BackgroundValidated clinician outcome scores are considered less associated with psychosocial factors than patient-reported outcome measurements (PROMs). This belief may lead to misconceptions if both instruments are related to similar factors.QuestionsWe asked: In patients with chronic shoulder pain, what biopsychosocial factors are associated (1) with PROMs, and (2) with clinician-rated outcome measurements?MethodsAll new patients between the ages of 18 and 65 with chronic shoulder pain from a unilateral shoulder injury admitted to a Swiss rehabilitation teaching hospital between May 2012 and January 2015 were screened for potential contributing biopsychosocial factors. During the study period, 314 patients were screened, and after applying prespecified criteria, 158 patients were evaluated. The median symptom duration was 9 months (interquartile range, 5.5–15 months), and 72% of the patients (114 patients) had rotator cuff tears, most of which were work injuries (59%, 93 patients) and were followed for a mean of 31.6 days (SD, 7.5 days). Exclusion criteria were concomitant injuries in another location, major or minor upper limb neuropathy, and inability to understand the validated available versions of PROMs. The PROMs were the DASH, the Brief Pain Inventory, and the Patient Global Impression of Change, before and after treatment (physiotherapy, cognitive therapy and vocational training). The Constant-Murley score was used as a clinician-rated outcome measurement. Statistical models were used to estimate associations between biopsychosocial factors and outcomes.ResultsGreater disability on the DASH was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.64; 95% CI, 0.25–1.03; p = 0.002) and social factors (language, professional qualification combined coefficient, −6.15; 95% CI, −11.09 to −1.22; p = 0.015). Greater pain on the Brief Pain Inventory was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.076; 95% CI, 0.021–0.13; p = 0.006). Poorer impression of change was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia coefficient, 0.93; 95% CI, 0.87–0.99; p = 0.026) and social factors (education, language, and professional qualification coefficient, 6.67; 95% CI, 2.77–16.10; p < 0.001). Worse clinician-rated outcome was associated only with psychological factors (Hospital Anxiety and Depression Scale (depression only), Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia combined coefficient, −0.35; 95% CI, −0.58 to −0.12; p = 0.003).ConclusionsDepressive symptoms and catastrophizing appear to be key factors influencing PROMs and clinician-rated outcomes. This study suggests revisiting the Constant-Murley score.Level of EvidenceLevel III, prognostic study.

Objectives: Patients are commonly advised to wear a sling for 4-6 weeks after rotator cuff repair (RCR) despite negative effects of early immobilization and benefits of motion rehabilitation. The study aimed to compare clinical and radiographic outcomes up to 6 months following RCR with sling immobilization and without sling immobilization. Methods: We randomized 80 patients scheduled for arthroscopic repair of small or medium superior rotator cuff tears into 2 equal groups: 'sling' and 'no-sling' groups. Passive mobilization was performed in both groups during the first 4 postoperative weeks followed by a progressive active mobilization. Patients were evaluated clinically at 10 days, 1.5, 3 and 6 months, and using ultrasound at 6 months. Uni-and multi-variable analyses were performed to determine if postoperative scores are associated with gender, age at surgery, immobilization, arm dominance, biceps procedure, resection of the distal clavicle, as well as preoperative scores. Results: The two groups had similar preoperative patient characteristics, function, or adjuvant procedures. At 10 days, there was no difference in pain among the two groups (5.2±2.3 vs 5.2±1.9, p=0.996). In comparison to the sling group, the no-sling group showed greater external rotation (23.5±15.6 vs 15.3±14.6, p=0.017) and active elevation (110.9±31.9 vs 97.0±25.0, p=0.038) at 1.5 months, as well as better active elevation (139.0±24.7 vs 125.8±24.4, p=0.015) and internal rotation (>T12 in 50% vs 27.5%, p=0.011) at 3 months. Ultrasound revealed no differences at 6 months in tendon thickness anteriorly (p=0.472) or posteriorly (p=639), bursitis (p=1.000), echogenicity (p=0.422), or repair integrity (p=0.902). Multi-variable analyses confirmed that ASES score increased with patient age (beta, 0.60; p=0.009), SANE decreased with sling immobilization (beta,-6.3; p=0.014), and that pain increased with sling immobilization (beta, 0.77; p=0.022). Conclusion: No immobilization after RCR is associated with better early mobility and functional scores in comparison to sling immobilization. Postoperative immobilization with slings may therefore not be required for patients treated for small or medium tears.

Background: Patients are commonly advised to wear a sling for 4 to 6 weeks after rotator cuff repair despite negative effects of early immobilization and benefits of motion rehabilitation. The aim of this study was to compare clinical and radiographic outcomes up to 6 months following rotator cuff repair with and without postoperative sling immobilization. Methods: We randomized 80 patients scheduled for arthroscopic repair of a small or medium superior rotator cuff tear into sling and no-sling groups (40 patients each). Passive mobilization was performed in both groups during the first 4 postoperative weeks, and this was followed by progressive active mobilization. Patients were evaluated clinically at 10 days and 1.5, 3, and 6 months and using ultrasound at 6 months. Univariable and multivariable analyses were performed to determine if postoperative scores were associated with sex, age at surgery, immobilization, arm dominance, a biceps procedure, resection of the distal part of the clavicle, or preoperative scores. Results: The sling and no-sling groups had similar preoperative patient characteristics, function, and adjuvant procedures. At 10 days, there was no difference in pain between the 2 groups (mean pain score [and standard deviation], 5.2 ± 2.3 versus 5.2 ± 1.9, p = 0.996). In comparison with the sling group, the no-sling group showed greater mean external rotation (23.5° ± 15.6° versus 15.3° ± 14.6°, p = 0.017) and active elevation (110.9° ± 31.9° versus 97.0° ± 25.0°, p = 0.038) at 1.5 months as well as better mean active elevation (139.0° ± 24.7° versus 125.8° ± 24.4°, p = 0.015) and internal rotation (T12 or above in 50% versus 28%, p = 0.011) at 3 months. Ultrasound evaluation revealed no significant differences at 6 months in tendon thickness anteriorly (p = 0.472) or posteriorly (p = 0.639), bursitis (p = 1.000), echogenicity (p = 0.422), or repair integrity (p = 0.902). Multivariable analyses confirmed that the mean American Shoulder and Elbow Surgeons (ASES) score increased with patient age (beta, 0.60; p = 0.009), the Single Assessment Numeric Evaluation (SANE) decreased with sling immobilization (beta, −6.33; p = 0.014), and pain increased with sling immobilization (beta, 0.77; p = 0.022). Conclusions: No immobilization after rotator cuff repair is associated with better early mobility and functional scores in comparison with sling immobilization. Postoperative immobilization with a sling may therefore not be required for patients treated for a small or medium tendon tear. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound (US) imaging is an efficient, easy to use and inexpensive tool allowing for facilitated diagnosis and management of the painful shoulder. It remains primarily used by radiologists and rheumatologists, despite having shown excellent diagnostic accuracy when used by different medical specialities in their office-based consultation. It also has advantages over other imaging modalities in the evaluation of the postoperative shoulder for rotator cuff integrity and correct anchor and suture placement, as well as rotator cuff analysis following arthroplasty. Integration of US imaging into the orthopaedic surgeon's toolbox can be aided by a basic understanding of US principles, accompanied by a guide outlining basic techniques for evaluation of the healthy, pathological and postoperative shoulder as well as US-guided treatment possibilities.