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Two-Point Minimum in Test May Determine Rotator Cuff Improvement after Nonoperative Treatment

Rotator cuff disease is really a condition where one of the four tendons that stabilize the shoulder joint is damaged or injured. It's one of the most common causes of shoulder pain. Sometimes rotator cuff injuries are treated with surgery, but others don't require surgery and can be treated by , nonoperative, no surgery, treatments.

Determining how effective shoulder treatment is often depends on the system used to measure the success and how the scores are obtained. There are many methods available aside from the two in this study, such as the Constant score, UCLS score, Western Ontario Rotator Cuff Index, Penn Shoulder Score, and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

The authors of this study wanted to determine the smallest difference it takes for a patient to feel that the treatment has helped his or her shoulder. To do this, researchers recruited 81 patients, average age 51 years) who had been diagnosed with either tendinitis (inflammation and irritation of the tendon) of the shoulder (14 patients total) or a tear in the rotator cuff (67 patients total). The researchers gathered data on the patients' history, a physical examination and x-rays of the affected shoulders. If patients had undergone magnetic resonance imaging (MRI), this information was also included. Some patients who were diagnosed with tendinitis but who did not have an MRI may actually have had a torn tendon, but this was not recorded.

To get the patients' point of view regarding their shoulder problems, they filled out baseline questionnaire forms, including the American Shoulder and Elbow Surgeons score (ASES) and the Simple Shoulder Test (SST). The ASES gave scores according to the pain and function of the shoulder, using three sets of scores: the 15-item function, 15-item pain, and four-item assessments. The SST asks patients about how they are or aren't able to function with their shoulder the way it is at the time the test is taken.

The types of non-surgical treatments the patients received varied according to their own needs. They included:
- rest
- application of ice
- restricting or modifying activity
- physical therapy
- anti-inflammatory pain medications
- cortisone injections into the shoulder

After at least six weeks, the patients were reevaluated with the questionnaire, the test, and three extra questions:

1- Since your last clinic visit, has there been any change in the function of your treated shoulder?
2- Since your last clinic visit, has there been any change in the pain in your treated shoulder?
3- Since your last clinic visit, please rate your response to treatment.

The results showed that there was a difference in scores in the SST of at least 2.33, in patients who had improvements in their shoulder, although many patients had more significant changes. Patients who had no positive progress had from a negative 0.33 point change up to only 1.72 points change. When looking at the ASES scores, the researchers found that the minimum number that showed changes were between 12 and 17: 12.01 for the 15-item function, 16.92 for the 15-item pain, and 16.72 in the four-item assessments.

Taking these numbers, the researchers were able to determine the lowest scores that would show that there was improvement in the affected shoulders. The authors did point out that the study had some limitations, not the least of which was that they may not have had accurate diagnosis for all the patients. As mentioned above, some patients were diagnosed with tendinitis, but they could have had a tear that was not known about.

References: Robert Z. Tashjian, MD, et al. Minimally Clinically Important Differences in ASES and Simple Shoulder Test Scores After Nonoperative Treatment of Rotator Cuff Disease. In The Journal of Bone & Joint Surgery. February 2010.  Vol. 92-A. No. 2. Pp. 296-303.

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