Curr Rheumatol Rep (2015) 17:476

DOI 10.1007/s11926-014-0476-x

OSTEOARTHRITIS (MB GOLDRING, SECTION EDITOR)

Rotator Cuff Biology and Biomechanics: a Review of Normal

and Pathological Conditions
Julianne Huegel & Alexis A. Williams & Louis J. Soslowsky

# Springer Science+Business Media New York 2014

Abstract The glenohumeral joint is a complex anatomic presence of a large network of ligaments, tendons, and other
structure commonly affected by injury such as tendinopathy connective tissue elements to provide stability and allow
and rotator cuff tears. This review presents an up-to-date functional movement. However, these tissues also have a
overview of research on tendon biology and structure, shoul- propensity for injuries and degenerative conditions due to
der joint motion and stability, tendon healing, and current and acute trauma or chronic overuse. Recent studies have investi-
potential future repair strategies. Recent studies have provided gated shoulder biomechanics, interactions between tissues
information demonstrating the serious impact on uninjured within the joint, the responses of these tissues to stress, and
tissues after a rotator cuff tear or other cause of altered shoul- the repair of the rotator cuff tendon after injury. Clinical
der joint mechanics. Another major focus of recent research is studies, cadaver studies, and animal models offer new clues
biological augmentation of rotator cuff repair with the goal of regarding the biology, biomechanics, and pathology of shoul-
successfully reinstating normal tendon-to-bone structure. To der injury, influencing the development of clinical solutions to
effectively treat shoulder pathologies, clinicians need to un- musculoskeletal problems.
derstand normal tendon biology, the healing process and
environment, and whole shoulder stability and function.
Anatomy and Background
Keywords Rotator cuff . Tendon . Shoulder . Biomechanics .
Orthopedic surgery . Overuse injury . Tendinopathy The Shoulder Girdle

The shoulder is formed by connections between the scapula,

the clavicle, and the humerus [1]. Scapular landmarks include
Introduction the coracoid process superiorly, the glenoid cavity laterally,
the subscapular fossa anteriorly, and the supraspinous and
The complex structure of the glenohumeral joint confers the infraspinous fossae divided by the scapular spine posteriorly.
shoulder with the most mobility of any major joint in the The scapular spine extends laterally to a free end, the
human body. This characteristic is primarily due to a limited acromion, which articulates with the lateral end of the clavicle.
interface between the humerus and the scapula, requiring the On the anterior proximal humerus, from medial to lateral, are
the lesser tuberosity, the bicipital groove, and the greater
This article is part of the Topical Collection on Osteoarthritis
tuberosity.
J. Huegel : A. A. Williams : L. J. Soslowsky (*) The medial side of the humeral head is composed of
McKay Orthopaedic Research Laboratory, Department of
articular cartilage, which is integral to providing a smooth
Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall
3450 Hamilton Walk, Philadelphia, PA 19104, USA gliding surface between the humeral head and the glenoid
e-mail: soslowsk@upenn.edu fossa [2]. It is a solid matrix composed predominantly of type
J. Huegel II collagen and the proteoglycan (PG) aggrecan that can be
e-mail: jhuegel@mail.med.upenn.edu divided into zones from the articular surface to the
A. A. Williams subchondral bone. Most superficially, the densely packed
e-mail: williams.alexis1@gmail.com collagen is oriented parallel to the articular surface and PG
476, Page 2 of 9 Curr Rheumatol Rep (2015) 17:476

content is low. In the middle zone, fibers are more randomly third largest, extends from the lateral aspect of the bicipital
oriented and PG content is the highest. The deep zone contains groove to this bare area. The overlap zone between the
large collagen fibers oriented perpendicular to the subchondral supraspinatus and infraspinatus is located just anterior to the
bone and low PG levels. tip of the bare area and serves as an arthroscopic landmark.
The supraspinatus, however, inserts closer to the articular
Glenohumeral Joint and Ligaments surface. Finally, the teres minor has the smallest insertional
footprint, directly inferior to the infraspinatus.
The glenohumeral (GH) joint is formed by the articulation of The tendon-to-bone insertion site is divided into four
the humeral head with the glenoid cavity. Although the hu- zones: tendon midsubstance, fibrocartilage, calcified
meral head is much larger than the glenoid cavity, their cur- fibrocartilage, and bone, with a gradual and continuous
vatures differ by as little as 1 % [3]. The shape and concavity change in composition [7]. Zone 1, the tendon midsubstance,
of the glenoid fossa may vary between individuals; however, is composed primarily of collagen types I and XII and the PGs
the cavity is typically 5°–7° retroverted relative to the decorin and biglycan and contains spindle-shaped cells. As
mediolateral axis of the scapula [4]. the tendon progresses toward the bony insertion, it takes on a
A variety of ligaments provide support to the shoulder, more fibrocartilaginous form, composed mostly of collagens
including the superior and inferior acromioclavicular (AC) II, IX, and X, and the PG aggrecan and its cells have a rounded
ligaments; the coracoclavicular (CC) ligament; the shape. Collagen orientation also transitions from well aligned
coracohumeral (CH) ligament; the coracoacromial (CA) liga- in zone 1 to randomly oriented in zone 4.
ment; and the superior, middle, and inferior GH ligaments [1]. A five-layer structure has been described at the confluence
The CA ligament acts as the roof of the subscapular space and of the supraspinatus and infraspinatus tendons [5]. Layer 1 is
forms the CA arch along with the acromion and coracoid the most superficial and contains fibers from the CH ligament.
process. The labrum is a band of fibrocartilaginous tissue that In layer 2, fibers come directly from the tendons and are
can vary in shape and attaches around the margin of the parallel and densely packed. Layer 3 corresponds to the gross
glenoid cavity. The articular capsule of the GH joint attaches overlap of the tendons, and the fibers in this layer are more
to the labrum, scapular neck, and anatomical neck of the loosely packed than in layer 2. Layer 4 contains loose con-
humerus. It is stabilized by the GH ligaments anteriorly and nective tissue and thick fibers from the deep extension of the
CH ligament superiorly and also by the CA and AC ligaments. CH ligament. Finally, layer 5 is the true capsular layer with
The inferior portion of the capsule is not reinforced, resulting randomly oriented fibers.
in the axillary recess. There are other adjacent structures in the shoulder that have
an interrelated connection with the rotator cuff. One such
The Rotator Cuff structure is the long head of the biceps tendon (LHBT), which
originates at the supraglenoid tubercle of the scapula. Its
There are four muscles that constitute the rotator cuff [1, 5]. tendon perforates the articular capsule, travels distally in the
The supraspinatus originates from the supraspinous fossa of bicipital groove, and ultimately, inserts on the radial tuberos-
the scapula; its tendon passes through the subscapular space ity. In the bicipital groove, the LHBT is ensheathed by fibers
and inserts on the superior and middle facets of the greater from the supraspinatus and subscapularis tendons [8].
tuberosity. The infraspinatus and teres minor both originate
from the infraspinous fossa and fibrous septum, and their
tendons insert on the middle and inferior facets of the greater
tuberosity, respectively. The subscapularis originates from the Biomechanics of the Glenohumeral Joint
subscapular fossa, and its tendon inserts on the lesser tuber-
osity. The rotator cuff is unique in that its tendons fuse to form General Properties of Tendons and Ligaments
a continuous structure near their insertions. Its bursal surface
is covered by deep extensions from the CH ligament, while its Rotator cuff tendons are characterized by their nonlinear,
articular surface is lined by the joint capsule. viscoelastic, and heterogeneous material properties. As the
The description of an anatomic footprint has aided in primary component of the extracellular matrix (ECM) of both
diagnosing and repairing rotator cuff tears [6]. The the tendon and its insertion, collagen is important to many of
subscapularis has the largest footprint, inserting along the these properties. The hierarchical arrangement of collagen
medial aspect of the bicipital groove. The second largest is molecules, fibrils, and fibers allows several steps of deforma-
that of the infraspinatus; its anterior border overlaps with the tion under axial loading, including uncrimping of wavy fibrils,
posterior border of the supraspinatus insertion. Between the straightening of twisted triple-helical molecules, and eventu-
articular surface and the inferior insertion of the infraspinatus ally molecular uncoiling. These effects provide the tendon
is a gap called the bare area. The supraspinatus insertion, the with significant extensibility and strain hardening [9]. Cyclic
Curr Rheumatol Rep (2015) 17:476 Page 3 of 9, 476

loading induces collagen alignment in the direction of the [19]. Posteriorly, the subscapularis muscle resists subluxation,
force, increasing tendon strength and creating nonlinear stiff- with the CH ligament contributing in neutral rotation [20].
ness in response to strain [10, 11]. Release of the CA ligament to treat impingement causes GH
Components of the rotator cuff have unique anatomies, laxity both anteriorly and inferiorly, indicating its importance
conferring specific mechanical properties and strain distribu- as a static restraint [21].
tions across regions and surfaces. For example, the Anatomical positioning of the rotator cuff muscles and the
supraspinatus tendon consists of anterior and posterior subre- LHBT creates an ideal configuration to actively compress the
gions, with a significantly higher modulus of elasticity occur- humeral head into the cavity of the glenoid [22]. Shoulder
ring in the anterior than the posterior subregion. This helps anatomy also provides the rotator cuff muscles with short
preserve the shape of the tendon during shoulder motion; lever arms, establishing a stable and dynamic fulcrum during
however, dissimilar rates of deformation may play a role in abduction (reviewed by Lugo et al.) [23]. Interestingly, indi-
initiating tears [12]. The inferior GH ligament can also be vidual shoulder anatomy, particularly acromion length and
divided into three anatomical regions with variations in strain glenoid inclination, may predispose a shoulder to either oste-
to failure. The weakest portion is the ligament midsubstance, oarthritis or rotator cuff tears, as the two pathologies occur
suggesting larger strains must occur near the insertion sites together infrequently [24].
[13]. However, this ligament interacts significantly with sur-
rounding capsular tissue and should be evaluated in the con-
text of a single sheet of fibrous tissue rather than discrete Anterior-Posterior Force Balance
regions [14]. Likewise, the complex interactions between each
component of connective tissue should be acknowledged Force couples occur when two opposing muscle groups create
during mechanical analyses. a given moment around a fulcrum. The rotator cuff creates a
force couple around the GH joint, with coordinated activation
Role of Tendons and Ligaments in Glenohumeral Joint and inactivation of agonist and antagonist muscles. The
Motion and Stability anterior-posterior force balance is defined by the subscapularis
anteriorly and infraspinatus posteriorly (Fig. 1). Cadaver stud-
The inherent bony stability of the shoulder is poor, as the ies determined that GH joint motion is not affected as long as
articular surface of the proximal humerus and the glenoid this force balance is intact [25]. Quantitative analysis con-
are mismatched in size. The addition of the fibrocartilaginous firmed that the direction and magnitude of joint reaction forces
labrum in conjunction with the joint capsule and GH liga- were most affected by the integrity of the anterior-posterior
ments aids in shoulder stability. Labral tissue increases the force balance, with no significant change after incomplete or
depth of the glenoid by 50 % and, together with compressive complete tear of the supraspinatus tendon [26]. This dynamic
forces of the rotator cuff, imparts a concave compression on relationship is an important aspect of understanding normal
the humeral head into the glenoid. Maintaining a negative shoulder motion as well as how a disrupted force balance can
intra-articular pressure in a closed system within the capsule play a role in shoulder pathologies, discussed below.
also helps to prevent translation of the humeral head [15, 16].
These soft tissue connections allow for a large range of motion
and define roles for tendons and ligaments as specific active
and passive restraints, respectively, during movement.
Early studies of shoulder stabilization involved dissection
of various connective tissue components in cadavers. At 0° of
abduction, the subscapularis muscle plays the primary stabi-
lizing role; at 45° of abduction, the subscapularis, middle GH
ligament, and a portion of the inferior GH ligament provide
stability; and nearing 90° of abduction, the inferior GH liga-
ment prevents dislocation [17]. Biomechanical loading studies
offer additional information regarding directional stability.
The LHBT provides more than 30 N of anterior stabilization
in neutral rotation, with the subscapularis providing the ma-
jority of the stabilization in external rotation. Ligaments play a
bigger role in stability as they become loaded at higher dis-
placements [18]. The supraspinatus and biceps muscles are
important active stabilizers in inferior stabilization, with the Fig. 1 Transverse plane force couple. The infraspinatus tendon posteri-
inferior GH ligament passively stabilizing in external rotation orly balances against the supraspinatus tendon anteriorly
476, Page 4 of 9 Curr Rheumatol Rep (2015) 17:476

Interaction of Tendons with Adjacent Tissues contacts the CA arch in normal shoulders in both cadaveric
studies and in healthy human subjects [40].
Rotator Cuff Tendon Response to Stress Fatigue damage initiates with isolated changes in micro-
structure and develops into severe matrix disruption and
While tendons and ligaments are important for creating a kinked deformations [42]. This degeneration as well as bio-
stable joint, they are also dynamic tissues that respond to logical changes due to aging or overuse can predispose a
loading and change due to age and use. Tendon tissue adapts tendon to failure. The severity and location of tears within
to mechanical loading via temporary upregulation of metabol- rotator cuff tendons vary considerably, being either full or
ic activity, specifically in collagen expression and synthesis partial thickness and located on either the bursal or articular
regulated by tenocytes experiencing strain [27]. In opposition, side of the tendon. However, partial thickness and bursal side
another response to exercise is an increase in the expression of tears in particular have been shown to induce significant
matrix metalloproteinases, promoting collagen turnover. A pos- localized tendon strain concentrations in regions adjacent to
itive net balance requires a period of rest, without which the the tear, leading to tear propagation [43•].
tendon will undergo continuous loss of collagen [28]. Conse-
quently, the tendon milieu changes significantly in response to Rotator Cuff Tears: Changes in Joint Kinematics
overuse, creating a mechanically inferior connective tissue.
Rotator cuff overuse has been modeled in an established rat As reviewed above, the rotator cuff musculature provides
model in order to study the effects of such chronic use common balanced forces that impart mobility and stability to the GH
in athletes and manual laborers performing repetitive overhead joint. Disruption of this innate force couple results in abnor-
activities. Initial studies demonstrated increased tendon size and mal joint kinematics, as the stable fulcrum for rotation of the
deteriorated mechanical properties after completion of an over- humeral head in the glenoid is lost [44]. Such force changes
use exercise protocol [29]. Rotator cuff tenocytes undergo are dependent on tear size and location. Anterior tears of the
phenotypic change toward chondrocyte-like behavior, with supraspinatus insertion are more likely to be symptomatic and
increased PG expression, glycosaminoglycan accumulation, progress as a result of increased regional strain patterns due to
and upregulated SOX9 [30, 31•]. Significant upregulation of joint force imbalance, potentially causing additional pain and
pro-inflammatory cytokines and apoptotic genes occurs over requiring surgical intervention [45]. However, completely
time as microinjuries develop and accumulate [32, 33]. In- repairing a rotator cuff after a chronic multi-tendon tear can
creased mechanoreceptor expression suggests that propriocep- be challenging due to tendon retraction and stiffening. Instead,
tion or pain is amplified after excessive physical activity [34]. restoring the balance of the anterior-posterior forces by
Together, these changes help define and model the degenera- repairing only the infraspinatus in a supraspinatus-
tive, tendinopathic state of the human rotator cuff. infraspinatus tear may be sufficient to restore shoulder func-
For the human patient, the diagnosis of tendinosis or tion [46].
tendinopathy is characterized by a chronic condition typically
lacking frank inflammation [35]. Characteristic pathological Joint Damage After Rotator Cuff Tears
changes include decreases in tenocyte numbers and more
rounded cell shape, increased apoptosis, increased PG content Disruption of the force balance and normal shoulder stability
and disorganized collagen, and increased adrenergic receptors and motion after loss of tendon function initiates changes in
[36]. Therefore, the terminology and treatment approach for almost all adjacent tissues. Rotator cuff tears are often accom-
an inflammatory condition (tendinitis) is largely unwarranted. panied by tears in the glenoid labrum. Superior humeral head
More recently, the field has also revised the way it defines translation and loading of the LHBT due to decreased stabili-
rotator cuff impingement. Over four decades ago, contact zation cause displacement of the labrum and increased labral
between the rotator cuff tendons and the acromion or the tissue strain [47]. A number of studies utilizing the rat model
undersurface of the AC joint was identified as a primary further investigated these and other changes. Without repair,
causative for rotator cuff disease [37]. Indeed, compressive rotator cuff tears can cause cartilage degeneration in the la-
forces initiate major physiological changes in the tendon, brum, putting it at risk for injury [48•]. Returning to a high
reminiscent of overuse pathology [38]. However, three recent level of activity increases the severity of this damage, signif-
reviews independently found no evidence to correlate tendon icantly decreasing the expression of cartilage matrix proteins
impingement and tendinopathy, particularly that associated such as type II collagen and aggrecan in the glenoid [49].
with aging. There is also no proven correlation between the Articular cartilage of the humeral head also shows surface
shape of the acromion and a positive surgical outcome or irregularities, loss of PGs, and clonal chondrocyte formation
degree of shoulder pain with rotator cuff pathology, suggest- 12 weeks after rotator cuff transection [50]. Mechanical prop-
ing that preventing contact between the two tissues is not the erties of adjacent untorn tendons, including the LHBT and the
most critical treatment [39–41]. In fact, the rotator cuff subscapularis, also deteriorate, becoming stiffer at both the
Curr Rheumatol Rep (2015) 17:476 Page 5 of 9, 476

insertion and the midsubstance [51, 52••]. Functional impair- greater resistance to suture pull through, and increased com-
ment of muscles associated with torn tendons decreases their pression throughout the tendon. Although radiological, clini-
potential to produce normal forces after repair, largely due to cal, and biomechanical data exist supporting its use over
atrophy and fatty infiltration [53•]. Moreover, chronic fibrosis single-row repairs of large and massive tears, statistically
increases muscle stiffness, increasing tension at the repair site significant data are not available for use in repairs of small
and impeding the repair process [54]. Adjacent muscles react and medium tears [67–69]. Following surgery, there is a
in a compensatory way, becoming hypertrophic [55]. Clearly, period of protection that is suggested in order to allow for
normal shoulder stability and motion defined by the rotator optimal healing without sacrificing range of motion (ROM)
cuff are crucial in maintaining the health of the entire shoulder. [70]. Currently, surgeons often recommend 6 weeks of immo-
bilization in a sling, especially in large and massive tears, after
Long Head of the Biceps Tendon Lesions and Tenodesis which active ROM exercises are gradually incorporated with
resistance exercises initiated around 3 months post-repair.
Biceps tendon injuries are associated with rotator cuff tears, Despite optimization of mechanical construct and post-
with increasing damage occurring as tear size increases [56, operative rehabilitation, failure rates range widely from 9 to
57]. The rat model reveals an increase in size of the LHBT of 94 % [71, 72••]. There are a number of factors that have been
up to 220 % after rotator cuff injury, as well as worsening implicated in the failure of cuff repair, including tear size,
mechanical properties over time [58]. Inflammation causes tissue quality, fatty infiltration, age, diabetes, smoking, osteo-
friction between the tendon and the bicipital groove, creating porosis, and duration from onset of symptoms to time of
significant pain. Tenodesis or tenotomy is an extremely suc- surgery [66, 73, 74, 75••, 76]. Of these, the most important
cessful treatment option, with persistent pain occurring with predictors of outcome have been found to be age, tear size,
an incidence of only 0.2 % [59]. Unlike major tendons of the extent of fatty infiltration, muscle atrophy, and amount of
rotator cuff, severing the LHBT does not dramatically alter retraction at the time of surgery [75••, 76].
dynamic GH movement, supporting the use of tenotomy in
conjunction with rotator cuff repair to reduce pain and in- Rotator Cuff Tendon Healing
crease function [60•]. A recent prospective, randomized study
determined no difference in shoulder function, strength, or Rotator cuff tendon healing involves three overlapping stages:
patient satisfaction between the two procedures. However, a inflammatory, fibroblastic, and remodeling, detailed in Table 1
shorter surgical time and faster pain relief for those treated [66, 76]. During these stages, there are complex interactions
with tenotomy may make this technique more advantageous between a variety of tissue growth factors and cells, ultimately
[61•]. Interestingly, detachment of the LHBT in the presence resulting in tissue that is markedly different from that of
of a multi-tendon cuff tear results in improved shoulder func- normal, uninjured tendon. The healing tendon is composed
tion and less joint damage in the rat model, indicating that primarily of collagens I and III, which are more characteristic
early management of biceps pathology may diminish long- of scar tissue. Studies have shown that despite advancements
term effects of rotator cuff tears to adjacent tissues (Fig. 2) in surgical techniques and rehabilitation protocols, the healed
[62•]. Overall, the procedure is gaining popularity and is well tendon fails to recreate the normal transition seen in uninjured
accepted by most patients with high satisfaction levels. tissue. Instead of four zones, a three-layer fibrovascular con-
struct is formed that has significantly less fibrocartilage than
normal. Developing ways to restore the composition and
structure of the normal transition site will be crucial in reduc-
Rotator Cuff Repairs ing the failure rates of rotator cuff repair procedures.tgroup
The growth factors that have been studied include IGF-1,
Current Practice for Rotator Cuff Repairs FGF-2, MMP-3, TIMP, VEGF, TGF-β1, PDGF, CTGF, and
BMP12-13. The exact roles that these factors play, however,
Rotator cuff tears are one of the most common shoulder are still unknown. Tenocytes from irreparable cuff tendons can
injuries, affecting more than 40 % of patients over the age of be stimulated to produce the ECM proteins of a healthy tendon
60 and resulting in 30,000–75,000 repairs performed annually after local delivery of PDGF [77•]. This would suggest that
[63]. The theoretical advantages of arthroscopic repair have not only do cuff tendons have healing capabilities but also that
led to its increased popularity over an open approach. Data this healing environment can be manipulated.
suggest that arthroscopy should be performed for repair of In the rat rotator cuff injury model, TGF-β1, an important
small and medium tears, while for large and massive tears, signaling molecule in remodeling, is localized to the repair
open repairs may result in superior outcomes in some cases tissue and correlates with a peak in cellular activity [78].
[64–66]. Double-row suture anchors, particularly with rip- TGF-β3, which is involved in tissue regeneration, is not
stop fixation, allows for better anatomic footprint coverage, detected at the repair site; however, it has been shown to
476, Page 6 of 9 Curr Rheumatol Rep (2015) 17:476

Fig. 2 Biceps tenotomy prevents

damage to uninjured tendon in the
presence of a rotator cuff tear.
Compared to the group without
tenotomy, the groups with
tenotomy showed a increased
elastic modulus for the lower
subscapularis insertion site and b
increased elastic modulus for the
upper subscapularis
midsubstance. c No significant
change in area was seen at the
insertion site, but d the cross-
sectional area of the lower
subscapularis midsubstance was
decreased within the group that
received tenotomy. Data are
shown as mean+SD. SI
supraspinatus and infraspinatus;
SIB supraspinatus, infraspinatus,
and LHBT; SUB subscapularis.
(Reproduced with permission
from [62•])

improve tendon-to-bone healing after exogenous delivery The Future of Rotator Cuff Repairs: Changing the Healing
[79]. Matrix protein expression also fluctuates during healing. Environment
While type III collagen is predominantly expressed at early
time points (day 10–14), by later time points (day 52) there is Recently, research has focused on augmenting the biological
also a large quantity of new type I collagen. This suggests that environment in the healing tendon. Based on their success in
while a significant period of healing occurs early, it is an other orthopedic procedures, two biological therapies—plate-
ongoing process. let-rich plasma fibrin matrix (PRPFM) and porcine small

Table 1 Phases of tendon

healing Phase General Time Cells involved Proteins
characteristics and scale expressed
cell activities

Inflammatory Hematoma Days Fibroblasts, Collagen type III,

formation, release of macrophages, MMP9 and 13, NOS,
proinflammatory phagocytes, VEGF, TGFβ, BMP-
molecules, neutrophils 12, bFGF, IGF
neovascularization,
cell recruitment and
infiltration
Fibroblastic Continued release of Weeks Fibroblasts Collagen types I and
growth factors, cell III, MMP2,
proliferation, and substance P, PDGF,
disorganized matrix bFGF, TGFβ
production
Remodeling Reorganization of Up to Fibroblasts, Collagen type I,
collagen, GAG 1 year tenocytes MMP2 and 14,
production, decreased TGFβ
cellularity and
vascularity
Curr Rheumatol Rep (2015) 17:476 Page 7 of 9, 476

intestine submucosa (SIS)—were tested in rotator cuff repairs. Louis J. Soslowsky declares the receipt of grants from DJO, Orthofix,
and Amniox, outside of the submitted work.
Numerous studies, however, have shown that PRPFM does
not improve clinical healing rates or outcomes and that por- Human and Animal Rights and Informed Consent This article does
cine SIS not only fail to decrease surgery failure rates but can not contain any studies with human or animal subjects performed by any
also lead to increased pain, decreased function, and sterile of the authors.
effusions [63, 66, 73]. Investigators have also studied the
effects of other growth factors and cell therapies, including
PDGF, TGF-β1, bone marrow-derived mesenchymal stem
cells treated with insulin, and FGF-2-coated sutures [73, 77•, References
78, 80]. These treatments beneficially alter the healing tissue
by causing it to express proteins and exhibit mechanical Papers of particular interest, published recently, have been
properties closer to that of native cuff tendons. Studies eval- highlighted as:
uating the efficacy of current FDA-approved ECM and syn- • Of importance
thetic scaffold devices have shown mixed results. The acellu- •• Of major importance
lar human dermal matrix device GraftJacket, for example, has
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to show a significant biomechanical improvement. Based on with osteoarthritis: human osteoarthritis and an experimental model
animal and clinical studies, the synthetic polycarbonate poly- of joint degeneration. Osteoarthr Cartil. 1999;7:2–14.
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791–812.
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because of poor study design (e.g., lack of control group, anatomy of the rotator cuff tendons, glenoid fossa, labrum, and
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