- Email: [email protected]
The effects of rotator cuff tears, including shoulders without pain, on activities of daily living in the general population
J Orthop Sci (2012) 17:136–140 DOI 10.1007/s00776-011-0186-4
ORIGINAL ARTICLE
The effects of rotator cuff tears, including shoulders without pain, on activities of daily living in the general population Daisuke Nakajima • Atsushi Yamamoto • Tsutomu Kobayashi Toshihisa Osawa • Hitoshi Shitara • Tsuyoshi Ichinose • Eiji Takasawa • Kenji Takagishi
•
Received: 2 August 2011 / Accepted: 9 December 2011 / Published online: 17 January 2012 Ó The Japanese Orthopaedic Association 2012
Abstract Background Few reports have so far evaluated the possible restrictions of activities of daily living (ADL) in patients with asymptomatic rotator cuff tears (RCTs). The purpose of this study was to examine the effects of RCTs, including shoulders without pain, on ADL in the general population. Methods We performed medical checkups on 462 individuals (924 shoulders). All participants completed a questionnaire regarding their background and medical history. We then assessed their shoulder functions with the Simple Shoulder Test (SST) and performed US (US) examinations of both shoulders to diagnose RCTs. We divided participants into tear and nontear groups and performed statistical analysis to compare total SST scores and each SST item between groups. Furthermore, we performed the same examinations for participants identified as having shoulders without pain. Results Among participants, those in the tear group showed significantly lower total SST scores than those in the nontear group. After examining each SST item, a significant difference was observed regarding the ability to sleep comfortably and to lift 3.6 kg to shoulder level. In
D. Nakajima (&) A. Yamamoto T. Kobayashi H. Shitara T. Ichinose E. Takasawa K. Takagishi Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan e-mail: [email protected] T. Osawa Department of Orthopaedic Surgery, National Hospital Organization Takasaki Hospital, 36, Takamatsu-machi, Takasaki, Gunma 370-8537, Japan
123
shoulders without pain, the tear group showed significantly lower total SST scores than the nontear group. A significant difference was observed only regarding the ability to lift 3.6 kg to shoulder level. Conclusions In the general population, ADL were restricted in participants with RCTs; they experienced night pain in the shoulder and muscle weakness during shoulder elevation. Furthermore, participants with RCTs, even if the condition itself did not induce any pain, tended to experience muscle weakness during shoulder elevation, thus resulting in restrictions of ADL.
Introduction A rotator cuff tear (RCT) is one of the most common disorders affecting the shoulder and cause pain and dysfunction. However, recent studies have found that there are cases of asymptomatic RCTs in which the patient exhibits no shoulder symptoms [1–10]. It is evident that patients with symptomatic RCTs tend to demonstrate restrictions in activities of daily living (ADL); however, few reports have so far evaluated the possible restrictions of ADL in patients with asymptomatic RCTs. We found no published reports examining what effects RCTs might have on ADL in the general population. There are several methods to evaluate the effects of shoulder joint disorders on ADL. The Simple Shoulder Test (SST) as proposed by Lippitt et al. [11] is a selfassessment tool that evaluates 12 common shoulder functions; participants answer by circling ‘‘Yes’’ or ‘‘No’’. These 12 questions are listed in Table 1. The SST is frequently used to evaluate ADL in cases of shoulder joint disorders because it is easy to perform but also sensitively reflects shoulder dysfunction attributed to shoulder joint
The effects of RCTs on the ADL Table 1 Simple Shoulder Test 1. Is your shoulder comfortable with your arm at rest by your side? 2. Does your shoulder allow you to sleep comfortably? 3. Can you reach the small of your back to tuck in your shirt with your hand? 4. Can you place your hand behind your head with the elbow straight out to the side? 5. Can you place a coin on a shelf at the level of your shoulder without bending your elbow? 6. Can you lift 1 pound (0.5 kg) to the level of your shoulder without bending your elbow? 7. Can you lift 8 pounds (3.6 kg) to the level of your shoulder without bending your elbow? 8. Can you carry 20 pounds (9.1 kg) at your side with the affected extremity? 9. Do you think you can toss a softball underhand 10 yards (9.1 m) with the affected extremity? 10. Do you think you can toss a softball overhand 20 yards (18.3 m) with the affected extremity? 11. Can you wash the back of your opposite shoulder with the affected extremity? 12. Would your shoulder allow you to work full time at your regular job?
disorders. It does not bias the examiner into a particular direction, and it has excellent reproducibility [11–21]. The purpose of this study was to examine the effects of RCTs on ADL in the general population, including shoulders without pain, using the SST.
Materials and methods This cross-sectional study was approved by the institutional review board of our institution. A medical checkup, which was intended to help prevent the occurrence of lifestylerelated disease and promote early detection of cancer, was conducted for the residents of a mountain village, where agriculture, forestry, and tourism remain the most important sources of income. Consent was obtained from 544 individuals participating in the study. First, all participants filled out a questionnaire regarding age, gender, presence of shoulder pain at the present time, history of shoulder joint trauma, history of surgery, history of outpatient hospital care, and then the range of motion of active and passive forward elevation of the shoulder joint was measured. We then assessed shoulder functions with the SST. We also conducted ultrasonographic (US) examinations of both shoulders in order to diagnose RCTs. US examinations were performed with the technique described by Middleton et al. [22] using LOGIQ e (GE Health Care, USA) with linear-array probes at 12 MHz. To avoid interobserver variation, all US examinations were
137
performed by one experienced shoulder joint surgeon who was blinded to the other items in the evaluation. In accordance with the report by Takagishi et al. [23], discontinuity and thinning of the rotator cuff were considered to be indications of full-thickness RCTs. Any suspected cases of partial-thickness RCTs were considered to be nontears. According to the US findings prior to surgery on 58 shoulders, which were performed by the shoulder joint surgeon who conducted the US examinations in this study, in cases that underwent arthroscopic rotator cuff repair in our institute from January 2010 to August 2011 after being diagnosed with RCTs, outcomes of 91.8% sensitivity, 77.8% specificity, 95.7% positive predictive value, 63.6% negative predictive value, and 89.7% accuracy were obtained (unpublished data). Participants were selected based on the following criteria: 1. All target evaluation items could be obtained; 2. individuals with both an active and/or passive forward elevation C100°, with the purpose here being to exclude any cases of shoulder joint contracture, such as frozen shoulders, with the limit angle selected based on reports by Bunker et al. [24] and Zuckerman et al. [25]; 3. No history of trauma and surgery to the shoulder joints; 4. No treatment on the shoulders at the time of this survey. Based on these inclusion criteria, 52 patients lacking all evaluation items, five observed with a limited range of motion, 11 with a history of trauma and surgery to the shoulder joints, and 14 undergoing treatment for shoulder pain during the investigation were excluded. With regard to the five patients in whom a limited range of motion was observed, no RCT was observed on US examinations, so they were not considered to be cases demonstrating a secondary contracture accompanying an RCT. Moreover, there were two patients with an active forward elevation of B100° and a passive forward elevation of C100°, and an RCT was observed in both patients based on US examinations. These 2 cases were diagnosed as pseudoparalysis accompanied by an RCT and were thus included in this study because they had normal elbow flexion strength and demonstrated no neurological abnormalities due to a suspicion of either cervical spine disease or a central nervous system disorder. Therefore, the study comprised 462 participants with 924 shoulders; 171 were men and 291 were women, with a mean age of 61.3 (28–87) years. As a statistical analysis, we first divided all participants into a tear and a nontear group, depending on the existence of an RCT, and conducted a comparative examination using the Mann–Whitney U test to ascertain that a difference existed between the two groups in the total SST score.
123
138
In addition, to examine factors that determined the two groups with respect to each SST item, we performed a logistic regression analysis using the existence of a tear as an objective variable and each SST item as an explanatory variable. It is known that the prevalence of RCTs increases with age [3, 4, 6, 7, 9, 10, 12]; therefore, age was used as a regulator in the examination, and the effect of age on ADL was excluded. Next, the participants who had no present pain in the shoulder joint, including pain on motion according to the questionnaire findings, and who also answered ‘‘Yes’’ to both SST items of question 1: ‘‘Is your shoulder comfortable at rest?,’’ which evaluates the presence of pain at rest; and question 2: ‘‘Does your shoulder allow you to sleep comfortably?,’’ which evaluates the presence of pain at night, were thus defined as having ‘‘shoulders without pain.’’ These participants were then examined in the previously described manner with respect to the total SST score and each item. Statistical analysis was carried out using the IBM SPSS Statistics 19 (IBM Japan, Ltd., Tokyo, Japan), and the critical values for significance were set at \5%.
Results Examination of all participants Of the 924 shoulders, 99 belonged to the tear group [mean age 70.5 (46–87) years] and 825 to the nontear group [mean age 60.2 (28–86) years]. Total SST score was 10.6 (3–12) in the tear group and 11.3 (5–12) in the nontear group, with the total SST score in the tear group being significantly lower (P \ 0.001) (Fig. 1). Upon examination of each SST item, there was a significant difference with respect to two items: question 2 ‘‘ability to sleep comfortably’’ [odds ratio (OR) 0.41, 95% confidence interval
Fig. 1 Comparison of Simple Shoulder Test (SST) total scores between all shoulders. SST score was significantly lower in the tear group (*P \ 0.001)
123
D. Nakajima et al.
Fig. 2 Comparison of Simple Shoulder Test (SST) total scores between shoulders without pain. SST score was significantly lower in the tear group (*P \ 0.001)
(CI) 0.19–0.88, P = 0.022], and question 7 ‘‘lift 3.6 kg to shoulder level’’ (OR 4.21, 95% CI 2.25–7.88, P \ 0.001). Examination of shoulders without pain A total of 708 shoulders had no pain, 57 of which belonged to the tear group [mean age 71.1 (56–87) years] and 651 to the nontear group [mean age 60.5 (28–86) years]. The total score for SST questions 3 through 12 (maximum score 10 points) was 9.0 (3–10) in the tear group and 9.5 (5–10) in the nontear group, with the total SST score in the tear group being significantly lower (P \ 0.001) (Fig. 2). There was a significant difference among the questions only in respect to question 7, ‘‘lift 3.6 kg to shoulder level’’ (OR 4.60, 95% CI 1.91–11.09, P = 0.001).
Discussion Several published reports have evaluated the SST score for ADL in patients with RCTs. Lippitt et al. [11] studied 50 shoulders with RCTs and reported that the patients had an impaired ability to sleep comfortably, lift 3.6 kg to shoulder level, and throw a ball 18.3 m overhand. Duckworth et al. [26] studied 123 shoulders with full-thickness RCTs and reported that the total SST score was 5 points on average and that many restrictions were found with respect to the ability to sleep comfortably, lift 3.6 kg to shoulder level, throw a ball 18.3 m overhand, wash the back of the opposite shoulder, and do regular work. Harryman et al. [27] studied 333 shoulders with full-thickness RCTs and reported that the total SST score was 4.4 points and that many restrictions were found in respect to the ability to sleep comfortably, lift 3.6 kg to shoulder level, and throw a ball 18.3 m overhand. The results of these studies agreed on the fact that RCTs restrict ADL. However, all of these studies examined symptomatic RCTs and did not evaluate RCTs in their entirety, including asymptomatic RCTs.
The effects of RCTs on the ADL
A few previous reports studied the effects of asymptomatic RCTs on ADL. Schibany et al. [5] studied 212 asymptomatic shoulders and reported that, although fullthickness RCTs were detected in 6% of the shoulders by US, there was no difference between the tear and nontear groups with respect to ADL evaluation. However, that study limited its participants to volunteers who had no shoulder symptoms, and the method of ADL evaluation was measured only by the constant subscores. Therefore, no detailed evaluation of ADL limitations that includes all RCTs has yet been published. Keener et al. [15] studied 196 participants with asymptomatic RCTs and 54 with an intact rotator cuff presenting with a painful RCT in the contralateral shoulder. The authors stated that participants with an intact rotator cuff had greater but clinically insignificant SST scores than those with an asymptomatic tear. However, it was not a population-based study intended for the general population, and therefore the individual SST items were not considered in detail. In our study, we considered each SST item in the investigated group of participants to be representative of the general population. The results of the overall examination confirmed ADL to be restricted in participants with RCTs; specifically, participants were prone to suffer night pain in the shoulder joint and muscle weakness during shoulder elevation. In addition, in the examination of shoulders without pain, detailed evaluations by SST confirmed that when there was a RCT, ADLs were restricted; specifically, participants were prone to suffer muscle weakness when engaging in shoulder elevation motions. These are the first-ever results from an inclusive study on RCTs in the general population to identify how RCTs affect ADL, regardless of whether or not participants exhibit any symptoms. Tashjian et al. [21], however, reported that patients with rotator cuff disease who are treated without surgery and had a 2-point change in the SST score experienced a clinically important change in self-assessed outcome. In our study, we found ADL to be restricted by evaluating each SST item, but further studies will be required to confirm whether any clinically important difference actually exists when evaluating participants by the total SST score. Regarding the relationship between asymptomatic RCT and muscular strength, Moosmayer et al. [4] studied 420 shoulders of asymptomatic volunteers aged between 50 and 79 years and reported that the strength of flexion significantly decreased in the group with RCTs. Kim et al. [1] also studied 237 asymptomatic shoulders and reported the abduction strength to significantly decrease in shoulders with a large to massive full-thickness RCT. The ADL restriction identified in our study with respect to shoulders without pain was the inability to lift 3.6 kg to shoulder level. It is believed that this restriction can be attributed to muscle weakness during shoulder elevation motions, and as
139
a consequence, no inconsistency is considered to exist between these reports and our study. Our study has several limitations. The first is that this study was not conducted with an examination of tear size, and we did not determine which tendons were involved. Yamaguchi et al. [9] noted that RCT size appeared to be an important factor in symptom development. As mentioned previously, Kim et al. [1] reported that abduction strength significantly decreased in shoulders with a large to massive full-thickness RCT. Harryman et al. [27] also demonstrated that patients who had an infraspinatus as well as a supraspinatus tendon tear tended to have a significantly worsened ability to use the arm overhead compared with those who had only a supraspinatus tear. It is therefore possible that ADL restrictions may differ depending on the size and extent of the tear. Second, ADL evaluation was done only by SST in this study. Some other evaluation methods on ADL in cases of shoulder joint disorder have been reported. In this study, evaluation was done by the STT in view of the fact that it allows evaluation of ADL in a larger number of participants within limited time constraints. The third point concerns the diagnosis of partial-thickness RCTs using US, the diagnostic criteria for which remain controversial. Therefore, in this study, partial-thickness RCTs were considered to be nontears. Fourth, with regard to the selection criteria, we excluded any participants who had restrictions in both active and passive forward elevation so as to exclude patients with other potential causes of shoulder pain, such as osteoarthritis. However, no other type of diagnostic imaging was conducted other than US, and thus we could not exclude such patients completely. Fifth, this was a cross-sectional study, and a longitudinal examination was not conducted. Yamaguchi et al. reported that about 50% of asymptomatic shoulders with RCTs became symptomatic within an average of 2.8 years [8]. Mall et al. [2] also reported that larger tears are more likely to develop pain in the short term than are smaller tears, so it is possible that observations over time may reveal changes in the degree of ADL restriction. Until now, the purpose of conservative treatment for RCTs was to maintain a painless condition even in the presence of a tear. However, results of this study demonstrate that RCTs cause restriction in ADL, even if the condition itself does not induce pain. In the case of RCTs without pain, the individual might not visit a medical institution, thinking that the restriction in ADL is merely the result of the normal aging process. We therefore consider that it is necessary to explain to such individuals the possibility that their RCTs, which cause no pain, may nevertheless eventually result in restriction in ADL. In addition, specialists who treat RCTs should be mindful of this phenomenon and try to provide optimal treatment to improve the quality of life for such patients.
123
140
In conclusion, we evaluated the effects on ADL caused by RCTs using the SST in a general population. Total SST score was significantly lower when participants had RCTs, which thus led to the onset of various types of dysfunctions: ‘‘sleep disturbances due to shoulder pain’’ and an ‘‘inability to lift 3.6 kg to shoulder level.’’ Total SST score was also significantly lower in shoulders without pain when there was an RCT, thus leading to the occurrence of a dysfunction; namely, an ‘‘inability to lift 3.6 kg to shoulder level.’’ Conflict of interest The authors did not receive and will not receive any benefits or funding from any commercial party related directly or indirectly to the subject of this article.
D. Nakajima et al.
12.
13.
14.
15.
16.
References 1. Kim HM, Teefey SA, Zelig A, Galatz LM, Keener JD, Yamaguchi K. Shoulder strength in asymptomatic individuals with intact compared with torn rotator cuffs. J Bone Joint Surg Am. 2009;91(2):289–96. 2. Mall NA, Kim HM, Keener JD, Steger-May K, Teefey SA, Middleton WD, Stobbs G, Yamaguchi K. Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical, sonographic variables. J Bone Joint Surg Am. 2010;92(16):2623–33. 3. Milgrom C, Schaffler M, Gilbert S, van Holsbeeck M. Rotatorcuff changes in asymptomatic adults. The effect of age, hand dominance, gender. J Bone Joint Surg Br. 1995;77(2):296–8. 4. Moosmayer S, Smith HJ, Tariq R, Larmo A. Prevalence characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic, clinical study. J Bone Joint Surg Br. 2009;91(2): 196–200. 5. Schibany N, Zehetgruber H, Kainberger F, Wurnig C, Ba-Ssalamah A, Herneth AM, Lang T, Gruber D, Breitenseher MJ. Rotator cuff tears in asymptomatic individuals: a clinical, ultrasonographic screening study. Eur J Radiol. 2004;51(3):263–8. 6. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10–5. 7. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296–9. 8. Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg. 2001;10(3):199–203. 9. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88(8):1699–704. 10. Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, Kobayashi T. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19(1):116–20. 11. Lippitt SB, Harryman DT 2nd, Matsen FA 3rd. A practical tool for evaluating function: the Simple Shoulder Test. In: Matsen FA
123
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
3rd, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobility and stability. Rosemont: American Academy of Orthopaedic Surgeons; 1993. p. 501–18. Fehringer EV, Sun J, VanOeveren LS, Keller BK, Matsen FA 3rd. Full-thickness rotator cuff tear prevalence and correlation with function and co-morbidities in patients sixty-five years and older. J Shoulder Elbow Surg. 2008;17(6):881–5. Fehringer EV, Sun J, Cotton J, Carlson MJ, Burns EM. Healed cuff repairs impart normal shoulder scores in those 65 years of age and older. Clin Orthop Relat Res. 2010;468(6):1521–5. Godfrey J, Hamman R, Lowenstein S, Briggs K, Kocher M. Reliability, validity, and responsiveness of the simple shoulder test: psychometric properties by age and injury type. J Shoulder Elbow Surg. 2007;16(3):260–7. Keener JD, Steger-May K, Stobbs G, Yamaguchi K. Asymptomatic rotator cuff tears: patient demographics and baseline shoulder function. J Shoulder Elbow Surg. 2010;19(8):1191–8. Matsen FA 3rd, Smith KL, DeBartolo SE, Von Oesen G. A comparison of patients with late-stage rheumatoid arthritis and osteoarthritis of the shoulder using self-assessed shoulder function and health status. Arthritis Care Res. 1997;10(1):43–7. Matsen FA 3rd. Early effectiveness of shoulder arthroplasty for patients who have primary glenohumeral degenerative joint disease. J Bone Joint Surg Am. 1996;78(2):260–4. Matsen FA 3rd, Smith KL. Effectiveness evaluation and the shoulder. In: Rockwood CA Jr, Matsen FA 3rd, editors. The shoulder. 2nd ed. Philadelphia: WB Saunders; 1998. p. 1313–40. Matsen FA 3rd, Ziegler DW, DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint disease. J Shoulder Elbow Surg. 1995;4(5):345–51. Roddey TS, Olson SL, Cook KF, Gartsman GM, Hanten W. Comparison of the University of California-Los Angeles Shoulder Scale and the Simple Shoulder Test with the shoulder pain and disability index: single-administration reliability and validity. Phys Ther. 2000;80(8):759–68. Tashjian RZ, Deloach J, Green A, Porucznik CA, Powell AP. Minimal clinically important differences in ASES and simple shoulder test scores after nonoperative treatment of rotator cuff disease. J Bone Joint Surg Am. 2010;92(2):296–303. Middleton WD, Reinus WR, Totty WG, Melson CL, Murphy WA. Ultrasonographic evaluation of the rotator cuff and biceps tendon. J Bone Joint Surg Am. 1986;68(3):440–50. Takagishi K, Makino K, Takahira N, Ikeda T, Tsuruno K, Itoman M. Ultrasonography for diagnosis of rotator cuff tear. Skeletal Radiol. 1996;25(3):221–4. Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br. 1995;77(5): 677–83. Zuckerman JD, Cuomo F, Rokito S. Definition and classification of frozen shoulder: a consensus approach. J Shoulder Elbow Surg. 1994;3(1):S72. Duckworth DG, Smith KL, Campbell B, Matsen FA 3rd. Selfassessment questionnaires document substantial variability in the clinical expression of rotator cuff tears. J Shoulder Elbow Surg. 1999;8(4):330–3. Harryman DT 2nd, Hettrich CM, Smith KL, Campbell B, Sidles JA, Matsen FA 3rd. A prospective multipractice investigation of patients with full-thickness rotator cuff tears: the importance of comorbidities, practice, and other covariables on self-assessed shoulder function and health status. J Bone Joint Surg Am. 2003;85-A(4):690–6.
ORIGINAL ARTICLE
The effects of rotator cuff tears, including shoulders without pain, on activities of daily living in the general population Daisuke Nakajima • Atsushi Yamamoto • Tsutomu Kobayashi Toshihisa Osawa • Hitoshi Shitara • Tsuyoshi Ichinose • Eiji Takasawa • Kenji Takagishi
•
Received: 2 August 2011 / Accepted: 9 December 2011 / Published online: 17 January 2012 Ó The Japanese Orthopaedic Association 2012
Abstract Background Few reports have so far evaluated the possible restrictions of activities of daily living (ADL) in patients with asymptomatic rotator cuff tears (RCTs). The purpose of this study was to examine the effects of RCTs, including shoulders without pain, on ADL in the general population. Methods We performed medical checkups on 462 individuals (924 shoulders). All participants completed a questionnaire regarding their background and medical history. We then assessed their shoulder functions with the Simple Shoulder Test (SST) and performed US (US) examinations of both shoulders to diagnose RCTs. We divided participants into tear and nontear groups and performed statistical analysis to compare total SST scores and each SST item between groups. Furthermore, we performed the same examinations for participants identified as having shoulders without pain. Results Among participants, those in the tear group showed significantly lower total SST scores than those in the nontear group. After examining each SST item, a significant difference was observed regarding the ability to sleep comfortably and to lift 3.6 kg to shoulder level. In
D. Nakajima (&) A. Yamamoto T. Kobayashi H. Shitara T. Ichinose E. Takasawa K. Takagishi Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan e-mail: [email protected] T. Osawa Department of Orthopaedic Surgery, National Hospital Organization Takasaki Hospital, 36, Takamatsu-machi, Takasaki, Gunma 370-8537, Japan
123
shoulders without pain, the tear group showed significantly lower total SST scores than the nontear group. A significant difference was observed only regarding the ability to lift 3.6 kg to shoulder level. Conclusions In the general population, ADL were restricted in participants with RCTs; they experienced night pain in the shoulder and muscle weakness during shoulder elevation. Furthermore, participants with RCTs, even if the condition itself did not induce any pain, tended to experience muscle weakness during shoulder elevation, thus resulting in restrictions of ADL.
Introduction A rotator cuff tear (RCT) is one of the most common disorders affecting the shoulder and cause pain and dysfunction. However, recent studies have found that there are cases of asymptomatic RCTs in which the patient exhibits no shoulder symptoms [1–10]. It is evident that patients with symptomatic RCTs tend to demonstrate restrictions in activities of daily living (ADL); however, few reports have so far evaluated the possible restrictions of ADL in patients with asymptomatic RCTs. We found no published reports examining what effects RCTs might have on ADL in the general population. There are several methods to evaluate the effects of shoulder joint disorders on ADL. The Simple Shoulder Test (SST) as proposed by Lippitt et al. [11] is a selfassessment tool that evaluates 12 common shoulder functions; participants answer by circling ‘‘Yes’’ or ‘‘No’’. These 12 questions are listed in Table 1. The SST is frequently used to evaluate ADL in cases of shoulder joint disorders because it is easy to perform but also sensitively reflects shoulder dysfunction attributed to shoulder joint
The effects of RCTs on the ADL Table 1 Simple Shoulder Test 1. Is your shoulder comfortable with your arm at rest by your side? 2. Does your shoulder allow you to sleep comfortably? 3. Can you reach the small of your back to tuck in your shirt with your hand? 4. Can you place your hand behind your head with the elbow straight out to the side? 5. Can you place a coin on a shelf at the level of your shoulder without bending your elbow? 6. Can you lift 1 pound (0.5 kg) to the level of your shoulder without bending your elbow? 7. Can you lift 8 pounds (3.6 kg) to the level of your shoulder without bending your elbow? 8. Can you carry 20 pounds (9.1 kg) at your side with the affected extremity? 9. Do you think you can toss a softball underhand 10 yards (9.1 m) with the affected extremity? 10. Do you think you can toss a softball overhand 20 yards (18.3 m) with the affected extremity? 11. Can you wash the back of your opposite shoulder with the affected extremity? 12. Would your shoulder allow you to work full time at your regular job?
disorders. It does not bias the examiner into a particular direction, and it has excellent reproducibility [11–21]. The purpose of this study was to examine the effects of RCTs on ADL in the general population, including shoulders without pain, using the SST.
Materials and methods This cross-sectional study was approved by the institutional review board of our institution. A medical checkup, which was intended to help prevent the occurrence of lifestylerelated disease and promote early detection of cancer, was conducted for the residents of a mountain village, where agriculture, forestry, and tourism remain the most important sources of income. Consent was obtained from 544 individuals participating in the study. First, all participants filled out a questionnaire regarding age, gender, presence of shoulder pain at the present time, history of shoulder joint trauma, history of surgery, history of outpatient hospital care, and then the range of motion of active and passive forward elevation of the shoulder joint was measured. We then assessed shoulder functions with the SST. We also conducted ultrasonographic (US) examinations of both shoulders in order to diagnose RCTs. US examinations were performed with the technique described by Middleton et al. [22] using LOGIQ e (GE Health Care, USA) with linear-array probes at 12 MHz. To avoid interobserver variation, all US examinations were
137
performed by one experienced shoulder joint surgeon who was blinded to the other items in the evaluation. In accordance with the report by Takagishi et al. [23], discontinuity and thinning of the rotator cuff were considered to be indications of full-thickness RCTs. Any suspected cases of partial-thickness RCTs were considered to be nontears. According to the US findings prior to surgery on 58 shoulders, which were performed by the shoulder joint surgeon who conducted the US examinations in this study, in cases that underwent arthroscopic rotator cuff repair in our institute from January 2010 to August 2011 after being diagnosed with RCTs, outcomes of 91.8% sensitivity, 77.8% specificity, 95.7% positive predictive value, 63.6% negative predictive value, and 89.7% accuracy were obtained (unpublished data). Participants were selected based on the following criteria: 1. All target evaluation items could be obtained; 2. individuals with both an active and/or passive forward elevation C100°, with the purpose here being to exclude any cases of shoulder joint contracture, such as frozen shoulders, with the limit angle selected based on reports by Bunker et al. [24] and Zuckerman et al. [25]; 3. No history of trauma and surgery to the shoulder joints; 4. No treatment on the shoulders at the time of this survey. Based on these inclusion criteria, 52 patients lacking all evaluation items, five observed with a limited range of motion, 11 with a history of trauma and surgery to the shoulder joints, and 14 undergoing treatment for shoulder pain during the investigation were excluded. With regard to the five patients in whom a limited range of motion was observed, no RCT was observed on US examinations, so they were not considered to be cases demonstrating a secondary contracture accompanying an RCT. Moreover, there were two patients with an active forward elevation of B100° and a passive forward elevation of C100°, and an RCT was observed in both patients based on US examinations. These 2 cases were diagnosed as pseudoparalysis accompanied by an RCT and were thus included in this study because they had normal elbow flexion strength and demonstrated no neurological abnormalities due to a suspicion of either cervical spine disease or a central nervous system disorder. Therefore, the study comprised 462 participants with 924 shoulders; 171 were men and 291 were women, with a mean age of 61.3 (28–87) years. As a statistical analysis, we first divided all participants into a tear and a nontear group, depending on the existence of an RCT, and conducted a comparative examination using the Mann–Whitney U test to ascertain that a difference existed between the two groups in the total SST score.
123
138
In addition, to examine factors that determined the two groups with respect to each SST item, we performed a logistic regression analysis using the existence of a tear as an objective variable and each SST item as an explanatory variable. It is known that the prevalence of RCTs increases with age [3, 4, 6, 7, 9, 10, 12]; therefore, age was used as a regulator in the examination, and the effect of age on ADL was excluded. Next, the participants who had no present pain in the shoulder joint, including pain on motion according to the questionnaire findings, and who also answered ‘‘Yes’’ to both SST items of question 1: ‘‘Is your shoulder comfortable at rest?,’’ which evaluates the presence of pain at rest; and question 2: ‘‘Does your shoulder allow you to sleep comfortably?,’’ which evaluates the presence of pain at night, were thus defined as having ‘‘shoulders without pain.’’ These participants were then examined in the previously described manner with respect to the total SST score and each item. Statistical analysis was carried out using the IBM SPSS Statistics 19 (IBM Japan, Ltd., Tokyo, Japan), and the critical values for significance were set at \5%.
Results Examination of all participants Of the 924 shoulders, 99 belonged to the tear group [mean age 70.5 (46–87) years] and 825 to the nontear group [mean age 60.2 (28–86) years]. Total SST score was 10.6 (3–12) in the tear group and 11.3 (5–12) in the nontear group, with the total SST score in the tear group being significantly lower (P \ 0.001) (Fig. 1). Upon examination of each SST item, there was a significant difference with respect to two items: question 2 ‘‘ability to sleep comfortably’’ [odds ratio (OR) 0.41, 95% confidence interval
Fig. 1 Comparison of Simple Shoulder Test (SST) total scores between all shoulders. SST score was significantly lower in the tear group (*P \ 0.001)
123
D. Nakajima et al.
Fig. 2 Comparison of Simple Shoulder Test (SST) total scores between shoulders without pain. SST score was significantly lower in the tear group (*P \ 0.001)
(CI) 0.19–0.88, P = 0.022], and question 7 ‘‘lift 3.6 kg to shoulder level’’ (OR 4.21, 95% CI 2.25–7.88, P \ 0.001). Examination of shoulders without pain A total of 708 shoulders had no pain, 57 of which belonged to the tear group [mean age 71.1 (56–87) years] and 651 to the nontear group [mean age 60.5 (28–86) years]. The total score for SST questions 3 through 12 (maximum score 10 points) was 9.0 (3–10) in the tear group and 9.5 (5–10) in the nontear group, with the total SST score in the tear group being significantly lower (P \ 0.001) (Fig. 2). There was a significant difference among the questions only in respect to question 7, ‘‘lift 3.6 kg to shoulder level’’ (OR 4.60, 95% CI 1.91–11.09, P = 0.001).
Discussion Several published reports have evaluated the SST score for ADL in patients with RCTs. Lippitt et al. [11] studied 50 shoulders with RCTs and reported that the patients had an impaired ability to sleep comfortably, lift 3.6 kg to shoulder level, and throw a ball 18.3 m overhand. Duckworth et al. [26] studied 123 shoulders with full-thickness RCTs and reported that the total SST score was 5 points on average and that many restrictions were found with respect to the ability to sleep comfortably, lift 3.6 kg to shoulder level, throw a ball 18.3 m overhand, wash the back of the opposite shoulder, and do regular work. Harryman et al. [27] studied 333 shoulders with full-thickness RCTs and reported that the total SST score was 4.4 points and that many restrictions were found in respect to the ability to sleep comfortably, lift 3.6 kg to shoulder level, and throw a ball 18.3 m overhand. The results of these studies agreed on the fact that RCTs restrict ADL. However, all of these studies examined symptomatic RCTs and did not evaluate RCTs in their entirety, including asymptomatic RCTs.
The effects of RCTs on the ADL
A few previous reports studied the effects of asymptomatic RCTs on ADL. Schibany et al. [5] studied 212 asymptomatic shoulders and reported that, although fullthickness RCTs were detected in 6% of the shoulders by US, there was no difference between the tear and nontear groups with respect to ADL evaluation. However, that study limited its participants to volunteers who had no shoulder symptoms, and the method of ADL evaluation was measured only by the constant subscores. Therefore, no detailed evaluation of ADL limitations that includes all RCTs has yet been published. Keener et al. [15] studied 196 participants with asymptomatic RCTs and 54 with an intact rotator cuff presenting with a painful RCT in the contralateral shoulder. The authors stated that participants with an intact rotator cuff had greater but clinically insignificant SST scores than those with an asymptomatic tear. However, it was not a population-based study intended for the general population, and therefore the individual SST items were not considered in detail. In our study, we considered each SST item in the investigated group of participants to be representative of the general population. The results of the overall examination confirmed ADL to be restricted in participants with RCTs; specifically, participants were prone to suffer night pain in the shoulder joint and muscle weakness during shoulder elevation. In addition, in the examination of shoulders without pain, detailed evaluations by SST confirmed that when there was a RCT, ADLs were restricted; specifically, participants were prone to suffer muscle weakness when engaging in shoulder elevation motions. These are the first-ever results from an inclusive study on RCTs in the general population to identify how RCTs affect ADL, regardless of whether or not participants exhibit any symptoms. Tashjian et al. [21], however, reported that patients with rotator cuff disease who are treated without surgery and had a 2-point change in the SST score experienced a clinically important change in self-assessed outcome. In our study, we found ADL to be restricted by evaluating each SST item, but further studies will be required to confirm whether any clinically important difference actually exists when evaluating participants by the total SST score. Regarding the relationship between asymptomatic RCT and muscular strength, Moosmayer et al. [4] studied 420 shoulders of asymptomatic volunteers aged between 50 and 79 years and reported that the strength of flexion significantly decreased in the group with RCTs. Kim et al. [1] also studied 237 asymptomatic shoulders and reported the abduction strength to significantly decrease in shoulders with a large to massive full-thickness RCT. The ADL restriction identified in our study with respect to shoulders without pain was the inability to lift 3.6 kg to shoulder level. It is believed that this restriction can be attributed to muscle weakness during shoulder elevation motions, and as
139
a consequence, no inconsistency is considered to exist between these reports and our study. Our study has several limitations. The first is that this study was not conducted with an examination of tear size, and we did not determine which tendons were involved. Yamaguchi et al. [9] noted that RCT size appeared to be an important factor in symptom development. As mentioned previously, Kim et al. [1] reported that abduction strength significantly decreased in shoulders with a large to massive full-thickness RCT. Harryman et al. [27] also demonstrated that patients who had an infraspinatus as well as a supraspinatus tendon tear tended to have a significantly worsened ability to use the arm overhead compared with those who had only a supraspinatus tear. It is therefore possible that ADL restrictions may differ depending on the size and extent of the tear. Second, ADL evaluation was done only by SST in this study. Some other evaluation methods on ADL in cases of shoulder joint disorder have been reported. In this study, evaluation was done by the STT in view of the fact that it allows evaluation of ADL in a larger number of participants within limited time constraints. The third point concerns the diagnosis of partial-thickness RCTs using US, the diagnostic criteria for which remain controversial. Therefore, in this study, partial-thickness RCTs were considered to be nontears. Fourth, with regard to the selection criteria, we excluded any participants who had restrictions in both active and passive forward elevation so as to exclude patients with other potential causes of shoulder pain, such as osteoarthritis. However, no other type of diagnostic imaging was conducted other than US, and thus we could not exclude such patients completely. Fifth, this was a cross-sectional study, and a longitudinal examination was not conducted. Yamaguchi et al. reported that about 50% of asymptomatic shoulders with RCTs became symptomatic within an average of 2.8 years [8]. Mall et al. [2] also reported that larger tears are more likely to develop pain in the short term than are smaller tears, so it is possible that observations over time may reveal changes in the degree of ADL restriction. Until now, the purpose of conservative treatment for RCTs was to maintain a painless condition even in the presence of a tear. However, results of this study demonstrate that RCTs cause restriction in ADL, even if the condition itself does not induce pain. In the case of RCTs without pain, the individual might not visit a medical institution, thinking that the restriction in ADL is merely the result of the normal aging process. We therefore consider that it is necessary to explain to such individuals the possibility that their RCTs, which cause no pain, may nevertheless eventually result in restriction in ADL. In addition, specialists who treat RCTs should be mindful of this phenomenon and try to provide optimal treatment to improve the quality of life for such patients.
123
140
In conclusion, we evaluated the effects on ADL caused by RCTs using the SST in a general population. Total SST score was significantly lower when participants had RCTs, which thus led to the onset of various types of dysfunctions: ‘‘sleep disturbances due to shoulder pain’’ and an ‘‘inability to lift 3.6 kg to shoulder level.’’ Total SST score was also significantly lower in shoulders without pain when there was an RCT, thus leading to the occurrence of a dysfunction; namely, an ‘‘inability to lift 3.6 kg to shoulder level.’’ Conflict of interest The authors did not receive and will not receive any benefits or funding from any commercial party related directly or indirectly to the subject of this article.
D. Nakajima et al.
12.
13.
14.
15.
16.
References 1. Kim HM, Teefey SA, Zelig A, Galatz LM, Keener JD, Yamaguchi K. Shoulder strength in asymptomatic individuals with intact compared with torn rotator cuffs. J Bone Joint Surg Am. 2009;91(2):289–96. 2. Mall NA, Kim HM, Keener JD, Steger-May K, Teefey SA, Middleton WD, Stobbs G, Yamaguchi K. Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical, sonographic variables. J Bone Joint Surg Am. 2010;92(16):2623–33. 3. Milgrom C, Schaffler M, Gilbert S, van Holsbeeck M. Rotatorcuff changes in asymptomatic adults. The effect of age, hand dominance, gender. J Bone Joint Surg Br. 1995;77(2):296–8. 4. Moosmayer S, Smith HJ, Tariq R, Larmo A. Prevalence characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic, clinical study. J Bone Joint Surg Br. 2009;91(2): 196–200. 5. Schibany N, Zehetgruber H, Kainberger F, Wurnig C, Ba-Ssalamah A, Herneth AM, Lang T, Gruber D, Breitenseher MJ. Rotator cuff tears in asymptomatic individuals: a clinical, ultrasonographic screening study. Eur J Radiol. 2004;51(3):263–8. 6. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10–5. 7. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296–9. 8. Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg. 2001;10(3):199–203. 9. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88(8):1699–704. 10. Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, Kobayashi T. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19(1):116–20. 11. Lippitt SB, Harryman DT 2nd, Matsen FA 3rd. A practical tool for evaluating function: the Simple Shoulder Test. In: Matsen FA
123
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
3rd, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobility and stability. Rosemont: American Academy of Orthopaedic Surgeons; 1993. p. 501–18. Fehringer EV, Sun J, VanOeveren LS, Keller BK, Matsen FA 3rd. Full-thickness rotator cuff tear prevalence and correlation with function and co-morbidities in patients sixty-five years and older. J Shoulder Elbow Surg. 2008;17(6):881–5. Fehringer EV, Sun J, Cotton J, Carlson MJ, Burns EM. Healed cuff repairs impart normal shoulder scores in those 65 years of age and older. Clin Orthop Relat Res. 2010;468(6):1521–5. Godfrey J, Hamman R, Lowenstein S, Briggs K, Kocher M. Reliability, validity, and responsiveness of the simple shoulder test: psychometric properties by age and injury type. J Shoulder Elbow Surg. 2007;16(3):260–7. Keener JD, Steger-May K, Stobbs G, Yamaguchi K. Asymptomatic rotator cuff tears: patient demographics and baseline shoulder function. J Shoulder Elbow Surg. 2010;19(8):1191–8. Matsen FA 3rd, Smith KL, DeBartolo SE, Von Oesen G. A comparison of patients with late-stage rheumatoid arthritis and osteoarthritis of the shoulder using self-assessed shoulder function and health status. Arthritis Care Res. 1997;10(1):43–7. Matsen FA 3rd. Early effectiveness of shoulder arthroplasty for patients who have primary glenohumeral degenerative joint disease. J Bone Joint Surg Am. 1996;78(2):260–4. Matsen FA 3rd, Smith KL. Effectiveness evaluation and the shoulder. In: Rockwood CA Jr, Matsen FA 3rd, editors. The shoulder. 2nd ed. Philadelphia: WB Saunders; 1998. p. 1313–40. Matsen FA 3rd, Ziegler DW, DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint disease. J Shoulder Elbow Surg. 1995;4(5):345–51. Roddey TS, Olson SL, Cook KF, Gartsman GM, Hanten W. Comparison of the University of California-Los Angeles Shoulder Scale and the Simple Shoulder Test with the shoulder pain and disability index: single-administration reliability and validity. Phys Ther. 2000;80(8):759–68. Tashjian RZ, Deloach J, Green A, Porucznik CA, Powell AP. Minimal clinically important differences in ASES and simple shoulder test scores after nonoperative treatment of rotator cuff disease. J Bone Joint Surg Am. 2010;92(2):296–303. Middleton WD, Reinus WR, Totty WG, Melson CL, Murphy WA. Ultrasonographic evaluation of the rotator cuff and biceps tendon. J Bone Joint Surg Am. 1986;68(3):440–50. Takagishi K, Makino K, Takahira N, Ikeda T, Tsuruno K, Itoman M. Ultrasonography for diagnosis of rotator cuff tear. Skeletal Radiol. 1996;25(3):221–4. Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br. 1995;77(5): 677–83. Zuckerman JD, Cuomo F, Rokito S. Definition and classification of frozen shoulder: a consensus approach. J Shoulder Elbow Surg. 1994;3(1):S72. Duckworth DG, Smith KL, Campbell B, Matsen FA 3rd. Selfassessment questionnaires document substantial variability in the clinical expression of rotator cuff tears. J Shoulder Elbow Surg. 1999;8(4):330–3. Harryman DT 2nd, Hettrich CM, Smith KL, Campbell B, Sidles JA, Matsen FA 3rd. A prospective multipractice investigation of patients with full-thickness rotator cuff tears: the importance of comorbidities, practice, and other covariables on self-assessed shoulder function and health status. J Bone Joint Surg Am. 2003;85-A(4):690–6.