Rotator Cuff Tear Susceptibility Is Associated With Variants in Genes Involved in Tendon Extracellular Matrix Homeostasis

Systematic Review of Relevant Biomarkers for Human Connective Tissue Repair and Healing Outcome: Implications for Understanding Healing Processes and Design of Healing Interventions

Objective: The healing process following connective tissue (CT) injuries is complex, resulting in variable and often suboptimal outcomes. Patients undergoing CT repair frequently experience healing failures, compromised function, and chronic degenerative diseases. The identification of biomarkers to guide improved clinical outcomes after CT injuries remains an emerging but promising field. [Figure: see text] [Figure: see text] Design: Systematic review. Data sources: Databases, including PubMed, MEDLINE Ovid, Web of Science, and Google Scholar, were searched up to August 2024. Eligibility criteria: To achieve the research objective, randomized control trials, cohort studies, and case-control studies on biomarkers associated with CT repair and healing outcomes were selected. The present analysis was confined to clinical and preclinical models, excluding imaging studies. The entire process of this systematic review adhered strictly to the guidelines outlined in the Preferred Reporting Items for Systematic Review and Meta-Analyses protocol checklist. Results: A total of 1,815 studies on biomarkers of CT repair were initially identified, with 75 studies meeting eligibility criteria and 55 passing quality assessments. For biomarkers associated with CT healing outcomes, 281 studies were considered, with 30 studies meeting eligibility criteria and 24 passing quality assessments. Twenty-one overlapping studies investigated the effects of biomarkers on both CT repair and healing outcomes. Specific biomarkers identified, and ranked from highest to lowest quality, include complement factor D, eukaryotic elongation factor-2, procollagen type I N-terminal propetide, procollagen type III N-terminal propetide, lactate, pyruvate, platelet-derived growth factor-BB, tissue inhibitor of metalloproteinase-3 (TIMP-3), cysteine-rich protein-1, plastin-3, periostin, protein S100-A11, vimentin, matrix metalloproteinases (MMP-2, MMP-7, and MMP-9), hepatocyte growth factor, interferon-γ, interleukins (IL-6, IL-8, and IL-10), MMP-1, MMP-3, tumor necrosis factor-α, fibroblast growth factor-2, IL-1α, chondroitin-6-sulfate, inter-alpha-trypsin inhibitor heavy chain-4, transforming growth factor-beta 1, vascular endothelial growth factor, C-C chemokine receptor 7, C-C chemokine ligand 19, IL-1β, IL-1Ra, IL-12p40, granulocyte-macrophage colony-stimulating factor (GM-CSF), and TIMP-1. Conclusions: All of the 37 identified potential biomarkers demonstrated regulatory effects on CT repair and mediated healing outcomes. Notably, the identified biomarkers from human studies can potentially play an essential role in the development of targeted treatment protocols to counteract compromised healing and can also serve as predictors for detecting CT healing processes and long-term outcomes.

Low skeletal muscle mass is associated with inferior preoperative and postoperative shoulder function in elderly rotator cuff tear patients

BACKGROUND

The age-related loss of skeletal muscle mass is an important characteristic of sarcopenia, an increasingly recognized condition with systemic implications. However, its association with shoulder function in elderly patients with rotator cuff tears (RCT) remains unknown. This study aimed to investigate the relationship between low skeletal muscle mass and shoulder function in elderly RCT patients.

METHODS

A retrospective analysis was conducted on RCT patients who underwent chest computed tomography (CT) scans for clinical evaluation. Preoperative CT scan images of the chest were used to calculate the cross-sectional area (CSA) of thoracic muscle at the T4 level. The medical records were reviewed. Shoulder function was assessed using the ASES score and CMS score both preoperatively and at the final follow-up. Data on the preoperative range of motion (ROM) for the affected shoulder, were collected for analysis. Subgroup analyses by sex were also performed.

RESULTS

A total of 283 RCT patients, consisting of 95 males and 188 females, with a mean age of 66.22 ± 4.89(range, 60-95 years) years were included in this retrospective study. The low muscle mass group showed significantly higher level of c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) compared to the normal group(3.75 ± 6.64 mg/L vs. 2.17 ± 2.30 mg/L, p = 0.021; 19.08 ± 12.86 mm/H vs.15.95 ± 10.76 mm/H, p = 0.038; respectively). In the normal group, pre-operative passive ROM, including forward elevation, abduction, lateral rotation, and abductive external rotation, was significantly better than that in the low muscle mass group (127.18 ± 34.87° vs. 89.76 ± 50.61°; 119.83 ± 45.76° vs. 87.16 ± 53.32°; 37.96 ± 28.33° vs. 25.82 ± 27.82°; 47.71 ± 23.56° vs. 30.87 ± 27.76°, all p < 0.01, respectively). Similar results were found in the active ROM of the shoulder. The female low muscle mass group exhibited significantly poorer passive and active ROM (p < 0.05). The post-operative ASES scores and CMS scores of the female low muscle mass group were also statistically worse than those of the female normal group (p < 0.05).

CONCLUSIONS

The results of present study revealed that the low skeletal muscle mass is associated with inferior ROM of the shoulder and per- and post-operative shoulder function, especially for elderly female patients.

Identification of rare genetic variants for rotator cuff tearing and repair in high-risk pedigrees

Background

Common genetic variants with small effect sizes have been associated with rotator cuff tearing although very few rare, highly penetrant variants have been identified. The purpose of this pilot study was to identify dominant coding variants that segregated with affected individuals in pedigrees at high risk for rotator cuff tears (RCTs). We hypothesize that rare variants contribute to symptomatic RCTs and that they can be identified in related cases with a full-thickness tear requiring surgical management.

Methods

We used the Utah Population Database to identify pedigrees that exhibited a significant excess of individuals who had undergone surgical repair of a full-thickness RCT. We analyzed whole exome sequence analysis to identify rare coding variants in 9 independent affected cousin pairs (first or second cousins) who had undergone arthroscopic surgery for repair of a full-thickness RCT (mean age at diagnosis 68 years). Validation of association of the candidate variants with risk for rotator cuff tearing was accomplished utilizing data from the UK Biobank and a separate cohort of unrelated cases of full-thickness RCTs.

Results

A total of 82 rare (minor allele frequency <0.005) coding variants were identified as shared in at least one cousin pair affected with full-thickness rotator cuff tearing belonging to a high-risk pedigree, which included variants in RUNX1, ADAM12, TGFBR2, APBB1, PDLIM7, LTBP1, MAP3K4, and MAP3K1. Analysis of 39 of these variants with data available in the UK Biobank (3899 cases with rotator cuff injury and 11,697 matched controls; mean case age 59.9 years) identified a significant association with the APBB1 gene (OR = 2.37, P = .007, uncorrected). The PDLIM7 allele was found to be in significant excess in RCT cases in a separate cohort of Utah patients with full-thickness RCTs (10 carriers out of 458 independent, unrelated patients; minor allele frequency of 0.022) compared to a minor allele frequency of 0.0058 for the European (non-Finnish) control population rate (749 carriers out of 128612 tested) (chi-square test: 19.3 [P < .001]).

Discussion

The analysis of closely related individuals with confirmed full-thickness RCTs from high-risk pedigrees has identified 82 rare, shared candidate genetic predisposition coding variants. Association of the PDLIM7 allele with risk for tear was confirmed in an independent cohort of RCTs. Further analysis of the variant alleles is required for confirmation of these genes in rotator cuff tearing.

Factors associated with genetic markers for rotator cuff disease in patients with atraumatic rotator cuff tears

For atraumatic rotator cuff tears, genetics contributes to symptomatic tear risk and may influence rotator cuff healing after surgical repair. But little is known about how genetic factors influence rotator cuff tear patient characteristics at presentation. We collected saliva samples for genotyping from atraumatic rotator cuff tear patients. We examined nine single nucleotide polymorphisms (SNPs) associated with cuff tears in prior literature. We estimated associations of SNP dosage with (1) age at tear diagnosis, (2) bilateral atraumatic tear prevalence, and (3) tear size. Linear regression was used to estimate associations with diagnosis age adjusted for sex and principal components. Logistic regression and ordinal logistic regression were used to estimate associations with bilateral tear prevalence and tear size category, respectively, adjusting for age, sex, and principal components. Of 344 eligible patients, 336 provided sufficient samples for genotyping. Median age at tear diagnosis was 61, 22% (N = 74) had bilateral atraumatic tears, and 9% (N = 29) had massive tears. SNP rs13107325 in the SLC39A8 gene and rs11850957 in the STXBP6 gene were associated with younger diagnosis age even after accounting for multiple comparisons (rs13107325: -4 years, 95% CI = -6.5, -1.4; rs11850957: -2.7 years, 95% CI = -4.3, -1.1). No other significant associations were observed with diagnosis age, tear size, or bilateral tear prevalence. SLC39A8 encodes a Mn transporter. STXBP6 may play a role in inflammatory responses by altering phagocytosis and antigen presentation of monocytes and macrophages. Further research is needed to determine if genetic markers can be used alongside patient characteristics to aid in identifying optimal surgical repair candidates.

Criteria, Timing, and Factors Associated With Return to Competitive Sport After Rotator Cuff Surgery

Rotator cuff pathology in competitive athletes is common and may produce chronic symptoms and joint disability, impairing sports participation and leading to premature retirement. Athletes are a high-functioning patient population with unique characteristics. Decision-making for return to sport is a complex and multifactorial process. Literature is sparse and does not provide precise guidelines to assist physicians to make the right decision. This review aimed to highlight factors affecting outcome, timing, and criteria for return to competitive sport after rotator cuff surgery to help physicians to clearly counsel athletes and make high-quality decisions for return to sport.

Progress in studying the impact of hyperlipidemia and statins on rotator cuff injury and repair

This review delves into the intersection of two prevalent conditions, hyperlipidemia and rotator cuff injuries, both of which bear substantial healthcare burdens. Our investigation begins with an exploration of rotator cuff injuries, common musculoskeletal disorders that severely impair shoulder functionality and quality of life. These injuries are notably pervasive among sports enthusiasts and the older adult, with an incidence rate estimated at 5-10% in the general population. Despite their widespread occurrence and the diverse, multifactorial etiological factors, effective treatment strategies remain elusive. We then examine hyperlipidemia, a metabolic disorder affecting approximately 40% of the global adult population. Characterized by elevated levels of cholesterol and triglycerides, hyperlipidemia can precipitate severe cardiovascular complications and presents a significant socioeconomic burden. Although current management strategies encompass lifestyle modifications and pharmacological interventions, the condition remains a formidable health challenge. Central to this review is the exploration of a potential association between hyperlipidemia and rotator cuff injuries. We aim to synthesize the current understanding of hyperlipidemia's role in the pathophysiology of rotator cuff injuries, thereby offering fresh insights into their common etiological underpinnings, potential therapeutic targets, and drugs, such as Statins. The influence of other lipid-lowering therapeutics on tendon health is also considered, and further research into the molecular pathways and potential therapeutic benefits of these drugs is required. This pursuit aligns with broader efforts to enhance patient outcomes, minimize healthcare burdens, and contribute to the global understanding of these prevalent conditions.

MRI is a Reliable Method for Measurement of Critical Shoulder Angle and Acromial Index

Objective  The objectives of this study are to compare absolute values of acromial index (AI) and critical shoulder angle (CSA) obtained in both radiographs and magnetic resonance image (MRI) of the shoulder; and to compare the interobserver and intra-observer agreement for AI and CSA values measured in these image modalities. Methods  Patients who had medical indication of investigating shoulders conditions through radiographs and MRI were included. Images were taken to two fellowship-trained shoulder surgeons, which conducted measurements of AI and CSA in radiographs and in MRI. Twelve weeks after the first evaluation, a second evaluation was conducted. Inter- and intra-observer reliability was presented as an Intraclass Correlation Coefficient (ICC) and agreement was classified according to Landis & Koch criteria. The differences between two measurements were evaluated using Bland-Altman plots. Results  134 shoulders in 124 subjects were included. Mean intra-observer ICC for CSA in X-rays and in MRI were 0.936 and 0.940, respectively; for AI, 0.908 and 0.022. Mean inter-observer ICC for CSA were 0.892 and 0.752 in X-rays and MRI respectively; for AI, ICC values were 0.849 and 0.685. All individual analysis reached statistical power ( p  < 0.001). Mean difference for AI values measured in X-rays and in MRI was 0.01 and 0.03 for observers 1 and 2, respectively. Mean difference for CSA values obtained in X-rays and MRI was 0.16 and 0.58 for observers 1 and 2, respectively. Conclusion  Both MRI and X-rays provided high intra- and interobserver agreement for measurement of AI and CSA. Absolute values found for AI and CSA were highly correlated in both image modalities. These findings suggest that MRI is a suitable method to measure AI and CSA. Level of Evidence II , Diagnostic Study.

Are commercial genetic injury tests premature?

INTRODUCTION

Several direct-to-consumer (DTC) genetic testing companies have emerged that claim to be able to test for susceptibility for musculoskeletal injuries. Although there are several publications on the emergence of this industry, none have critically evaluated the evidence for the use of genetic polymorphisms in commercial tests. The aim of this review was to identify, where possible, the polymorphisms and to evaluate the current scientific evidence for their inclusion.

RESULTS

The most common polymorphisms included COL1A1 rs1800012, COL5A1 rs12722, and GDF5 rs143383. The current evidence suggests that it is premature or even not viable to include these three polymorphisms as markers of injury risk. A unique set of injury-specific polymorphisms, which do not include COL1A1, COL5A1, or GDF5, identified from genome-wide association studies (GWAS) is used by one company in their tests for 13 sports injuries. However, of the 39 reviewed polymorphisms, 22 effective alleles are rare and absent in African, American, and/or Asian populations. Even when informative in all populations, the sensitivity of many of the genetic markers was low and/or has not been independently validated in follow-up studies.

CONCLUSIONS

The current evidence suggests it is premature to include any of the reviewed polymorphisms identified by GWAS or candidate gene approaches in commercial genetic tests. The association of MMP7 rs1937810 with Achilles tendon injuries, and SAP30BP rs820218 and GLCCI1 rs4725069 with rotator cuff injuries does warrant further investigation. Based on current evidence, it remains premature to market any commercial genetic test to determine susceptibility to musculoskeletal injuries.

Optimizing repair of tendon ruptures and chronic tendinopathies: Integrating the use of biomarkers with biological interventions to improve patient outcomes and clinical trial design

Tendons are dense connective tissues of the musculoskeletal system that link bones with muscles to foster mobility. They have complex structures and exist in varying biomechanical, metabolic and biological environments. In addition, tendon composition and mechanical properties can change over the lifespan as an individual ages. Many tendons function in high stress conditions with a low vascular and neuronal supply, conditions often leading to development of chronic tendinopathies, and in some cases, overt rupture of the tissues. Given their essential nature for human mobility and navigation through the environment, the effective repair and regeneration of different tendons after injury or damage is critical for quality of life, and for elite athletes, the return to sport participation at a high level. However, for mainly unknown reasons, the outcomes following injury are not always successful and lead to functional compromise and risk for re-injury. Thus, there is a need to identify those patients who are at risk for developing tendon problems, as well those at risk for poor outcomes after injury and to design interventions to improve outcomes after injury or rupture to specific tendons. This review will discuss recent advances in the identification of biomarkers prognostic for successful and less successful outcomes after tendon injury, and the mechanistic implications of such biomarkers, as well as the potential for specific biologic interventions to enhance outcomes to improve both quality of life and a return to participation in sports. In addition, the implication of these biomarkers for clinical trial design is discussed, as is the issue of whether such biomarkers for successful healing of one tendon can be extended to all tendons or are valid only for tendons in specific biomechanical and biological environments. As maintaining an active lifestyle is critical for health, the successful implementation of these advances will benefit the large number of individuals at risk.

Sports-Related Shoulder Injuries Among Female Athletes

PURPOSE OF REVIEW

The objectives of this review are to explore the recent literature evaluating sports-related shoulder injuries among female athletes.

RECENT FINDINGS

Recent literature has highlighted sex-related differences in injury trends and patterns among athletes. Increased participation of women in both recreational and professional sports has resulted in increased exposure to injury. While men experience greater rates of shoulder injury overall, women tend to experience more overuse-related injuries. Evidence also suggests women are more susceptible to shoulder laxity and rotator cuff tears. In comparison to their male counterparts, women note poorer function, increased pain, and decreased activity level following shoulder injuries. Women may also be more likely to experience worse outcomes following surgical intervention. Sex-related differences in injury patterns and outcomes results from a combination of molecular and environmental influences, including hormone pathways, shoulder morphology, and differing rates of participation in, and athletic regulations among, certain sports. Sex-related differences occur in how athletes sustain, experience, and recover from sports-related injuries. A comprehensive understanding of sex-related injuries enhances clinical decision making, treatment, and recovery. Further research is needed to clarify sex as an independent variable when evaluating sports-related shoulder injuries.

Sex Differences in Utilization and Perioperative Outcomes of Arthroscopic Rotator Cuff Repair

Background

As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes.

Methods

Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex.

Results

Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P < .001) and less healthy as indicated by American Society of Anesthesiologists class (P < .001) and rates of obesity (52.0% vs. 47.8%, P < .001), chronic obstructive pulmonary disease (4.0% vs. 2.7%, P < .001), and steroid use (2.7% vs. 1.6%, P < .001). Females experienced shorter operative times (mean difference [MD] 11.5 minutes, P < .001), longer hospital stays (MD 0.03 days, P < .001), longer times from operation to discharge (MD 0.03 days, P < .001), and more minor adverse events (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.24-2.47) after baseline adjustment. Conversely, rates of serious adverse events (OR, 0.69; 95% CI, 0.55-0.86) and readmissions (OR, 0.88; 95% CI, 0.66-0.97) were lower among females. Disparities in utilization increased over the study period (P = .008), whereas length of stay (P = .509) and adverse events (P = .967) remained stable.

Conclusion

Sex differences among patients undergoing arthroscopic rotator cuff repair are evident, indicating the need for further research to understand and address the root causes of inequality and optimize care for all.

Tendon and Ligament Genetics: How Do They Contribute to Disease and Injury? A Narrative Review

A significant proportion of patients requiring musculoskeletal management present with tendon and ligament pathology. Our understanding of the intrinsic and extrinsic mechanisms that lead to such disabilities is increasing. However, the complexity underpinning these interactive multifactorial elements is still not fully characterised. Evidence highlighting the genetic components, either reducing or increasing susceptibility to injury, is increasing. This review examines the present understanding of the role genetic variations contribute to tendon and ligament injury risk. It examines the different elements of tendon and ligament structure and considers our knowledge of genetic influence on form, function, ability to withstand load, and undertake repair or regeneration. The role of epigenetic factors in modifying gene expression in these structures is also explored. It considers the challenges to interpreting present knowledge, the requirements, and likely pathways for future research, and whether such information has reached the point of clinical utility.

Advances in sports genomics

Sports genomics is the scientific discipline that focuses on the organization and function of the genome in elite athletes, and aims to develop molecular methods for talent identification, personalized exercise training, nutritional need and prevention of exercise-related diseases. It postulates that both genetic and environmental factors play a key role in athletic performance and related phenotypes. This update on the panel of genetic markers (DNA polymorphisms) associated with athlete status and soft-tissue injuries covers advances in research reported in recent years, including one whole genome sequencing (WGS) and four genome-wide association (GWAS) studies, as well as findings from collaborative projects and meta-analyses. At end of 2020, the total number of DNA polymorphisms associated with athlete status was 220, of which 97 markers have been found significant in at least two studies (35 endurance-related, 24 power-related, and 38 strength-related). Furthermore, 29 genetic markers have been linked to soft-tissue injuries in at least two studies. The most promising genetic markers include HFE rs1799945, MYBPC3 rs1052373, NFIA-AS2 rs1572312, PPARA rs4253778, and PPARGC1A rs8192678 for endurance; ACTN3 rs1815739, AMPD1 rs17602729, CPNE5 rs3213537, CKM rs8111989, and NOS3 rs2070744 for power; LRPPRC rs10186876, MMS22L rs9320823, PHACTR1 rs6905419, and PPARG rs1801282 for strength; and COL1A1 rs1800012, COL5A1 rs12722, COL12A1 rs970547, MMP1 rs1799750, MMP3 rs679620, and TIMP2 rs4789932 for soft-tissue injuries. It should be appreciated, however, that hundreds and even thousands of DNA polymorphisms are needed for the prediction of athletic performance and injury risk.

Association of COL5A1 gene polymorphisms and musculoskeletal soft tissue injuries: a meta-analysis based on 21 observational studies

Objective

Inconsistent findings existed on the correlation of collagen type V α1 (COL5A1) gene polymorphisms and musculoskeletal soft tissue injuries (MSTIs). The purpose of this study was to collect and combine the current evidences by a meta-analysis approach.

Methods

Six online databases were searched up to August, 2021. The methodological quality of each individual study was evaluated based upon Newcastle–Ottawa Scale (NOS). The strength of the effect size was presented by odds ratio (OR) with 95% confidence interval (95%CI) in five genetic models. The data were analyzed using Review Manager 5.3.

Results

Twenty-one studies were eligible to this meta-analysis. The study quality was deemed fair to excellent according to NOS. In the overall analyses, the merged data suggested that rs12722, rs71746744, and rs3196378 polymorphisms were correlated to an increased susceptibility to MSTIs. But the association was not established in rs13946 or rs11103544 polymorphism. For rs12722 polymorphism, stratified analyses by injury type and ethnicity identified the association mainly existed in ligament injury and among Caucasian population. For rs13946 polymorphism, subgroup analysis suggested the association existed in tendon and ligament injuries.

Conclusion

This study supports that rs12722 is associated with an elevated susceptibility to ligament injury, especially in the Caucasian population. Rs13946 polymorphism appears to increase the risk to tendon and ligament injuries. Rs71746744 and rs3196378 polymorphisms have a tendency to confer an elevated risk to MSTIs. However, no relevance is found between rs11103544 polymorphism and MSTIs.

Association between matrix metalloproteinase-3 gene polymorphisms and tendon-ligament injuries: evidence from a meta-analysis

Background

Tendon-ligament injuries (TLIs), including Achilles tendinopathy, cruciate ligament injury, tennis elbow, rotator cuff injury, patellar tendinopathy, and tibial tendinopathy, are common musculoskeletal soft injuries during physical activity. Matrix metalloproteinase-3 (MMP-3) gene polymorphisms have been implicated in the etiology of TLIs in several genetic association studies with inconsistent results. The purpose of this study was to collect and synthesize the current evidences on the association of MMP-3 polymorphisms and TLIs.

Methods

The search was conducted using PubMed, Web of Science, EMBASE, Cochrane Library, CNKI and Wanfang databases, prior to July, 2021. Newcastle Ottawa Scale was used to appraise the study quality. Strengths of association were represented by odds ratios (ORs) and 95% confidence intervals (95% CIs).

Results

Thirteen studies with 2871 cases and 4497 controls met the eligibility criteria, and each study was in high quality. The overall analyzes suggested rs3025058 was associated with an increased TLIs risk (5A vs. 6A, OR = 1.20, 95% CI 1.03–1.40, P = 0.020). However, the association was not found for rs679620, rs591058, and rs650108 polymorphisms. Subgroup analysis by injury type suggested that rs679620 polymorphism was associated with a reduced risk to Achilles tendon rupture (AA + AG vs. GG, OR = 0.46, 95% CI 0.25–0.87, P = 0.020), and rs3025058 was associated with an elevated risk to anterior cruciate ligament injury (5A5A + 5A6A vs. 6A6A, OR = 1.46, 95% CI 1.03–2.06, P = 0.030). When stratified by ethnicity, the findings indicated that rs3025058 polymorphism was associated with an increased TLIs risk among Caucasians (5A6A vs. 6A6A, OR = 1.55, 95% CI 1.09–2.42, P = 0.020) and Brazilians (5A5A vs. 5A6A + 6A6A, OR = 2.80, 95% CI 1.44–5.45, P = 0.002).

Conclusion

Findings of this study suggest that rs679620 polymorphism is associated with a reduced Achilles tendon rupture risk, and rs3025058 polymorphism contributes to an increased TLIs risk in Caucasians and Brazilians. However, rs591058 and rs650108 polymorphisms do not show any association with TLIs.

What Factors Are Associated with Symptomatic Rotator Cuff Tears: A Meta-analysis

BACKGROUND

Rotator cuff tears are common. A previous systematic review reported on factors associated with rotator cuff tears; however, it included relatively few studies and few variables, and in addition, it had considerable heterogeneity. To identify the factors associated with symptomatic rotator cuff tears and to help guide clinicians to potentially modifiable factors, we felt a broader and more inclusive meta-analysis would be useful.

QUESTIONS/PURPOSES

In this systematic review and meta-analysis, we asked what (1) demographic, (2) disease, and (3) imaging factors are associated with symptomatic rotator cuff tears?

METHODS

PubMed, Embase, and Web of Science were searched, and the search period were from the inception of each database through February 2021. The keywords included "risk factor," "rotator cuff injury," "rotator cuff tears," and "rotator cuff tendinitis." All comparative studies on symptomatic rotator cuff tears were included. We considered that the diagnosis of rotator cuff tear could be made by any imaging tool (MRI or ultrasound). We considered either partial- or full-thickness tears to be a rotator cuff tear. No language restrictions were applied. Twenty-six articles from 14 countries involving 9809 individuals, consisting of 3164 patients and 6645 controls, were included. The Newcastle-Ottawa Scale and the Agency for Healthcare Research and Quality (AHRQ) scale were used to evaluate the risk of bias of the included studies, and the highest scores were 9 and 11, respectively. The Newcastle-Ottawa Scale was used for retrospective comparative studies, and the AHRQ was used to evaluate prospective comparative studies. The eight retrospective comparative studies we included were scored from 4 to 9. The quality score of the 18 prospective comparative studies ranged from 6 to 9. Publication bias was explored using the Egger test. Heterogeneity was estimated using the I2 value. If there was no heterogeneity (I2 ≤ 50%), a fixed-effects model was used to determine the overall effect size; if there was heterogeneity (I2 > 50%), a random-effects model was used to merge the effect values. A meta-analysis was performed with RevMan 5.3, and the risk ratio (RR) and weighted mean difference of related factors were calculated.

RESULTS

Our meta-analysis identified the following demographic factors associated with an increased risk of rotator cuff tears: older age (mean difference 3.1 [95% CI 1.4 to 4.8]; p < 0.001), greater BMI (mean difference 0.77 [95% CI 0.37 to 1.17]; p < 0.001), smoking (RR 1.32 [95% CI 1.17 to 1.49]; p < 0.001), dominant arm (RR 1.15 [95% CI 1.06 to 1.24]; p < 0.001), greater height (mean difference 0.9 [95% CI 0.4 to 1.4]; p < 0.001), and heavier weight (mean difference 2.24 [95% CI 0.82 to 3.66]; p = 0.002). Regarding disease factors, we found that traumatic events (RR 1.91 [95% CI 1.40 to 2.54]; p < 0.001) and hypertension (RR 1.50 [95% CI 1.32 to 1.70]; p < 0.001) were associated with symptomatic rotator cuff tears. Regarding imaging factors, we found that the following three factors were associated with symptomatic rotator cuff tears: greater acromion index (mean difference 0.11 [95% CI 0.06 to 0.16]; p < 0.001), greater critical shoulder angle (mean difference 1.9 [95% CI 1.5 to 2.3]; p < 0.001), and smaller glenoid version angle (mean difference -1.3 [95% CI -1.9 to -0.8]; p < 0.001). We found no association between the patient's sex or the presence or absence of thyroid disease and the likelihood of a rotator cuff tear being present.

CONCLUSION

This study identified several factors associated with symptomatic rotator cuff tears, including blood glucose, blood pressure, weight, and smoking. Clinicians may seek to modify these factors, possibly in patients with symptomatic rotator cuff tears, but also in symptomatic patients who have not yet been diagnosed with rotator cuff tears because there would be no harm or risk associated with modifying any of the factors we identified. Future research should further study whether addressing these factors can delay the progression and size of rotator cuff tears.Level of Evidence Level III, prognostic study.

Risk factors for full-thickness rotator cuff tears: a systematic review and meta-analysis

Rotator cuff tears are a common condition of the shoulder, and 20.7% of people with the condition have a full-thickness rotator cuff tear. The purpose of this study was to explore the risk factors for full-thickness rotator cuff tears and to provide evidence to support the accurate diagnosis of full-thickness rotator cuff tears.Studies from PubMed, Embase and Web of Science published before 30 January 2021 were retrieved. All cohort studies and cross-sectional studies on risk factors for full-thickness rotator cuff tears were included. A meta-analysis was performed in RevMan 5.3 to calculate the relative risks (RRs) or weighted mean differences (WMDs) of related risk factors. Stata 15.1 was used for the quantitative analysis of publication bias.In total, 11 articles from six countries, including 4047 cases, with 1518 cases and 2529 controls, were included. The meta-analysis showed that age (MD = 0.76, 95% CI: 0.24 to 1.28, P = 0.004), hypertension (RR = 1.46, 95% CI: 1.17 to 1.81, P = 0.0007) and critical shoulder angle (CSA) (MD = 2.02, 95% CI: 1.55 to 2.48, P < 0.00001) were risk factors for full-thickness rotator cuff tears.Our results also suggested that body mass index, sex, dominant hand, smoking, diabetes mellitus and thyroid disease were not risk factors for full-thickness rotator cuff tears. Early identification of risk factors for full-thickness rotator cuff tears is helpful in identifying high-risk patients and choosing the appropriate treatment. Cite this article: EFORT Open Rev 2021;6:1087-1096. DOI: 10.1302/2058-5241.6.210027.

Risk Factors for Supraspinatus Tears: A Meta-analysis of Observational Studies

BACKGROUND

The pathogenesis of rotator cuff tears remains unclear, and there is a lack of high-quality evidence-based research on the risk factors for supraspinatus tears.

PURPOSE

To explore 10 potential risk factors for supraspinatus muscle tears.

STUDY DESIGN

Systematic review; Level of evidence, 3.

METHODS

This review was conducted according to the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) guidelines. PubMed, Embase, and Web of Science were searched for cohort, case-control and cross-sectional studies published before January 2021 on supraspinatus tears. The following potential risk factors were analyzed: age, body mass index, male sex, female sex, arm dominance, diabetes mellitus, smoking, hypertension, thyroid disease, and the critical shoulder angle (CSA). Risk ratios (RRs) or weighted mean differences (WMDs) of related risk were calculated. The Egger test was used to evaluate publication bias.

RESULTS

A total of 9 articles from 8 countries were included; among the 3240 patients, 687 were included in the supraspinatus tear group, and 2553 were included in the nonsupraspinatus tear group. The meta-analysis showed that older age (WMD, 3.36 [95% confidence interval (CI), 0.53-6.20]; P = .02), male sex (RR, 0.87 [95% CI, 0.78-0.97]; P = .01), smoking (RR, 2.21 [95% CI, 1.56-3.14]; P < .00001), diabetes (RR, 1.67 [95% CI, 1.03-2.70]; P = .04), hypertension (RR, 1.51 [95% CI, 1.16-1.97]; P = .002), and the CSA (WMD, 2.25 [95% CI, 1.39-3.12]; P < .00001) were risk factors for supraspinatus tears.

CONCLUSION

Older age, male sex, smoking, diabetes, hypertension, and a higher CSA were found to be risk factors for supraspinatus tears in this meta-analysis review. Identifying risk factors for supraspinatus tears early can help clinicians identify these high-risk patients and choose appropriate treatments.

A genome-wide association study for shoulder impingement and rotator cuff disease

BACKGROUND

The purpose of the study was to identify genetic variants associated with rotator cuff disease by performing a genome-wide association study (GWAS) for shoulder impingement using the UK Biobank (UKB) cohort and then combining the GWAS data with a prior GWAS for rotator cuff tears. The loci identified by the GWAS and meta-analysis were examined for changes in expression following rotator cuff tearing using RNA sequencing.

METHODS

A GWAS was performed using data from UKB with 3864 cases of shoulder impingement. The summary statistics from shoulder impingement and a prior study on rotator cuff tears were combined in a meta-analysis. Also, the previous association of 2 single-nucleotide polymorphisms (SNPs) with shoulder impingement from a published GWAS using the UKB was tested. Rotator cuff tendon biopsies were obtained from 24 patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair (cases) and 9 patients who underwent open reduction internal fixation for a proximal humeral fracture (controls). Total RNA was extracted and differential gene expression was measured by RNA sequencing for genes with variants associated with rotator cuff tearing.

RESULTS

The shoulder impingement GWAS identified 4 new loci: LOC100506457, LSP1P3, LOC100506207, and MIS18BP1/LINC00871. Combining data with a prior GWAS for rotator cuff tears in a meta-analysis resulted in the identification of an additional 7 loci: SLC39A8/UBE2D3, C5orf63, ASTN2, STK24, FRMPD4, ACOT9/SAT1, and LINC00890/ALG13. Many of the identified loci have known biologic functions or prior associations with diseases, suggesting possible biologic pathways leading to rotator cuff disease. RNA sequencing experiments show that expression of STK24 increases whereas expression of SAT1 and UBE2D3 decreases following rotator cuff tearing. Two SNPs previously reported to show an association with shoulder impingement from a prior UKB GWAS were not validated in our study.

CONCLUSION

This is the first GWAS for shoulder impingement in which new data from UKB enabled the identification of 4 loci showing a genetic association. A meta-analysis with a prior GWAS for rotator cuff tearing identified an additional 7 loci. The known biologic roles of many of the 11 loci suggest plausible biologic mechanisms underlying the etiology of rotator cuff disease. The risk alleles from each of the genetic loci can be used to assess the risk for rotator cuff disease in individual patients, enabling preventative or restorative actions via personalized medicine.

Identification of a Novel Genetic Marker for Risk of Degenerative Rotator Cuff Disease Surgery in the UK Biobank

BACKGROUND

While evidence indicates that familial predisposition influences the risk of developing degenerative rotator cuff disease (RCD), knowledge of specific genetic markers is limited. We conducted a genome-wide association study of RCD surgery using the UK Biobank, a prospective cohort of 500,000 people (40 to 69 years of age at enrollment) with genotype data.

METHODS

Cases with surgery for degenerative RCD were identified using linked hospital records. The cases were defined as an International Classification of Diseases, Tenth Revision (ICD-10) code of M75.1 determined by a trauma/orthopaedic specialist and surgery consistent with RCD treatment. Cases were excluded if a diagnosis of traumatic injury had been made during the same hospital visit. For each case, up to 5 controls matched by age, sex, and follow-up time were chosen from the UK Biobank. Analyses were limited to European-ancestry individuals who were not third-degree or closer relations. We used logistic regression to test for genetic association of 674,405 typed and >10 million imputed markers, after adjusting for age, sex, population principal components, and follow-up.

RESULTS

We identified 2,917 RCD surgery cases and 14,158 matched controls. We observed 1 genome-wide significant signal (p < 5 × 10-8) for a novel locus tagged by rs2237352 in the CREB5 gene on chromosome 7 (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.11 to 1.24). The single-nucleotide polymorphism (SNP) rs2237352 was imputed with a high degree of confidence (info score = 0.9847) and is common, with a minor allele frequency of 47%. After expanding the control sample to include additional unmatched non-cases, rs2237352 and another SNP in the CREB5 gene, rs12700903, were genome-wide significant. We did not detect genome-wide significant signals at loci associated with RCD in previous studies.

CONCLUSIONS

We identified a novel association between a variant in the CREB5 gene and RCD surgery. Validation of this finding in studies with imaging data to confirm diagnoses will be an important next step.

CLINICAL RELEVANCE

Identification of genetic RCD susceptibility markers can guide understanding of biological processes in rotator cuff degeneration and help inform disease risk in the clinical setting.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Regulatory VCAN polymorphism is associated with shoulder pain and disability in breast cancer survivors

Background and purpose

Shoulder morbidity following breast cancer treatment is multifactorial. Despite several treatment- and patient-related factors being implicated, unexplained inter-individual variability exists in the development of such morbidity. Given the paucity of relavant genetic studies, we investigate the role of polymorphisms in candidate proteoglycan genes.

Patients and methods

We conducted a cross-sectional study on 254 South African breast cancer survivors, to evaluate associations between shoulder pain/disability and ten single nucleotide polymorphisms (SNPs) within four proteoglycan genes: ACAN (rs1126823 G>A, rs1516797 G>T, rs2882676 A>C); BGN (rs1042103 G>A, rs743641 A>T, rs743642 G>T); DCN rs516115 C>T; and VCAN (rs11726 A>G, rs2287926 G>A, rs309559). Participants were grouped into no–low and moderate–high shoulder pain/disability based on total pain/disability scores: < 30 and ≥ 30, respectively using the Shoulder Pain and Disability Index (SPADI).

Results

The GG genotype of VCAN rs11726 was independently associated with an increased risk of being in the moderate-to-high shoulder pain (P = 0.005, OR = 2.326, 95% CI = 1.259–4.348) or disability (P = 0.011, OR = 2.439, 95% CI = 1.235–4.762) categories, after adjusting for participants’ age. In addition, the T-T-G inferred allele combination of BGN (rs74364–rs743642)–VCAN rs11726 was associated with an increased risk of being in the moderate-to-high shoulder disability category (0 = 0.002, OR = 2.347, 95% CI = 1.215–4.534).

Conclusion

Our study is first to report that VCAN rs11726, independently or interacting with BGN polymorphisms, is associated with shoulder pain or disability in breast cancer survivors. Whereas our findings suggest an involvement of proteoglycans in the etiology of shoulder pain/disability, further studies are recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40246-021-00337-0.

Rotator Cuff Healing

The present article broadly addresses the aspects that interfere with the healing process of the rotator cuff. Life habits, such as smoking and alcoholism, are considered, systemic factors such as diabetes mellitus, hypertension, and obesity, as well as local factors, among which are those related to the pre, peri, and postoperative periods. From an extensive literature review, with the citation of 60 scientific articles from both Western and Eastern literature, the authors intend to deepen the theme by bringing to medical practice conducts based on new established concepts.

Shoulder and elbow pathology in the female athlete: sex-specific considerations

Unique biologic and biomechanical aspects of the female body make women more prone to certain orthopedic injuries. Sex differences are well understood with regard to certain orthopedic pathologies such as anterior cruciate ligament injury, hallux valgus, carpal tunnel, and carpometacarpal joint arthritis; however, sex differences are less commonly discussed with regard to shoulder and elbow pathology. The purpose of this review is to elucidate sex differences specific to sports-related shoulder and elbow injuries in the female athlete population.

Genetic variants associated with rotator cuff tearing utilizing multiple population-based genetic resources

BACKGROUND

The etiology of rotator cuff tearing is likely multifactorial, including a potential genetic predisposition. The purpose of the study was to identify genetic variants associated with rotator cuff tearing utilizing the UK Biobank (UKB) cohort, confirm variants using a separate genetic database, and evaluate tissue expression of genes with associated variants following rotator cuff tearing using RNA sequencing.

METHODS

Genome-wide association study (GWAS): A GWAS was performed using data from UKB with 5701 cases of rotator cuff injury. RNA sequencing analyses: rotator cuff biopsies were obtained from 24 patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair (cases) and 9 patients who underwent open reduction internal fixation for a proximal humerus fracture (controls). Total RNA was extracted and differential gene expression was measured by RNAseq for genes with variants associated with rotator cuff tearing.

RESULTS

The results of the UKB GWAS identified 3 loci that reached genome-wide statistical significance: 2 loci on chromosome 7 in GLCCI1 (rs4725069; P = 5.0E-09) and THSD7A (rs575224171; P = 5.3E-09), and 1 locus on chromosome 2 in ZNF804A (rs775583810; P = 3.9E-09). The association with rotator cuff injury of the GLCCI1 single-nucleotide polymorphism (SNP; rs4725069) was confirmed in the Kaiser Permanente Research Bank cohort (P = .008). Twenty previously reported SNPs in 12 genes were evaluated using summary statistics from the UKB GWAS, which confirmed 3 SNPs in TNC with rotator cuff injury (rs1138545, rs72758637, and rs7021589; all P < .0024). Of 17 genes with variants associated with rotator cuff injury (14 previously from literature plus 3 new genes from current UKB GWAS), TIMP2, Col5A1, TGFBR1, and TNC were upregulated (P < .001 for all) and THSD7A was downregulated (P = .005) in tears vs. controls in the RNA sequencing data set.

CONCLUSION

The UKB GWAS has identified 3 novel loci associated with rotator cuff tearing (ZNF804A, GLCCI1, THSD7A). Expression of the THSD7A gene was significantly downregulated in rotator cuff tears vs. controls supporting a potential functional role. Three previously reported SNPs in the TNC gene were validated in the UKB GWAS, supporting a role for this gene in rotator cuff tearing. Finally, TIMP2, Col5A1, TGFBR1, and TNC genes were found to have significantly upregulated tissue expression in cases vs. controls supporting a biologic role in tearing for these genes.

Association of the matrix metalloproteinase 3 (MMP3) single nucleotide polymorphisms with tendinopathies: case-control study in high-level athletes

BACKGROUND

Matrix metalloproteinases (MMPs) play an important role in matrix remodelling, as well as in tendon integrity. Due to overuse, athletes often develop chronic tendinopathies. If not treated, they lead to severe impairment, even complete tendon ruptures.

AIM

The main purpose of this study was to investigate whether three functional polymorphisms within the MMP3 gene are associated with increased risk of developing tendinopathies in high-level Croatian athletes.

METHODS

We have recruited one hundred fifty-five (63 high-level athletes with diagnosed tendinopathies and 92 asymptomatic controls) unrelated Caucasians for this case-control genetic study. All participants were genotyped for three single nucleotide polymorphisms (SNP) within the MMP3 gene: rs591058 C/T, rs650108 A/G and rs679620 G/A using the pyrosequencing method.

RESULTS

The MMP3 rs650108 GG (P = 0.0074) and rs679620 AA (P = 0.0119) genotypes were significantly over-represented in cases compared with controls, while rs591058 TT (P = 0.0759), as well as haplotype variant T - G - A (P = 0.06), implicated that there is an indication of predisposition for tendinopathies.

CONCLUSION

These results support association between functional variants within the MMP3 gene and the risk of tendinopathies in high-level athletes. Further research is needed to replicate these results in a larger population.