Background/hypothesis: Shoulder pain in elite swimmers is common, and its pathogenesis is uncertain. Hypothesis/study design: The authors used a crosssectional study design to test Jobe's hypothesis that repetitive forceful swimming leads to shoulder laxity, which in turn leads to impingement pain. Methods: Eighty young elite swimmers (13-25 years of age) completed questionnaires on their swimming training, pain and shoulder function. They were given a standardised clinical shoulder examination, and tested for glenohumeral joint laxity using a non-invasive electronic laxometer. 52/80 swimmers also attended for shoulder MRI. Results: 73/80 (91%) swimmers reported shoulder pain. Most (84%) had a positive impingement sign, and 69% of those examined with MRI had supraspinatus tendinopathy. The impingement sign and MRIdetermined supraspinatus tendinopathy correlated strongly (r s =0.49, p<0.00001). Increased tendon thickness correlated with supraspinatus tendinopathy (r s =0.37, p<0.01). Laxity correlated weakly with impingement pain (r s =0.23, p<0.05) and was not associated with supraspinatus tendinopathy (r s =0.14, p=0.32). The number of hours swum/week (r s =0.39, p<0.005) and weekly mileage (r s =0.34, p=0.01) both correlated signifi cantly with supraspinatus tendinopathy. Swimming stroke preference did not. Conclusions: These data indicate: (1) supraspinatus tendinopathy is the major cause of shoulder pain in elite swimmers; (2) this tendinopathy is induced by large amounts of swimming training; and (3) shoulder laxity per se has only a minimal association with shoulder impingement in elite swimmers. These fi ndings are consistent with animal and tissue culture fi ndings which support an alternate hypothesis: the intensity and duration of load to tendon fi bres and cells cause tendinopathy, impingement and shoulder pain.

Objective: To determine the interobserver and intraobserver reliability of the interpretation of MRIs for supraspinatus tendinosis. Methods: In the interobserver trial, the MRIs of 52 athletes' shoulders were observed by 3 observers on one occasion within a 2-month period. All 52 images were read by the most experienced musculoskeletal radiologist on 3 different occasions on separate days without access to the previous readings for the intraobserver trial. Supraspinatus tendinosis was graded using a modified 4-point scale from grades 0 to grade 3. Results: The grading of MRI-determined supraspinatus tendinosis was reliable, having an intraclass correlation (ICC) of 0.85 when assessed by the single well-trained observer. Interobserver reliability was only fair to good (ICC = 0.55). Conclusions: Supraspinatus tendinosis can be accurately identified on MRI with little variation by a single well-trained observer. Interobserver reliability was only fair to good. Our data indicated that the reliability of the assessment was much greater in more experienced radiologists than in those with less experience. M RI has proven to be useful in the assessment of rotator cuff injuries. MRI is a non-invasive method of imaging and is unique in that it allows the differentiation of soft tissue structures.1 Improvements in MRI techniques, including fast spin-echo imaging and fat saturation, have facilitated demonstration of tendinous abnormalities of the rotator cuff.The MRI findings of rotator cuff tendinopathy are characterised by thickened inhomogeneous rotator cuff tendon with increased signal intensity on all pulse sequences. 2 Fluid intensity filling an incomplete gap in the tendon on fatsuppressed T2-weighted sequences changes are seen on MRI for partial-thickness tears.3 On MRI, an area of high signal intensity on all pulse sequences outlines complete disruption of the tendon.

The HR 12-25 programme was the most effective implementation strategy. Estimation of the break-even cost of health expenditure savings will enable optimal future programme design, implementation and expenditure.

Treatment costs are highest during two phases over the natural cycle of the disease, the initial diagnosis phase and the metastatic treatment phase. Both the initial phase costs and low-risk category costs are driven largely by the rates of radical prostatectomy. Our study provides comprehensive long-term estimates of PCa costs.

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