A prospective, multipractice study of shoulder function and health status in patients with documented rotator cuff tears

Elevated Body Mass Index Is Associated With Rotator Cuff Disease: A Systematic Review and Meta-analysis

Purpose

To analyze the literature regarding obesity, body mass index (BMI), and rotator cuff disease (RCD).

Methods

In this Systematic Review and Meta-analysis, we queried PubMed, Embase, Cochrane, Cumulative Index to Nursing & Allied Health, and Science Direct using key words (August 25, 2023). Analytic observational studies (cohort, case-control, and cross-sectional studies) with more than 30 participants per comparison group, evaluating the association between obesity and rotator cuff pathology, were eligible for inclusion. Meta-analysis was performed to quantitatively summarize associations between BMI and RCD to report odds ratios and corresponding 95% confidence intervals (CIs) for regression-based models and BMI mean differences between cases and controls. Risk Of Bias In Non-randomised Studies - of Interventions tool was used to evaluate risk of bias across all studies in the systematic review.

Results

After full-text review of 248 articles, 27 presented data on obesity and RCD, and 17 qualified for meta-analysis. Individuals with RCD were 1.21 times (95% CI 1.10-1.34) as likely to have overweight and 1.44 times (95% CI 1.32-1.59) as likely to have obesity compared with those without RCD. Each 5-unit increase in BMI was associated with 35% greater odds of having rotator cuff tear (95% CI 1.06-1.71). In-depth assessment for risk of bias shows quality of studies varies greatly and highlights outcome heterogeneity, lack of temporality, confounding and selection bias as major concerns for individual studies.

Conclusions

In this study, we found a positive association between elevated BMI and RCD.

Level of Evidence

Level III, systematic review and meta-analysis of Level II-III studies.

Comparative effectiveness of low-level laser therapy versus muscle energy technique among diabetic patients with frozen shoulder: a study protocol for a parallel group randomised controlled trial

BACKGROUND

Diabetes mellitus is one of the fastest-growing health challenges of the twenty-first century with multifactorial impact including high rates of morbidity and mortality as well as increased healthcare costs. It is associated with musculoskeletal complications, with frozen shoulder being commonly reported. While low-level laser therapy (LLLT) and muscle energy technique (MET) are commonly used to manage  this condition, there remains a lack of agreement on the most effective approach, with limited research available on their comparative efficacy.

OBJECTIVES

To evaluate the comparative effectiveness of LLLT versus MET among diabetic patients with frozen shoulder.

METHODS

This is a single-centre, prospective, single-blind, randomised controlled trial with three parallel groups to be conducted at Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria. Sixty diabetic patients with frozen shoulder will be randomly assigned into LLLT group, MET group, or control group in a 1:1:1 ratio. All the groups will receive treatment three times weekly for 8 weeks. The primary outcome will be shoulder function and the secondary outcomes will include pain intensity, shoulder ROM, interleukin-6 (IL-6), depression, anxiety, and quality of life (QoL). All outcomes will be assessed at baseline, at post 8-week intervention, and at 3 months follow-up.

DISCUSSION

This will be the first randomised controlled trial to evaluate the comparative effectiveness of LLLT versus MET on both clinical and psychological parameters among diabetic patients with frozen shoulder. The findings of the study may provide evidence on the efficacy of these interventions and most likely, the optimal treatment approach for frozen shoulder related to diabetes, which may guide clinical practice.

TRIAL REGISTRATION

Pan African Clinical Trials Registry (PACTR202208562111554). Registered on August 10, 2022.

Deep-Learning-Based Segmentation of the Shoulder from MRI with Inference Accuracy Prediction

Three-dimensional (3D)-image-based anatomical analysis of rotator cuff tear patients has been proposed as a way to improve repair prognosis analysis to reduce the incidence of postoperative retear. However, for application in clinics, an efficient and robust method for the segmentation of anatomy from MRI is required. We present the use of a deep learning network for automatic segmentation of the humerus, scapula, and rotator cuff muscles with integrated automatic result verification. Trained on N = 111 and tested on N = 60 diagnostic T1-weighted MRI of 76 rotator cuff tear patients acquired from 19 centers, a nnU-Net segmented the anatomy with an average Dice coefficient of 0.91 ± 0.06. For the automatic identification of inaccurate segmentations during the inference procedure, the nnU-Net framework was adapted to allow for the estimation of label-specific network uncertainty directly from its subnetworks. The average Dice coefficient of segmentation results from the subnetworks identified labels requiring segmentation correction with an average sensitivity of 1.0 and a specificity of 0.94. The presented automatic methods facilitate the use of 3D diagnosis in clinical routine by eliminating the need for time-consuming manual segmentation and slice-by-slice segmentation verification.

Reliability and validity of the Shoulder Pain and Disability Index in a sample of patients with frozen shoulder

BACKGROUND

The Shoulder and Pain Disability Index (SPADI) is a widely used outcome measure. The aim of this study is to explore the reliability and validity of SPADI in a sample of patients with idiopathic frozen shoulder.

METHODS

The SPADI was administered to 124 patients with idiopathic frozen shoulder. A sub-group of 29 patients were retested after 7 days. SPADI scores were correlated with other outcome measures (i.e., Disabilities of the Arm, Shoulder and Hand Questionnaire - DASH; Numerical Pain Rating Scale-NPRS; and 36-item Short Form Health Survey-SF-36) to examine construct validity. Structural validity was assessed by a Two-Factors Confirmatory Factor Analysis (CFA). Internal consistency, test-retest reliability, and measurement error were also analyzed.

RESULTS

The construct validity was satisfactory as seven out of eight of the expected correlations formulated (≥ 75%) for the subscales were satisfied. The CFA showed good values of all indicators for both Pain and Disability subscales (Comparative Fit Index = 0.999; Tucker-Lewis Index = 0.997; Root Mean Square Error of Approximation = 0.030). Internal consistency was good for pain (α = 0.859) and disability (α = 0.895) subscales. High test-retest reliability (Intraclass correlation coefficient [ICC]) was found for pain (ICC = 0.989 [95% Confidence Interval (CI = 0.975-0.995]) and disability (ICC = 0.990 [95% CI = 0.988-0.998]). Standard Error of Measurement values of 2.27 and 2.32 and Minimal Detectable Change values of 6.27 and 6.25 were calculated for pain and disability subscales, respectively.

CONCLUSION

The SPADI demonstrated satisfactory reliability and validity properties in a sample of patients with idiopathic frozen shoulder.

Glomus tumor of the scapular neck with axillary nerve compression at the shoulder. A case report

Background

Glomus tumors, also known as benign acral tumors are extremely rare. Previous glomus tumors from other regions of the body have been linked to neurological compression symptoms, however axillary compression at the scapular neck has never been described.

Case presentation

Here, we report a case of axillary nerve compression in a 47-year-old man, secondary to a glomus tumor of the neck of the right scapula, initially misdiagnosed with biceps tenodesis performed and no pain improvement. The magnetic resonance imaging demonstrated a well-contoured, 12 mm tumefaction at the inferior pole of the scapular neck T2-hyperintense and T1-isointense and interpreted as a neuroma. An axillary approach allowed the dissection of the axillary nerve, and the tumor was completely removed. The pathological anatomical analysis resulted in a nodular red lesion measuring 14 × 10 mm, delimited and encapsulated with a definitive diagnostic of glomus tumor. The neurologic symptoms and pain disappeared 3 weeks after surgery and the patient reported satisfaction with the surgical procedure. After 3 months, the results remain stable with a complete resolution of the symptoms.

Conclusions

In cases of unexplained and atypical pain in the axillary area, and to avoid potential misdiagnoses and inappropriate treatments, an in-depth exploration for a compressive tumor should be performed as a differential diagnosis.

Nocturnal pain in patients with rotator cuff related shoulder pain: A prospective study

INTRODUCTION

Nocturnal pain is a common complaint in rotator cuff related shoulder pain (RCRSP), and there is no study in literature that has evaluated the relationship between nocturnal pain severity and other evaluation parameters in RCRSP. The objective of the study was to investigate the relationship between the severity of nighttime pain and demographic and clinical data including physical examination findings, magnetic resonance imaging (MRI) findings, disability, kinesiophobia, and quality of life scores in patients diagnosed with RCRSP.

MATERIALS AND METHODS

We assessed 61 patients (52.4% female) using the Visual Analog Scale (VAS) for nighttime and daytime, Shoulder Pain and Disability Questionnaire (SPADI), Tampa Scale of Kinesiophobia (TSK), and Short Form-36 (SF-36). Demographic and clinical data were recorded and rotator cuff specific examinations were performed and documented. RCRSP lesions were evaluated in terms of tendonitis and rupture by MRI.

RESULTS

The nighttime VAS score was positively correlated with SPADI disability and total scores, and daytime VAS score, and negatively correlated with SF-36 physical function subscale. The nighttime VAS score was associated with presence of calcific tendonitis in supraspinatus, infraspinatus tendinosis, and subscapularis tendinosis. On multivariate analysis with a linear regression model, presence of subscapularis tendinosis was an independent predictor of nighttime VAS score. In shoulder clinical tests, the nighttime VAS score correlated with only Neer test positivity.

CONCLUSIONS

Our results suggest that there is a relationship between nocturnal pain severity and disability. Presence of subscapularis tendinosis appears to be a predictor of nocturnal pain severity. Additionally, patients with positive Neer test may experience more nocturnal pain.

Efficacy of balance training on postural control in patients with rotator cuff disease: a randomized controlled study

We evaluated the efficacy of adding balance training to a physical therapy program on postural control and health-related quality of life in patients with rotator cuff disease. Forty-two participants were randomly allocated to the control and intervention groups. Both groups received physical therapy (education, stretching, supervised strength training, and home exercise program) 3 days/week for 6 weeks. The intervention group was instructed to perform balance exercises at home. The primary outcomes were the stability index, the Fourier transformation (F5 and F6), the weight distribution index, and the fall index, as assessed by the posturography during eight conditions with different combinations of standing (solid surface, pillows, and different head positions) and vision (eyes open/closed). The secondary outcomes included the Western Ontario Rotator Cuff Index to assess the health-related quality of life, the Shoulder Pain and Disability Index, and the Numeric Pain Rating Scale. The adherence to in-person and home-based therapy was high (>83%). The intervention group significantly improved the stability index, F5, and F6 parameters but each in only one condition (P < 0.05). No significant improvement was found in the conditions for the other primary outcomes and in the health-related quality of life. (P > 0.05). We conclude that adding the balance training protocol to the physical therapy program does not improve postural control and health-related quality of life in patients with rotator cuff disease.

Three-Dimensional Kinematics during Shoulder Scaption in Asymptomatic and Symptomatic Subjects by Inertial Sensors: A Cross-Sectional Study

Shoulder kinematics is a measure of interest in the clinical setting for diagnosis, evaluating treatment, and quantifying possible changes. The aim was to compare shoulder scaption kinematics between symptomatic and asymptomatic subjects by inertial sensors. Methods: Scaption kinematics of 27 subjects with shoulder symptomatology and 16 asymptomatic subjects were evaluated using four inertial sensors placed on the humerus, scapula, forearm, and sternum. Mobility, velocity, and acceleration were obtained from each sensor and the vector norm was calculated from the three spatial axis (x,y,Z). Shoulder function was measured by Upper Limb Functional Index and Disabilities of the Arm, Shoulder, and Hand questionnaires. One way ANOVA was calculated to test differences between the two groups. Effect size was calculated by Cohen’s d with 95% coefficient Intervals. Pearson’s correlation analysis was performed between the vector norms humerus and scapula kinematics against DASH and ULFI results in symptomatic subjects. Results: The asymptomatic group showed higher kinematic values, especially in the humerus and forearm. Symptomatic subjects showed significantly lower values of mobility for scapular protraction-retraction (Cohen’s d 2.654 (1.819–3.489) and anteriorisation-posteriorisation (Cohen’s d 1.195 (0.527–1.863). Values were also lower in symptomatic subjects for velocity in all scapular planes of motion. Negative correlation showed that subjects with higher scores in ULFI or DASH had lower kinematics values. Conclusion: Asymptomatic subjects tend to present greater kinematics in terms of mobility, velocity, and linear acceleration of the upper limb, and lower humerus and scapula kinematics in symptomatic subjects is associated with lower levels of function.

The associations of emotional health with pain, disability, and health-related quality of life in patients with rotator cuff disease

BACKGROUND

Psychosocial factors have been associated with poor outcomes in patients with rotator cuff disease. Emotional health is one of these factors, and relationships between emotional health and outcome measures evaluated before and after physical therapy have not been reported.

AIM

To investigate the associations of baseline emotional health status with pre-treatment, post-treatment, and pre-to-post changes in pain, disability and health-related quality of life in patients with rotator cuff disease.

METHODS

Forty-one patients with rotator cuff disease were included. Emotional health was measured with the emotions domain of the Western Ontario Rotator Cuff Index (WORC). The outcomes were the WORC-total, the Shoulder Pain and Disability Index, and the numeric pain rating scale. All outcomes were measured at baseline and 6-week follow-up.

RESULTS

The baseline emotional health score and the outcomes scores were moderate to strong, and weak to moderate correlated at baseline and at follow-up, respectively. There was no correlation between the baseline emotional health score and the changes in the outcome measures from baseline to follow-up.

CONCLUSIONS

Lower baseline emotional health status was associated with worse outcomes in pain, disability and health-related quality of life at baseline and follow-up in patients with rotator cuff disease. However, the changes in these outcome measures from baseline to follow-up were not correlated with the baseline emotional health status. In clinical practice, an assessment of patients' emotional health status using standardised measures may help to predict post-treatment outcomes, and a multidisciplinary cooperation (e.g., among physical therapists and psychologists) may enhance outcomes.

Shoulder Arthroscopic Rotator Cuff Repair With Biceps Tenodesis and Acromioplasty Using a Single Working Portal

Rotator cuff repair, acromioplasty, and biceps tenodesis operations have become some of the most common shoulder surgical procedures, evolving from open techniques to minimally invasive arthroscopic techniques. The use of many arthroscopic portals has been associated with surgical risks to many surrounding anatomic structures. We present an arthroscopic technique using a single anterolateral working portal for rotator cuff repair, acromioplasty, distal clavicle excision, and long head of the biceps tenodesis; this technique decreases the risk of injury to the surrounding neurovascular and musculotendinous structures, enables a faster recovery, and is minimally invasive.

The relationship of range of motion and muscle strength to patients' perspectives in pain, disability, and health-related quality of life in patients with rotator cuff disease

BACKGROUND

The literature emphasizes that a consideration of patients' perspectives is an important part of the assessment process; however, it is ignored by many clinicians because they believe physical impairment measures can reflect patients' perspectives about their symptoms. But the relevance of changes in physical impairments to changes in patient-reported outcome scores in rotator cuff disease is ambiguous.

AIMS

The purpose of this study is to determine the relationship between changes in glenohumeral range of motion (ROM) and shoulder muscle strength and changes in pain, disability, and health-related quality of life scores before and after physical therapy in patients with rotator cuff disease.

METHODS

This was a retrospective study of thirty-nine patients with unilateral rotator cuff disease. All patients received a 6-week physical therapy program. The outcome measures were glenohumeral ROM, shoulder muscle strength, pain and disability using the Shoulder Pain and Disability Index (SPADI), and health-related quality of life as measured by the Western Ontario Rotator Cuff Index. All outcomes were measured before and after the treatment period.

RESULTS

There were weak correlations between the changes in abduction ROM and the SPADI-total score (r = - 0.32, p < 0.05), and the changes in external rotation strength and the SPADI-disability score (r = - 0.32, p < 0.05). There was no correlation between the changes in the other parameters.

CONCLUSIONS

This study implies that the changes in glenohumeral ROM and shoulder muscle strength do not represent the changes in patients' perspectives in pain, disability, and health-related quality of life after the physical therapy program in patients with rotator cuff disease.

Evaluation of animal models and methods for assessing shoulder function after rotator cuff tear: A systematic review

BACKGROUND AND OBJECTIVE

Restoring the shoulder function is a crucial demand of patients with rotator cuff (RC) tears. Most preclinical studies only focused on biological and mechanical measurements. Functional assessment was less investigated in the preclinical studies. This study aims to review the literature of shoulder function in animal models for RC tears and evaluate the strengths and weaknesses of different shoulder functional assessments and animal models.

METHOD

A literature search for studies used RC tear animal models to evaluate changes in shoulder function was performed. We searched databases of PubMed, Embase, Web of Science, and Scopus from inception to September 2019. Animal species, functional parameters, injury and repair types, and study durations were summarised. Cluster analyses were then used to separate animal models with different levels of injury and timings of repair. The reliability and clinical relevance of the included assessments and animal models were then discussed.

RESULTS

Fourteen animal studies that related to shoulder function in animal models of RC tears were reviewed. Five methods (gait analysis, passive range of motion test, open field test, staircase test, and running endurance test) to assess shoulder function were identified. Single or massive RC tendon tears and immediate or delayed RC repair models were found. We reported and discussed factors to be considered when researchers would select assessments and animal models for different study purposes.

CONCLUSION

Based on current evidences, gait analysis is the most appropriate method to assess changes in shoulder function of animal models of RC tears. More studies are required to further elucidate the reliability of passive range of motion measurement, open field test, staircase test, and running endurance test. Models that use massive tears and delayed repair better represent the clinical condition found in humans.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

Using more clinically relevant animal models and assessments for shoulder function identified in this review may help to investigate the value of preclinical researches and promote translation of preclinical interventions into clinical practices.

Increased Health Care Costs and Opioid Use in Patients with Anxiety and Depression Undergoing Rotator Cuff Repair

PURPOSE

To (1) quantify the prevalence of mood disorders in patients undergoing arthroscopic rotator cuff repair (RCR) by use of a large claims database and (2) compare opioid use and medical costs in the year before and the year after RCR between patients with and without comorbid mood disorders.

METHODS

A large claims database was queried to identify patients who underwent arthroscopic RCR (Current Procedural Terminology code 29827) between October 2010 and December 2015. All patients were then screened for insurance claims relating to either anxiety or depression. We compared net costs and opioid use both 1 year preoperatively and 1 year postoperatively between patients with and without mood disorders by use of an analysis of covariance.

RESULTS

A total of 170,329 patients (97,427 male patients [57.2%] and 72,902 female patients [42.8%]) undergoing arthroscopic RCR were identified. Of the 170,329 patients, 46,737 (27.4%) had comorbid anxiety or depression, and after adjustment for preoperative cost, sex, age, and both preoperative and postoperative opioid use, the 1-year postoperative cost was 7.05% higher for those with a preoperative mood disorder than for those without a mood disorder. In addition, opioid use both in the 180 days prior to surgery (36.7% vs 26.9%) and more than 90 days after surgery (33.0% vs 27.2%) was substantially greater in the group with comorbid depression or anxiety.

CONCLUSIONS

In patients with comorbid mood disorders, opioid use and health care costs were increased both preoperatively and postoperatively. The increased cost in this patient population is estimated at $62.3 million annually. In an effort to provide high-quality, value-based care, treatment strategies should be developed to identify these patients preoperatively and provide the appropriate resources needed to improve the probability of a successful surgical outcome.

LEVEL OF EVIDENCE

Level III, retrospective, comparative therapeutic study.

The effect of psychological factors on pain, function and quality of life in patients with rotator cuff tendinopathy: A systematic review

BACKGROUND

Psychological factors may affect the pain level, shoulder function and quality of life in patients with rotator cuff tendinopathy.

OBJECTIVE

To systematically review the prevalence of psychological factors reported in patients with rotator cuff tendinopathy; and to determine the association between psychological factors and pain, function and quality of life in patients with rotator cuff tendinopathy.

STUDY DESIGN

Systematic review METHODS: Pubmed, Embase, CINAHL and Web of Science were systematically searched from inception to June 2019. Studies that investigated patients with signs and symptoms suggestive of rotator cuff tendinopathy, and reported psychological variables and patient-reported outcome measures including pain, shoulder function or disability and quality of life.

RESULTS

A total of 14 studies were included. Our results showed that 22.8%-26.2% of patients with rotator cuff tendinopathy reported depression; 23% reported anxiety; and 70.2%-89% of patients reported sleep disturbance or insomnia. Overall, nine psychological factors were identified to be associated with pain, function and quality of life in patients with rotator cuff tendinopathy. Low-to-moderate quality of evidence suggests that various psychological factors are associated with pain, function and quality of life in patients with rotator cuff tendinopathy CONCLUSION: This review identified various psychological factors may affect the pain level, shoulder function and quality of life in patients with rotator cuff tendinopathy, and the causal relationship warrants future high-quality prospective studies.

The Effect of Psychosocial Factors on Outcomes in Patients With Rotator Cuff Tears: A Systematic Review

PURPOSE

To determine whether psychosocial factors affect patient-reported outcomes in individuals with rotator cuff tears or after rotator cuff repair.

METHODS

A systematic review was conducted using a computerized search of the PubMed and Web of Science electronic databases in adherence with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Articles were then evaluated based on inclusion and exclusion criteria. The Newcastle-Ottawa Scale was used to assess study quality and risk of bias. Because of study heterogeneity and varied levels of evidence, meta-analysis was not possible.

RESULTS

Of 980 identified articles, 15 met the inclusion and exclusion criteria. In those reported, the visual analog scale correlation with distress scales ranged from -0.476 to 0.334, depending on outcome, with a trend toward increased pain in patients with distress. The depression subscale of the Hospital Anxiety and Depression Scale was negatively correlated with the American Shoulder and Elbow Surgeons score in 2 of 3 studies (-0.309 to 0.235). Six studies evaluated the presence of psychosocial factors and their correlation with patient-reported outcomes prior to surgery. These showed a significant correlation between rotator cuff pathology and psychological distress (i.e., depression or anxiety) as identified on standardized patient-reported outcome measures. Nine studies evaluated psychosocial factors either before and after surgery or only postoperatively. Of these 9 studies, 3 found no statistically significant differences in outcomes as related to psychosocial factors. In contrast, 6 of 9 reported an association between outcomes and psychosocial factors. Moreover, 2 of these 6 studies reported a direct relationship between patient expectations and outcomes, with 1 of these 2 studies finding that higher expectations improved baseline scores on the mental component summary of the Short Form 36 (r = 0.307). One study found significant differences in mental status in patients with rotator cuff tears based on age and sex.

CONCLUSIONS

This review found that most studies support that psychosocial factors do significantly influence the level of disability and pain experienced by patients preoperatively; however, 3 of 9 studies showed significant improvements in postoperative pain and function even with significant psychosocial confounders. These studies, however, do support that there is a direct relation between patient expectations and outcomes in rotator cuff surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Synovitis as a concomitant disease in shoulder pathologies

INTRODUCTION

Shoulder pathologies are often accompanied by rotator interval synovitis. This phenomenon is poorly described in the literature so far. The aim of the study was to analyze the occurrence of macroscopically visible synovial reaction in the rotator interval in patients with chronic shoulder pathologies and to perform a histopathological evaluation.

MATERIALS AND METHODS

In this prospective cohort study, 167 consecutive patients undergoing arthroscopic shoulder surgery for chronic shoulder pathology were included (♀ = 45, ♂ = 122; [Formula: see text]54.5 years ± 12.8). Included patients were divided into subgroups according to the encountered chronic shoulder pathology: (1) impingement syndrome with or without bursal sided partial rotator cuff tear (RCT); (2) articular sided partial RCT; (3) full-thickness RCT; (4) RCT that involves at least two tendons; (5) shoulder instability; and (6) cartilage damage. Standardized soft tissue biopsies from the rotator interval were taken. The synovitis score of Krenn/Morawietz was used for histopathological examination.

RESULTS

Extraarticular pathology (group 1) showed significantly decreased synovitis scores compared to all the other groups. Increased size of rotator cuff tears (group 4), as well as cartilage damage (group 6) showed significantly higher synovitis scores than group 3 (p < 0.05). Moreover, the synovitis score was significantly increased in patients with concomitant pathologies of the long head of the biceps (p = 0.001).

CONCLUSIONS

This study suggests that chronic intra- and extraarticular shoulder diseases are very often accompanied by a histopathologically verifiable low-grade synovitis. Intraarticular pathologies seem to induce increased levels of synovitis. Furthermore, the increased size of rotator cuff tears is accompanied by a higher degree of synovitis.

STUDY DESIGN

Cohort study, level of evidence, 2b.

Asymptomatic Rotator Cuff Tears

Asymptomatic rotator cuff tears (RCTs) are prevalent in the general population; they are positively associated with age and are common in the contralateral shoulder of individuals who are being treated for shoulder pain or a symptomatic RCT. Asymptomatic RCTs are likely to become symptomatic over time, corresponding with decreased patient-reported function, strength, and range of motion. Previous studies have largely reported inconsistent findings regarding patient-reported outcomes, strength, range of motion, and kinematics in individuals with asymptomatic RCTs. Future research would benefit from characterizing any functional alteration that is associated with asymptomatic rotator cuff pathology, including determining whether such alterations are detrimental or compensatory and understanding the mechanism by which an asymptomatic RCT becomes symptomatic.

What Imaging-Detected Pathologies Are Associated With Shoulder Symptoms and Their Persistence? A Systematic Literature Review

Objective

Shoulder symptoms are common, and imaging is being increasingly used to help with management. However, the relationship between imaging and symptoms remains unclear. This review aims to understand the relationship between imaging‐detected pathologies, symptoms, and their persistence.

Methods

A systematic review using Medline, EMBASE, Cochrane, and grey literature was conducted to April 2017. The cross‐sectional and longitudinal relationships between imaging‐detected abnormalities and symptoms were analyzed and associations qualitatively characterized by a best‐evidence synthesis based on study design, covariate adjustment, and the Grade of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Modalities included ultrasound, magnetic resonance imaging (MRI), radiographs, positron emission tomography (PET), bone scintigraphy, and computed tomography.

Results

A total of 6,569 abstracts was screened and 56 articles were included. In total, 50 studies did not adjust for covariates and 36 analyzed individual pathologies only. The majority of studies showed conflicting results. There was no significant association between most imaging features and symptoms among high‐quality, cross‐sectional studies. There was low‐quality evidence that enhancement of the joint capsule on MRI and increased uptake on PET were associated with symptoms in adhesive capsulitis. Based on high‐quality longitudinal studies, enlarging rotator cuff tears were associated with an increased incidence of symptoms.

Conclusion

There were conflicting results on the association of imaging features with shoulder symptoms and their persistence. The existing evidence was very low in quality, based on the GRADE methodology. Further high‐quality studies are required to understand the relationship between imaging and shoulder symptoms and to determine the appropriate role of imaging in care pathways.

A lightweight sensing platform for monitoring sleep quality and posture: a simulated validation study

Background

The prevalence of self-reported shoulder pain in the UK has been estimated at 16%. This has been linked with significant sleep disturbance. It is possible that this relationship is bidirectional, with both symptoms capable of causing the other. Within the field of sleep monitoring, there is a requirement for a mobile and unobtrusive device capable of monitoring sleep posture and quality. This study investigates the feasibility of a wearable sleep system (WSS) in accurately detecting sleeping posture and physical activity.

Methods

Sixteen healthy subjects were recruited and fitted with three wearable inertial sensors on the trunk and forearms. Ten participants were entered into a ‘Posture’ protocol; assuming a series of common sleeping postures in a simulated bedroom. Five participants completed an ‘Activity’ protocol, in which a triphasic simulated sleep was performed including awake, sleep and REM phases. A combined sleep posture and activity protocol was then conducted as a ‘Proof of Concept’ model. Data were used to train a posture detection algorithm, and added to activity to predict sleep phase. Classification accuracy of the WSS was measured during the simulations.

Results

The WSS was found to have an overall accuracy of 99.5% in detection of four major postures, and 92.5% in the detection of eight minor postures. Prediction of sleep phase using activity measurements was accurate in 97.3% of the simulations. The ability of the system to accurately detect both posture and activity enabled the design of a conceptual layout for a user-friendly tablet application.

Conclusions

The study presents a pervasive wearable sensor platform, which can accurately detect both sleeping posture and activity in non-specialised environments. The extent and accuracy of sleep metrics available advances the current state-of-the-art technology. This has potential diagnostic implications in musculoskeletal pathology and with the addition of alerts may provide therapeutic value in a range of areas including the prevention of pressure sores.

Electronic supplementary material

The online version of this article (10.1186/s40001-018-0326-9) contains supplementary material, which is available to authorized users.

Primary and Secondary Consequences of Rotator Cuff Injury on Joint Stabilizing Tissues in the Shoulder

Rotator cuff tears (RCTs) are one of the primary causes of shoulder pain and dysfunction in the upper extremity accounting over 4.5 million physician visits per year with 250,000 rotator cuff repairs being performed annually in the U.S. While the tear is often considered an injury to a specific tendon/tendons and consequently treated as such, there are secondary effects of RCTs that may have significant consequences for shoulder function. Specifically, RCTs have been shown to affect the joint cartilage, bone, the ligaments, as well as the remaining intact tendons of the shoulder joint. Injuries associated with the upper extremities account for the largest percent of workplace injuries. Unfortunately, the variable success rate related to RCTs motivates the need for a better understanding of the biomechanical consequences associated with the shoulder injuries. Understanding the timing of the injury and the secondary anatomic consequences that are likely to have occurred are also of great importance in treatment planning because the approach to the treatment algorithm is influenced by the functional and anatomic state of the rotator cuff and the shoulder complex in general. In this review, we summarized the contribution of RCTs to joint stability in terms of both primary (injured tendon) and secondary (remaining tissues) consequences including anatomic changes in the tissues surrounding the affected tendon/tendons. The mechanical basis of normal shoulder joint function depends on the balance between active muscle forces and passive stabilization from the joint surfaces, capsular ligaments, and labrum. Evaluating the role of all tissues working together as a system for maintaining joint stability during function is important to understand the effects of RCT, specifically in the working population, and may provide insight into root causes of shoulder injury.

Analysis of hydrodilatation as part of a combined service for stiff shoulder

BACKGROUND

Adhesive capsulitis is a common cause of stiff shoulder and may result in pain and restriction of movement. The study aimed to investigate the role of hydrodilatation of the glenohumeral joint in the management of adhesive capsulitis.

METHODS

Patients referred from the shoulder clinic underwent hydrodilatation under ultrasound guidance. Of 209 referred for hydrodilatation, 163 underwent the procedure and attended follow-up physiotherapy. Outcome measures were available for 118 patients (58 men and 60 women). Mean age of the study group was 52.6 years.

RESULTS

There was a statistically significant improvement in both Oxford Shoulder Score (OSS) and Disability Arm Shoulder Hand Scores (Quick DASH) in the first 4 weeks after the procedure, which was maintained but not improved to the end of the study period. Patients presenting with pain, those who had a history of steroid injections and older patients all had worse functional scores at presentation. Diabetes (both Type I and II), previous physiotherapy, length of history and whether pain or stiffness, or both, were the predominant symptom did not have any statistical significance at presentation. These factors were not predictors of any statistically significant improvement in functional scores.

CONCLUSIONS

Hydrodilatation results in a significant improvement of symptoms in patients with adhesive capsulitis.

Influence of psychological factors on the prognosis of chronic shoulder pain: protocol for a prospective cohort study

INTRODUCTION

Shoulder pain is a highly prevalent condition. Psychological factors could play an essential role in the prognosis of chronic shoulder pain (CSP). The aims of the study will be to analyse the level of association between psychological factors and pain-disability at baseline and prospectively to assess their prognostic role; to evaluate the association of pain catastrophising and kinesiophobia at baseline and prospectively in the relationship between pain intensity and disability, or between self-efficacy and disability in patients with CSP; to explore the association of self-efficacy at baseline and prospectively in the relationship between pain intensity and disability, in comparison with kinesiophobia and pain catastrophising.

METHODS AND ANALYSIS

The study is a longitudinal, prospective cohort study with a 12-month follow-up. It will be conducted in 4 primary-care centres and one hospital of the province of Malaga, Spain. 307 participants aged between 18 and 70 years suffering from CSP (3 months or more) will be included. Primary outcomes will include pain, disability and self-efficacy, whereas kinesiophobia, pain-related fear, pain catastrophising, anxiety, depression, patient expectations of recovery, age, gender, duration/intensity of symptoms, educational level and other factors will be predictive measures.

FOLLOW-UP

baseline, 3, 6 and 12 months.

ETHICS AND DISSEMINATION

The local ethics committee (The Costa del Sol Ethics Committee, Malaga, 28042016) has approved this protocol. Dissemination will occur through presentations at National and International conferences and publications in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02738372; pre-results.

Ultrasound-detected pathologies cluster into groups with different clinical outcomes: data from 3000 community referrals for shoulder pain

Background

Ultrasound is increasingly used to evaluate shoulder pain, but the benefits of this are unclear. In this study, we examined whether ultrasound-defined pathologies have implications for clinical outcomes.

Methods

We extracted reported pathologies from 3000 ultrasound scans of people with shoulder pain referred from primary care. In latent class analysis (LCA), we identified whether individual pathologies clustered in groups. Optimal group number was determined by the minimum Bayesian information criterion. A questionnaire was sent to all patients scanned over a 12-month period (n = 2322). Data collected included demographics, treatments received, current pain and function. The relationship between pathology-defined groups and clinical outcomes was examined.

Results

LCA revealed four groups: (1) bursitis with limited inflammation elsewhere (n = 1280), (2) bursitis with extensive inflammation (n = 595), (3) rotator cuff tears (n = 558) and (4) limited pathology (n = 567). A total of 777 subjects (33%) completed questionnaires. The median (IQR) duration post-ultrasound scan was 25 (22–29) months. Subsequent injections were most common in groups 1 and 2 (groups 1–4 76%, 67%, 48% and 61%, respectively); surgery was most common in group 3 (groups 1–4 23%, 21%, 28% and 16%, respectively). Shoulder Pain and Disability Index scores were highest in group 3 (median 48 and 30, respectively) and lowest in group 4 (median 32 and 9, respectively). Patients in group 4 who had surgery reported poor outcomes.

Conclusions

In a community-based population, we identified clusters of pathologies on the basis of ultrasound. Our retrospective data suggest that these groups have different treatment pathways and outcomes. This requires replication in a prospective study to determine the value of a pathology-based classification in people with shoulder pain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1235-y) contains supplementary material, which is available to authorized users.

Rotator cuff rehabilitation: current theories and practice

A fully functioning, painless shoulder joint is essential to maintain a healthy, normal quality of life. Disease of the rotator cuff tendons (RCTs) is a common issue that affects the population, increasing with age, and can lead to significant disability and social and health costs. RCT injuries can affect younger, healthy patients and the elderly alike, and may be the result of trauma or occur as a result of chronic degeneration. They can be acutely painful, limited to certain activities or completely asymptomatic and incidental findings. A wide variety of treatment options exists ranging from conservative local and systemic pain modalities, to surgical fixation. Regardless of management ultimately chosen, physiotherapy of the RCT, rotator cuff muscles and surrounding shoulder girdle plays an essential role in proper treatment. Length of treatment, types of therapy and timing may vary if therapy is definitive care or part of a postoperative protocol. Allowing time for adequate RCT healing must always be considered when implementing ROM and strengthening after surgery. With current rehabilitation methods, patients with all spectrums of RCT pathology can improve their function, pain and quality of life. This manuscript reviews current theories and practice involving rehabilitation for RCT injuries.

Increasing Capacity for the Treatment of Common Musculoskeletal Problems: A Non-Inferiority RCT and Economic Analysis of Corticosteroid Injection for Shoulder Pain Comparing a Physiotherapist and Orthopaedic Surgeon

BACKGROUND

Role substitution is a strategy employed to assist health services manage the growing demand for musculoskeletal care. Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic standards. This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinically and cost effective as that from an orthopaedic surgeon.

METHODS

A double blind non-inferiority randomized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service, from January 2013 to June 2014. Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon. The main outcome measure was total Shoulder Pain and Disability Index (SPADI) score at baseline, six and 12 weeks, applying a non-inferiority margin of 15 points. Secondary outcomes tested for superiority included pain, shoulder movement, perceived improvement, adverse events, satisfaction, quality of life and costs.

RESULTS

278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon, with 64 randomised (physiotherapist 33, orthopaedic surgeon 31). There were no significant differences in baseline characteristics between groups. Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks (upper limit of the 95% one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks, respectively). There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks. From the perspective of the health funder, the physiotherapist was less expensive.

CONCLUSIONS

Corticosteroid injection for shoulder pain, provided by a suitably qualified physiotherapist is at least as clinically effective, and less expensive, compared with similar care delivered by an orthopaedic surgeon. Policy makers and service providers should consider implementing this model of care.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry 12612000532808.

Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review

INTRODUCTION

Excessive thoracic kyphosis is considered a predisposing factor for shoulder pain, though there is uncertainty about the nature of the relationship between shoulder pain and thoracic spine posture. The aim of this systematic review was to investigate the relationship between thoracic kyphosis and shoulder pain, shoulder range of motion (ROM) and function.

METHODS

Two reviewers independently searched eight electronic databases and identified relevant studies by applying eligibility criteria. Sources of bias were assessed independently by two reviewers using a previously validated tool (Ijaz et al., 2013). Data were synthesised using a level of evidence approach (van Tulder et al., 2003).

RESULTS

Ten studies were included. Four studies were rated as low risk of bias, three at moderate risk of bias and three at high risk of bias. There is a moderate level of evidence of no significant difference in thoracic kyphosis between groups with and without shoulder pain. One study at high risk of bias demonstrated significantly greater thoracic kyphosis in people with shoulder pain (p < 0.05). There is a strong level of evidence that maximum shoulder ROM is greater in erect postures compared to slouched postures (p < 0.001), in people with and without shoulder pain.

CONCLUSIONS

Thoracic kyphosis may not be an important contributor to the development of shoulder pain. While there is evidence that reducing thoracic kyphosis facilitates greater shoulder ROM, this is based on single-session studies whose long-term clinical relevance is unclear. Higher quality research is warranted to fully explore the role of thoracic posture in shoulder pain.

The effects of exercise using PNF in patients with a supraspinatus muscle tear

[Purpose] The aim of this study was to examine the effects of proprioceptive neuromuscular facilitation techniques and simple exercise on subjective pain reduction and blood flow velocity in supraspinatus tear patients and to evaluate muscle recovery. [Subjects and Methods] The 20 subjects of this study were diagnosed with supraspinatus tears by MRI. The subjects have performed PNF techniques and Simple exercise for 12 weeks. [Results] After 12 weeks of proprioceptive neuromuscular facilitation techniques and simple exercise, the blood flow velocity, Visual Analogue Scale, and disabilities of the arm, shoulder, and hand score showed statistically significant difference. Also, the difference between the proprioceptive neuromuscular facilitation techniques and simple exercise was statistically significant. [Conclusion] In conclusion, 12 weeks of proprioceptive neuromuscular facilitation treatment and simple exercise therapy had no effect on pain reduction in patients with supraspinatus tear, but in terms of functionality, the proprioceptive neuromuscular facilitation treatment was effective.

Can self-report instruments of shoulder function capture functional differences in older adults with and without a rotator cuff tear?

Rotator cuff tears (RCT) are prevalent in older individuals and may compound age-associated functional declines. Our purpose was to determine whether self-report measures of perceived functional ability are valid for older patients with RCT. Twenty five subjects participated (12M/13F; age=63.9±3.0years); 13 with RCT and 12 controls (CON). Participants completed self-report measures of shoulder function (SST, ASES, WORC) and health-related quality of life (SF-36). Isometric joint moment and range of motion (ROM) were measured at the shoulder. Relationships among functional self-reports, and between these measures and joint moment and ROM were assessed; group differences for total and subcategory scores were evaluated. There were significant correlations among self-reports (rs=0.62-0.71, p⩽0.02). For RCT subjects, ASES was associated with all joint moments except adduction (p⩽0.02); SST, ASES, and WORC were associated with abduction and external rotation ROM (p⩽0.04). For RCT subjects, SST and WORC were associated with SF-36 physical function subcategory scores (p⩽0.05). The RCT group scored worse than CON on all functional self-reports (p<0.01) and WORC and ASES subcategories (p<0.01). In conclusion, SST, ASES, and WORC demonstrate utility and discriminant validity for older individuals by distinguishing those with RCT, but this work suggests prioritizing ASES given its stronger association with functional group strength.

A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder

BACKGROUND

There is little evidence for the optimal form of nonoperative treatment in the management of frozen shoulder. This study assesses the efficacy of current physiotherapy strategies.

METHODS

All primary care referrals of frozen shoulder to our physiotherapy department were included during a 12-month period. Of these referrals, 17% met the inclusion criteria for primary idiopathic frozen shoulder. The 75 patients were randomly assigned to 1 of 3 groups: group exercise class, individual physiotherapy, and home exercises alone. A single independent physiotherapist, who was blinded to the treatment groups, made all assessments. Range of motion, Constant score, Oxford Shoulder Score, Short Form 36, and Hospital Anxiety and Disability Scale (HADS) outcome measures were performed at baseline, 6 weeks, 6 months, and 1 year.

RESULTS

The exercise class group improved from a mean Constant score of 39.8 at baseline to 71.4 at 6 weeks and 88.1 at 1 year. There was a significant improvement in shoulder symptoms on Oxford and Constant scores (P < .001). This improvement was greater than with individual physiotherapy or home exercises alone (P < .001). The improvement in range of motion was significantly greater in both physiotherapy groups over home exercises (P < .001). HADS scores significantly improved during the course of treatment (P < .001). The improvement in HADS anxiety score was significantly greater in both physiotherapy intervention groups than in home exercises alone.

CONCLUSIONS

A hospital-based exercise class can produce a rapid recovery from a frozen shoulder with a minimum number of visits to the hospital and is more effective than individual physiotherapy or a home exercise program.

Effects of shoulder stabilization exercise on pain and functional recovery of shoulder impingement syndrome patients

[Purpose] This study examined the effects of scapular stabilization exercises immediately after surgery on pain and function in patients diagnosed with shoulder impingement syndrome. [Subjects] The subjects were assigned by random sampling to an experimental group (n=15) to which stabilization exercise was applied and a control group (n=15) to which ordinary physical treatment was applied. [Methods] To evaluate the degree of pain, a 100 mm visual analogue scale (VAS) was used. The Constant-Murley Scale (CMS) was used to evaluate the functions of the shoulder joints. To determine the range of motion, a goniometer was used to measure range of shoulder motion. The simple shoulder test (SST) was used to determine the condition of the shoulder joints of the subjects. [Results] There were significant differences in all the items of the experimental group. The results of comparison of the therapeutic effect in the experimental and control groups revealed significant differences in active abduction, passive abduction, VAS, SST, and the CMS, except for pain. [Conclusion] The results suggest that shoulder stabilization exercise positively affects pain alleviation and functional recovery in shoulder impingement patients.

The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair

BACKGROUND

Psychological status may be an important predictor of outcome and patient satisfaction after treatment for rotator cuff disease. Few prior studies have considered these factors. The objective of the study was to investigate the prevalence of psychological distress and its effect on self-assessed pain, disability, and health-related quality of life in patients scheduled for rotator cuff repair.

MATERIALS AND METHODS

We assessed 107 consecutive patients preoperatively using the Hospital Anxiety and Depression Scale (HADS); visual analog scale pain score; American Shoulder and Elbow Surgeons (ASES) scale; Korean Shoulder Scale (KSS); and World Health Organization Quality of Life Scale, Abbreviated Version (WHOQOL-BREF). Preoperative demographic, clinical, and radiologic parameters were also evaluated.

RESULTS

Of the patients, 28 (26.2%) had depression and 25 (23.4%) had anxiety. The HADS depression score was positively correlated with the visual analog scale pain score (P = .048) and negatively correlated with the ASES, KSS, and WHOQOL-BREF scores (P = .005, P = .004, and P < .0001, respectively). The HADS anxiety score was negatively correlated with the ASES, KSS, and WHOQOL-BREF scores (P = .034, P = .037, and P < .0001, respectively). On multivariate analysis with a linear regression model, the HADS depression score was an independent predictor of ASES, KSS, and WHOQOL-BREF scores (P = .02, P = .005, and P = .001, respectively).

CONCLUSION

Depression and anxiety had a negative impact on self-assessed outcome measurements in patients scheduled for rotator cuff repair. Depression was a strong predictor of functional disability and health-related quality of life. Our results suggest that preoperative psychological status may influence postoperative outcome after rotator cuff repair and thus is an essential part of preoperative assessment.

Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement

BACKGROUND

Impingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting.

OBJECTIVES

To evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders.

SEARCH METHODS

We searched electronic databases for primary studies in two stages. In the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). In the second stage, we searched MEDLINE, EMBASE and AMED (2005 to 15 February 2010). Searches were delimited to articles written in English.

SELECTION CRITERIA

We considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed.

MAIN RESULTS

We included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. The majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. In two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. The studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition.

AUTHORS' CONCLUSIONS

There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.

Predictors of success of corticosteroid injection for the management of rotator cuff disease

BACKGROUND

The use of subacromial corticosteroid injection (CSI) to treat rotator cuff tendinopathy is controversial. We hypothesized that characteristics such as activity level, American Shoulder and Elbow Surgeons (ASES) score, duration of symptoms, and status of the rotator cuff may be prognostic factors for resolution of symptoms postinjection.

METHODS

During a 12-month period, consecutive patients with rotator cuff disease were analyzed. Patients received subacromial CSI, oral NSAIDs, and physical therapy. Baseline ASES score, simple shoulder test, an activity scale, and demographic data were recorded. Patients who remained symptomatic and were indicated for surgery were considered failures. Patients that did not undergo surgery were reassessed after a minimum of 1 year.

RESULTS

Forty-nine patients met our criteria. Follow-up was obtained for 81.6%. Sixteen cases (40%) failed conservative treatment at final follow-up (22.4 ± 11 months). CSI were successful in 76.2% of males and 45% of females (p = 0.04). Full-thickness tears were present in 8% of the patients with symptom resolution and 25% of those that failed conservative treatment (p = 0.29). No significant difference was found in age, hand dominance, duration of symptoms, or any of the scoring systems.

CONCLUSION

It is difficult to predict outcomes after CSI. Our treatment strategy showed a 40% failure rate.

Measurement of in vivo tendon function

Chronic tendon pathologies (eg, rotator cuff tears, Achilles tendon ruptures) are common, painful, debilitating, and a significant source of medical expense. Treatment strategies for managing tendon pathologies vary widely in invasiveness and cost, with little scientific basis on which to base treatment selection. Conventional techniques for assessing the outcomes of physical therapy or surgical repair typically rely on patient-based assessments of pain and function, physical measures (eg, strength, range of motion, or stability), and qualitative assessments using magnetic resonance imaging or ultrasound. Unfortunately, these conventional techniques provide only an indirect assessment of tendon function. The inability to make a direct quantitative assessment of the tendon's mechanical capabilities may help to explain the relatively high rate of failed tendon repairs and has led to an interest in the development of tools for directly assessing in vivo tendon function. The purpose of this article is to review methods for assessing tendon function (ie, mechanical properties and capabilities) during in vivo activities. This review will describe the general principles behind the experimental techniques and provide examples of previous applications of these techniques. In addition, this review will characterize the advantages and limitations of each technique, along with its potential clinical utility. Future efforts should focus on developing broadly translatable technologies for quantitatively assessing in vivo tendon function. The ability to accurately characterize the in vivo mechanical properties of tendons would improve patient care by allowing for the systematic development and assessment of new techniques for treating tendon pathologies.

Systematic review of rotator cuff tears in workers' compensation patients

BACKGROUND

The burden imposed by workplace rotator cuff (RC) injuries has been reasonably defined. However, literature associated with the demographic characteristics and 'best practices' to manage such injuries among workers' compensation (WC) patients is scant.

AIMS

To consolidate the existing literature on full-thickness RC tears among WC patients. Subject, shoulder and injury characteristics were examined to determine if and how WC recipients may differ from their non-compensable counterparts.

METHODS

A systematic search (databases, clinical practice guideline web resources, conference proceedings and reference lists) revealed 450 abstracts. Two blinded reviewers independently assessed abstracts for inclusion. Sixty abstracts were subsequently included in a blinded full manuscript review. Seventeen of these manuscripts (3.8% of sample; 11 intervention and 6 determinant) were included in the present review.

RESULTS

Previous studies demonstrate that operative interventions are appropriate for full-thickness RC tears as substantial gains in range of motion, strength and quality of life were witnessed within the first post-operative year. Non-operative interventions, including workplace-based work hardening, physical therapy and the use of an early referral system, were shown to improve outcomes. Conflicting results exist with respect to determinants such as age and sex. Importantly, WC patients had consistently poorer outcomes than non-WC patients.

CONCLUSIONS

Our results show that although WC patients experience substantial benefits from various treatments for full-thickness RC tears, disparities exist between them and their non-WC counterparts. The lack of WC-specific literature limited our results. Larger studies, particularly ones comparing WC patients with their non-compensable counterparts, are crucial to allow for future evidence-based recommendations.

Health-related quality of life, patient satisfaction, and physical activity 8-11 years after arthroscopic subacromial decompression

BACKGROUND

The aim of the present study was to report health-related quality of life, patient satisfaction with present shoulder function, and physical activity 8-11 years after arthroscopic subacromial decompression (ASD) in patients with primary impingement syndrome stage II and early stage III. Ninety-five patients (105 shoulders, 48 female), mean age 54 years (range, 26-69) were included.

METHODS

Quality of life in relation to shoulder function was evaluated with the Western Ontario Osteoarthritis Shoulder Index (WOOS). For perceived health, the EQ-5D and EQ rating scale were used and patient satisfaction was evaluated with a 5-grade Likert scale. To describe the patient's level of physical activity, the International Physical Activity Questionnaire (IPAQ) was used. Pain, during activity and at rest, was evaluated using a visual analogue scale (VAS), and Constant score to report the level of shoulder function.

RESULTS

In all patients (n = 105), the WOOS showed 83% of optimal shoulder-related quality of life. The mean value for the EQ-5D(index), in all patients was 0.77, while the EQ rating scale mean value was 75% of best imaginable health. Forty-one patients were active at a high level of physical activity and 34 at moderate level. Eighty-eight patients stated very or quite satisfied with current shoulder function. Fifty-three patients indicated no pain during activity and 70 patients no pain at rest. The mean of the Constant Score (n = 99) was 77 points.

CONCLUSION

Positive long-term results were shown, as patients reported a high level of health-related quality of life, patient satisfaction and physical activity 8-11 years after ASD.

Outcomes of revision arthroscopic type II superior labral anterior posterior repairs

BACKGROUND

Outcomes of arthroscopic type II superior labral anterior posterior (SLAP) repairs have been reported with success. However, published data regarding outcomes of revision arthroscopic type II SLAP repairs are lacking.

HYPOTHESIS

Outcomes of revision arthroscopic type II SLAP repairs are inferior to those of primary repairs.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective chart review was performed to identify patients who had undergone revision arthroscopic type II SLAP repairs at our institution. Patients who underwent concomitant rotator cuff repairs or labral repairs for instability were excluded. Twelve patients were contacted, and the following outcome data were prospectively gathered: American Shoulder and Elbow Surgeons (ASES) score, patient satisfaction level, return to work, return to sports, and physical examination. Demographics and intraoperative report data were also collected from the charts.

RESULTS

The mean age at the time of revision arthroscopic type II SLAP repairs was 32.6 years (range, 19-67 years) with a mean follow-up of 50.5 months (range, 8-81 months). There were 5 workers' compensation patients and 6 overhead athletes. Pain was the chief complaint at the time of initial and revision SLAP repairs. The mean ASES score was 72.5, patient satisfaction level was 6.4 (scale of 0-10), mean return to work was at 57.8% of the previous level, and mean return to sports was at 42.2% of the previous level. In overhead athletes, mean return to sports was at 41.3% of the previous level, and none of the 4 baseball players returned to preinjury level. The mean values for all outcome data and range of motion values were lower in workers' compensation patients. There were no reported complications, but 2 patients required additional arthroscopic surgeries.

CONCLUSION

Arthroscopic revision type II SLAP repairs yield worse results than primary repairs as reported in the literature, with workers' compensation patients and overhead athletes doing especially worse. A larger prospective study of this relatively rare procedure is needed to better determine which patients may benefit from this procedure.

Does passive mobilization of shoulder region joints provide additional benefit over advice and exercise alone for people who have shoulder pain and minimal movement restriction? A randomized controlled trial

BACKGROUND

Passive mobilization of shoulder region joints, often in conjunction with other treatment modalities, is used for the treatment of people with shoulder pain and minimal movement restriction. However, there is only limited evidence supporting the efficacy of this treatment modality.

OBJECTIVE

The purpose of this study was to determine whether passive mobilization of shoulder region joints adds treatment benefit over exercise and advice alone for people with shoulder pain and minimal movement restriction.

DESIGN

This was a randomized controlled clinical trial with short-, medium- and longer-term follow-up.

SETTING

The study was conducted in a metropolitan teaching hospital.

PATIENTS

Ninety-eight patients with shoulder pain of local mechanical origin and minimal shoulder movement restriction were randomly allocated to either a control group (n=51) or an experimental group (n=47).

INTERVENTION

Participants in both groups received advice and exercises designed to restore neuromuscular control at the shoulder. In addition, participants in the experimental group received passive mobilization specifically applied to shoulder region joints.

MEASUREMENTS

Outcome measurements of shoulder pain and functional impairment, self-rated change in symptoms, and painful shoulder range of motion were obtained at 1, 3, and 6 months after entry into the trial. All data were analyzed using the intention-to-treat principle by repeated-measures analyses of covariance.

RESULTS

No statistically significant differences were detected in any of the outcome measurements between the control and experimental groups at short-, medium-, or longer-term follow-up.

LIMITATIONS

Therapists and participants were not blinded to the treatment allocation.

CONCLUSION

This randomized controlled clinical trial does not provide evidence that the addition of passive mobilization, applied to shoulder region joints, to exercise and advice is more effective than exercise and advice alone in the treatment of people with shoulder pain and minimal movement restriction.

Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both?

The etiology of rotator cuff tendinopathy is multi-factorial, and has been attributed to both extrinsic and intrinsic mechanisms. Extrinsic factors that encroach upon the subacromial space and contribute to bursal side compression of the rotator cuff tendons include anatomical variants of the acromion, alterations in scapular or humeral kinematics, postural abnormalities, rotator cuff and scapular muscle performance deficits, and decreased extensibility of pectoralis minor or posterior shoulder. A unique extrinsic mechanism, internal impingement, is attributed to compression of the posterior articular surface of the tendons between the humeral head and glenoid and is not related to subacromial space narrowing. Intrinsic factors that contribute to rotator cuff tendon degradation with tensile/shear overload include alterations in biology, mechanical properties, morphology, and vascularity. The varied nature of these mechanisms indicates that rotator cuff tendinopathy is not a homogenous entity, and thus may require different treatment interventions. Treatment aimed at addressing mechanistic factors appears to be beneficial for patients with rotator cuff tendinopathy, however, not for all patients. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes.

Relationship between self-reported shoulder function/quality of life, body mass index, and other contributing factors in patients awaiting rotator cuff repair surgery

HYPOTHESES

We hypothesized that body mass index (BMI) would be negatively associated with self-reported shoulder function/pain. A second objective was to investigate the significance of other potential contributing factors: age, sex, smoking status, tear size, and workers' compensation (WC) involvement.

METHODS

In this retrospective cohort study, consecutive patients who underwent arthroscopic rotator cuff repair surgery between 2002 and 2007 were reviewed. Preoperative American Shoulder and Elbow Society (ASES) and Simple Shoulder Test (SST) scores were compared with regard to age, sex, height, weight, smoking status, WC status, and rotator cuff tear size.

RESULTS

Fifty-four patients were enrolled in this study. At a level of significance of P < .05, BMI showed no correlation with preoperative SST or ASES scores. WC status was negatively correlated with ASES scores. Female sex, WC status, and smoking were each negatively correlated with SST scores. The regression model predictive of preoperative SST scores included sex, WC status, and smoking status. WC status was predictive of ASES scores.

DISCUSSION

To our knowledge, this is the first study to examine BMI as a contributing factor in the magnitude of pain and level of function in patients with chronic rotator cuff tears. Our data suggest that there is no impact of BMI on function/pain. The inter-relationships between factors such as BMI, sex, age, and others are complex, and further study is needed to fully establish that there is no effect.

CONCLUSION

Our hypothesis that BMI is negatively related to magnitude of pain/level of function was not supported. Factors found to be related were sex, WC involvement, and smoking.

Effectiveness of individualized physiotherapy on pain and functioning compared to a standard exercise protocol in patients presenting with clinical signs of subacromial impingement syndrome. A randomized controlled trial

Background

Shoulder impingement syndrome is a common musculoskeletal complaint leading to significant reduction of health and disability. Physiotherapy is often the first choice of treatment although its effectiveness is still under debate. Systematic reviews in this field highlight the need for more high quality trials to investigate the effectiveness of physiotherapy interventions in patients with subacromial impingement syndrome.

Methods/Design

This randomized controlled trial will investigate the effectiveness of individualized physiotherapy in patients presenting with clinical signs and symptoms of subacromial impingement, involving 90 participants aged 18-75. Participants are recruited from outpatient physiotherapy clinics, general practitioners, and orthopaedic surgeons in Germany. Eligible participants will be randomly allocated to either individualized physiotherapy or to a standard exercise protocol using central randomization.

The control group will perform the standard exercise protocol aiming to restore muscular deficits in strength, mobility, and coordination of the rotator cuff and the shoulder girdle muscles to unload the subacromial space during active movements. Participants of the intervention group will perform the standard exercise protocol as a home program, and will additionally be treated with individualized physiotherapy based on clinical examination results, and guided by a decision tree. After the intervention phase both groups will continue their home program for another 7 weeks.

Outcome will be measured at 5 weeks and at 3 and 12 months after inclusion using the shoulder pain and disability index and patients' global impression of change, the generic patient-specific scale, the average weekly pain score, and patient satisfaction with treatment. Additionally, the fear avoidance beliefs questionnaire, the pain catastrophizing scale, and patients' expectancies of treatment effect are assessed. Participants' adherence to the protocol, use of additional treatments for the shoulder, direct and indirect costs, and sick leave due to shoulder complaints will be recorded in a shoulder log-book.

Discussion

To our knowledge this is the first trial comparing individualized physiotherapy based on a defined decision making process to a standardized exercise protocol. Using high-quality methodologies, this trial will add evidence to the limited body of knowledge about the effect of physiotherapy in patients with SIS.

Trial registration

Current Controlled Trials ISRCTN86900354

Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial

OBJECTIVE

To investigate the efficacy of a programme of manual therapy and exercise treatment compared with placebo treatment delivered by physiotherapists for people with chronic rotator cuff disease.

DESIGN

Randomised, participant and single assessor blinded, placebo controlled trial.

SETTING

Metropolitan region of Melbourne, Victoria, Australia.

PARTICIPANTS

120 participants with chronic (>3 months) rotator cuff disease recruited through medical practitioners and from the community.

INTERVENTIONS

The active treatment comprised a manual therapy and home exercise programme; the placebo treatment comprised inactive ultrasound therapy and application of an inert gel. Participants in both groups received 10 sessions of individual standardised treatment over 10 weeks. For the following 12 weeks, the active group continued the home exercise programme and the placebo group received no treatment.

MAIN OUTCOME MEASURES

The primary outcomes were pain and function measured by the shoulder pain and disability index, average pain on movement measured on an 11 point numerical rating scale, and participants' perceived global rating of overall change.

RESULTS

112 (93%) participants completed the 22 week trial. At 11 weeks no difference was found between groups for change in shoulder pain and disability index (3.6, 95% confidence interval -2.1 to 9.4) or change in pain (0.7, -0.1 to 1.5); both groups showed significant improvements. More participants in the active group reported a successful outcome (defined as "much better"), although the difference was not statistically significant: 42% (24/57) of active participants and 30% (18/61) of placebo participants (relative risk 1.43, 0.87 to 2.34). The active group showed a significantly greater improvement in shoulder pain and disability index than did the placebo group at 22 weeks (between group difference 7.1, 0.3 to 13.9), although no significant difference existed between groups for change in pain (0.9, -0.03 to 1.7) or for the percentage of participants reporting a successful treatment outcome (relative risk 1.39, 0.94 to 2.03). Several secondary outcomes favoured the active group, including shoulder pain and disability index function score, muscle strength, interference with activity, and quality of life.

CONCLUSION

A standardised programme of manual therapy and home exercise did not confer additional immediate benefits for pain and function compared with a realistic placebo treatment that controlled for therapists' contact in middle aged to older adults with chronic rotator cuff disease. However, greater improvements were apparent at follow-up, particularly in shoulder function and strength, suggesting that benefits with active treatment take longer to manifest.

TRIAL REGISTRATION

Clinical trials NCT00415441.

Comparison of patients undergoing primary shoulder arthroplasty before and after the age of fifty

BACKGROUND

The reported outcomes of shoulder arthroplasty in patients under the age of fifty years are worse than those in patients over fifty. While there are several possible explanations for this finding, we explored the possibility that patients who had a primary shoulder arthroplasty when they were under fifty years of age differed from those who had the procedure when they were over fifty with respect to their pre-arthroplasty self-assessed comfort and function, sex distribution, and specific type of arthritis.

METHODS

The study group consisted of patients with glenohumeral arthritis who were treated with a primary shoulder arthroplasty by the same surgeon between 1990 and 2008. For each decade of age, the sex distribution, the pre-arthroplasty self-assessed shoulder comfort and function, and the prevalence of twelve different diagnoses were documented. We reviewed the series for three potential causes of worse outcomes in patients under fifty years of age as compared with those over fifty years of age: (1) a higher percentage of women, (2) a lower score for pre-arthroplasty self-assessed comfort and function, and (3) more complex pathological conditions.

RESULTS

Patients under the age of fifty years were not more likely than those over fifty to be female or to have a lower pre-arthroplasty self-assessed comfort and function score, but they did have more complex pathological conditions, such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic arthritis. Only 21% of the younger patients had primary degenerative joint disease, whereas 66% of the older patients had that diagnosis. This difference was significant (p < 0.000000001).

CONCLUSIONS

Surgeons performing shoulder arthroplasty in individuals under the age of fifty should be prepared to encounter pathological conditions such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic arthritis rather than primary osteoarthritis, which is more common in individuals older than fifty. The pathoanatomy in these younger patients may complicate the surgery, the rehabilitation, and the outcome of the shoulder arthroplasty.

Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial

QUESTION

Is the addition of passive mobilisation of shoulder region joints to advice and exercise for patients with shoulder pain and stiffness more effective than advice and exercise alone?

DESIGN

Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

90 people who had shoulder pain and stiffness for more than one month.

INTERVENTION

All participants received advice and exercise. The experimental group also received passive joint mobilisation of shoulder region joints.

OUTCOME MEASURES

Primary outcome measures included pain and disability measured with the 13-point Shoulder Pain and Disability Index. Secondary outcome measures were self-perceived global improvement measured on a 6-point scale and active ranges of motion. Subjects received a maximum of 10 sessions of therapy. Outcome measurements were taken at baseline, one month, and six months.

RESULTS

The experimental group had 3% (95% CI -5 to 11) less pain and disability than the control group at one month and 1% (95% CI -13 to 16) less pain at six months, which are statistically nonsignificant. Their global perceived effect was 0.1 out of 5 (95% CI -0.2 to 0.4) worse than the control group at one month and 0.1 (95% CI -0.5 to 0.7) better at 6 months, which are also statistically non-significant. Differences between groups in all range of motion measures were small and statistically non-significant.

CONCLUSION

The addition of passive joint mobilisation of shoulder region joints is not more effective than advice and exercise alone for shoulder pain and stiffness.

TRIAL REGISTRATION

ACTRN 12605000080628.

Early loading in physiotherapy treatment after full-thickness rotator cuff repair: a prospective randomized pilot-study with a two-year follow-up

Objective: To describe the clinical changes following two different physiotherapy treatment protocols after rotator cuff repair.

Design: A prospective, randomized pilot study with a two-year follow-up.

Subjects: Five women and nine men, 55 (40—64) years old, were included.

Intervention: The progressive group (n = 7) started with dynamic, specific muscle activation of the rotator cuff the day after surgery as well as passive range of motion. After four weeks of immobilization the loading to the rotator cuff increased and in a progressive manner throughout the rehabilitation. In the traditional group (n = 7) the rotator cuff was protected from loading. Patients were immobilized for six weeks and started with passive range of motion the day after surgery. No specific exercises to the rotator cuff were introduced during this period.

Main measures: A clinical evaluation was made preoperatively, 3, 6, 12 and 24 months after surgery. Pain rating during activity and at rest, patient satisfaction, active range of motion and muscle strength, Constant score, hand in neck, hand in back and pour out of a pot, as well as Functional Index of the Shoulder were used.

Results: At two years follow-up, the progressive group and traditional group scored pain during activity visual analogue scale (VAS) 2/0 mm and pain at rest 0/0 mm, respectively. The groups attained 170/175° in active abduction in standing and 70/90° in passive external rotation while lying in supine. Using Constant score, the groups attained 82/77 points respectively.

Conclusion: The present study showed that the progressive protocol produced no adverse effects compared with the traditional protocol.

Patients with workers' compensation claims have worse outcomes after rotator cuff repair

BACKGROUND

Previous studies have demonstrated varying correlations between Workers' Compensation status and the outcome of rotator cuff repair. However, none of those studies have formally accounted for potential confounding factors with multivariable analysis. We hypothesized that patients with Workers' Compensation claims who undergo rotator cuff repair have worse outcomes, even after controlling for confounding factors.

METHODS

One hundred and twenty-five patients (including thirty-nine with Workers' Compensation claims) who underwent unilateral primary repair of a chronic rotator cuff tear by a single surgeon were studied prospectively and were evaluated one year postoperatively, prior to the settlement of any claims. Outcomes were assessed with the Simple Shoulder Test (SST); the Disabilities of the Arm, Shoulder and Hand (DASH) index; three visual analog scales (shoulder pain, shoulder function, and quality of life); and the Short Form-36 (SF-36).

RESULTS

Patients in the Workers' Compensation group were significantly younger, had greater work demands, and had lower marital rates, education levels, and preoperative expectations for the outcome of treatment as compared with those in the non-Workers' Compensation group (p = 0.001 to 0.016). Preoperatively, patients in the Workers' Compensation group had significantly lower scores on the SST, the SF-36 Physical Function scale, and the SF-36 Social Function scale (p = 0.01 to 0.038). One year postoperatively, those patients reported worse performance on the SST, the DASH, all three visual analog scales, and the SF-36 (p = 0.0007 to 0.05) and had worse improvement on the DASH, the visual analog scales for shoulder pain and function, and the SF-36 Bodily Pain and Role Emotional scales (p = 0.0028 to 0.038). Multivariable analysis controlling for age, sex, comorbidities, smoking, marital status, education, duration of symptoms, work demands, expectations, and tear size confirmed that Workers' Compensation status was an independent predictor of worse DASH scores.

CONCLUSIONS

Patients with Workers' Compensation claims report worse outcomes, even after controlling for confounding factors. The present study provides further evidence that the existence of a Workers' Compensation claim portends a less robust outcome following rotator cuff repair.

LEVEL OF EVIDENCE

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