LINKÖPING UNIVERSITY MEDICAL DISSERTATIONS No. 1312 Treatment of Subacromial Pain and Rotator Cuff Tears Hanna Björnsson Hallgren Division of Orthopaedic Surgery Department of Clinical and Experimental Medicine Faculty of Health Sciences Linköping University Sweden Linköping 2012 © Hanna Björnsson Hallgren 2012 Cover by Hanna Björnsson Hallgren, Gustaf Hallgren and Lars Adolfsson Published papers are reprinted with permission from the publisher. Printed by LiU-Tryck, Linköping, Sweden, 2012 ISBN 978-91-7519-862-0 ISSN 0345-0082 To Gustaf, Oscar, Emmy and my parents “If I have seen further than others, it is by standing upon the shoulders of giants” - Isaac Newton CONTENTS 1 LIST OF STUDIES .......................................................................................................... 9 2 ABSTRACT .................................................................................................................... 10 3 SVENSK SAMMANFATTNING (ABSTRACT IN SWEDISH) ..................................... 11 4 ABBREVIATIONS ......................................................................................................... 12 5 INTRODUCTION ........................................................................................................ 13 6 BACKGROUND ........................................................................................................... 14 6.1 Anatomy of the shoulder .............................................................................................................. 14 6.1.1 Glenohumeral joint .................................................................................................................................................. 14 6.1.2 Scapula ........................................................................................................................................................................ 15 6.1.3 Acromioclavicular joint ........................................................................................................................................... 16 6.1.4 Bursae ......................................................................................................................................................................... 17 6.1.5 Deltoid muscle .......................................................................................................................................................... 17 6.1.6 Rotator cuff ................................................................................................................................................................ 17 6.1.7 Long head of biceps tendon ................................................................................................................................... 19 6.2 Subacromial pain and pathology .................................................................................................. 20 6.2.1 Extrinsic mechanisms of subacromial pain ......................................................................................................... 21 6.2.2 Intrinsic mechanisms of subacromial pain ........................................................................................................... 22 6.3 Rotator cuff tears ........................................................................................................................... 24 6.3.1 Acute rotator cuff tear ........................................................................................................................................... 25 6.3.2 Degenerative rotator cuff tear .............................................................................................................................. 25 6.3.3 Partial-thickness tears ............................................................................................................................................. 26 6.3.4 Full-thickness tears ................................................................................................................................................... 27 7 AIMS OF THIS THESIS ................................................................................................ 31 8 PARTICIPANTS ............................................................................................................ 32 8.1 Patients and control participants ................................................................................................. 32 9 METHODS ................................................................................................................... 35 9.1 Outcome assessments ................................................................................................................... 35 9.1.1 Constant-Murley score ........................................................................................................................................... 35 9.1.2 Disability of the Arm, Shoulder and Hand ......................................................................................................... 35 9.1.3 The Western Ontario Rotator Cuff Index (WORC) ...................................................................................... 36 9.1.4 Visual Analogue Scale .............................................................................................................................................. 36 9.1.5 EuroQol Instrument ................................................................................................................................................ 37 9.1.6 Patients Global Impression of Change ................................................................................................................ 37 9.1.7 Hospital Anxiety and Depression scale ............................................................................................................... 37 9.2 Imaging modalities ........................................................................................................................ 37 9.2.1 Radiology .................................................................................................................................................................... 37 9.2.2 Ultrasound ................................................................................................................................................................. 38 9.3 Clinical assessment ........................................................................................................................ 40 9.4 Surgical procedures ....................................................................................................................... 42 9.4.1 Arthroscopic subacromial decompression ......................................................................................................... 42 9.4.2 Rotator cuff repair ................................................................................................................................................... 43 9.5 Physiotherapy interventions ......................................................................................................... 45 9.5.1 Specific exercise programme ................................................................................................................................. 45 9.5.2 Control exercise programme ................................................................................................................................ 45 9.5.3 Rehabilitation after rotator cuff repair and ASD .............................................................................................. 45 9.5.4 Rehabilitation after ASD ......................................................................................................................................... 45 9.6 Laboratory methods ...................................................................................................................... 46 9.6.1 Enzyme-linked Immunosorbent Assay (ELISA) .................................................................................................. 46 9.6.2 Luminex ...................................................................................................................................................................... 46 10 STATISTICAL METHODS ........................................................................................... 48 11 RESULTS ....................................................................................................................... 49 11.1 Study I ............................................................................................................................................ 49 11.1.1 Structural outcome ................................................................................................................................................ 49 11.1.2 Clinical outcome .................................................................................................................................................... 49 11.2 Study II ........................................................................................................................................... 50 11.2.1 Structural outcome ................................................................................................................................................ 50 11.2.2 Clinical outcome .................................................................................................................................................... 51 11.3 Study III .........................................................................................................................................