked not to reveal their allocation to assessors. DISCUSSION: This study aims to explore the superiority of manipulation under anesthesia in reducing pain and improving shoulder function in frozen shoulder patients accompanied with rotator cuff injury. To provide a scientific basis for the dissemination and application of manipulation under anesthesia, and a better knowledge for the role of MUA in the treatment of frozen shoulder accompanied with rotator cuff injury. TRIAL REGISTRATION: Chictr.org.cn ChiCTR2200067122 . Registered on 27 December 2022. ChiCTR is a primary registry of the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) network and includes all items from the WHO Trial Registration data set in Trial registration.

Efficacy of five-step shoulder manipulation for rotator cuff-related shoulder pain: protocol for a multicenter randomized controlled trial.

BACKGROUND: Rotator cuff-related shoulder pain (RCRSP) is the most common cause of shoulder disorders. In China, manipulation has been used extensively for the treatment of patients with RCRSP. However, high-quality clinical evidence to support the therapeutic effect of manipulation is still limited. METHODS: A multicenter, participant-, outcome assessor-, and data analyst-blinded, randomized, placebo-controlled trial will be conducted. A total of 280 participants with RCRSP will be recruited from three hospitals and randomly assigned to a five-step shoulder manipulation (FSM) group or a sham manipulation (SM) group. Each group will receive four weekly treatment sessions, with all participants performing exercises at home for 12 weeks. Assessments, namely the Constant-Murley score, visual analog scale, range of motion, and 36-Item Short Form Survey, will be made at baseline, 4, 12, 18, and 24 weeks. Adverse events during the study will also be recorded. DISCUSSION: This is a pragmatic clinical trial to evaluate the efficacy and safety of FSM in patients with RCRSP. The findings of this study will provide worthy clinical evidence for manual therapy for RCRSP. TRIAL REGISTRATION: China Registered Clinical Trial Registration Center ChiCTR2000037577. Registered on 29 August 2020.

Preoperative vitamin D supplementation is a cost-effective intervention in arthroscopic rotator cuff repair.

BACKGROUND: This study investigates the potential role of preoperative 25(OH)D supplementation as a cost-effective strategy to decrease revision rotator cuff repair (RCR) rates and lower the total health care burden from patients undergoing primary arthroscopic RCR. Previous literature has emphasized the importance of vitamin D on bone health maintenance, soft tissue healing, and outcomes in RCR. Inadequate preoperative vitamin D levels may increase revision RCR rates following primary arthroscopic RCR. Although 25(OH)D deficiency is common in RCR patients, serum screening is not routinely performed. METHODS: A cost-estimation model was developed to determine the cost-effectiveness of both preoperative selective and nonselective 25(OH)D supplementation in RCR patients in order to reduce revision RCR rates. Prevalence and surgical cost data were obtained from published literature through systematic reviews. Cost of serum 25(OH)D assay and supplementation were obtained from public-use data. Mean and lower and upper bounds of 1-year cost savings were calculated for both the selective and nonselective supplementation scenarios. RESULTS: Preoperative 25(OH)D screening and subsequent selective 25(OH)D supplementation was calculated to result in a mean cost savings of $6,099,341 (range: -$2,993,000 to $15,191,683) per 250,000 primary arthroscopic RCR cases. Nonselective 25(OH)D supplementation of all arthroscopic RCR patients was calculated to result in a mean cost savings of $11,584,742 (range: $2,492,401-$20,677,085) per 250,000 primary arthroscopic RCR cases. Univariate adjustment projects that selective supplementation is a cost-effective strategy in clinical contexts where the cost of revision RCR exceeds $14,824.69 and prevalence of 25(OH)D deficiency exceeds 6.67%. Additionally, nonselective supplementation is a cost-effective strategy in clinical scenarios where revision RCR cost is ≥$4216.06 and prevalence of 25(OH)D deficiency is ≥1.93%. CONCLUSIONS: This cost-predictive model promotes the role of preoperative 25(OH)D supplementation as a cost-effective mechanism to reduce revision RCR rates and lower the overall health care burden from arthroscopic RCR. Nonselective supplementation appears to be more cost-effective than selective supplementation, likely due to the lower cost of 25(OH)D supplementation compared to serum assays.

Dry needling in a multimodal rehabilitation protocol following rotator cuff repair surgery: study protocol for a double-blinded randomized sham-controlled trial.

BACKGROUND: Rotator cuff tear (RCT) is one of the main causes of shoulder pain and dysfunction. Rotator cuff repair (RCR) is a common surgical procedure for the management of RCTs. Presence of myofascial trigger points (MTrP) as a result of surgical procedure can aggravate postoperative shoulder pain. The purpose of this protocol is to describe a randomized controlled trial design to evaluate the effect of implementing 4 sessions of myofascial trigger point dry needling (MTrP-DN) within a multimodal rehabilitation protocol following RCR surgery. METHODS: Forty-six participants aged 40-75 will be recruited having postoperative shoulder pain after RCR and meeting the inclusion criteria. Participants will be randomly divided into 2 groups: One group will undergo MTrP-DN, manual therapy, exercise therapy and electrotherapy and the other will receive sham dry needling (S-DN), manual therapy, exercise therapy and electrotherapy. This protocol will cover 4 weeks of intervention. The primary outcome measure will be the Numeric Pain Rating Scale (NPRS) for pain. Secondary outcome measures will be Shoulder Pain and Disability Index (SPDI), range of motion (ROM), strength and adverse events. DISCUSSION: This is the first study to investigate the use of 4 sessions of MTrP-DN in combination with a multimodal rehabilitation protocol for postoperative shoulder pain, restriction, weakness and dysfunction following RCR. The results of this study may help to determine the effect of MTrP-DN on various outcomes after RCR surgery. TRIAL REGISTRATION: This trial was registered at the ( https://www.irct.ir ), (IRCT20211005052677N1) on 19/2/2022.

Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA), initially indicated for cuff tear arthropathy, is increasingly used to treat elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff. This is often done to avoid revision surgery in elderly patients for rotator cuff failure with anatomic total shoulder arthroplasty (TSA) despite traditionally good outcomes of TSA. We sought to determine whether there was a difference in outcomes in patients aged ≥70 years who received RTSA vs. TSA for GHOA. METHODS: A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged ≥70 years who underwent primary shoulder arthroplasty for GHOA with an intact rotator cuff were included (2012-2021). RTSA was compared with TSA. Multivariable Cox proportional hazard regression was used to evaluate all-cause revision risk during follow-up, whereas multivariable logistic regression was used to evaluate 90-day emergency department (ED) visits and 90-day readmissions. RESULTS: The final study sample comprised 685 RTSA patients and 3106 TSA patients. The mean age was 75.8 years (standard deviation, 4.6 years), and 43.4% of patients were men. After accounting for confounders, we observed no significant difference in all-cause revision risk for RTSA vs. TSA (hazard ratio, 0.79; 95% confidence interval [CI], 0.39-1.58). The most common reason for revision following RTSA was glenoid component loosening (40.0%). Over half of revisions following TSA were for rotator cuff tear (54.0%). No difference based on procedure type was observed in the likelihood of 90-day ED visits (odds ratio, 0.94; 95% CI, 0.71-1.26) and 90-day readmissions (odds ratio, 1.32; 95% CI, 0.83-2.09). CONCLUSION: RTSA and TSA for GHOA with an intact rotator cuff in patients aged ≥70 years had a similar revision risk, as well as a similar likelihood of 90-day ED visits and readmissions. Although revision risk was similar, the most common causes of revision were different, with rotator cuff tears in TSA patients and glenoid component loosening in RTSA patients.

Editorial Commentary: Social Determinants of Health Influence the Success of Shoulder Rotator Cuff Repair Outcomes: When You Do Everything Right, Yet Things Still Go Wrong.

Our ability to perform a technically sound surgery is not sufficient to ensure patients have an excellent clinical outcome. Social determinants of health disparities (SDHDs) profoundly impact health equality. Health disparities that exist in the United States are risk factors for inferior patient-reported outcomes and result in greater complication rates following rotator cuff repair surgery. The presence of SDHDs was associated with an increased risk of revision, stiffness, emergency department visits, medical complications, and costs. Economic and educational SDHDs were associated with the greatest risk of 1-year revision surgery. Improved understanding of these social variables can help with risk identification preoperatively. Surgeons may employ additional, holistic, bio-psycho-social, perioperative resources to provide high-quality, value-based care to at-risk patients who might be marginalized by our health care system.

Effectiveness of Exercises With Electromyographic Biofeedback in Conservative Treatment of Massive Rotator Cuff Tears: A Randomized Controlled Study.

OBJECTIVE: The aim of the study is to investigate the effectiveness of a rehabilitation program with electromyographic biofeedback compared with the control group on patients with massive rotator cuff tear. DESIGN: Forty-six adults with massive rotator cuff tears, randomly assigned to 2 groups (23 electromyographic biofeedback group vs. 23 control group). The electromyographic biofeedback group (experimental group) performed the exercises under the guidance of electromyographic biofeedback, unlike the control group. All patients underwent a 45-minute training session a day, 3 times a week over a 6-wk duration, and followed up until 1-year. The outcome measures were American Shoulder and Elbow score, shoulder flexion strength, shoulder range of motion, Numeric Pain Rating Scale, and Global Rating of Change Scale. RESULTS: Compared with the control group, the electromyographic biofeedback group demonstrated a significant change in shoulder flexion strength and patient satisfaction from baseline to 6 wks (posttraining) and from baseline to 12-mo follow-up ( F = 4.671, P = 0.005). There were significant improvements in within groups statistics for American Shoulder and Elbow score, shoulder flexion strength, shoulder range of motion, and Numeric Pain Rating Scale in both groups ( P < 0.05). CONCLUSIONS: The results demonstrate that deltoid-focused structured rehabilitation program combined with electromyographic biofeedback can be used to increase shoulder flexion strength and patient satisfaction in conservative treatment of massive rotator cuff tear.

Clinical efficacy of different shoulder joint drug injections for rotator cuff injuries: A network meta-analysis.

BACKGROUND: Rotator cuff injury is a common clinical disorder of the musculoskeletal system. It is one of the most common causes of shoulder pain and shoulder joint dysfunction. Intra-articular injection therapy is one of the common conservative treatments for rotator cuff injury in clinical practice, but scholars have been controversial about the different drugs used for injection therapy and their clinical effectiveness, and there is no complete agreement on the choice of different injectables, and the existing original studies are mostly direct comparisons in 1 arm, lacking indirect comparisons, making it difficult to have a clear and comprehensive understanding. OBJECTIVE: A network Meta-analysis was used to comprehensively compare the effectiveness of drug injection therapies for rotator cuff injuries. METHODS: The PubMed, The Cochrane Library, EMbase, Chinese national knowledge infrastructure, Chinese BioMedical Literature on disc, China Science and Technology Journal Database, and Wan-Fang databases were searched for randomized controlled trials on the effectiveness of steroid injections for the comparative treatment of rotator cuff injury for the period April 19, 2013 to April 19, 2022 (the last decade). Two investigators independently screened the literature, extracted data according to inclusion and exclusion criteria, and evaluated the quality of the literature in parallel. Statistical analysis was performed using Stata 16.0 software to compare the differences in efficacy of each treatment measure and rank the efficacy using the ratio and 95% confidence interval (CI) as the effect indicator. RESULTS: 10 RCTs with a total of 861 patients with rotator cuff injury were included, involving 4 therapeutic measures: corticosteroid injection therapy (COR), platelet-rich plasma injection therapy (PRP), Hyaluronic acid injection therapy (HA), and prolotherapy therapy (PRO).Meta-analysis results showed that the ranking results of the 4 therapeutic measures were: corticosteroid injection + hyaluronic acid injection > platelet-rich plasma injection + corticosteroid injection > corticosteroid injection > platelet-rich plasma injection > PRO > platelet-rich plasma injection + hyaluronic acid injection > hyaluronic acid injection. CONCLUSION: we recommend that corticosteroid injections combined with hyaluronic acid injections can be used for the non-surgical conservative clinical management of rotator cuff injuries.

Muscle-Specific Micro-Ribonucleic Acids miR-1-3p, miR-133a-3p, and miR-133b Reflect Muscle Regeneration After Single-Dose Zoledronic Acid Following Rotator Cuff Repair in a Rodent Chronic Defect Model.

BACKGROUND: Zoledronic acid improves bone microarchitecture and biomechanical properties after chronic rotator cuff repair (RCR) in rats. Besides the positive effects of zoledronic acid on bone mineral density and bone microarchitecture, bisphosphonates have positive effects on skeletal muscle function. PURPOSES/HYPOTHESIS: The purposes of this study were to (1) longitudinally evaluate circulating bone- and muscle-specific serum micro-ribonucleic acids (miRNAs) and (2) investigate supraspinatus muscle tissue after tenotomy and delayed RCR in a rat model. It was hypothesized that zoledronic acid would improve muscle regeneration after chronic RCR in rats. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 34 male Sprague-Dawley rats underwent unilateral (left) supraspinatus tenotomy (time point 1) with delayed transosseous RCR after 3 weeks (time point 2). All rats were sacrificed 8 weeks after RCR (time point 3). Animals were randomly assigned to 2 groups. One day after RCR, the control group was given 1 mL of subcutaneous saline solution, and the intervention group was treated with a subcutaneous single-dose of 100 µg/kg body weight of zoledronic acid. All 34 study animals underwent miRNA analysis at all 3 time points. In 4 animals of each group, histological analyses as well as gene expression analyses were conducted. RESULTS: Circulating miRNAs showed significantly different expressions between both study groups. In the control group, a significant downregulation was observed for muscle-specific miR-1-3p (P = .004), miR-133a-3p (P < .001), and miR-133b (P < .001). Histological analyses showed significantly higher rates of regenerating myofibers on the operated side (left) of both study groups compared with the nonoperated side (right; P = .002). On the nonoperated side, significantly higher rates of regenerating myofibers were observed in the intervention group compared with the control group (P = .031). The myofiber cross-sectional area revealed significantly smaller myofibers on both sides within the intervention group compared with both sides of the control group (P < .001). Within the intervention group, significantly higher expression levels of muscle development/regeneration marker genes embryonal Myosin heavy chain (P = .017) and neonatal Myosin heavy chain (P = .016) were observed on the nonoperated side compared with the operated side. CONCLUSION: An adjuvant single-dose of zoledronic acid after RCR in a chronic defect model in rats led to significant differences in bone- and muscle-specific miRNA levels. Therefore, miR-1-3p, miR-133a-3p, and miR-133b might be used as biomarkers for muscle regeneration after RCR. CLINICAL RELEVANCE: Adjuvant treatment with zoledronic acid may improve muscle regeneration after chronic RCR in humans, thus counteracting fatty muscle infiltration and atrophy.

Are psychosocial variables, sleep characteristics or central pain processing prognostic factors for outcome following rotator cuff repair? A protocol for a prospective longitudinal cohort study.

INTRODUCTION: Prognosis following surgical rotator cuff repair (RCR) is often established through the assessment of non-modifiable biomedical factors such as tear size. This understates the complex nature of recovery following RCR. There is a need to identify modifiable psychosocial and sleep-related variables, and to find out whether changes in central pain processing influence prognosis after RCR. This will improve our knowledge on how to optimise recovery, using a holistic rehabilitation approach. METHODS AND ANALYSIS: This longitudinal study will analyse 141 participants undergoing usual care for first time RCR. Data will be collected 1-21 days preoperatively (T1), then 11-14 weeks (T2) and 12-14 months (T3) postoperatively. We will use mixed-effects linear regression to assess relationships between potential prognostic factors and our primary and secondary outcome measures-the Western Ontario Rotator Cuff Index; the Constant-Murley Score; the Subjective Shoulder Value; Maximal Pain (Numeric Rating Scale); and Quality of Life (European Quality of Life, 5 dimensions, 5 levels). Potential prognostic factors include: four psychosocial variables; pain catastrophising, perceived stress, injury perceptions and patients' expectations for RCR; sleep; and four factors related to central pain processing (central sensitisation inventory, temporal summation, cold hyperalgesia and pressure pain threshold). Intercorrelations will be assessed to determine the strength of relationships between all potential prognostic indicators.Our aim is to explore whether modifiable psychosocial factors, sleep-related variables and altered central pain processing are associated with outcomes pre-RCR and post-RCR and to identify them as potential prognostic factors. ETHICS AND DISSEMINATION: The results of the study will be disseminated at conferences such as the European Pain Congress. One or more manuscripts will be published in a peer-reviewed SCI-ranked journal. Findings will be reported in accordance with the STROBE statement and PROGRESS framework. Ethical approval is granted by the Ethical commission of Canton of Zurich, Switzerland, No: ID_2018-02089 TRIAL REGISTRATION NUMBER: NCT04946149.

The investigation of acute effects of fascial release technique in patients with arthroscopic rotator cuff repair: A randomized controlled trial.

BACKGROUND: Fascial release technique is used for releasing fascial tissue to decrease pain, to increase range of motion, and to improve functional level. OBJECTIVE: To investigate the acute effects of fascial release technique on pain, range of motion, upper extremity functional level, and fear of movement in individuals with arthroscopic rotator cuff repair. METHODS: Thirty volunteers with an arthroscopic rotator cuff repair were included in the study. The individuals were randomly divided into two groups. One group received only conventional physiotherapy including hot pack, interferential current, and exercise program, while the fascial release technique was applied to the other group in addition to the conventional physiotherapy program for 2 weeks with 2 sessions per week. Individuals were assessed for pain intensity, range of motion, functional level, fear of movement before and after treatment, and satisfaction level after treatment. RESULTS: Demographic and clinical characteristics of the groups were similar (p > 0.05). Both groups showed improvement in pain, range of motion, and upper extremity functions (p < 0.05). Improvements in the treatment group were better than the conventional physiotherapy group (p < 0.05). Fear of movement was significantly decreased in the treatment group (p < 0.05). Both groups were similar in terms of satisfaction level (p > 0.05). CONCLUSION: Fascial release technique is acutely effective on the pain, joint range of motion and upper extremity functions in the treatment of individuals with arthroscopic rotator cuff repair and more successful results can be obtained by including it in the early rehabilitation program after arthroscopic rotator cuff surgery.

Effectiveness of Ultrasound-Guided Corticosteroid Injections, Prolotherapy, and Exercise Therapy on Partial-Thickness Supraspinatus Tears.

CONTEXT: To investigate the effects of steroid injection (STE), prolotherapy (PRO), and exercise therapy in the treatment of partial tears of the supraspinatus. DESIGN: A retrospective cohort study. METHODS: A total of 64 patients with clinically and radiologically diagnosed partial-thickness supraspinatus tear who received either a cortisone injection (STE), dextrose PRO, or physical therapy combined with home-based exercise therapy were included. Main outcome measures were patients' visual analog scale scores, Western Ontario Rotator Cuff (WORC) Index scores, and the Shoulder Pain and Disability Index scores at the baseline, 3 weeks, and 3 months. RESULTS: The effect of group, time, and group-time interaction on visual analog scale, WORC, and Shoulder Pain and Disability Index scores was statistically significant (P < .001). Visual analog scale and Shoulder Pain and Disability Index scores were the lowest in the STE group at week 3, and the lowest in the PRO group at month 3 (P < .001). WORC scores of the STE group were the highest at week 3 (P < .001). At month 3, WORC scores of STE and PRO groups were similar (P = .089), but significantly higher than exercise therapy. CONCLUSIONS: Corticosteroids provide a fast pain-relieving effect and improvement in function in partial-thickness rotator cuff tears, but these effects diminish over time, whereas PRO provides a long-lasting effect.

Prevalence of sport injuries in Olympic combat sports: a cross-sectional study examining one Olympic period.

BACKGROUND: Due to full contact impacts in combat sports, the risk of injuries is elevated. The aim of this study is to report severe injuries among athletes in Olympic combat sports. Specific injury types, time loss, and the performance level after injury are examined. METHODS: Survey to investigate injuries in Olympic combat sports during the time period from 2012-2016. Reported injuries were analyzed by anatomical location, injury type, gender, time loss, and performance level. RESULTS: The three injuries resulting in the longest time loss (ACL rupture: judo= 37 weeks; karate = 49 weeks; shoulder dislocation: wrestling = 41 weeks; shoulder rotator cuff injury: wrestling = 32 weeks) also accounted for the largest proportion of athletes with career-ending injuries (ACL rupture: judo = 28%; karate = 67%; shoulder dislocation: wrestling = 40%; shoulder rotator cuff injury: wrestling = 50%). Taekwondo and fencing had the shortest time loss (<12 weeks) among all combat sports. More injuries occurred during training (58%) as compared to competition (42%). Injury prevalence of competitive athletes was significantly higher as compared to recreational athletes. Male athletes suffered significantly more anterior cruciate ligament injuries (72% vs. 56%; P<0.05), unspecific shoulder injuries (89% vs. 47%; P<0.01), and elbow ligament injuries (57% vs. 30%; P<0.05) during training. CONCLUSIONS: The study shows that there are important differences between "punching and kicking" and "throwing" martial arts in terms of specific injury types. In judo and wrestling, the injuries are more likely to affect the joints (knee and shoulder). Therefore, injury prevention these sports should focus on strength training of the muscles surrounding the joints and on defensive reactionary movements to avoid dangerous biomechanical joint angles. In "punching and kicking" sports, injuries of the hands and feet, due to the large impact forces of strikes and kicks, could be reduced by improved protective equipment on hands and feet.

Does vitamin C supplementation improve rotator cuff healing? A preliminary study.

PURPOSE: One of the complications after rotator cuff repair is a tendon non-healing. It has already been posited in the literature that vitamin C (VC) promotes tendon healing through its antioxidant properties and its role as a cofactor in collagen synthesis. The aim of this study was to evaluate the effect of postoperative VC supplementation on the tendon healing following repair. METHODS: This randomized monocentric prospective study included 98 patients who underwent arthroscopic rotator cuff repair in 1-year period and follow-up ultrasound 6 months postoperatively. The cohort was divided into two groups: the VC+ group (500 mg/day PO for 45 days postoperatively) and the VC- group (no supplementation). The evaluation criterion was tendon healing at 6 months postoperatively according to the Sugaya ultrasound classification. Preoperative and postoperative clinical evaluations were based on active mobilities, the Constant score and the subjective shoulder value. RESULTS: There was no difference in term of postoperative outcomes between the two groups. At an average follow-up of 6.3 months, the non-healing rate in the overall population was 17%. This rate was higher in VC- compared to VC+, respectively, 23% vs. 11%), p = 0.2. CONCLUSION: This study showed a trend to improve tendon healing after rotator cuff repair with VC supplementation. However, a prospective study with a larger patient population should be conducted to confirm this finding.

Orthobiologics: Diagnosis and Treatment of Common Tendinopathies.

Orthobiologics, including platelet-rich plasma, prolotherapy, and mesenchymal stem cells, are seeing increasing use in the treatment of osteoarthritis (OA), muscle injury, and tendinopathy. This article reviews the biology and applications of orthobiologics in tendons, muscles, and joints, and focuses on platelet-rich plasma (PRP). Clinical evidence-based literature related to the use of PRP in the treatment of rotator cuff injury, lateral epicondylosis, Achilles tendinopathy, plantar fasciitis, knee OA, and acute muscle injury are discussed.