Background
Methods
Panel selection
Systematic review of the literature
Data extraction and statement development
1 | Evidence obtained from: • systematic review of randomized controlled trials; • high-quality randomized controlled trials; • high-quality prospective studies (e.g., all patients were enrolled at the same point of their disease with 80 % follow-up of enrolled patients); or • testing of previously developed diagnostic criteria in series of consecutive patients. |
2 | Evidence obtained from: • systematic review of level 2 studies or level 1 studies with inconsistent results; • lesser quality randomized controlled trials (e.g., < 80 % follow-up, no blinding, or improper randomization); • prospective comparative studies; • retrospective studies; • lesser quality prospective studies (e.g., patients enrolled at different points in their disease or <80 % follow-up); or • development of diagnostic criteria on the basis of consecutive patients (with universally applied reference gold standard). |
3 | Evidence obtained from: • systematic review of level 3 studies; • case control studies; • retrospective comparative studies; or • study of nonconsecutive patients (without consistently applied reference gold standard). |
4 | Evidence obtained from: • case series; or • case control study with poor reference standard. |
5 | Evidence obtained from: • expert opinion. |
Round 1
Round 2
Round 3
Results
Panel selection
Systematic review of the literature
Data extraction and statement development
Round 1
Round 2
Round 3
Clinical domain | Consensus statement | Level of evidencea
|
---|---|---|
Screening | The following thirteen questions should be included during history taking to determine a patient’s relative priority of need and the proper place of treatment: | |
• How old are you [73]? | 2 | |
• Do you smoke [74]? | 3 | |
• Did your problem occur at work or because of a work-related incident (i. e., Is this Workers’ Compensation Board related) [75]? | 2 | |
• Is your shoulder problem part of an active medicolegal or third party claim [76]? | 2 | |
• Do you have neck pain? If yes, is this separate from your shoulder pain [77]? | 2 | |
• Do you have unexplained sensory deficits in your arm, wrist, or hand (i.e., numbness, tingling, burning) [77]? | 2 | |
2-3 | ||
• Is your shoulder problem associated with fevers, chills, and/or weight loss [77]? | 2 | |
• Are you currently receiving treatment at a chronic pain clinic? If yes, is your shoulder problem part of a generalized pain condition [81]? | 2 | |
• Are you currently receiving active treatment for a generalized joint condition (e.g., arthritis involving multiple joints in your body)? If yes, is this affecting your current shoulder problem [82]? | 3 | |
• Are you currently receiving active treatment for a neurological/neuromuscular condition (e.g., stroke, multiple sclerosis)? If yes, is this affecting your current shoulder problem [77]? | 2 | |
• Are you currently receiving active treatment for a diagnosis of cancer? If yes, is this affecting your current shoulder problem [77]? | 2 | |
• Are you currently receiving active treatment for a medical condition such as diabetes, renal disease, respiratory disease, or ischemic heart disease? If yes, is this affecting your current shoulder problem [77]? | 2 | |
Diagnosis | The following seventeen questions should be included during history-taking to confirm rotator cuff pathology and/or rule out other conditions: | |
• What is your sex [83]? | 2 | |
• What is your dominant hand [77]? | 2 | |
• What is your occupation [77]? | 2 | |
• When did you first notice you had shoulder pain or a problem with your shoulder [77]? | 2 | |
• Do you have pain in your shoulder [77]? | 2 | |
• Is your shoulder pain a result of a specific injury? If yes, describe how you injured your shoulder in as much detail as possible [84]? | 2 | |
2-3 | ||
• Does anything help to relieve the pain? If yes, please specify [79]? | 2 | |
• Where do you feel the most pain (i.e., top, side, front, back of shoulder) [85]? | 3 | |
• Does your shoulder feel stiff [79]? | ||
• Does your shoulder feel loose or unstable [77]? | 2 | |
• Does your shoulder come out of place [77]? | 2 | |
• Does your shoulder dislocate [77]? | 2 | |
• Has your shoulder dislocated in the past [77]? | 2 | |
• Do you hear or feel unusual sensations such as catching, locking, or grinding in your shoulder joint [86]? | 2 | |
• Do you have painful clicking, grinding, or clunking in your shoulder [86]? | 2 | |
• Does your shoulder feel weak [86]? | 2 | |
Physical Examination | The following eighteen items should be included during a physical examination to confirm rotator cuff pathology and/or rule out other conditions: | |
• In observing the patient, the shoulder should be exposed and observed from the front and back [85]. | 3 | |
• Active range of motion for the cervical spine should be performed for all planes (i.e., flexion, extension, side flexion, rotation) [87] | 2 | |
• Active range of motion for the shoulder should be performed bilaterally including: shoulder elevation in the scapular plane; shoulder elevation in the sagittal plane; external rotation at 0 degrees abduction; and internal rotation at the spinal level (i.e., the highest vertebral level reached with the thumb extended) [85, 87, 88]. | 2 | |
• Range of motion should be assessed for a painful arc [89]. | 2 | |
• Scapulohumeral rhythm should be assessed for scapular dyskinesis [90]. | 2 | |
• Passive range of motion should only be assessed if active range of motion is limited [85]. | 3 | |
2 | ||
• If active and passive ranges of motion are limited, assess isolated glenohumeral joint range of motion [93]. | 2 | |
• If adhesive capsulitis is suspected, bilaterally assess forward elevation and external rotation at 0 degrees abduction at the glenohumeral joint [94]. | 3 | |
• Palpation of the shoulder should occur at the point of maximum tenderness [89]. | 2 | |
• Manual muscle testing should be performed for the supraspinatus muscle in the scapular plane (i.e., thumb pointing down), and having the patient resist against a downward pressure placed on the forearms [95]. | 2 | |
• Manual muscle testing should be performed for the infraspinatus muscle by having the patient externally rotate from 45 degrees of internal rotation against resistance [96]. | 2 | |
• The Belly Press test should be used to assess subscapularis strength [97]. | 2 | |
• The Lift-off test should be used to assess subscapularis strength [98]. | 2 | |
• Neer’s impingement sign should be used to confirm impingement [99]. | 2 | |
• Hawkins-Kennedy sign should be used to confirm impingement [95]. | 2 | |
• Speed’s test should be used to confirm biceps muscle or tendon pathology [100]. | 2 | |
• Cross body adduction test should be used to rule out acromioclavicular joint sprain [87]. | 2 | |
Investigations | The following four guidelines for investigations are recommended for patients that present with rotator cuff pathology: | |
• From a diagnostic and treatment perspective, a x-ray is a necessary test [49]. | 2 | |
2 | ||
• Ultrasound is the cost-effective investigation for defining a full-thickness rotator cuff tear [50]. | 2 | |
With respect to full-thickness rotator cuff tears, magnetic resonance imaging (MRI) is only required for surgical planning [102]. | 2 | |
Treatment | The following seven guidelines for investigations are recommended for patients that present with rotator cuff pathology. These guidelines were expanded and merged to create clinical care pathways for three classifications of rotator cuff injuries: acute, chronic, and acute-on-chronic injuries. | |
Acute rotator cuff pathology
| ||
• Patients without pre-existing history of rotator cuff problems, presenting with an acute, traumatic injury (i.e., definable traumatic event) of the rotator cuff resulting in dramatic loss of shoulder function, should be referred to a surgeon, and seen by the surgeon within 6 weeks after consultation with a primary care practitioner [103]. | 2 | |
Chronic and acute-on-chronic rotator cuff pathology
| ||
2 | ||
• Patients presenting to healthcare professionals with chronic rotator cuff disorder should be prescribed a non-operative rotator cuff rehabilitation program at the initial visit, if one has not already been prescribed [56]. | 2 | |
• Stage 1 home programs (Weeks 0–6) should focus on decreasing shoulder pain and increasing shoulder range of motion through exercise, stretching, and high repetition movement patterns, four times every day (i.e., pulley exercises, assisted range of motion for abduction, elevation, external rotation, internal rotation) [56]. | 2 | |
• Stage 2 home programs (Weeks 6–12) should focus on improving strength and muscular control at least once a day (i.e., banding exercises, scapular stabilizing exercises) [56]. | 2 | |
• Patients that are not able to achieve pain-free status with improved range of motion after 6 weeks should attempt additional pain control (i.e., cortisone injection) in adjunct to the non-operative rotator cuff home program [56]. | 2 | |
2 |