liu.seSearch for publications in DiVA
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Treatment of subacromial pain and rotator cuff tears
Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics. Linköping University, Faculty of Health Sciences.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Shoulder pain is very common, affecting 14-21 % of the population at some time during their lifetime. The aims of this thesis were to improve the understanding of various aspects concerning the pathogenesis and treatment of subacromial pain and rotator cuff tears. Patients and healthy individuals were examined and compared in five studies:

Study I) Seventy patients were retrospectively examined, clinically and with ultrasound, 15 years after arthroscopic subacromial decompression. All patients had an intact rotator cuff at surgery. Ultrasound showed significantly fewer rotator cuff tears compared to the prevalence of asymptomatic tears reported in the literature for the same age group. This indicates that arthroscopic subacromial decompression might protect the rotator cuff.

Study II) Forty-two patients were retrospectively examined, clinically and with ultrasound, 39 months (mean) after an acute rotator cuff repair. All patients had pseudoparalysis after trauma, a full thickness tear and no previous history of shoulder symptoms. A delay in surgical treatment of three months and the number of tendons injured did not affect the outcome. Age affected outcome negatively.

Study III) Plasma samples from 17 patients with cuff tears and 16 plasma samples from healthy age- and gender-matched controls were collected and analysed regarding the levels of matrix metalloproteinases and their inhibitors, TIMP1-4. Elevated levels of TIMP-1 were found in the patients with cuff tears compared to controls. Higher levels of TIMP-1, TIMP-3 and MMP-9 were found in patients with full-thickness tears compared to patients with partial-thickness tears.

Study IV) Ninety-seven patients with longstanding subacromial pain, on the waiting-list for arthroscopic subacromial decompression, were prospectively randomised to specific shoulder exercises or control exercises for three months. Thereafter they were clinically examined and asked if they still wanted surgery. The specific shoulder exercises focusing on eccentric exercise for the rotator cuff and scapula stabilisers were found to be effective in reducing subacromial pain and improving shoulder function, thereby reducing the need for surgery.

Study V) All patients including those operated, in Study IV were re-examined after one year using clinical assessment scores. The option of surgery was continuously available up to the one-year follow-up. Ultrasound and radiological examinations performed at inclusion were analysed in relation to the choice of surgery. The positive effects of the specific exercise programme were maintained after one year and significantly fewer patients in this group chose surgery. Surgery was significantly more often chosen by patients who had a low baseline shoulder score, and/or a full thickness rotator cuff tear.  All patients showed significant improvement in the clinical scores one year after inclusion or one year after surgery.

These results support the concept that subacromial pain has a multifactorial aetiology and that the first line of treatment should be specific shoulder exercises. When conservative treatment fails, an acceptable result can be achieved with arthroscopic subacromial decompression. The rotator cuff status is important to consider when treating and studying these patients.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. , 90 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1312
Keyword [en]
Shoulder, rotator cuff tear, ultrasound, surgery, exercises
National Category
Clinical Medicine
Identifiers
URN: urn:nbn:se:liu:diva-82094ISBN: 978-91-7519-862-0 (print)OAI: oai:DiVA.org:liu-82094DiVA: diva2:557934
Public defence
2012-10-26, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2012-10-02 Created: 2012-09-28 Last updated: 2013-03-15Bibliographically approved
List of papers
1. Fewer rotator cuff tears fifteen years after arthroscopic subacromial decompression
Open this publication in new window or tab >>Fewer rotator cuff tears fifteen years after arthroscopic subacromial decompression
2010 (English)In: Journal of shoulder and elbow surgery, ISSN 1058-2746, E-ISSN 1532-6500, Vol. 19, no 1, 111-115 p.Article in journal (Refereed) Published
Abstract [en]

Background: A successful clinical result is reported in 75% to 85% of impingement patients after arthroscopic subacromial decompression. The result is maintained over time, but few studies have investigated the integrity of the rotator cuff in these patients. Materials and methods: Using ultrasonography, we examined the integrity of the rotator cuff in 70 patients 15 years after arthroscopic subacromial decompression. All patients had an intact rotator cuff at the index procedure. Results: Tendons were still intact in 57 patients (82%), 10 (14%) had partial-thickness tears, and 3 (4%) had full-thickness tears. Discussion: The total number of 18% tears (partial and full thickness) in this study, including patients clinically diagnosed with subacromial impingement at a mean age of 60 years, is unexpectedly low compared with 40% degenerative tears reported in asymptomatic adults of the same age. Conclusion: Arthroscopic subacromial decompression seems to reduce the prevalence of rotator cuff tears in impingement patients. This appears attributable to elimination of extrinsic factors such as mechanical wear and bursitis. The potential effect of surgery on intrinsic cuff degeneration is unknown, but intrinsic factors may explain tears still developing despite decompression.

Place, publisher, year, edition, pages
Elsevier Science B.V., Amsterdam, 2010
Keyword
Impingement, long-term follow up, arthroscopic subacromial decompression, rotator cuff tear, rotator cuff degeneration, ultrasonography
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-56522 (URN)10.1016/j.jse.2009.04.014 (DOI)000277367800020 ()19556145 (PubMedID)
Available from: 2010-05-21 Created: 2010-05-21 Last updated: 2017-12-12
2. The influence of age, delay of repair, and tendon involvement in acute rotator cuff tears Structural and clinical outcomes after repair of 42 shoulders
Open this publication in new window or tab >>The influence of age, delay of repair, and tendon involvement in acute rotator cuff tears Structural and clinical outcomes after repair of 42 shoulders
2011 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 82, no 2, 187-192 p.Article in journal (Refereed) Published
Abstract [en]

Background and purpose Few authors have considered the outcome after acute traumatic rotator cuff tears in previously asymptomatic patients. We investigated whether delay of surgery, age at repair, and the number of cuff tendons involved affect the structural and clinical outcome. Patients and methods 42 patients with pseudoparalysis after trauma and no previous history of shoulder symptoms were included. A full-thickness tear in at least 1 of the rotator cuff tendons was diagnosed in all patients. Mean time to surgery was 38 (6-91) days. Follow-up at a mean of 39 (12-108) months after surgery included ultrasound, plain radiographs, Constant-Murley score, DASH score, and western Ontario rotator cuff (WORC) score. Results At follow-up, 4 patients had a full-thickness tear and 9 had a partial-thickness tear in the repaired shoulder. No correlation between the structural or clinical outcome and the time to repair within 3 months was found. The patients with a tendon defect at follow-up had a statistically significantly lower Constant-Murley score and WORC index in the injured shoulder and were significantly older than those with intact tendons. The outcomes were similar irrespective of the number of tendons repaired. Interpretation A delay of 3 months to repair had no effect on outcome. The patients with cuff defects at follow-up were older and they had a worse clinical outcome. Multi-tendon injury did not generate worse outcomes than single-tendon tears at follow-up.

Place, publisher, year, edition, pages
Informa Healthcare, 2011
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67743 (URN)10.3109/17453674.2011.566144 (DOI)000289170900011 ()
Available from: 2013-04-11 Created: 2011-04-26 Last updated: 2017-12-11Bibliographically approved
3. Elevated plasma levels of TIMP-1 in patients with rotator cuff tear
Open this publication in new window or tab >>Elevated plasma levels of TIMP-1 in patients with rotator cuff tear
2012 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 83, no 5, 523-528 p.Article in journal (Refereed) Published
Abstract [en]

Background and purpose:Extracellular matrix remodelling is altered in rotator cuff tears,16partly due to altered expression of matrix metalloproteinases (MMPs) and their inhibitors. It is unclear if this altered expression can be traced as changes in plasma protein levels.

The purposes were to measure the plasma level of MMPs and their tissue inhibitors (TIMPs) inpatients with rotator cuff tears and to relate changes in the pattern of MMP and TIMP levels with the extent of the rotator cuff tear.

Methods: Blood samples were collected from 17 patients, median 61 (range 39-77) years, with sonographically verified rotator cuff tears (partial- or full-thickness). These were compared with 16 gender and age matched control persons with sonographically intact rotator cuffs. Plasma levels of MMPs and TIMPs were measured simultaneously using Luminex technology and ELISA.

Results: The plasma level of TIMP-1 was elevated in patients with rotator cuff tears, especially in those with full-thickness tears. The levels of TIMP-1, TIMP-3 and MMP-9 were higher in patients with full-thickness tears compared to those with partial-thickness tears, but only TIMP-1 was different from controls.

Interpretation: The observed elevation of TIMP-1 in plasma might reflect local pathological processes in or around the rotator cuff, or a genetic predisposition in these patients. That levels of TIMP-1 and certain MMP´s was found to differ between partial and full thickness tears may reflect the extent of the lesion or different aetiology and pathomechanisms.

Keyword
Rotator cuff tear, matrix metalloproteinases, ultrasound, degeneration
National Category
Orthopedics
Identifiers
urn:nbn:se:liu:diva-82116 (URN)10.3109/17453674.2012.736174 (DOI)000310015700015 ()
Available from: 2012-10-01 Created: 2012-10-01 Last updated: 2017-12-07Bibliographically approved
4. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study
Open this publication in new window or tab >>Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study
Show others...
2012 (English)In: BMJ. British Medical Journal (International Ed.), ISSN 0959-8146, E-ISSN 0959-535X, Vol. 344, e787- p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To evaluate if a specific exercise strategy, targeting the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression.

DESIGN: Randomised, participant and single assessor blinded, controlled study.

SETTING: Department of orthopaedics in a Swedish university hospital.

PARTICIPANTS: 102 patients with long standing (over six months) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed, recruited through orthopaedic specialists.

INTERVENTIONS: The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific movement exercises for the neck and shoulder. Patients in both groups received five to six individual guided treatment sessions during 12 weeks. In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks.

MAIN OUTCOME MEASURES: The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain. Secondary outcomes were patients' global impression of change because of treatment and decision regarding surgery.

RESULTS: Most (97, 95%) participants completed the 12 week study. There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group (24 points (95% confidence interval 19 to 28.0) v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). Significantly more patients in the specific exercise group reported successful outcome (defined as large improvement or recovered) in the patients' global assessment of change because of treatment: 69% (35/51) v 24% (11/46); odds ratio 7.6, 3.1 to 18.9; P<0.001. A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery: 20% (10/51) v 63% (29/46); odds ratio 7.7, 3.1 to 19.4; P<0.001).

CONCLUSION: A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study.

TRIAL REGISTRATION: Clinical trials NCT01037673.

Place, publisher, year, edition, pages
BMJ Publishing Group, 2012
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-75436 (URN)10.1136/bmj.e787 (DOI)000300881600009 ()22349588 (PubMedID)
Note

funding agencies|physiotherapy orthopaedic department of the University Hospital in Linkoping, Sweden||research council in the south east of Sweden (FORSS)||

Available from: 2012-03-01 Created: 2012-03-01 Last updated: 2017-12-07
5. A specific exercise strategy for patients with subacromial pain significantly reduced the need for surgery: one-year results of a randomised controlled study
Open this publication in new window or tab >>A specific exercise strategy for patients with subacromial pain significantly reduced the need for surgery: one-year results of a randomised controlled study
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: A specific exercise strategy focusing on eccentric exercises, for treating sbacromial pain has in a previous study been found effective at three-month followup.

The aim of the present study was to investigate if the positive short-term results were maintained after one year. A further aim was to examine if baseline clinical score, rotator cuff status and radiological findings influenced the choice of surgery.

Methods: 97 patients on the waiting-list for arthroscopic subacromial decompression were in the first study randomized to a three-month specific exercise strategy or unspecific exercises (controls). Patients were examined with radiology, ultrasound and assessed with clinical scores: primary Constant-Murley score. After three months of exercises the patients were asked if they still wanted surgery and this option was available until the one-year follow-up. All patients were re-assessed with clinical scores one year after inclusion or one year after surgical intervention and the number of patients that had chosen surgery in each group was compared. The baseline Constant-Murley score and the status of subacromial structures were analyzed in relation to patient's choice of surgery.

Results: The positive short-term effect (improved shoulder function and pain) of the specific exercises was maintained after one-year. Compared to the three-month followup all patients had improved significantly (p < 0.0001) in Constant-Murley score. The number of patients that had chosen surgery in the control exercise group (63%) was significantly larger (p < 0.0001) than in the specific exercise group (24%). Patients that had chosen surgery had a significantly lower baseline Constant-Murley score and significantly more often a full-thickness tear. Patients with partial-thickness tears did not differ from those with intact cuff tendons.

Conclusions: The positive short-term outcomes after specific exercises were maintained after one year and reduced the need of surgery significantly more than the unspecific control exercises. Patients with low baseline clinical score and/or a full-thickness tear significantly more often chose surgery.

Level of evidence: I, Randomized controlled trail according to Consort statement.

Keyword
Subacromial pain patients, exercises, eccentric, rotator cuff tear
National Category
Orthopedics Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-82118 (URN)
Note

The original title of this article was: A specific exercise strategy reduces the need of surgery in subacromial pain patients: one-year results after a randomised controlled study. The title was changed before submitted to the journal.

On the day of the defence day the status of this article was Manuscript                        

Available from: 2012-10-01 Created: 2012-10-01 Last updated: 2014-06-24Bibliographically approved

Open Access in DiVA

Treatment of subacromial pain and rotator cuff tears(1006 kB)6143 downloads
File information
File name FULLTEXT01.pdfFile size 1006 kBChecksum SHA-512
8827c9900c14d859e791c7c0893b553f4684ae848afea0bed3679ea81acfd222e403ccd23b5d4ccf57cf347a9d10dfa9dafdf092e9998c2ae3b75b669de1348b
Type fulltextMimetype application/pdf
omslag(535 kB)131 downloads
File information
File name COVER01.pdfFile size 535 kBChecksum SHA-512
c86df3855ade51cb2de1650a99983308498ed39c568c6e17e1bb022147b448fa00b81381d9cae53b988e87c58480641dcb6673c0f95e8f00cb6bedace753e444
Type coverMimetype application/pdf

Authority records BETA

Björnsson Hallgren, Hanna Cecilia

Search in DiVA

By author/editor
Björnsson Hallgren, Hanna Cecilia
By organisation
OrthopaedicsFaculty of Health Sciences
Clinical Medicine

Search outside of DiVA

GoogleGoogle Scholar
Total: 6143 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 3534 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf