Adherence to clinical guidelines in treating degenerative disorders of the supraspinatus tendon: A descriptive baseline analysis of surgical vs. conservative approaches in a 12-month observational study

Abstract

Background

Shoulder pain (SP) is prevalent, costly, and linked to low quality of life, high pain levels, disability, and mental health issues. Despite guidelines, orthopaedic surgeons vary in surgical indicators and clinical decision-making. This study investigates if clinicians adhere to guidelines in an observational study.

Methods

In a French prospective multicentre study, four clinicians assessed patients with shoulder pain, recommended surgery or conservative management, and followed up at 4, 6, and 12 months. Comparative demographic and clinical data were used at baseline. Participants receiving surgery or conservative care within diagnostic and pain severity categories were compared to guidelines. An attrition analyses compared participants at baseline and 12-month follow-up.

Results

Of 189 participants, the majority of impingement and tendinopathy diagnoses were managed conservatively. More full-thickness tear diagnoses were recommended for surgical repair, and those recommended for surgery had more severe pain. Participants with high SMS completion (≥80%) and low SMS completion (<80%) were similar at baseline (based on age, sex, education, pain severity, duration, and disability) and at 12-month follow-up.

Conclusion

Clinicians recommended treatment in line with guidelines, emphasising rotator cuff tear presence and high pain intensity. Patients recommended surgery differed from those recommended conservative management, so future analyses should compare these treatment groups.

Keywords

Shoulder pain clinical guidelines rotator cuff disorders longitudinal study

Background

Shoulder pain is a common and costly presentation with up to a third of the general population reporting pain within one month and >3 billion USD spent annually on rotator cuff repairs in the United States of America (USA).^1–5 Individuals with shoulder pain report low scores on health-related quality of life,⁶ high levels of pain and disability,⁷ generally low health status,⁷ and commonly have depression, anxiety, or disturbed sleep.⁸ Shoulder pain can be persistent, with 40% of new cases having not recovered within 12 months.⁹

There are several treatment approaches for acute and chronic shoulder pain, including surgical and conservative treatment, the latter including e.g., exercise therapy, manual therapy, massage, trigger point therapy, acupuncture, education, analgesics, and/or cortisone injection.¹⁰ It remains unclear what the ideal treatment is for rotator cuff tears or subacromial pain syndrome (SAPS). Surgical repair appears to provide better patient outcomes (as measured via Constant-Murley Score) at 12 months, but no difference when compared to conservative care at 24 months.¹¹ In those presenting with SAPS there is no evidence to support surgical approaches over conservative management.¹² Identifying the appropriate use of guidelines for both rotator cuff tears and SAPS is of great importance considering the impact and cost of shoulder pain to individuals and society.

Current research indicates similar outcomes when comparing surgical intervention with conservative treatment, yet surgery is associated with much greater risk and cost.^1,13 Clinical practice guidelines from the USA¹⁴ indicate an asymptomatic full-thickness tear should not be surgically repaired, but the presence of a full thickness tear with significant pain should be the primary indicator for surgical repair. Australian clinical practice guidelines¹⁵ for managing rotator cuff disorders support significant pain and loss of function as indicators for surgical referral and also reference younger workers with manual occupations as candidates. Further, expert consensus gathered from specialist shoulder surgeons, using a two-round Delphi questionnaire method, established that severe pain, functional limitation and no presence of an active frozen shoulder were key referral criteria for surgery.¹⁶ Finally, several clinical guidelines recommend surgery be reserved for those patients that have not sufficiently recovered after a conservative management period of 12 weeks.^10,12,15

Despite these clinical guidelines, orthopaedic surgeons do not consistently employ the same indicators for surgical repair of the rotator cuff¹⁷ and when presented with clinical vignettes do not consistently reach agreement in clinical decision making.¹⁸ For this reason, in observational studies researchers should work with clinicians to ensure choices in patient management strategies are consistent with current clinical guidelines. There is a lack of contemporary French guidelines for the management of rotator cuff related shoulder pain.^19,20

To further the evidence of the clinical course of shoulder pain, within a French cohort, patients were recruited into a multicentre two-arm observational study providing treatment by orthopaedic surgeons or a dual trained chiropractor/physiotherapist.²¹ The aim of this project was to observe the shoulder pain patterns over a one-year period in the two treatment groups in a non-experimental setting. Data were collected by clinicians during treatment and at a final follow-up after 12 months. Information was also obtained from patients fortnightly via text-messages (SMS). A previous feasibility study concluded that, although it was difficult to obtain co-operation from clinicians, collecting data on the impact of shoulder pain via SMS tracking software was well received by patients, useful and cost-effective.²¹

In our present study we aim to describe and scrutinise the study sample to see if there were any potentially important subgroups that could be included in the analyses of their one-year trajectory and if the patients could be considered typical of those treated either surgically or conservatively. Our first two objectives were therefore: i) to describe and compare those treated surgically and conservatively on all baseline variables and ii) to investigate if clinicians in this study selected patients in accordance with clinical guidelines. We also iii) performed an attrition analysis regarding the SMS-reporting throughout the study and the final follow-up question on outcome status.

Materials and methods

Study design, setting, and participants

This prospective multicentre observational study was conducted in France and has been previously described in a feasibility study.²¹ Participants were examined, treated, and re-examined by their health practitioner at baseline, 4, 6 and 12-months. Participants also answered three questions via text message every fortnight over the 12-month study. Participation was voluntary, with written informed consent obtained. This project was reviewed and received approval from the Comité de Protection des Personnes, Île-de-France (ID RCB: 2014-A01031–46) and the Murdoch University Human Research Ethics Committee (project number: 2019/105).

Eleven clinicians were asked to participate in patient recruitment, with only four (three orthopaedic surgeons and one physiotherapist/chiropractor) ultimately including patients and completing the study.

Between September 2015 and March 2019, patients consulting a university hospital, an orthopaedic department in a private hospital, or a private physical therapy clinic in various parts of France were recruited. Participants were eligible if they presented with shoulder pain related to a lesion of the supraspinatus tendon (encompassing clinical features of bursitis, tendinopathy, partial-thickness tears, and full-thickness tears) and considered suitable either for surgery or conservative treatment.

Exclusion criteria were pain incurred by severe trauma, shoulder instability, presence of complex regional pain syndrome, frozen shoulder, presence of glenohumeral arthritis, symptomatic acromioclavicular osteoarthritis, calcific tendinitis, diabetes, inflammatory conditions, or regional metastases.

Baseline evaluation

During the initial evaluation, clinicians gathered demographic information (age, sex, level of education, employment status, and involvement in physical work, monotonous work, or overhead sports) and performed a physical examination. The examination included an assessment of ROM and relevant orthopaedic tests. Clinicians also obtained an X-Ray and diagnostic ultrasound of the glenohumeral joint and surrounding structures. Diagnostic categories (subacromial pain syndrome, partial-thickness tear, and full-thickness tear) were determined by the treating clinician based on imaging findings and clinical presentation. Although no formalised diagnostic algorithm was imposed across sites, diagnoses were made by experienced orthopaedic surgeons or a physiotherapist/chiropractor using routine clinical practice standards. Participants completed the QuickDASH questionnaire, which is described below.²² All baseline data were entered in a structured booklet by the recording clinician.

Outcome measurements

At months 4, 6, and 12 information was sought relating to the intensity of pain, impact of night pain, impact on daily activities, and overall evolution of shoulder function since the last consultation. At the 12-month follow-up the QuickDASH questionnaire was repeated and the overall impact on the participant's activities of daily living (ADLs) was recorded. All follow-up information was included in the study booklet. The schedule of assessments is summarised in Table 1. More specifically information obtained at the follow-up were:

Pain was measured at baseline via a Visual Analogue Scale (VAS) and at each follow-up divided into four categories (absent, mild, moderate, or severe).^23–25

Night pain was identified by asking the participants to evaluate how often, during the previous month, their waking was directly related to shoulder pain (“did not wake up”, “woke up a few times”, “frequently woke up”, or “woken up almost every night”).

Activities of daily living (ADLs) were measured by asking the patient how many days in the previous month they were hindered in their daily activities by their shoulder pain (0 days, 1–7 days, 8–14 days, 15–21 days, or about every day of that period).

Evolution (change in condition status) since the last consultation was defined by asking the patient of the “overall evolution of the shoulder since the last consultation” (“significant improvement”, “incomplete improvement”, “no change”, “moderate aggravation”, or “severe aggravation”).

Functional disability was measured via the QuickDASH questionnaire. This is an 11-item patient reported outcome measure for assessing physical function and symptoms in people with upper limb musculoskeletal conditions.²² The responses are summed to form a raw score that is then converted to a 0-to-100 scale with the following formula: [(sum of score/n) − 1] × 25, where n is the number of completed responses.

Impact on ADLs (only at 12-month follow-up) in the previous month was measured by asking “In the last month, what is the situation that you feel best describes your difficulties in performing your activities of daily living because of your shoulder?” (“I do not have any difficulties (or almost none)”, “I am more often relieved than impaired”, “I am more often impaired than relieved”, or “I am constantly impaired”). For those participants that did not have a face-to-face clinical consultation after 12-months, this question was asked via a telephonic follow-up.

Table 1.

Schedule of assessments.

Assessment/Procedure	Visit 1 Baseline/Screening	Visit 2 (4 months)	Visit 3 (6 months)	Visit 4 (12 months)
Informed Consent	x
Demographic Information	x
Physical Examination Range of Motion Orthopaedic Tests	x
QuickDASH questionnaire	x			x
X-Ray and MRI or Ultrasound	x
Clinician Follow-up days affected nights affected pain severity (0–10) evolution of condition		x	x	x
Impact on ADLs				x
Telephone follow-up for participants not attending the 12-month visit				x

Interventions

Treatment was provided according to the usual protocol in the relevant institution, i.e., a surgical procedure such as arthroscopic or direct repair of the torn tendon, or conservative treatment. Conservative treatment could consist of a combination of the following: shoulder rehabilitation with strengthening exercises of the deltoid muscle and the rotator cuff, manual therapy, acupuncture, education, analgesics, and /or cortisone injection. The clinicians did not record the details regarding the duration, number, or frequency of conservative treatment sessions within the study booklet.

Sample size considerations

This study was exploratory and observational in nature; therefore, no a priori sample size calculation was conducted. Recruitment was constrained by clinician participation and study feasibility. The present manuscript reports descriptive baseline data from all participants recruited during the study period and does not aim to test predefined hypotheses. The broader study design originally aimed for a larger cohort to support planned analyses of pain trajectories and recovery patterns; however, the current paper focuses on describing the characteristics of the recruited sample and evaluating alignment between treatment allocation and clinical guideline recommendations.

Statistical analysis in the present report

Descriptive statistics for demographic and outcome data are based on frequency distributions for categorical data, and means and standard deviations or medians, interquartile ranges, and ranges for continuous data, as appropriate. Bivariate analysis for group comparisons included χ2 tests for categorical comparisons, and t-tests for continuous outcomes. We defined limited ROM to be <160° of shoulder elevation and categorised participants into three groups: neither AROM or PROM limited, AROM limited but not PROM, and both AROM and PROM limited. For the attrition analysis, we defined an acceptable response rate to be ≥80% of SMS responses. Data were analysed using IBM SPSS version 27.0 (Armonk, NY).

Results

Description of study sample

A total of 189 participants had complete clinical files, but 13 participants did not respond to the initial SMS (resulting in no SMS file). Ultimately, we had 176 participants with both complete files and SMS at baseline. Figure 1 is a flow diagram illustrating the participants’ progression throughout the study.

Figure 1.

Modified STROBE flow diagram.

Table 2 shows there were 95 and 94 participants diagnosed with subacromial pain syndrome and a partial or full-thickness tear of the supraspinatus respectively. The majority were: males, aged 50 or more with a post high school education, an employment status of ‘employed’, and a problem duration of at least six months. The mean severity of pain was approximately 6/10 and the mean QuickDASH score was almost 40/100, i.e., essentially in the lower part of ‘moderate’.

Table 2.

Baseline description of the study subjects at baseline, by intervention groups.

Baseline variables	Conservative n = 149	Surgery n = 40	Total N = 189	Group comparison (t-test† or χ²)
Demographic variables
Age, y, mean (SD) (n = 182)	54.97 (10.08)*	55.55 (11.75)*	55.43 (11.39)*	−0.58 (p = 0.38)†
Age categories, n (%) (n = 182)
<40	13 (9.1)	3 (7.7)	16 (8.8)	0.144
40–49	27 (18.9)	6 (15.4)	33 (18.1)
50–59	42 (29.4)	17 (43.6)	59 (32.4)
60–69	43 (30.1)	12 (30.8)	55 (30.3)
≥70	18 (12.6)	1 (2.6)	19 (10.4)
Sex (male), n (%) (n = 186)	89 (60.5)	18 (46.2)	107 (57.5)	0.106
Level of education, n (%) (n = 186)Pre-high school educationPost-high school education	61 (41.5)66 (58.5)	19 (48.7)20 (51.3)	80 (43.0)106 (57.0)	0.170
Employment status, n (%) (n = 185)Self-employedEmployeeRetiredUnemployed	27 (18.5)82 (56.2)34 (23.3)3 (2.1)	1 (2.6)26 (65.7)9 (23.1)3 (7.7)	28 (14.7)108 (56.8)43 (22.6)6 (3.2)	0.033
Heavy work (yes), n (%) (n = 185)	60 (41.1)	18 (46.2)	78 (42.2)	0.57
Monotonous work (yes), n (%) (n = 183)	7 (4.9)	4 (10.3)	11 (6.0)	0.21
Sport using shoulder (yes), n (%) (n = 185)	51 (34.9)	20 (51.3)	71 (38.4)	0.06
Workplace accident (yes), n (%) (n = 184)	4 (2.8)	11 (28.2)	15 (8.2)	<0.001
Clinical variables
Final diagnosis, n (%) (n = 189)Subacromial Pain Syndrome(impingement, bursitis, or tendinopathy)Partial supraspinatus tearFull-thickness supraspinatus tear.	91 (61.1)22 (14.8)36 (24.2)	4 (10)11 (27.5)25 (62.5)	95 (50.3)33 (17.5)61 (32.2)	<0.001
Pain severity (0–10), mean (SD) (n = 188)	5.61 (2.05)*	6.55 (2.06)*	5.81 (2.09)*	0.94 (p = 0.011)†
QuickDASH (0–100), mean (SD) (n = 189)	37.77 (19.98)*	47.50 (17.54)*	39.83 (19.9)*	9.73 (p = 0.006)†
Pain duration, n (%) (n = 187)≤ 6 months> 6 months	73 (49.7)74 (50.3)	15 (37.5)25 (62.5)	88 (47.1)99 (52.9)	0.172
Pain on AROM (yes), n (%) (n = 182)	103 (72.5)	37 (92.5)	140 (76.9)	0.008
Pain on PROM (yes), n (%) (n = 181)	96 (67.6)	32 (80)	128 (70.7)	0.130
Combined ROM groups, n (%) (n = 183)No pain on ROMPain on only AROMPain on only PROMPain on both AROM & PROM	38 (25.5)9 (6.0)2 (1.3)94 (63.1)	3 (7.5)5 (12.5)032 (80.0)	41 (22.4)14 (7.7)2 (1.1)126 (68.9)	0.043
AROM, n (%) (n = 188)<160°≥160°	13 (8.8)135 (91.2)	7 (17.5)33 (82.5)	20 (10.6)168 (89.4)	0.113
PROM, n (%) (n = 188)<160°≥160°	7 (4.7)141 (95.3)	040 (100)	7 (3.7)181 (96.3)	0.161
ROM groups, n (%) (n = 188)No reduction in ROMReduction in AROM onlyReduction in AROM and PROM	135 (90.6)6 (4.0)7 (4.7)	33 (82.5)7 (17.5)0	168 (88.4)13 (6.9)7 (3.7)	0.006

* mean (+/- standard deviation); † independent t-test with a p-value; Significant differences between groups have been bolded.

Objective 1

The two treatment groups were comparable in age, sex, education, history of heavy work, and pain duration (Table 2). However, several baseline characteristics differed between groups. Participants in the surgery group were more likely to have a full-thickness supraspinatus tear, while those managed conservatively were more commonly diagnosed with subacromial pain syndrome (p < .001). The surgery group also reported higher pain severity and greater disability on the QuickDASH (p = .011 and p = .006, respectively). Workplace injuries were more frequent in the surgical group (p < .001), and self-employment was more common in the conservative group (p = .033). Pain during active range of motion (AROM) was also more frequently reported by surgical candidates (p = .008), and group differences were evident in combined AROM/PROM pain profiles (p = .043). Although not statistically significant, the surgery group showed higher rates of pain on PROM, shoulder-related sport participation, and longer pain duration. AROM reduction was also more common in this group, with no surgical participants demonstrating combined AROM and PROM reduction.

Objective 2

The number of participants that received surgery or conservative care within diagnostic and pain severity categories is summarised in Table 3. In a comparison between findings in our study sample and clinical guidelines/recommendations we noted that: i) the majority of impingement and tendinopathy diagnosis were managed conservatively, ii) there were larger numbers of full thickness tear diagnosis that were recommended for surgical repair, and iii) within each diagnostic group those recommended for surgery more frequently had severe pain. There were no pain free participants in the sample. The majority of those with full thickness tears and mild pain received conservative care. Though seven participants with mild pain, regardless of diagnosis, were still directed towards surgery.

Table 3.

Comparison of surgically and conservatively managed patients by diagnosis and pain intensity.

Final diagnosis	Pain category	Conservative n (%) (n = 148)	Surgery n (%) (n = 40)
Impingement	Absent	0	0
	Mild	8 (100)	0
	Moderate	24 (100)	0
	Severe	21 (95.5)	1 (4.5)
Tendinopathy	Absent	0	0
	Mild	4 (80)	1 (20)
	Moderate	20 (100)	0
	Severe	13 (86.7)	2 (13.3)
Partial RC Tear	Absent	0	0
	Mild	7 (87.5)	1 (12.5)
	Moderate	9 (100)	0
	Severe	16 (66.7)	10 (33.3)
Full RC Tear	Absent	0	0
	Mild	8 (61.5)	5 (38.5)
	Moderate	15 (71.4)	6 (28.6)
	Severe	13 (48.1)	14 (51.9)

Objective 3

Table 4 provides a comparison of participants with high SMS completion (≥80%), low SMS completion (<80%), and those without an SMS file. The groups were similar based on age, sex, level of education, pain severity, pain duration, and disability at baseline. Participants with high and low SMS completion also appeared similar at the 12-month follow-up based on the overall impact question.

Table 4.

Comparison of participants with high SMS completion (≥80%), low SMS completion (<80%), and those without an SMS file, based on demographic and clinical variables at baseline.

Baseline variables	≥80% SMS responses n = 161	<80% SMS responses n = 15	No SMS n = 13
Age, n (%) (n = 182)>50 years	116 (74.4)	8 (61.5)	9 (69.2)
Sex, n (%) (n = 186)Male	89 (56.0)	9 (64.3)	9 (69.2)
Education, n (%) (n = 186)Pre-high school	68 (42.8)	7 (50)	5 (38.5)
Pain Severity, n (%) (n = 187)AbsentMildModerateSevere	028 (17.5)63 (39.4)69 (43.1)	02 (13.3)7 (46.7)6 (40.0)	04 (30.8)4 (30.8)5 (38.5)
Pain duration, n (%) (n = 187)≤ 6 months> 6 months	76 (47.8)83 (52.2)	8 (53.3)7 (46.7)	4 (30.8)9 (69.2)
QuickDASH (0–100), mean (SD) (n = 189)	39.9 (19.9)	37.3 (18.9)	42.5 (21.5)
Treatment, n (%) (n = 189)SurgeryConservative	33 (20.5)128 (79.5)	3 (20)12 (80)	4 (30.8)9 (69.2)
Final Follow-up, n (%) (n = 179)Almost no impairmentMore often not impairedMore often impaired or always impaired	79 (52)45 (29.6)28 (18.4)	8 (57.1)3 (21.4)3 (21.4)	7 (53.8)2 (15.4)4 (30.8)

Note. Categorical variables are reported as counts (n) and percentages; continuous variables are reported as mean (M) and standard deviation (SD).

Discussion

In this study, we aimed to describe the two treatment groups at baseline, examine whether treatment allocation aligned with clinical guideline recommendations, and compare characteristics of those with high and low response rates to SMS follow-up. Patients who underwent surgery were significantly more likely to have sustained a workplace injury, report higher pain severity and disability, and experience pain during active range of motion. The surgery group also included proportionally fewer self-employed individuals and more patients with full-thickness supraspinatus tears. Conservative care was more commonly offered in cases of subacromial pain syndrome, while surgical intervention was more often used for rotator cuff tears with high pain severity. Patients who did not consistently respond to follow-up SMS tracking were broadly similar to responders in terms of both baseline and outcome characteristics.

Explanation of findings and comparisons to existing literature

Baseline comparisons revealed several statistically significant differences between treatment groups, most notably in employment status, history of work-related injury, diagnosis, and range of motion pain profiles. Surgical patients were more likely to report shoulder injury related to work and were less commonly self-employed. Clinically, the surgical group presented with a higher proportion of full-thickness supraspinatus tears and more frequent pain during active range of motion. Although the differences in pain severity and QuickDASH scores between treatment groups were statistically significant, they did not exceed established thresholds for minimal clinically important differences (typically ≥2 points for pain and 12–15 points for the QuickDASH).^26,27

In-line with clinical guidelines, patients selected for surgery more frequently had structural pathology such as full- or partial-thickness tears, higher levels of pain and disability, and longer symptom duration.^14,16 This is a reassuring finding, given prior research has raised concerns about variation in treatment decisions and the inconsistent application of evidence-based criteria.^17,28 There is research suggesting that women may receive surgery less frequently than similar men for the same musculoskeletal complaints.²⁹ However, in our sample, the surgery group had a higher proportion of females.

These findings support the need for future trajectory-based studies to consider stratification by treatment group, given the clear baseline differences in pathology and presentation. Further work is also warranted to determine whether guideline-concordant surgical decision-making is consistent across clinicians, institutions, and healthcare systems.

High response rates, real time data, and reduced clinical bias aid in the accuracy of this clinical information.³⁰ SMS-Track software has previously been implemented on a large scale in the CHAMPS study in Denmark, where information on back pain was collected weekly via automated text messages.³¹ A validation study compared SMS-Track reporting with verbal reporting and found a sensitivity of 0.98, a specificity of 0.87, a positive predictive value of 0.94 and a negative predictive value of 0.95.³² Another study reported strong agreement between SMS reporting and telephone interviews, indicating that SMS data remain accurate for recall periods of up to one month.³³ SMS is a cost-effective and efficient method for not only tracking but also managing mental health issues and pain in post-operative periods.^30,33,34

Methodological considerations

Participants were recruited from various sites and by a multidisciplinary team that included orthopaedic surgeons, physiotherapists, and chiropractors. This was a convenience sample of clinicians, and their involvement was established through personal meetings. The surgeons that participated were from typical orthopaedic departments in a university-based and private hospital. The physiotherapist/chiropractor at the time of recruitment had a general practice and was not seeing patients with complicated cases, therefore we have reasonable confidence that these patients accurately represent the general population of shoulder pain patients. It should also be noted that patients presenting to an orthopaedic department may be more likely to present with higher pain intensity, longer pain duration, and more disability than the general population of people with shoulder pain.

Although imaging was obtained for all participants, diagnostic classification was clinician-led and no centralised diagnostic algorithm was enforced across sites. This pragmatic approach reflects real-world practice but may introduce some diagnostic variability, which should be considered when interpreting comparisons with clinical guideline recommendations. The participants were not randomly selected for this multi-centred observational study. However, they were recruited consecutively if they fit the inclusion criteria and we have no reason to believe that there would be any bias in the patient selection process. The treatment allocation was pragmatic based on clinical rationale. The research group did not gather information on whether clinicians referred clients to treatment type based on clinical guidelines. Future research of this type should record the components of the patient's assessment that guided the clinician's treatment decision. For this purpose, we performed comparisons of the treatment groups to assess if the clinicians generally followed clinical guidelines on surgery.

The SMS questions attracted a high response rate, with approximately 90% of participants with clinical files at baseline responding to at least 80% of texts for all three questions. The collection of data via SMS allows for the immediacy of response and reduces the likelihood of memory decay or recall bias. Furthermore, there is less potential influence from clinicians that may occur in a clinical encounter. In contrast, the clinical follow-ups were not as well attended by patients. This was accounted for by phoning patients that had not presented for follow-up to gather information about their progression overall.

Further limitations have been previously discussed in a feasibility study for the SMS tracking study.²¹ This included clinician compliance issues in both recruiting participants and returning completed data files. A follow-up telephone interview accounted for a drop off in clinical follow-up throughout the 12 months. This fortunately will not influence the pain pattern analysis in a future paper but will need to be considered when comparing clinician and SMS-gathered data. This would require comparing the dropouts and those that completed.

Detail regarding the duration, number, and frequency of conservative treatments was not recorded. This was a result of the number of clinicians recruiting participants and the already lengthy structured patient booklet. Lack of detail for conservative interventions is a common fault of clinical research and researchers should follow the Template for Intervention Description and Replication (TIDieR) when describing intervention methodology.³⁵ It is possible that participants were seen more regularly than three follow-ups in the conservative group.^36–38 This could have resulted in further improvements via the therapeutic alliance formed between clinician and patient.^36,39

Generalisability of study results

The results of our study suggest that the clinicians involved tended to follow previously published guidelines for surgery decision-making. The clinicians were all from France and only included orthopaedic surgeons and a physiotherapist/chiropractor. While this type of clinician would commonly be guiding patients on management, for these results to be generalisable to a larger population it would be ideal to have had a higher number and a more diverse clinician group. In France, these procedures are covered by government funded healthcare, which contrasts with the privately funded procedures in countries such as the USA. This would make these results relevant to predominantly European nations with similar health funding models.

Future research should aim to illustrate pain patterns and groupings for individuals with shoulder pain and compare SMS-gathered data with clinician-gathered data. Furthermore, future research should focus on comparing clinician-gathered data and SMS-gathered data regarding response rates and similarity of responses.

Conclusion

The clinicians in this study appeared to recommend treatment in line with published guidelines, which place high importance on the presence of a rotator cuff tear and high pain intensity. While this result is important for further analysis of this cohort, it cannot be generalised to orthopaedic surgeons, physiotherapists, and chiropractors throughout France or the rest of the world. The patients recommended surgery differed at baseline to those recommended conservative management; therefore, future analyses of shoulder pain patterns from this cohort should be compared by treatment groups.

Footnotes

Acknowledgements

Bruce Walker and Charlotte Leboeuf-Yde were previously the primary and co-supervisors respectively of the research student (CH) and involved in planning the study. Olivier Gagey was involved in the planning of the study and recruited/managed patients throughout the study period. Olivier also assisted CH with data input prior to analysis.

ORCID iDs

Christopher J Hodgetts

Karl Vincent

Lee Daffin

Yvonne Learmonth

Ethical approval

This project was reviewed and received approval from the Comité de Protection des Personnes, Île-de-France (ID RCB: 2014-A01031–46) and the Murdoch University Human Research Ethics Committee (project number: 2019/105).

* The guarantor is the person willing to take full responsibility for the article, including for the accuracy and appropriateness of the reference list. This will often be the most senior member of the research group and is commonly also the author for correspondence. Please use initials only: Shoulder & Elbow operates a double-blind peer review process so full names of authors should not be listed on this form.

Contributorship

CH and KV researched literature and conceived the study. CH and KV were involved in protocol development, gaining ethical approval, patient recruitment and data analysis. CH wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Conflicts of interest

The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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