BACKGROUND:People with shoulder pain due to rotator cuff disorder are commonly managed within physiotherapy clinics, yet modifiable lifestyle factors that may contribute to the onset and persistence of pain are not routinely addressed. The COMBINED approach has been developed to integrate brief behaviour change interventions targeting relevant lifestyle factors into routine care. OBJECTIVES:To undertake sequential usability and feasibility testing of The COMBINED approach prior to evaluation in a randomised controlled trial. MATERIALS AND METHODS:A mixed-methods, staged evaluation was conducted. Stage 1 comprised usability testing of the initial prototype, using observations, fidelity assessment, and interviews with physiotherapists and patients. Stage 2 was a pragmatic, multicentre, feasibility study within NHS physiotherapy clinics, assessing intervention fidelity, implementation determinants (TDF-informed survey), patient experience, and recruitment feasibility. FINDINGS:The intervention was acceptable and deliverable within routine care. Usability testing with three physiotherapists and six patients identified low initial fidelity and challenges related to ingrained practice behaviours and clinician confidence, informing refinements, including enhanced training and audit and feedback. Feasibility testing involving eight physiotherapists and 17 patients across four NHS trusts demonstrated improved fidelity, particularly in assessment of lifestyle factors and initiating discussions, although complex behaviour change skills remained challenging. Survey findings showed improved implementation following delivery, though prioritisation amid competing demands, habit formation/automaticity and confidence under time pressure remained barriers. Recruitment of patients with relevant lifestyle factors was feasible. CONCLUSION:The COMBINED approach is sufficiently optimised to progress to future trial evaluation, although implementation support will be required to ensure consistent delivery.

Background Modifiable lifestyle factors (smoking, inactivity, overweight) could contribute to the onset and persistence of rotator cuff disorders, yet physiotherapy practice rarely addresses them. Brief interventions (BIs) can support behaviour change but are not routinely embedded in musculoskeletal care. Objectives To develop The COMBINED approach: a physiotherapist-supported intervention integrating BI’s targeting modifiable health behaviours into routine consultations for people with rotator cuff disorders; and to explore how physiotherapists can be supported to deliver it. Materials and methods A theory-, evidence-, and pragmatic-based development process incorporated stakeholder co-design, behavioural theory, and evidence across three workstreams: (1) narrative review of BIs targeting smoking, inactivity, and weight management; (2) four co-design workshops with 26 stakeholders (physiotherapists, patients, experts) to select and adapt a BI and identify key intervention features; (3) theoretical modelling using COM-B, TDF, and BCTTv1 to map barriers/facilitators, select behaviour change techniques, and develop prototype components. Findings Fourteen BIs were identified; Moving Medicine had greatest utility. Barriers included time constraints, limited skills and confidence, and fear of offending patients, contrasting with patients’ acceptability of lifestyle conversations. Recommendations included embedding the BI into routine care, scripts, infographics, patient resources, and training. Twelve TDF domains and 20 BCTs informed prototype development comprising: (1) patient-level intervention: a BI (adapted from Moving Medicine) embedded in routine consultations with tailored resources; (2) clinician-level implementation toolkit. Conclusion The COMBINED approach is the first formally developed intervention supporting integration of BI’s within routine consultations for people with rotator cuff disorders and is now ready for feasibility testing.

The development of pre-operative interventions to improve clinical outcomes following total knee replacement surgery has been identified as a research priority. In the first step of a programme of research, we conducted a feasibility cohort study, which investigated the effect of modifiable lifestyle factors, including alcohol consumption, smoking, physical inactivity and living with overweight, on clinical outcomes following total knee replacement (PRO Knee). Alongside PRO Knee, we conducted an integrated qualitative study to understand the acceptability of the methods used in the PRO Knee study and to explore the experiences of patients waiting for total knee replacement surgery, along with their beliefs and experiences regarding lifestyle interventions. Adult patients awaiting total knee replacement surgery, who had consented to participate in the PRO Knee study were eligible to participate. Semi structured interviews were conducted with all patients who provided informed consent for the qualitative study. Interviews were audio-recorded; transcribed in an intelligent verbatim format and data were analysed using the Framework Method. Ten participants (9 female, 1 male) were recruited (average age 70, range 56–88) and all interviews were conducted over the telephone. The recruitment and data collection processes of the PRO Knee study were acceptable to participants. Five further themes relating to the lived experience of waiting for and undergoing total knee replacement surgery were identified: 1) Osteoarthritis of the knee and co-morbidity; 2) The decision to have surgery; 3) Waiting for total knee replacement; 4) Lifestyle conversations and interventions; 5) Recovery from total knee replacement. The burden of living with osteoarthritis of the knee was significant and participants had often experienced multiple unsuccessful interventions. Participants could recall lifestyle conversations, which they were open to, but were not offered support. Most participants were positive about participating in lifestyle interventions prior to surgery. The participants who had poor outcomes were left with intrusive pain, and feelings of regret. The recruitment and data collection processes for the PRO-Knee feasibility cohort study were acceptable to participants and further study in this area is now warranted.

Background Frozen shoulder, also known as adhesive capsulitis, is a common and disabling condition that causes shoulder pain and progressive stiffness. Patient information leaflets (PILs) are produced by UK National Health Service (NHS) Trusts to help patients understand frozen shoulder and treatment options. However, the content and consistency of these PILs and their alignment with national clinical guidance are currently unclear.Objectives This study aimed to identify, analyse and describe the non-surgical management recommendations presented in publicly available NHS Trust PILs for frozen shoulder and to assess their alignment with the National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary and British Elbow and Shoulder Society (BESS) best practice resources.Methods An online search was undertaken by one reviewer to identify publicly available PILs produced by NHS Trusts detailing non-surgical management of frozen shoulder. Relevant data were extracted and analysed by one reviewer and verified by five reviewers. Descriptive statistics were used to summarise findings.Results Thirty-eight PILs were identified from 38 NHS Trusts with publication dates ranging from April 2013 to March 2025. Considerable variation was observed in the content, including reference to analgesia, activity modification, exercise prescription and corticosteroid injections. No single PIL reflected all key elements recommended in the NICE Clinical Knowledge Summary and BESS best practice.Conclusion The findings demonstrate substantial variation in content, frequent misalignment with current national guidance and best practice exercise recommendations. Such variation may limit and may reduce the clarity, consistency and usefulness of information provided to patients.

Informed consent is fundamental to ethical research, yet participant information leaflets (PILs) are often technical and difficult to understand. Although the importance of accessible study materials is widely recognised, practical guidance on how to develop them remains limited. For RaCeR 2, a randomised controlled trial evaluating different approaches to rehabilitation after shoulder rotator cuff repair, the baseline PIL was developed using Health Research Authority guidance. Early PPI consultation identified major concerns including dense formatting, overly complex language, and an unwelcoming tone, indicating the need for substantial redesign to support informed participation. A diverse PPI group (n = 5) supported the development of an accessible PIL. Contributors varied in age, gender identity, ethnicity, preferred language, employment status, disability, and experience of shoulder surgery. Engagement methods were tailored to participant needs and included online discussions, written feedback, and in-person “think-aloud” sessions. Given the depth of insight provided during initial PPI consultation, we adopted an iterative, user-centred approach drawing on co-design principles to enable contributors to directly influence the content, structure, and presentation of the PIL. Contributors identified challenges with the original materials, including confusing layout, inaccessible formatting, technical terminology, and a tone that did not feel supportive. Through iterative cycles of review and refinement guided by co-design principles, the leaflet was substantially redesigned to include clearer headings, formatting aligned with British Dyslexia Association guidance, bullet-pointed and tiered information, simplified explanations of data protection, and a more conversational tone. Accessibility testing confirmed compatibility with freely available online screen-reading software. During the subsequent regulatory review, inconsistencies between legal requirements and participant preferences highlighted tensions that may limit the accessibility of study materials. This commentary provides a pragmatic example of integrating co-design principles within PPI to create a more accessible PIL. Early engagement, flexible methods, iterative feedback, and testing with screen reading software were central to the process. Our experience also highlights the need for continued dialogue between researchers and regulators to ensure that participant-facing materials meet ethical and legal requirements while remaining understandable to all potential participants. When people take part in health research, it is important they understand what the study involves so they can make an informed choice. Researchers usually provide a written information leaflet, but many are difficult to read, particularly for people with lower literacy, disabilities, neurodivergent conditions, or for whom English is not their first language.RaCeR2 is a study comparing two approaches to helping people recover after shoulder surgery. When preparing to start the study, we drafted an initial leaflet using official guidance, but patients reported that it was hard to read, the images were confusing, it was long, and the tone felt “cold.” In response, we collaborated with a group of patients and public contributors to make the leaflet more accessible. Some joined online meetings, others provided written feedback, and one participated in in-person sessions, sharing thoughts aloud while reading the leaflet. This led to major changes: simplified language, clearer layout, bullet points, improved fonts and colours, and testing with screen readers.However, when submitting the leaflet for Health Research Authority approval, several changes were requested, including additional legal information, making the document longer, more complex, and less aligned with patient preferences.Our experience shows that involving patients and the public makes information leaflets clearer and easier to use. But we also learned that current rules can make it difficult to keep the leaflet simple and accessible. We need better ways for researchers and regulators to work together so that study information meets legal requirements and is easy for everyone to understand when deciding whether to take part.

INTRODUCTION:RaCeR 2 is a pragmatic multicentre, open-label, randomised controlled trial, with full economic evaluation. The primary aim is to assess whether individualised (early) patient-directed rehabilitation (EPDR) results in less shoulder pain and disability at 12 weeks postrandomisation following surgical repair of full-thickness tears of the rotator cuff of the shoulder compared with the current standard (delayed) rehabilitation. This paper provides the protocol for the RaCeR 2 health economic evaluation. METHODS AND ANALYSIS:The health economic analysis of RaCeR 2 is made up of three phases: (1) development of an initial state-transition model structure, (2) within-trial cost consequence analysis and (3) long-term model-based cost-effectiveness analysis (CEA) from the National Health Service and Personal Social Service perspective in England. Descriptive statistics (eg, mean, standard deviation, 95% confidence intervals and minimum and maximum values) will be reported for within-trial resource use, costs and health-related quality of life (HRQoL). Health state-specific costs and HRQoL will be estimated using regression model approaches and used to inform a state-transition simulation model designed to quantify the long-term costs and quality-adjusted life years (QALYs) experienced by patients over the model's time horizon. Where appropriate, final CEA model results will be reported as cost per QALY gained for individualised EPDR versus standard (delayed) rehabilitation. Model assumptions and overall parameter uncertainty will be tested using probabilistic sensitivity analysis and scenario analyses. All regression analyses will be adjusted for baseline participant demographic and symptomatic characteristics. ETHICS AND DISSEMINATION:A favourable ethical review was granted by London-Stanmore Research Ethics Committee (23/LO/0195) on 13 April 2023. Findings will be disseminated in peer-reviewed journals, at scientific conferences, and via the study website. TRIAL REGISTRATION NUMBER:ISRCTN11499185.

ObjectiveTo investigate the experience of people with shoulder osteoarthritis and their perception of non-surgical management in the U.K. National Health Service (NHS).DesignQualitative design, using semi-structured telephone interviews. Two authors (SL and MM) performed coding and theme development following principles of reflexive thematic analysis.SettingPhysiotherapy services within three NHS trusts in England. Individual interviews were conducted with patients with a diagnosis of shoulder osteoarthritis.ParticipantsTen participants were recruited (age range 57-86 years; six females; five with bilateral shoulder osteoarthritis).ResultsParticipants reported significant pain, functional limitations, and emotional distress. Non-surgical management experiences varied, with some finding relief from steroid injections, analgesia, and physiotherapy, while others reported limited perceived effectiveness. All participants expressed a desire for more information and support. There were divergent views on the need for surgery.ConclusionThis is the first study to explore the experiences of people with symptomatic shoulder osteoarthritis who have received care within an NHS setting. It highlights the significant impact of shoulder osteoarthritis on daily life and the challenges faced in accessing appropriate care. Findings emphasise the need for patient-centred care, including education, support, information provision and consideration of psychosocial factors. Future research is required to develop an evidence-based guideline for non-surgical management of shoulder osteoarthritis.

OBJECTIVES:The decision to undergo total shoulder replacement surgery is a major one and should be a joint one between the patient and surgeon. It is important that patients are provided with accessible, meaningful and appropriate information to enable an informed decision. The aim of this study was to explore the content and language used within publicly available information leaflets produced by UK National Health Service (NHS) Trusts for people considering shoulder replacement surgery and to consider how this may influence surgical decision making. DESIGN:An online search of publicly available NHS shoulder replacement patient information leaflets (PIL) was undertaken. The text within the PIL was analysed using reflexive thematic analysis. RESULTS:Thirty-eight PIL were identified. The volume of information and content varied greatly. All PIL discussed the clinical problem, mainly within a biomedical framework and from a clinician's perspective in which normal shoulder anatomy was contrasted with shoulder pathology. Only a minority of the PIL discussed non-surgical treatments and of those that did, such approaches were predominantly portrayed as a temporary management option only, whilst surgery was frequently portrayed as the optimum treatment. CONCLUSION:There is variation in the content of NHS shoulder replacement PIL. The content and language used may not adequately support people in making an informed decision about whether surgery is the right treatment option for them. We need to better understand the information needs of people considering shoulder replacement surgery, and provide information that is accessible, culturally sensitive, and capable of facilitating shared decision making.

ObjectiveTo explore the patient experience of shared decision-making following a displaced collarbone injury, focusing on how patients understand their injury and how this influences decisions.DesignDescriptive qualitative study design using individual semi-structured interviews.SettingParticipants recruited from three United Kingdom National Health Service hospitals.ParticipantsPatients with a displaced collarbone injury were interviewed about their experiences of shared decision-making.Main measuresInterviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis.ResultsThree themes emerged: (1) Understanding of the injury, (2) Factors influencing treatment decision and (3) Experience of shared decision-making. Patients' interpretation of their injury, including the language used by clinicians, shaped their understanding and decisions. Factors such as previous injuries, employment, clinician advice and expectations also influenced treatment choices. Some patients described uncertainty during decision-making conversations and felt unsupported in choosing the option that best suited them. Others felt steered towards specific treatments without fully grasping their implications.ConclusionThis is the first qualitative interview study exploring patients' perspectives of shared decision-making following a displaced collarbone injury. While patients considered several factors when deciding between treatment options, many described limited involvement in decision-making and felt directed towards clinician-preferred treatments without fully understanding the implications. This highlights inconsistency in the implementation of shared decision-making in practice. Despite the United Kingdom National Health Service emphasis on shared decision-making, further efforts are needed to ensure that patients are actively supported in making informed, preference-sensitive decisions, in line with the goals of personalised care.

OBJECTIVE:To explore the information needs of people with elbow osteoarthritis. DESIGN:Qualitative interview study using reflexive thematic analysis. SETTING:A single National Health Service Teaching Hospital Trust and associated primary care services, providing musculoskeletal care across the clinical pathway. Interviews were conducted in person, by phone or video call according to participant preference. PARTICIPANTS:Twelve adults with clinically diagnosed elbow osteoarthritis, under the care of a general practitioner or consultant elbow surgeon, were included. RESULTS:Four themes were developed: (1) self-management in action, (2) experience of treatment options and navigating surgical decision making, (3) negotiating uncertainty and (4) active information seeking. Participants experiences were wide ranging and their varied information needs were at times unmet, particularly when related to treatment options, prognosis and surgical decision making. Across the clinical pathway, information was reported by some to be unclear or contradictory. Participants discussed a range of preferences for information sources. Accessing information was challenging for some participants and various barriers were discussed. CONCLUSIONS:This is the first study to report the lived experience of people with elbow osteoarthritis and their information needs. For some, accessing information can be challenging, and the unmet information needs can affect the ability to self-manage ongoing symptoms and participate in treatment decisions. These findings provide a platform for the development of accessible, meaningful and culturally sensitive information sources capable of contributing to optimal treatment pathways.

AimsTo evaluate the feasibility of a substantive cohort study to determine whether modifiable lifestyle factors, including smoking, physical inactivity, alcohol consumption and being overweight, affect patient-reported clinical outcomes after total knee replacement surgery.MethodsAdults awaiting total knee replacement surgery were recruited pre-operatively and completed self-reported questionnaires at baseline and 3- and 6-months post-surgery. Feasibility outcomes, including recruitment, retention and response rate of the primary outcome questionnaire were analysed descriptively.Results40 participants were recruited from 183 eligible patients (22%). 87.5% (35/40) participants returned questionnaires at 6-months. 85% (34/40) of participants were overweight (BMI > 24.9), 25% (10/40) drank alcohol (AUDIT-C > 4), 5% (2/40) smoked tobacco and 67.5% (27/40) were physically inactive (GPPAQ classification of 'moderately inactive', or 'inactive').ConclusionModifiable lifestyle factors including smoking, alcohol use, physical inactivity and being overweight are highly prevalent in patients waiting for total knee replacement. Based on this study, a future substantive cohort study investigating the effect of lifestyle factors on clinical outcomes post total knee replacement in the UK NHS is feasible.

BackgroundClinical guidelines recommend treatment by a physiotherapist for people with shoulder pain due to rotator cuff disorder. Despite this recommendation, research evidence supporting the effectiveness of treatment by a physiotherapist is uncertain. While developing a randomised controlled trial to test the effectiveness of treatment by a physiotherapist for people with shoulder pain due to rotator cuff disorders, we first aimed to understand current practice as a basis for defining usual care.MethodsAn online survey was developed based on a clinical vignette used in a previous survey exploring physiotherapy practice for people with shoulder pain due to rotator cuff disorder. UK-based physiotherapists were invited to complete the survey via X and email across professional networks.ResultsOne Hundred Seventy complete responses were received. 167 (98%) respondents would offer advice/education to patients with shoulder rotator cuff disorders; 146 (86%) would use isotonic exercise (including concentric/eccentric strengthening); 20 (12%) would offer a corticosteroid injection; 7 (4%) would use joint mobilisation. 168/169 (99%) would offer in-person assessment; 115 (68%) expect to deliver treatment over three to four sessions. Fifty percent agreed there is uncertainty about the effectiveness of physiotherapy treatment for patients with shoulder rotator cuff disorders. Seventy six percent agreed that patients with this condition can recover without physiotherapy intervention.ConclusionsExercise and advice remain the most common treatments offered by physiotherapists for people with shoulder pain due to rotator cuff disorder. Corticosteroid injections are infrequently considered. Uncertainty about the effectiveness of treatment by a physiotherapist for shoulder pain due to rotator cuff disorder is evident.

BackgroundFrozen shoulder is a condition associated with severe shoulder pain and loss of function impacting on a persons' physical and mental health. Hydrodistension treatment that has been widely adopted within the UK National Health Service for the condition. However, evidence of clinical effectiveness and understanding of the patient experiences of this treatment are lacking. This study explored the experiences of people with a frozen shoulder who received hydrodistension treatment.MethodsA qualitative design with repeat semi-structured interviews was used to explore participants' experiences of hydrodistension treatment. Participants were interviewed 2-4 weeks and again at 8-10 weeks after treatment. Interviews were audio-recorded and transcribed verbatim. Findings were analysed using an inductive thematic analysis framework. The study is reported in accordance with the consolidated criteria for reporting qualitative (COREQ) research.Results15 participants were interviewed online or over the phone. Three themes were identified: 'Preparing for and having a hydrodistension', 'Physiotherapy after hydrodistension', and 'Outcome of hydrodistension '. Participants believed hydrodistension would benefit them, was well tolerated by many, and the effects were apparent to most within the first week. Physiotherapy still seemed to be valued to support recovery beyond this timepoint, despite these early effects. Some participant's experienced harms including severe procedural pain and blood sugar dysregulation.ConclusionThis is the first study to investigate the experiences of people who undergo hydrodistension for frozen shoulder. Hydrodistension appears an acceptable treatment to participants with a frozen shoulder, acceptability is enhanced through adequate shared decision making. Further high-quality research is required to understand the comparative effectiveness of hydrodistension as a treatment for frozen shoulder, including adverse events, and the benefit of treatment by a physiotherapist after hydrodistension.

We propose a short-cut heuristic approach to rapidly estimate value of information (VOI) using information commonly reported in a research funding application to make a case for the need for further evaluative research. We develop a “Rapid VOI” approach, which focuses on uncertainty in the primary outcome of clinical effectiveness and uses this to explore the health consequences of decision uncertainty. We develop a freely accessible online tool, Rapid Assessment of the Need for Evidence (RANE), to allow for the efficient computation of the value of research. As a case study, the method was applied to a proposal for research on shoulder pain rehabilitation. The analysis was included as part of a successful application for research funding to the UK National Institute for Health and Care Research. Our approach enables research funders and applicants to rapidly estimate the value of proposed research. Rapid VOI relies on information that is readily available and reported in research funding applications. Rapid VOI supports research prioritisation and commissioning decisions where there is insufficient time and resources available to develop and validate complex decision-analytic models. The method provides a practical means for implementing VOI in practice, thus providing a starting point for deliberation and contributing to the transparency and accountability of research prioritisation decisions.

Objectives To explore the acceptability of an optimised physiotherapy (OPTimisE) intervention for people with lateral elbow tendinopathy (LET) and feasibility of comparing it to usual care in a randomised controlled trial.Design Semistructured interviews, analysed using thematic analysis and mapped onto the COM-B model of behaviour change.Setting Conducted as part of the OPTimisE Pilot & Feasibility randomised controlled trial within physiotherapy departments in the United Kingdom National Health Service.Participants 17 patients with LET (purposively sampled to provide representativeness based on age, sex, ethnicity, deprivation index and treatment allocation) and all 8 physiotherapists involved as treating clinicians or site principal investigators.Results Four themes were identified. First, participants reported the OPTimisE intervention as acceptable. Second, differences between the OPTimisE intervention and usual care were identified, including the use of an orthosis, holistic advice/education including modifiable risk factors, forearm stretches, general upper body strengthening and a more prescriptive exercise-dosing regimen. Third, participants provided feedback related to the trial resources, which were viewed positively, but identified language translation as a need. Fourth, feedback related to trial processes identified the need for changes to outcome collection and reduction of administrative burden. From the perspective of adopting the OPTimisE intervention, we found evidence that participants were able to change their behaviour. Considering the findings through the lens of the COM-B model, the intervention is likely to be deliverable in practice and the trial can be delivered at scale with some additional support for physiotherapists.Conclusions Overall, the OPTimisE intervention was found to be different to usual care and acceptable to patients and physiotherapists. The study highlighted the need to refine trial processes and resources prior to a full-scale trial, to reduce administrative burden, increase support for physiotherapists, improve return rate of outcome questionnaires and provide language translation.Trial registration number ISRCTN database 19 July 2021. https://www.isrctn.com/ISRCTN64444585.

Purpose: Our aim was to explore the experiences and perceptions of participants in a pilot randomised controlled trial that compared physiotherapist-led exercise to waiting-list control in adults with tears of the rotator cuff awaiting surgery.

BACKGROUND:Shoulder fractures (proximal humerus fractures) are common, painful, debilitating injuries. Recovery is a long process often hindered by complications such as mal-union and frozen shoulder. The purpose of this qualitative study was to explore the experiences and information needs of people at different time points after a shoulder fracture and how views on recovery change over time. METHODS:This longitudinal telephone interview study used a semi-structured approach based on a pre-planned interview topic guide. Recruitment was from June to November 2023. Participants were interviewed approximately two months and five to six months after their injury. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis. RESULTS:14 participants were recruited (age range 44-80 years; three male). The themes identified were dependence, vulnerability, information needs, and recovery. Loss of function and identity were associated with dependence. Feelings of vulnerability were present for most participants at six months post-injury. Information needs evolved, with information about the extent of the injury and practical advice needed first, but later participants emphasized the importance of reassurance and expected timelines for recovery. Recovery meant regaining function and independence, and returning to meaningful activities, which was also not fully achieved for most participants by six months. CONCLUSIONS:This study is the first to explore information needs and experiences along the timeline of recovery from a shoulder fracture. What recovery means to individual patients, along with recognition of the extent to which feelings of vulnerability affect recovery are important factors to consider. Clinicians should be aware of the full impact of these injuries to guide patients on their recovery journey, including identifying feelings of vulnerability and regaining their identity. Adopting a person-centred care approach, and considering the changing priorities and information needs of patients throughout their recovery journey may lead to improved patient care.

Introduction Despite the high number of operations and surgical advancement, rehabilitation after rotator cuff repair has not progressed for over 20 years. The traditional cautious approach might be contributing to suboptimal outcomes. Our aim is to assess whether individualised (early) patient-directed rehabilitation results in less shoulder pain and disability at 12 weeks after surgical repair of full-thickness tears of the rotator cuff compared with current standard (delayed) rehabilitation.Methods and analysis The rehabilitation after rotator cuff repair (RaCeR 2) study is a pragmatic multicentre, open-label, randomised controlled trial with internal pilot phase. It has a parallel group design with 1:1 allocation ratio, full health economic evaluation and quintet recruitment intervention. Adults awaiting arthroscopic surgical repair of a full-thickness tear are eligible to participate. On completion of surgery, 638 participants will be randomised. The intervention (individualised early patient-directed rehabilitation) includes advice to the patient to remove their sling as soon as they feel able, gradually begin using their arm as they feel able and a specific exercise programme. Sling removal and movement is progressed by the patient over time according to agreed goals and within their own pain and tolerance. The comparator (standard rehabilitation) includes advice to the patient to wear the sling for at least 4 weeks and only to remove while eating, washing, dressing or performing specific exercises. Progression is according to specific timeframes rather than as the patient feels able. The primary outcome measure is the Shoulder Pain and Disability Index total score at 12-week postrandomisation. The trial timeline is 56 months in total, from September 2022.Trial registration number ISRCTN11499185.

Background Many factors may influence a patient's decision to undergo rotator cuff repair surgery. The aim of this survey was to understand from a clinician's perspective how different factors influence the likelihood of a patient undergoing a repair. Methods An online survey presenting a range of clinical scenarios was distributed through professional networks to understand how each patient related factor influenced the likelihood of a patient undergoing a rotator cuff repair. Results One hundred three clinicians completed the survey. Clinicians indicated that patients were more likely to undergo a repair if they were younger, had a traumatic or larger tear, high pain levels (64.1%), high functional demands (93.2%), and arm weakness (86.4%). Surgery was less likely in older patients who had degenerative or smaller tears, diabetics (62.1%), smokers (78.9%) and those with high body mass index (57.3%). 74.8% of clinicians indicated a repair was more likely if the patient expected that surgery was required to improve symptoms. Discussion From a clinician's perspective, the decision to undergo surgery is complex, it is influenced by onset, age, tear size and other health related factors. Patient expectations of treatment also appear to influence the decision, and this is an area that needs further exploration.

Purpose: Whilst the impact of Lateral Elbow Tendinopathy (LET) has been studied in relation to work absence and healthcare utilisation, the experience of living with the condition has not been investigated. The objective of this study was to explore the lived experience of people with LET and its impact on quality-of-life.