Despite their frequency and related functional impairment, the aetiology and pathogenesis of rotator cuff tears always create intense debate. The first speaker was Dr Umile Giuseppe Longo, Trauma and Orthopaedic Surgeon at the Campus Biomedico University, Rome, who discussed the Physiopathology of Rotator Cuff Disease. He explained: “It is well accepted that multiple factors contribute to tendon tears. Extrinsic factors are anatomic variables, such as acromial morphologic characteristics, os acromiale and acromial spurs that compress tendons by bony impingement or direct pressure from the surrounding soft tissue. Intrinsic factors arise from the tendon itself, because of tensile overload, aging, or microvascular supply, traumatisms, or degeneration.” Dr Longo outlined how little information is available from a cellular and molecular point of view, but he believes that understanding the mechanism of rotator cuff pathology would facilitate the rationale for therapeutic interventions, by guiding the design, selection and implementation of treatment strategies, such as biologic modulation and preventive measures.
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| Above: Dr Umile Giuseppe Longo, Professor Nicola Maffulli, Mr Andrew Wallace, Mr Peter Reilly |
Partial and full rotator cuff tears were discussed by leading UK experts, Mr Peter Reilly Shoulder and Elbow Surgeon at St. Mary’s Hospital and Honorary Senior Lecturer Imperial College, London and Mr Andrew Wallace, surgeon at the Shoulder Unit, Hospital of St John & St Elizabeth. Mr Reilly pointed out that partial thickness tears of the rotator cuff were common but whilst many may be asymptomatic, some can cause symptoms, particularly pain and loss of function. He believes that there is a strong role for conservative treatment in these cases, but that minority surgical intervention can be necessary to alleviate symptoms.
Rotator cuff disease and pathology of the tendon of the long head of the biceps (LHB) was covered by Dr Longo who said tendinopathy, rupture, SLAP lesions, pulley tears and tendon instability are important causes of shoulder pain. Conservative management of symptomatic LHB tendinopathy (rest, non-steroidal anti-inflammatory drugs, corticosteroid injections and physical therapy) is commonly accepted as the first-line of treatment. Biceps tenotomy and tenodesis are the most common surgical procedures to manage both isolated LHB pathology and biceps-glenoid complex tears combined with rotator cuff tears. However, controversy persists about the superiority of one of them because there is no evidence of significant differences in functional scores or patient satisfaction between the two techniques.
The final speaker of the morning’s session was Prof Nicola Maffulli, Centre Lead and Professor of Sports and Exercise Medicine at Barts and the London School of Medicine and Dentistry. Prof Maffulli, who chaired the meeting, considered the case for using Autologous Platelet-Rich Plasma (PRP) in the shoulder. PRP, which is thought to speed up the healing process in musculoskeletal injuries, is increasingly used in the musculoskeletal system. Prof Maffulli called for further clinical studies: in his view, evidence to support its use is limited. He said: “The idea behind the use of PRP is that healing processes are regulated by cytokines and growth factors which could locally influence the various cell functions through endocrine, paracrine, autocrine and intracrine mechanisms. There are different methods to prepare PRP and therefore in reality there are several different products available on the market. Each one is likely to have a different biology and, at present, very few randomised controlled trials with appropriate outcome measures and a decent follow-up are available.” He told the delegates that preliminary results from a randomised controlled trial on PRP augmentation for arthroscopic rotator cuff repair undertaken by his team shows no statistically significant difference in total Constant Score when comparing arthroscopic rotator cuff repair with or without PRP at 16 months from the procedure. He concluded that there was also no statistically significant difference in MRI tendon score when comparing arthroscopic rotator cuff repair with or without PRP. “Hence, these preliminary data do not support the use of autologous PRP for augmentation of a rotator cuff repair to improve the healing of rotator cuff tears. We prompt researchers to undertake appropriately powered level I studies with adequate and relevant outcome measures and clinically appropriate follow up.”
The afternoon’s session on Exercise Prescription was developed and opened by Dr Christopher Hughes, a Specialist in Sport and Exercise Medicine, General Practitioner and Associate Editor of the Clinical Journal of Sport Medicine. He said: “We have become an increasingly sedentary population and physical inactivity is increasingly being recognised as an important independent risk factor for morbidity and mortality in the general population.” He presented the evidence for efficacy of exercise as a therapeutic intervention for primary, secondary and tertiary disease prevention. Dr Hughes also took the opportunity to discuss Prescription and Recommendation for exercise, and encouraged the audience to support the ‘Exercise Is Medicine’ initiative’ (www.exerciseismedicine.org) co-ordinated by the American College of Sports Medicine (ACSM) which is calling on healthcare professionals, schools and communities to promote physical activity as an essential part of their lifestyle. Later in the afternoon, Dr John Rogers, a GP who specialises in Sports & Exercise Medicine and a medical officer for UK Athletics went through the ACSM Guidelines for exercise prescription.
‘Health Behaviour Change and Motivational Interviewing’ was presented by Dr Jeff Breckon a BPS chartered sport and exercise psychologist and chief assessor for the Qualification in Sport and Exercise Psychology (QSEP). He explained how motivational interviewing “is a person-centred psychotherapeutic approach for resolving ambivalence and promoting positive change by eliciting and strengthening the person’s own motivation.” His workshop presentation examined its application in the context of physical activity and provided both a theoretical review and an overview of the empirical evidence. Dr Breckon was trained in MI as a trainer by Miller and Rollnick and is a Reader in Exercise Psychology at Sheffield Hallam University.
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| Above: Dr John Rogers, Professor Nicola Maffulli, Dr Jeff Breckon, Dr Steph Hemmings, Dr Christopher Hughes |
Exercise Prescription for Children was covered by Dr Steph Hemmings, Research Assistant at Institute of Health Sciences Education at Barts and The London. Her research interests include the role of maturation in the development of physiological characteristics of elite young athletes. She said: “The current obesity epidemic and concomitant decreasing activity levels of children and adolescents has led to expert committees from the world over developing physical activity guidelines for young people.” However, as those guidelines have not been based on strong scientific or epidemiologic evidence, she said there is marginal evidence that physical activity during youth is directly beneficial for health. Based on this, she argued, physical activity guidelines should focus on other aspects than possible long-term health benefits.
One sports doctor who attended the meeting at Chandos House said: “The training day on rotator cuff tears and exercise prescriptions was the second CSEM-DJO Education Meeting that I had attended. The training days are aimed at those health care professionals with an interest in sports medicine. The learning was lecture based, with a traditional format typically starting with pathophysiology and epidemiology, through to diagnosis and management.
“I thoroughly enjoyed the presentations and was impressed again by the quality of the speakers, all of whom are experts in their specialisations, and who are able to blend primary research and literature reviews with their own experience. The use of video footage, especially of operative procedures, was particularly informative. Prof Maffulli, who hosts the sessions, actively promotes professional discussions which provide further learning opportunities. Overall, I have found the training days to be a very welcome and useful addition to my CPD.”
The next meetings are 21st October 2011 (Women’s Football and Women’s Sport) and 9th December 2011 (Foot and Ankle plus Core Stability). For a booking form visit: www.djoglobal.eu/en_UK/DJO_Education_Events.html or email Barry Hill at barryghill@hotmail.com
