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Understanding Outcomes and the Ability to Return to Work After Rotator Cuff Repair in the Workers' Compensation Population

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Introduction Patients with a worker compensation claim are associated with a greater probability of continued symptoms and activity intolerance. This study aims to determine predictors of improved patient-reported outcomes in the workers' compensation population. Methods Patients with workers' compensation claims undergoing arthroscopic rotator cuff repair between 2010 and 2015 were included. Age, gender, dominant hand, occupation, and number of tendons involved were analyzed. At a minimum of two years, patients were contacted to complete American Shoulder and Elbow Surgeons (ASES) Survey, Simple Shoulder Test (SST), and return-to-work status (RTW). Preoperative characteristics and scores were then compared. Results Seventy patients were available for follow-up at an average of 5.4 years (range: 2.1-8.8 years). Average age was 55 years (range: 37-72); 55 (78.6%) were males, 23 (32.9%) were laborers; and 59 (84.2%) patients returned to work. The sole predictor for RTW was surgery on the non-dominant arm (96.5% versus 75.6%; p = 0.021). Laborers showed decreased RTW (p = 0.03). Patients who completed RTW had excellent outcomes with higher ASES (87 versus 50; p value < 0.001) and SST scores (10.4 versus 4.6; p < 0.001). Patients with three tendon tears had inferior ASES (p = 0.026) and SST (p = 0.023) scores than those with less. Conclusion Most workers' compensation patients have excellent outcomes from rotator cuff repair. Patients with three tendon tear repairs demonstrated the worst functional outcomes. Laborers showed decreased ability to RTW with nearly one-third unable.
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Understanding Outcomes and the Ability to
Return to Work After Rotator Cuff Repair in the
Workers' Compensation Population
Michael J. Gutman , Manan S. Patel , Akhil Katakam , Nathan Liss , Benjamin M. Zmistowski , Mark D.
Lazarus , John G. Horneff
1. Shoulder and Elbow Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, USA 2.
Shoulder and Elbow Surgery, Washington University Orthopedics, Saint Louis, USA 3. Department of Orthopedic
Surgery, University of Pennsylvania, Philadelphia, USA
Corresponding author: Michael J. Gutman, michaelgutman@gmail.com
Abstract
Introduction
Patients with a worker compensation claim are associated with a greater probability of continued symptoms
and activity intolerance. This study aims to determine predictors of improved patient-reported outcomes in
the workers’ compensation population.
Methods
Patients with workers’ compensation claims undergoing arthroscopic rotator cuff repair between 2010 and
2015 were included. Age, gender, dominant hand, occupation, and number of tendons involved were
analyzed. At a minimum of two years, patients were contacted to complete American Shoulder and Elbow
Surgeons (ASES) Survey, Simple Shoulder Test (SST), and return-to-work status (RTW). Preoperative
characteristics and scores were then compared.
Results
Seventy patients were available for follow-up at an average of 5.4 years (range: 2.1-8.8 years). Average age
was 55 years (range: 37-72); 55 (78.6%) were males, 23 (32.9%) were laborers; and 59 (84.2%) patients
returned to work. The sole predictor for RTW was surgery on the non-dominant arm (96.5% versus 75.6%; p =
0.021). Laborers showed decreased RTW (p = 0.03). Patients who completed RTW had excellent outcomes
with higher ASES (87 versus 50; p value < 0.001) and SST scores (10.4 versus 4.6; p < 0.001). Patients with
three tendon tears had inferior ASES (p = 0.026) and SST (p = 0.023) scores than those with less.
Conclusion
Most workers’ compensation patients have excellent outcomes from rotator cuff repair. Patients with three
tendon tear repairs demonstrated the worst functional outcomes. Laborers showed decreased ability to RTW
with nearly one-third unable.
Categories: Orthopedics
Keywords: workers compensation, functional outcomes, rotator cuff repair, laborers, return to work
Introduction
In the United States, there are over 4.5 million annual physician visits due to rotator cuff tears [1,2]. Rotator
cuff tears are one of the most common forms of upper extremity injury in the workers’ compensation
population [3]. Work-related rotator cuff injuries are a common source of limited work productivity and are
associated with high costs in compensation claims [3,4]. To date, literature has demonstrated decreased
functional outcomes in workers’ compensation patients who underwent rotator cuff tears, total shoulder
arthroplasty, and reverse shoulder arthroplasty [5-7]. Although rotator cuff repairs in the workers’
compensation population do have statistically significant improvement after one year following surgery,
these patients still show a higher level of disability compared to their non-workers' compensation
counterparts [8].
Previous studies have demonstrated significantly worse outcomes in workers’ compensation patients who
underwent rotator cuff repair compared to non-workers’ compensation patients who underwent the same
procedure [9-11]. Others have compared the characteristics of workers’ compensation patients to those of
non-workers’ compensation patients to identify the confounding factors that lead to such worse
outcomes [9,10]. Henn et al. reported that even after multivariable analysis controlled for possible
confounding factors between the workers’ and non-workers’ compensation populations, worker
compensation status independently predicted worse outcomes [12]. The cause of these observed differences
1 1 1 1 2
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Open Access Original
Article DOI: 10.7759/cureus.14213
How to cite this article
Gutman M J, Patel M S, Katakam A, et al. (M arch 31, 2021) Understanding Outcomes and the Ability to Return to Work After Rotator Cuff Repair in
the Workers' Compensation Population. C ureus 13(3): e14213. DOI 10.7759/cureus.14213
between these patient populations is not well understood. Many believe that the worse outcomes
demonstrated in the workers’ compensation population can be explained by external issues not related to
pathophysiology, such as psychosocial factors or secondary gains like salary or other financial benefits while
not in work [9-11]. However, other authors have suggested that fear of reinjury from returning to heavy
labor may explain the lower recovery rates [8,13,14]. Although the outcomes of the procedure itself may be
good, patients often take longer time to return to work (RTW) after an occupational injury compared to non-
occupational injuries [15-17]. This delayed timing of RTW may be a major factor in the perception of poorer
outcomes in the workers’ compensation population [14].
Unreliable results can cause hesitation among surgeons in the management of workers’ compensation in
patients with rotator cuff pathology. While many previous manuscripts have compared workers’
compensation patients to non-workers’ compensation patients in the rotator cuff repair population, no
studies have investigated which factors lead to worsened surgical outcomes within the workers’
compensation population itself. The purpose of this study is to determine predictors of improved patient-
reported outcomes in this population as well as the ability to RTW following rotator cuff repair. We
hypothesize that patients in this population with larger tears would have worse outcomes and those with
“labor-intensive” occupations that require heavy lifting would have lower rates of returning to work.
Materials And Methods
Following institutional review board approval, a query was performed of all patients with rotator cuff tears
and billed via workers’ compensation at one institution. The surgeries were performed by one of four
fellowship-trained surgeons between January 2010 and December 2015. This query yielded 175 cases in 174
patients. Inclusion criteria required that rotator cuff repairs be performed on patients with workers’
compensation claims and had a minimum follow-up period of two years. Work-related injuries from both
acute trauma and repetitive trauma were included. Exclusion criteria were revision of prior rotator cuff
tears and patients having undergone any rotator cuff surgery that was not a complete repair. At a minimum
of two years, patients were contacted to complete an American Shoulder and Elbow Surgeons (ASES) survey,
Simple Shoulder Test (SST), and Visual Analog Scale (VAS) and to provide patient-reported satisfaction
score based on a 1-10 Likert scale. Patients were also queried regarding RTW and permanent disability
status. In 174 patients meeting inclusion criteria, 70 were available for follow-up at two years. All patients
had a magnetic resonance imaging (MRI) scan to determine the number of tendons torn. Operative reports
were analyzed to confirm MRI findings and determine number of anchors used in the rotator cuff
repair. Chart review was performed on all of these patients to collect age, gender, hand dominance, body
mass index, occupation, mechanism of injury, and medical comorbidities including heart disease,
hypertension, hyperlipidemia, diabetes, Charlson Comorbidity Index age-adjusted and not age-adjusted,
smoking status, and alcohol use. Patients were defined as laborers if they stated that they worked the
majority of the time using their shoulders or arms for activities such as lifting (>10 pounds), carrying (>10
pounds), climbing, or repetitive reaching. Patients’ preoperative and intraoperative characteristics and
functional scores were compared to assess predictors of ability to RTW.
Postoperative therapy
All patients participated in formal postoperative physical therapy as instructed by our surgeons. Patients
wore a sling for six weeks, and formal therapy with a licensed physical therapist was started after six weeks
to assist with Phase 1 and Phase 2 stretching followed by progression to Phase 1 and Phase 2 strengthening
of the rotator cuff. Strength exercises were delayed until 12 weeks postoperatively. Patients were given
progressive lifting restrictions for six months before being allowed to use the arm as tolerated.
Statistics
The data was analyzed by comparing those who returned to work versus those who did not. Continuous data
are presented as mean (standard deviation) for parametric data or median (first quartile; third quartile) for
nonparametric data. All categorical data are presented as cell count (percent of total count). T-tests were
used to calculate p values for parametric data. Mann-Whitney U tests were used for nonparametric data for
continuous variables. Chi-square test or Fisher’s exact test was used to calculate p values for all categorical
data. Following the univariate, a set of bivariate regressions were analyzed to determine which factors had a
relationship with returning to work. Significance was established at p < 0.05. Receiver operator
characteristic (ROC) curve analysis was performed on functional scores, and RTW and area under the curve
(AUC) values were determined. All statistical analyses were done using RStudio (Version 3.6.1, RStudio,
Vienna, Austria).
Results
Data of 70 workers’ compensation patients who had undergone rotator cuff repair with a minimum two-year
follow-up were included in this analysis. The mean follow-up time was 64.9 months (range: 26-105 months)
(Table 1). The patients had an average age of 55.1 years (range: 37-72) and were composed of 55 (78.6%)
males and 15 (21.4%) females. Out of the 70 patients, 23 (32.9%) were defined as laborers and 47 (67.1%) as
non-laborers. Sixty-seven patients (95.7%) reported traumatic injuries rather than repetitive injuries. Forty
patients (57.1%), including three ambidextrous patients, experienced injury in their dominant arm (Table 1).
2021 Gutman et al. Cureus 13(3): e14213. D OI 10.7759/cureus.14213 2 of 7
Total (N =
70)
Unable to Return to Work (N =
11)
Return to Work (N =
59) P Value
Age (SD) 55.1 (7.2) 52.7 (6.0) 55.5 (7.4) 0.191
Sex 0.233
Female 15 (21.4%) 4 (36.4%) 11 (18.6%)
Male 55 (78.6%) 7 (63.6%) 48 (81.4%)
Side of Surgery 1.000
Left 35 (50.0%) 5 (45.5%) 30 (50.8%)
Right 35 (50.0%) 6 (54.5%) 29 (49.2%)
Dominant Side 0.021
Non-dominant 29 (41.4%) 1 (9.1%) 28 (47.5%)
Dominant 41 (58.6%) 10 (90.9%) 31 (52.5%)
Body Mass Index (SD) 30.6 (5.7) 30.6 (5.0) 30.7 (5.9) 0.988
Laborer 0.032
No 47 (67.1%) 4 (36.4%) 43 (72.9%)
Yes 23 (32.9%) 7 (63.6%) 16 (27.1%)
Mental Illness 1.000
No 68 (97.1%) 11 (100%) 57 (96.6%)
Yes 2 (2.9%) 0 (0.00%) 2 (3.4%)
Heart Disease 0.602
No 62 (88.6%) 9 (81.8%) 53 (89.8%)
Yes 8 (11.4%) 2 (18.2%) 6 (10.2%)
Hypertension 0.387
No 37 (52.9%) 4 (36.4%) 33 (55.9%)
Yes 33 (47.1%) 7 (63.6%) 26 (44.1%)
High Cholesterol 0.046
No 45 (64.3%) 4 (36.4%) 41 (69.5%)
Yes 25 (35.7%) 7 (63.6%) 18 (30.5%)
Diabetes 1.000
No 56 (80.0%) 9 (81.8%) 47 (79.7%)
Yes 14 (20.0%) 2 (18.2%) 12 (20.3%)
Charlson Comorbidity Index 0.740
0 44 (62.9%) 6 (54.5%) 38 (64.4%)
1 20 (28.6%) 4 (36.4%) 16 (27.1%)
2 4 (5.7%) 1 (9.09%) 3 (5.1%)
3 2 (2.9%) 0 (0.00%) 2 (3.4%)
Charlson Comorbidity Index Age-Adjusted
(SD) 1.8 (1.3) 1.4 (1.2) 1.9 (1.3) 0.247
TABLE 1: Patient demographics
2021 Gutman et al. Cureus 13(3): e14213. D OI 10.7759/cureus.14213 3 of 7
SD, Standard deviation.
At two-year follow-up, the average satisfaction score with their current shoulder function was 7.9 (range: 0-
10), and the mean ASES score was 81.1 (range: 20-100) (Table 2). Fifty-nine patients (84.2%) returned to
work. The sole independent predictor of RTW in this population was surgery on the non-dominant arm
(96.5% versus 75.6%; p = 0.021). Patients who returned to work had higher final ASES scores (86.9 versus
49.8; p < 0.001), SST scores (10.4 versus 4.54; p < 0.001), and overall satisfaction (8.5 versus 5; p = 0.001).
Patients who had lower VAS pain scores had higher rates of returning to work (1.1 versus 4.0; p < 0.001)
(Table 2, Figure 1). Laborers showed decreased ability to RTW (p = 0.03) with an incidence of 69.6% (n = 23).
However, laborers with non-dominant arm injury compared to laborers with dominant arm injury had RTW
rates of 90% (n = 10) and 53.8% (n = 13), respectively (p = 0.09).
Total (N = 70) Unable to Return to Work (N = 11) Returned to Work (N = 59) P Value
ASES 81.1 ± 22.4 49.9 ± 22.2 87.0 ± 17.0 p < 0.001
SST 9.5 ± 3.1 4.5 ± 2.7 10.4 ± 2.1 p < 0.001
VAS 1.6 ± 2.5 4.1 ± 2.5 1.1 ± 2.2 p < 0.001
Satisfaction With Shoulder Function 7.9 ± 2.7 5.0 ± 2.7 8.5 ± 2.4 p < 0.001
TABLE 2: Association between shoulder function and ability to return to work
ASES, American Shoulder and Elbow Score; SST, Simple Shoulder Test Score; VAS, Visual Analog Scale.
FIGURE 1: Mean shoulder pain, function, and satisfaction scores
ASES, American Shoulder and Elbow Score; SST, Simple Shoulder Test Score; VAS, Visual Analog Scale.
ROC curve analysis was performed on functional scores and satisfaction to assess whether there were any
cut-off values that were predictive of RTW. Excellent predictive capabilities were found for SST (AUC =
0.937), and good predictive tests were found for ASES score (AUC = 0.896) (Table 3).
2021 Gutman et al. Cureus 13(3): e14213. D OI 10.7759/cureus.14213 4 of 7
Score AUC Cut-off 1 Sensitivity Specificity Cut-off 2 Sensitivity Specificity
ASES 0.90 54.17 89.8% 72.7% 84.2 25.4% 90.9%
SST 0.94 6.0 94.1% 77.2% 7.0 93.3% 86.3%
Satisfaction 0.84 7.5 83.0% 81.8% 8.5 67.8% 90.9%
TABLE 3: Receiver operating characteristics curve analysis to assess cut-off values to predict
return to work
AUC, Area Under the Curve; ASES, American Shoulder and Elbow Score; SST, Simple Shoulder Test Score.
The number of tendons torn ranged from one to three tendons. Twenty-eight patients had one tendon torn,
25 had two tendons torn, and 17 had three tendons torn. Patients with three tendons torn had inferior ASES
(p = 0.026), SST (p = 0.023), VAS (p = 0.056), and shoulder satisfaction scores after surgery (p = 0.042)
compared to all other patients (Table 4). The number of tendons torn was not associated with the ability to
go back to work (p = 0.12). In the 11 patients who did not RTW, four patients underwent a postoperative MRI.
In these patients, two were shown to have a recurrence of their tear.
1 Tendon Tear (N = 28) 2 Tendon Tear (N = 25) 3 Tendon Tear (N = 17) P Value
ASES 78.6 + 26.0 89.1 + 15.2 73.6 + 22.3 0.026
SST 8.8 + 3.7 10.9 + 1.5 8.5 + 3.0 0.023
VAS 1.82 + 2.7 1.1 + 2.6 1.94 + 1.9 0.059
Satisfaction With Shoulder Function 7.9 + 2.9 8.6 + 2.4 6.9 + 2.8 0.042
TABLE 4: Functional outcomes based on rotator cuff size
ASES, American Shoulder and Elbow Score; SST, Simple Shoulder Test Score; VAS, Visual Analog Scale.
There was no statistically significant association with age (p = 0.2), gender (p = 0.2), and body mass index (p
= 0.8) with ability to RTW. Medical comorbidities were analyzed to assess their impact on rotator cuff healing
affecting their RTW (Table 1). Heart disease (p = 0.6), hypertension (p = 0.4), diabetes (p = 1.00), mental
illness (p = 1.00), Charlson Comorbidity Index not age-adjusted (p = 0.74), Charlson Comorbidity Index age-
adjusted (p = 0.2), smoking (p = 0.3), and alcohol use (p = 0.6) were not associated with decreased ability to
RTW. However, patients with elevated cholesterol were less likely to RTW (p = 0.05).
Discussion
A number of published manuscripts have found that outcomes of rotator cuff repair in workers’
compensation are worse than those in the non-workers’ compensation population [5,8,11,12]. To our
knowledge, no study has solely analyzed patients within the workers’ compensation rotator cuff repair
population to determine which factors within this population can be used to predict superior functional
outcomes and ability to RTW after rotator cuff repair.
In our study, we found that patients who did not RTW had a higher frequency of rotator cuff tear in the
dominant arm. This was especially evident when looking at patients who held labor-intensive occupations
that required use of their upper extremities. In general, laborers were less likely to return to work than non-
laborers (p = 0.032), but when they had sustained a dominant arm injury, the ability to RTW was decreased
even further in 90% of laborers with non-dominant cuff tears able to return to work compared to only 54% of
laborers with dominant arm cuff tears. Other authors have attributed this decline in RTW to the inability to
meet the demands that a labor-intensive job requires or to psychological factors beyond the loss of shoulder
function such as fear of reinjury [8,13,14]. Previous studies have demonstrated that the workers’
compensation population has decreased shoulder function and increased pain after rotator cuff repair
surgery compared to the non-workers’ compensation patients [10,11,13,16,18].
As demonstrated in our study, the majority of patients achieved excellent functional outcomes and the
ability to RTW. Our authors acknowledge that while other studies demonstrate workers’ compensation has
2021 Gutman et al. Cureus 13(3): e14213. D OI 10.7759/cureus.14213 5 of 7
inferior outcomes compared to non-workers' compensation on a population level, workers’ compensation
patients on the individual level have the ability to achieve excellent outcomes [8,12]. Our study
demonstrates that patients who were able to RTW had significantly improved shoulder pain, functional
scores, and surgical satisfaction than those unable to RTW. Moshe et al. showed that in patients with upper
extremity disorders, DASH score was the “only independent predictor of RTW” [19]. Likewise, in our cohort
composed entirely of workers’ compensation patients, shoulder function and shoulder pain scores were
highly predictive of ability to RTW. Patients who returned to work had significantly higher shoulder
satisfaction and shoulder function, assessed via ASES and SST surveys, as well as lower pain scores, assessed
via the VAS survey. Therefore, within the workers’ compensation population, current shoulder function and
pain can be used as predictors of patients’ ability to RTW. As seen by the ROC analysis, cut-offs of 54.2 and
6.0 for ASES and SST are predictive with sensitivities of approximately 90% or greater for RTW. Hence,
monitoring postoperative functional progression via these scores can be an effective means to evaluate how
close a patient is to returning to work. The correlation of increased functional limitations with being unable
to RTW may be either a reflection of severe functional limitation, perceived functional limitation by the
patient, the presence of pain interfering with the patients’ activities of daily living, or possibly the result of
litigation causing patients’ surveys to be adversely affected. Further studies are warranted to clarify this.
Three tendon tears have been shown to have the highest rate of re-tear rate and worse functional
outcomes [20,21]. In the current study, while size of tear (p = 0.12) was not predictive of ability to RTW,
patients with three torn tendons experienced the lowest rates of returning to work and the worst functional
outcomes. Interestingly patients with two tendon tears experienced better functional outcomes than one
tendon tears. One would expect the opposite, given that a larger tear size is typically correlated with worse
outcomes. One possible reason for this anomaly in our study could be attributed to the small number of
patients. While full-thickness tears can be managed nonoperatively, it is ideal to repair the tendon to
prevent further tear extension and muscle atrophy [22,23]. As such, the authors still recommend repair of
full-thickness tears regardless of size.
Several limitations exist in this study. This is a retrospective study, which confers to its limitations
associated with accurate identification of pathology along with uniform data collection at the time of
surgery and preoperative function. Also, factors such as atrophy and fatty degeneration can affect rotator
cuff healing and function, which were not assessed in this study. Additionally, although all patients
completed extensive postoperative surveys, our study does not have preoperative shoulder functional
surveys to assess baseline shoulder function prior to surgery. Ideally, job satisfaction would have been
assessed prospectively and preoperatively. This would have allowed our authors to better assess the effects
of job satisfaction on long-term outcomes of rotator cuff surgery in the workers’ compensation population.
However, preoperative surveys of both shoulder function and job satisfaction may not be as accurate in the
workers’ compensation population, since compensation involvement can directly affect patient-reported
outcomes including pain, depression, and disability [24]. When assessing ability to RTW, we did not inquire
if patients returned to work with the same physical demands or if patients returned to a modified level of
work. Additionally, in some patients who were unable to RTW, postoperative imaging was not performed to
assess the integrity of the rotator cuff repair. In this cohort, our small sample size may have limited our
ability to reach statistical significance. Lastly, we did not inquire on the results of patient litigation for
disability. Despite the fact that all consented to be part of the study and were informed that the surveys
collected would only be used for research purposes and not recorded in the patients’ medical records, results
of litigation may have had a role in how patients answered the questionnaires in our survey [25].
Conclusions
The majority of patients with workers’ compensation claims have excellent outcomes from rotator cuff
repair. Those patients that returned to work were more likely to work as non-laborers, had better functional
scores and greater satisfaction with their treatment. Patients with three tendon tear repairs demonstrated
worse functional outcomes than small full-thickness tendon repairs.
Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Office of Human
Research Institutional Review Board issued approval 17D.353. In accordance with Federal-Wide Assurance
#00002109 to the US Department of Health and Human Services. This study was administratively approved
on 6/27/17. Animal subjects: All authors have confirmed that this study did not involve animal subjects or
tissue. Conf licts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.
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Background and purpose — There is a need to understand the reasons why a high proportion of rotator cuff repairs fail to heal. Using data from a large randomized clinical trial, we evaluated age and tear size as risk factors for failure of rotator cuff repair. Patients and methods — Between 2007 and 2014, 65 surgeons from 47 hospitals in the National Health Service (NHS) recruited 447 patients with atraumatic rotator cuff tendon tears to the United Kingdom Rotator Cuff Trial (UKUFF) and 256 underwent rotator cuff repair. Cuff integrity was assessed by imaging in 217 patients, at 12 months post-operation. Logistic regression analysis was used to determine the influence of age and intra-operative tear size on healing. Hand dominance, sex, and previous steroid injections were controlled for. Results — The overall healing rate was 122/217 (56%) at 12 months. Healing rate decreased with increasing tear size (small tears 66%, medium tears 68%, large tears 47%, and massive tears 27% healed). The mean age of patients with a healed repair was 61 years compared with 64 years for those with a non-healed repair. Mean age increased with larger tear sizes (small tears 59 years, medium tears 62 years, large tears 64 years, and massive tears 66 years). Increasing age was an independent factor that negatively influenced healing, even after controlling for tear size. Only massive tears were an independent predictor of non-healing, after controlling for age. Interpretation — Although increasing age and larger tear size are both risks for failure of rotator cuff repair healing, age is the dominant risk factor.
Article
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Lesions of the rotator cuff (RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an age-dependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears (PTT) can be bursal-sided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears (FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations - cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, anti-inflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being cost-effective, this helps in providing a functional shoulder with a stable cuff. An easily reproducible technique of maximal strength and sturdiness should by chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with debridement while more severe lesions mandate repair either by trans-tendon technique or repair following conversion into FTT. Early repair of repairable FTT can avoid appearance and progression of disability and weakness. The choice of surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the current scenario. The double-row repairs have an edge over the single-row technique in some patients especially those with massive tears. Stronger, cost-effective and improved functional scores can be obtained by the former. Both early and delayed postoperative rehabilitation programmes have led to comparable outcomes. Guarded results may be anticipated in patients in extremes of age, presence of comorbidities and severe tear patters. Overall, satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.
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Partial thickness rotator cuff tears are a common cause of pain in the adult shoulder. Despite their high prevalence, the diagnosis and treatment of partial thickness rotator cuff tears remains controversial. While recent studies have helped to elucidate the anatomy and natural history of disease progression, the optimal treatment, both nonoperative and operative, is unclear. Although the advent of arthroscopy has improved the accuracy of the diagnosis of partial thickness rotator cuff tears, the number of surgical techniques used to repair these tears has also increased. While multiple repair techniques have been described, there is currently no significant clinical evidence supporting more complex surgical techniques over standard rotator cuff repair. Further research is required to determine the clinical indications for surgical and nonsurgical management, when formal rotator cuff repair is specifically indicated and when biologic adjunctive therapy may be utilized.
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Converging lines of evidence suggest that attorneys are influencing data relied upon by psychological experts in forensic cases. This is a problem because a consequence of attorney prompting may be invalid expert opinions that mislead rather than inform the trier of fact. Attorneys influence psychological data by a variety of means. They advise their clients how to respond to psychological tests, make suggestions of what to tell examining psychologists and what to emphasize, and lead patients not to disclose certain information important to psychologists. The purpose of this article is to alert psychologists to a growing threat to the validity of psychological and neuropsychological evaluations in forensic matters. Several examples of attorney preparation of clients for examinations are described.
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Return to work (RTW) is a key goal in the proper management of upper limb disorders (ULDs). ULDs stem from diverse medical aetiologies and numerous variables can affect RTW. The abundance of factors, their complex interactions and the diversity of human behaviour make it difficult to pinpoint those at risk of not returning to work (NRTW) and to intervene effectively. To weigh various clinical, functional and occupational parameters that influence RTW in ULD sufferers and to identify significant predictors. A retrospective analysis of workers with ULD referred to an occupational health clinic and further examined by an occupational therapist. Functional assessment included objective and subject ive [Disability of the Arm, Shoulder and Hand (DASH) score] parameters. Quantification of work requirements was based on definitions from the Dictionary of Occupational Titles web site. RTW status was confirmed by a follow-up telephone questionnaire. Among the 52 subjects, the RTW rate was 42%. The DASH score for the RTW group was 27 compared with 56 in the NRTW group (P < 0.001). In multivariate analyses, only the DASH score was found to be a significant independent predictor of RTW (P < 0.05). Physicians and rehabilitation staff should regard a high DASH score as a warning sign when assessing RTW prospects in ULD cases. It may be advisable to focus on workers with a large discrepancy between high DASH scores and low objective disability and to concentrate efforts appropriately. © The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
Article
Studies have demonstrated that receiving workers' compensation (WC) benefits can be a negative predictor of outcomes after orthopedic procedures. This study compares postoperative outcomes of anatomic total shoulder arthroplasty (TSA) between patients receiving WC benefits and a control group that did not. A cohort of 13 consecutive TSA patients with WC benefits were compared with a control group of 63 consecutive patients with a minimum of 2 years of follow-up during the same period. Patient demographics, American Shoulder and Elbow Surgeons scores, 12-Item Short Form Health Survey scores, return to work status, and time out of work were evaluated. The WC TSA cohort consisted of 13 men and no women with a mean age of 55.9 years. Twelve of the 13 were laborers. The TSA control group consisted of 36 men and 27 women with a mean age of 63.2 years (P = .01). The American Shoulder and Elbow Surgeons scores at final follow-up were significantly lower in the WC cohort (73.6) compared with the control group (86.6; P = .01). However, the 12-Item Short Form Health Survey physical and mental component summary scores were not significantly different (P = .09 and P = .6). Only 4 of the 13 WC patients returned to work. Compared with a non-WC population, patients with WC who received an anatomic TSA are more likely to be male, younger, and a laborer. Outcomes are generally excellent and better than those of other WC shoulder surgery cohorts in the literature; however, the outcomes are relatively worse than in the non-WC TSA patients. A significant number of WC patients are unable to return to work after TSA. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Article
Background: The effect of workers' compensation claims on outcomes after reverse shoulder arthroplasty (RSA) has not been investigated. The purpose of this study was to evaluate outcomes after RSA in patients with a workers' compensation claim and to compare them with a control group without a workers' compensation claim. Methods: We identified 14 primary RSAs completed in patients with a workers' compensation claim and a minimum of 2 years of follow-up in a prospective shoulder arthroplasty registry. Fourteen patients without a workers' compensation claim served as the age-, gender-, and diagnosis-matched control group. The Constant score, the American Shoulder and Elbow Surgeons score, the Western Ontario Osteoarthritis of the Shoulder Index, the Single Assessment Numeric Evaluation score, mobility, and the patient's satisfaction were assessed for both groups preoperatively and at final follow-up. Results: There were no differences between the groups regarding patient demographics, duration of follow-up, complications, preoperative shoulder function scores, or preoperative mobility (P > .05). Both groups significantly improved on all shoulder function scores and for mobility from preoperative to final follow-up (all P < .001); however, the workers' compensation group had significantly worse Constant (P = .002), American Shoulder and Elbow Surgeons (P = .003), and Western Ontario Osteoarthritis of the Shoulder Index (P = .001) scores. Only 57% of the workers' compensation group reported that they were satisfied or very satisfied at final follow-up compared with 93% in the control group. The workers' compensation group had a lower return to work rate (14.2% vs 41.7%), but this did not reach statistical significance (P = .117). Conclusion: Patients with a workers' compensation claim had significant improvements after RSA, but they achieved significantly worse outcomes compared with the control group.
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Management of massive chronic rotator cuff tears remains controversial, with no clearly defined clinical presentation as yet. The purpose of the study was to evaluate the effect of tear size and location on active motion in patients with chronic and massive rotator cuff tears with severe muscle degeneration. One hundred patients with massive rotator cuff tears accompanied by muscle fatty infiltration beyond Goutallier stage 3 were prospectively included in this study. All patients were divided into 5 groups on the basis of tear pattern (supraspinatus, superior subscapularis, inferior subscapularis, infraspinatus, and teres minor). Active range of shoulder motion was assessed in each group and differences were analyzed. Active elevation was significantly decreased in patients with 3 tear patterns involved. Pseudoparalysis was found in 80% of the cases with supraspinatus and complete subscapularis tears and in 45% of the cases with tears involving the supraspinatus, infraspinatus, and superior subscapularis. Loss of active external rotation was related to tears involving the infraspinatus and teres minor; loss of active internal rotation was related to tears of the subscapularis. This study revealed that dysfunction of the entire subscapularis and supraspinatus or 3 rotator cuff muscles is a risk factor for pseudoparalysis. For function to be preserved in patients with massive chronic rotator cuff tears, it may be important to avoid fatty infiltration with anterior extension into the lower subscapularis or involvement of more than 2 rotator cuff muscles.
Article
The purpose of this matched case-control study was to examine the impact of an active compensation claim following a work-related shoulder injury on reporting disability, as measured by subjective and objective outcomes at 1 year postoperatively. Data of 517 consecutive patients who had undergone a decompression or rotator cuff repair were reviewed. One-hundred and ten patients were on compensation related to their shoulder problems. These patients were matched with a historical control group (patients without a compensation claim) based on age, sex, and level of pathology. Outcome measures used were the Western Ontario Rotator Cuff Index, the American Shoulder and Elbow Score, and the Constant-Murley score. Nonparametric Wilcoxon and Ranked sign tests were conducted to examine the difference between and within groups. Data of 220 patients were used for analysis (mean age, 48+/-10; range, 20-69). Out of 110 patients in each group, 45 patients (41%) had undergone a repair and 65 (59%) had undergone a decompression surgery (acromioplasty with or without resection of lateral clavicle). Both groups improved significantly regardless of their claim status (P < .0001). There was a significant difference between injured and noninjured workers at baseline, 1-year postoperatively, and in overall improvement with the compensation group having a significantly higher level of disability. Our results show that although injured workers report a statistically significant higher level of disability before and after rotator cuff surgery, they still show significant improvement 1 year following decompression or repair of the rotator cuff tendon(s).