Research Review By Dr. Michael Haneline©


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Date Posted:

April 2022

Study Title:

Shoulder pain across more movements is not related to more rotator cuff tendon findings in people with chronic shoulder pain diagnosed with subacromial pain syndrome


Alaiti R, Caneiro J, Gasparin J et al.

Author's Affiliations:

Nucleus of Neuroscience and Behavior and Nucleus of Applied Neuroscience, Universidade de Sao Paulo, Sao Paulo, Brazil; Research, Technology, and Data Science Unit, Projeto Superador, Sao Paulo, Brazil; School of Physiotherapy and Exercise Science, Curtin University, Australia; Body Logic Physiotherapy, Perth, Australia

Publication Information:

Pain Reports 2021; 6(4): e980. doi: 10.1097/PR9.0000000000000980.

Background Information:

Chronic shoulder pain often interferes with daily activities that involve arm movements and is commonly diagnosed as subacromial pain syndrome with rotator cuff tendinopathy or tear (1). Clinical decisions are often based on a patient’s reports of pain with movement, considering patterns of movement that provoke the pain or by performing provocative movements to determine the mechanical causes of the pain (2, 3).

General measures of shoulder pain are poorly correlated with radiological imaging (4) and the connection between tissue damage and movement-related shoulder pain has not been properly investigated. Nevertheless, many clinicians consider that more intense pain or pain with more shoulder movements are accurate measures of more tissue damage to the rotator cuff tendons (5). Unfortunately, studies thus far have relied on pain-intensity measures that do not actually measure the variability of shoulder pain during life’s daily activities!

The aim of this study was to determine whether movement-related pain that occurs across a wider variety of activities was associated with the number or severity of rotator cuff radiological findings on magnetic resonance imaging (MRI). The authors hypothesized that such pain would not be associated with the number or severity of rotator cuff MRI findings.

The study comprised 3 successive phases:
  1. select the activities commonly perceived as painful from 3 well-established outcome measures,
  2. develop and evaluate the measurement properties of a tool that assesses the occurrence of pain across clinically relevant arm movements, and
  3. analyze the data collected in phase 2.

Pertinent Results:

Put simply, movement-related pain that is reported across a wider variety of shoulder activities was not associated with the number nor severity of rotator cuff MRI findings. In other words, neither the number of abnormal rotator cuff tendons nor the severity of tendon findings was associated with pain occurrence across clinically relevant arm movements.

Univariate regression analyses revealed that pain intensity and pain during rest were associated with MRPDS, such that as pain increased or decreased, so did MRPDS.

Clinical Application & Conclusions:

The findings of this study are similar to what other studies have found, that neither the presence nor severity of imaging findings are associated with general measures of pain intensity or disability. However, this study did show that participants who reported pain across more activities were more prone to notice pain during rest.

Clinicians may utilize this information when developing treatment plans for patients with chronic shoulder pain and to reassure those with increased pain on various shoulder movements concerning their prognosis.

EDITOR’S NOTE: this is yet another study showing us that imaging findings don’t correlate well with clinical findings – this time in relation to shoulder movement limitations and evidence of rotator cuff damage on MRI. As always, treat the patient, not their pictures!

Study Methods:

In the first phase of the study, 30 people with subacromial pain syndrome were recruited to determine the most commonly reported, clinically relevant arm movements and activities that were and associated with pain during daily activities. Initially, 16 movements related to reaching, grasping and hand manipulations were selected from 3 well-established outcome measures, including:
  • Constant–Murley (6)
  • Shoulder Pain and Disability Index (7)
  • American Shoulder and Elbow Surgeons Questionnaire (1)
The following 10 activities were selected to represent the most commonly reported pain provoking activities for people with shoulder pain: unilateral and bilateral reach at 60°, 90°, and 120° of flexion; hand to mouth, head, and back pocket of the pants; and hold 4 kg with the affected limb next to the body. These activities were referred to as “clinically relevant arm movements” for people with shoulder pain.

In phase 2 of the study, 100 people diagnosed with chronic subacromial pain syndrome were recruited to develop a measurement tool that assesses pain across the clinically relevant arm movements selected in the first phase. Data collected in phase 2 of this study were analyzed in phase 3.

Shoulder pain patients from a hospital orthopedic department who were between 40 and 65 years-of-age, sedentary, and symptomatic were consecutively invited to participate in the study. Patients were diagnosed for the presence of subacromial pain syndrome by clinical examination with positive results for 3 of the following 5 tests: Neer, Hawkins-Kennedy, painful arc, pain or weakness with resisted external rotation, and Jobe (8).

Patients were excluded if they had cognitive impairment, used medications for pain control in the previous 24 hours, neurological disease, limited shoulder passive range of motion, previous shoulder surgery, or rheumatic disease.

Pain occurrence across 10 different activities commonly reported as painful by people with chronic shoulder pain was the study’s outcome variable. Measurements were made using the Movement-Related Pain Distribution Scale – Shoulder (MRPDS) which was developed in the study’s second phase. The MRPDS provides an index that indicates whether pain occurrence is widespread across activities or whether it is specific to certain movements, as well as providing information on the degree of pain intensity across the activities.

Sociodemographic data and pain-related variables were collected via questionnaire. A 10 cm Visual Analogue Scale (VAS) was administered before the MRPDS to rate overall pain intensity. A blinded, experienced physician radiologist analyzed participants’ shoulder MRI findings, providing the number of abnormal rotator cuff tendons and the severity of any tendon tears.

Study Strengths / Weaknesses

This was a very well conducted study that provides useful clinically relevant information. However, it utilized a cross-sectional design rather than the gold-standard randomized clinical trial, thus negating its ability to demonstrate cause and effect relationships.

The authors mentioned several other study limitations, including:
  • the way activities most commonly reported and associated with pain during daily life activities were developed may not be representative of the population of people with chronic shoulder pain;
  • the MRPDS did not include every possible shoulder activity, so other clinically important activities might not have been assessed; and
  • the group of participants included in this study met specific entry criteria and possessed certain characteristics that may not be the same as other individuals or groups, so the study’s findings may not apply universally.

Additional References:

  1. Unruh K, Kuhn J, Sanders R, et al. The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross sectional study of patients with atraumatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg 2014; 23: 1052-8.
  2. Cools AM, Struyf F, De Mey K et al. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med 2014; 48: 692-7.
  3. Lewis J, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg 2005; 14: 385-92.
  4. Brophy R, Dunn W, Kuhn J. Shoulder activity level is not associated with the severity of symptomatic, atraumatic rotator cuff tears in patients electing nonoperative treatment. Am J Sports Med 2014; 42: 1150-4.
  5. Caneiro J, Bunzli S, O’Sullivan P. Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther 2021; 25: 17-29.
  6. Constant C, Murley A. Constant score for shoulder evaluation. Clin Orthop Relat Res 1987; (214): 160-4.
  7. Breckenridge J, McAuley J. Shoulder Pain and Disability Index (SPADI). J Physiother 2011; 57(3): 197.
  8. Angst F, Schwyzer H, Aeschlimann A, Simmen B, Goldhahn J. Measures of adult shoulder function: disabilities of the arm, shoulder, and hand questionnaire (DASH) and its short version (QuickDASH), shoulder pain and disability index (SPADI), American shoulder and elbow surgeons (ASES) society standardized shoulder assessment form, constant (Murley) score (CS), simple shoulder test (SST), Oxford shoulder score (OSS), shoulder disability questionnaire (SDQ), and Western Ontario shoulder instability index (WOSI). Arthritis Care Res (Hoboken) 2011; 63(suppl 11): S174-88.
  9. Michener L, Walsworth M, Doukas W, Murphy K. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil 2009; 90: 1898-903.

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