Predictors of pain
and function in patients with symptomatic, atraumatic full-thickness rotator
cuff tears: a time-zero analysis of a prospective patient cohort enrolled in a
structured physical therapy program.
and function in patients with symptomatic, atraumatic full-thickness rotator
cuff tears: a time-zero analysis of a prospective patient cohort enrolled in a
structured physical therapy program.
Harris JD, Pedroza A,
Jones GL; MOON (Multicenter Orthopedic Outcomes Network) Shoulder Group. Am J
Sports Med. 2012 Feb;40(2):359-66. Epub 2011 Nov 17.
Jones GL; MOON (Multicenter Orthopedic Outcomes Network) Shoulder Group. Am J
Sports Med. 2012 Feb;40(2):359-66. Epub 2011 Nov 17.
A high prevalence of
functional asymptomatic rotator cuff tears exists, with symptoms commonly developing
and progressing over time. Predicting which tears will become symptomatic
and/or require surgery is a major clinical challenge. Identifying the factors that relate function
and pain in symptomatic rotator cuff tears would be instrumental in helping to
identify at-risk individuals and guide treatment strategies. Therefore, the purpose of this study was to
determine the patient factors (modifiable and non-modifiable) associated with function
and pain, based on the Western Ontario Rotator Cuff (WORC) index (a self-report questionnaire
regarding quality of life) and American
Shoulder and Elbow Surgeons (ASES) score (a self-report questionnaire
regarding pain and function), in patients with symptomatic, atraumatic full thickness
rotator cuff tears. 389 patients (18 to 100 years of age, unilateral
full-thickness rotator cuff tear, significant weakness, pain with activities of
daily living, impingement symptoms >3 months) who elected to participate in
a non-operative physical therapy program were included in this study. Patients completed a self-administered
outcome questionnaire that included their demographics, WORC index, and ASES scores.
The minimal clinically important
difference (MCID; the
smallest change in scores that patients perceive) for the WORC index and ASES
scores are 11.7 and 6.4 points, respectively.
Additionally, patients underwent routine physical examination and
determination of tear characteristics (i.e., tear size, tear retraction, and
presence of scapulothoracic dyskinesis, humeral head migration, and/or muscle
atrophy). The following variables were
determined to be associated with higher WORC and ASES scores (reflecting
increased function): female sex, higher education levels, increased active
abduction range of motion (ROM), and increased strength in forward elevation
and abduction. The modifiable parameters
with greatest association (having MCID) were full muscle strength in forward
elevation (increased WORC by 18.39 points compared to less strength) and
abduction (increased WORC by 13.79 points compared to less strength), while
increased active abduction and forward elevation ROM (every 10 degrees) were
associated with increased ASES scores of only 0.78 and 0.85 points,
respectively. The following variables
were determined to be associated with lower WORC and ASES scores (reflecting
decreased function): male sex, atrophy of the supraspinatus and infraspinatus,
and presence of scapulothoracic dyskinesia. Specifically, the presence of
scapulothoracic dyskinesis was associated with a decrease in the WORC index and
ASES scores of 6.85 and 4.07 points, respectively. Additionally, tear size was
not identified as a significant predictor unless comparing isolated
supraspinatus tears to multi-tendon tears (i.e., involving the supraspinatus,
infraspinatus, and subscapularis).
functional asymptomatic rotator cuff tears exists, with symptoms commonly developing
and progressing over time. Predicting which tears will become symptomatic
and/or require surgery is a major clinical challenge. Identifying the factors that relate function
and pain in symptomatic rotator cuff tears would be instrumental in helping to
identify at-risk individuals and guide treatment strategies. Therefore, the purpose of this study was to
determine the patient factors (modifiable and non-modifiable) associated with function
and pain, based on the Western Ontario Rotator Cuff (WORC) index (a self-report questionnaire
regarding quality of life) and American
Shoulder and Elbow Surgeons (ASES) score (a self-report questionnaire
regarding pain and function), in patients with symptomatic, atraumatic full thickness
rotator cuff tears. 389 patients (18 to 100 years of age, unilateral
full-thickness rotator cuff tear, significant weakness, pain with activities of
daily living, impingement symptoms >3 months) who elected to participate in
a non-operative physical therapy program were included in this study. Patients completed a self-administered
outcome questionnaire that included their demographics, WORC index, and ASES scores.
The minimal clinically important
difference (MCID; the
smallest change in scores that patients perceive) for the WORC index and ASES
scores are 11.7 and 6.4 points, respectively.
Additionally, patients underwent routine physical examination and
determination of tear characteristics (i.e., tear size, tear retraction, and
presence of scapulothoracic dyskinesis, humeral head migration, and/or muscle
atrophy). The following variables were
determined to be associated with higher WORC and ASES scores (reflecting
increased function): female sex, higher education levels, increased active
abduction range of motion (ROM), and increased strength in forward elevation
and abduction. The modifiable parameters
with greatest association (having MCID) were full muscle strength in forward
elevation (increased WORC by 18.39 points compared to less strength) and
abduction (increased WORC by 13.79 points compared to less strength), while
increased active abduction and forward elevation ROM (every 10 degrees) were
associated with increased ASES scores of only 0.78 and 0.85 points,
respectively. The following variables
were determined to be associated with lower WORC and ASES scores (reflecting
decreased function): male sex, atrophy of the supraspinatus and infraspinatus,
and presence of scapulothoracic dyskinesia. Specifically, the presence of
scapulothoracic dyskinesis was associated with a decrease in the WORC index and
ASES scores of 6.85 and 4.07 points, respectively. Additionally, tear size was
not identified as a significant predictor unless comparing isolated
supraspinatus tears to multi-tendon tears (i.e., involving the supraspinatus,
infraspinatus, and subscapularis).
This cross-sectional study
identified several modifiable factors that related to function and pain in patients
with symptomatic rotator cuff tears (e.g., scapulothoracic dyskinesis, range of
motion in active abduction and forward elevation, as well as strength in abduction
and forward elevation). The authors
conclude that rehabilitation programs should address these factors to improve and/or
eliminate symptoms in patients with atraumatic, full-thickness rotator cuff
tears. However, before definitive
recommendations can be made, it is important to consider the strength of the
associations identified. In particular,
the parameters of increased active abduction and forward elevation ROM were
associated with minimal increases in ASES score and therefore, modifying these
factors alone may not be sufficient to be perceived as a clinically important
difference. Successful modification of
a combination of several of these factors may be necessary to induce changes
that patients may perceive as beneficial.
Additionally, in order to determine if successful modification of these
factors improves clinical outcome, longitudinal follow-up investigations (e.g.,
clinical trials) are necessary. Previous
studies have identified rotator cuff tear size as a significant predictor of
patient outcomes, with larger tears associated with both decreased shoulder
function and patient satisfaction.
Surprisingly, tear size was not found to be significantly associated
with pain and function in this study.
The cohort included only patients who elected non-operative rehabilitation
treatment, excluding patients undergoing operative treatment. It is likely that patients with symptomatic
larger tears may have elected operative management, which may account for the
discrepancy observed. Nevertheless, this
study has important clinical implications and it is likely that targeting these
modifiable factors will improve patient pain and symptoms with the potential of
converting symptomatic rotator cuff tears to asymptomatic tears. Do you currently target any of the factors
identified in this study to treat patients with rotator cuff tears? Have you notice improved outcomes? Would the results of this study alter how you treat patients?
identified several modifiable factors that related to function and pain in patients
with symptomatic rotator cuff tears (e.g., scapulothoracic dyskinesis, range of
motion in active abduction and forward elevation, as well as strength in abduction
and forward elevation). The authors
conclude that rehabilitation programs should address these factors to improve and/or
eliminate symptoms in patients with atraumatic, full-thickness rotator cuff
tears. However, before definitive
recommendations can be made, it is important to consider the strength of the
associations identified. In particular,
the parameters of increased active abduction and forward elevation ROM were
associated with minimal increases in ASES score and therefore, modifying these
factors alone may not be sufficient to be perceived as a clinically important
difference. Successful modification of
a combination of several of these factors may be necessary to induce changes
that patients may perceive as beneficial.
Additionally, in order to determine if successful modification of these
factors improves clinical outcome, longitudinal follow-up investigations (e.g.,
clinical trials) are necessary. Previous
studies have identified rotator cuff tear size as a significant predictor of
patient outcomes, with larger tears associated with both decreased shoulder
function and patient satisfaction.
Surprisingly, tear size was not found to be significantly associated
with pain and function in this study.
The cohort included only patients who elected non-operative rehabilitation
treatment, excluding patients undergoing operative treatment. It is likely that patients with symptomatic
larger tears may have elected operative management, which may account for the
discrepancy observed. Nevertheless, this
study has important clinical implications and it is likely that targeting these
modifiable factors will improve patient pain and symptoms with the potential of
converting symptomatic rotator cuff tears to asymptomatic tears. Do you currently target any of the factors
identified in this study to treat patients with rotator cuff tears? Have you notice improved outcomes? Would the results of this study alter how you treat patients?
Written by: Katherine
Reuther
Reviewed by: Jeffrey
Driban
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Harris JD, Pedroza A, Jones GL, & MOON (Multicenter Orthopedic Outcomes Network) Shoulder Group (2012). Predictors of pain and function in patients with symptomatic, atraumatic full-thickness rotator cuff tears: a time-zero analysis of a prospective patient cohort enrolled in a structured physical therapy program. The American Journal of Sports Medicine, 40 (2), 359-66 PMID: 22095706