Original Research

Patient Preference Before and After Arthroscopic Rotator Cuff Repair: Which Is More Important, Pain Relief or Strength Return?

Am J Orthop. 2017 July;46(4):E244-E250

Mandeep S. Virk, MD

David M. Levy, MD

Benjamin D. Kuhns, MD, MS

James S. Krecher, MD

Billy K. Parsley, MD

Stephen S. Burkhart, MD

Anthony A. Romeo, MD

Nikhil N. Verma, MD

Brian J. Cole, MD, MBA

Our understanding of patients’ desired outcomes and expectations of arthroscopic rotator cuff repair (ARCR) is limited, particularly regarding the importance of pain relief and strength return relative to each other. We conducted a study of patient’s ratings of the importance of pain relief and strength return after ARCR. Before undergoing surgery, 60 patients completed a shoulder questionnaire on which they assessed severity of symptoms and rated, on a 10-point scale, the importance of postoperative improvements in pain relief and strength return. After surgery, they completed the same questionnaire, again rating the importance of pain relief and strength return. About 50% of the patients valued pain relief and strength return equally before and after ARCR. However, overall patient ratings were higher for strength return over pain relief, both before surgery, mean (SD), 9.2 (2.1) vs 8.6 (2.3) (P = .02), and afterward, at a follow-up of 5.2 (0.2) years, 8.9 (1.9) vs 8.2 (3.1) (P = .03). This significant preference for strength return held irrespective of sex, age, active sports involvement, preoperative self-assessed pain score, and subjective shoulder weakness. Before surgery, increasing age was associated with a stronger preference for pain relief (r = 0.33, P = .01), and retirees preferred pain relief over strength return. These results show the patterns of patient preference for pain relief and strength return after ARCR. Improved understanding of these patients’ expectations will allow meaningful changes in patient satisfaction.

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References

2. Huijsmans PE, Pritchard MP, Berghs BM, van Rooyen KS, Wallace AL, de Beer JF. Arthroscopic rotator cuff repair with double-row fixation. J Bone Joint Surg Am. 2007;89(6):1248-1257.

3. Wilson F, Hinov V, Adams G. Arthroscopic repair of full-thickness tears of the rotator cuff: 2- to 14-year follow-up. Arthroscopy. 2002;18(2):136-144.

4. Denard PJ, Jiwani AZ, Lädermann A, Burkhart SS. Long-term outcome of a consecutive series of subscapularis tendon tears repaired arthroscopically. Arthroscopy. 2012;28(11):1587-1591.

5. Richards RR, An KN, Bigliani LU, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. 1994;3(6):347-352.

6. Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res. 1991;4(4):143-149.

7. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;(214):160-164.

8. Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11(6):587-594.

9. Romeo AA, Bach BR Jr, O’Halloran KL. Scoring systems for shoulder conditions. Am J Sports Med. 1996;24(4):472-476.

10. Tashjian RZ, Bradley MP, Tocci S, Rey J, Henn RF, Green A. Factors influencing patient satisfaction after rotator cuff repair. J Shoulder Elbow Surg. 2007;16(6):752-758.

11. Henn RF 3rd, Kang L, Tashjian RZ, Green A. Patients’ preoperative expectations predict the outcome of rotator cuff repair. J Bone Joint Surg Am. 2007;89(9):1913-1919.

12. O’Holleran JD, Kocher MS, Horan MP, Briggs KK, Hawkins RJ. Determinants of patient satisfaction with outcome after rotator cuff surgery. J Bone Joint Surg Am. 2005;87(1):121-126.

13. Namdari S, Donegan RP, Chamberlain AM, Galatz LM, Yamaguchi K, Keener JD. Factors affecting outcome after structural failure of repaired rotator cuff tears. J Bone Joint Surg Am. 2014;96(2):99-105.

14. Nho SJ, Brown BS, Lyman S, Adler RS, Altchek DW, MacGillivray JD. Prospective analysis of arthroscopic rotator cuff repair: prognostic factors affecting clinical and ultrasound outcome. J Shoulder Elbow Surg. 2009;18(1):13-20.

15. Sonnabend DH, Watson EM. Structural factors affecting the outcome of rotator cuff repair. J Shoulder Elbow Surg. 2002;11(3):212-218.

16. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87(6):1229-1240.

17. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg Am. 2007;89(5):953-960.

18. DeFranco MJ, Bershadsky B, Ciccone J, Yum JK, Iannotti JP. Functional outcome of arthroscopic rotator cuff repairs: a correlation of anatomic and clinical results. J Shoulder Elbow Surg. 2007;16(6):759-765.

19. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219-224.

20. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73(7):982-989.

21. Romeo AA, Hang DW, Bach BR Jr, Shott S. Repair of full thickness rotator cuff tears. Gender, age, and other factors affecting outcome. Clin Orthop Relat Res. 1999;(367):243-255.

Take-Home Points

Pain relief and return of strength are important satisfaction variables for patients undergoing ARCR.
Pain relief and strength return are equally desirable in the majority (50%) of the patients before and after ARCR.
Overall, patient preference for strength return dominates pain relief in long-term.
Increasing age is associated with a stronger preference for pain relief.

Improved understanding of patient expectations after ARCR will promote meaningful changes in patient satisfaction.

A rotator cuff tear (RCT) can cause significant pain, weakness, stiffness, and loss of function in the shoulder. In most patients, arthroscopic rotator cuff repair (ARCR) provides significant and reproducible pain relief and variable return of shoulder strength and function.^1-4 ARCR outcomes are well described and well represented by validated outcome measures.^5-9 However, these outcomes do not always correlate with patient satisfaction. For example, after ARCR, 2 patients with similar outcome scores may have different satisfaction levels.

Patient satisfaction involves multiple factors and varies with the patient’s preoperative expectations and the degree to which the surgery matches the patient’s desired outcomes.^10-15 In clinical studies, Tashjian and colleagues,¹⁰ Henn and colleagues,¹¹ and O’Holleran and colleagues¹² found patient satisfaction correlated most highly with postoperative shoulder pain, shoulder function, general health status, and outcome scores. However, our understanding of patients’ desired outcomes and expectations of ARCR is limited, particularly regarding the importance of pain relief and strength return relative to each other. We believe patients’ preoperative expectations are influenced by their self-assessments of symptom severity and by their understanding of the outcomes of surgical procedures and of the information they receive from their surgeons during preoperative evaluation.

We conducted an observational study to determine patients’ preoperative preferences and the importance of post-ARCR pain relief and strength return relative to each other. After surgery, preferences and ratings of pain relief and strength return were reevaluated to determine if they were altered by outcomes. We also studied the influence of multiple factors, including severity of preoperative symptoms (pain, weakness), age, sex, occupation, and active sports involvement, on patients’ preoperative ratings of the importance of post-ARCR improvements in pain relief and strength return. We hypothesized that patients would vary in how they preoperatively value and desire post-ARCR pain relief and strength return.

Materials and Methods

The simple shoulder questionnaire (Figure) designed for this study had 12 items. Patients subjectively assessed the severity of their symptoms (pain level, shoulder weakness) and rated the importance of both pain relief and strength return to their occupational and personal life.

Figure.

They quantified their perceived level of pain over the preceding 7 days by rating it 0 (no pain) to 10 (worst pain imaginable). Preoperative pain level was evaluated to determine if patients with the worst pain would rate the importance of pain relief and strength return differently. Patients also rated their painful shoulder’s strength deficit as a percentage of the contralateral shoulder’s strength. In addition, patients rated the importance of pain relief and strength return from 0 (not important) to 10 (very important). Strength-to-pain difference (SPD) was calculated by subtracting the pain relief preference from the strength return preference, with positive values indicating a preference for strength return and negative values indicating a preference for pain relief.

Before patients underwent surgery for symptomatic suspected RCTs, they were approached to participate in this prospective study. Sixty-five patients provided informed consent on forms approved by an Institutional Review Board. Inclusion criteria were suspected unilateral rotator cuff pathology and willingness to participate. Of the 65 patients, 60 underwent ARCR without another procedure, such as shoulder instability repair, SLAP (superior labrum anterior-to-posterior) repair, or distal clavicle excision; the other 5 patients elected nonoperative treatment and were excluded from review. At a mean (SD) follow-up of 5.2 (0.2) years, the 60 patients who had surgery completed the questionnaire again and rated the importance of pain relief and strength return relative to each other.

Patients with RCTs were divided according to age, sex, shoulder dominance, occupation type, and active sports involvement. Standard definitions for occupation types were used: blue-collar, manual labor jobs; white-collar, salaried/educated positions; and retired.

Matched-pairs t tests were used to compare preoperative and postoperative continuous variables (strength return preference, pain relief preference, SPD). One-way analysis of variance (ANOVA) was used to compare categorical variables (sex, shoulder dominance, active sports involvement) with continuous variables (SPD), and bivariate regression was used to compare groups with continuous data (age, SPD). In cases involving more than 2 groups (occupation types), the Tukey honestly significant difference (HSD) test was used to evaluate intergroup differences. P < .05 was used for statistical significance.

References

1. Cole BJ, McCarty LP 3rd, Kang RW, Alford W, Lewis PB, Hayden JK. Arthroscopic rotator cuff repair: prospective functional outcome and repair integrity at minimum 2-year follow-up. J Shoulder Elbow Surg. 2007;16(5):579-585.

2. Huijsmans PE, Pritchard MP, Berghs BM, van Rooyen KS, Wallace AL, de Beer JF. Arthroscopic rotator cuff repair with double-row fixation. J Bone Joint Surg Am. 2007;89(6):1248-1257.

3. Wilson F, Hinov V, Adams G. Arthroscopic repair of full-thickness tears of the rotator cuff: 2- to 14-year follow-up. Arthroscopy. 2002;18(2):136-144.

4. Denard PJ, Jiwani AZ, Lädermann A, Burkhart SS. Long-term outcome of a consecutive series of subscapularis tendon tears repaired arthroscopically. Arthroscopy. 2012;28(11):1587-1591.

5. Richards RR, An KN, Bigliani LU, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. 1994;3(6):347-352.

6. Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res. 1991;4(4):143-149.

7. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;(214):160-164.

8. Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11(6):587-594.

9. Romeo AA, Bach BR Jr, O’Halloran KL. Scoring systems for shoulder conditions. Am J Sports Med. 1996;24(4):472-476.

10. Tashjian RZ, Bradley MP, Tocci S, Rey J, Henn RF, Green A. Factors influencing patient satisfaction after rotator cuff repair. J Shoulder Elbow Surg. 2007;16(6):752-758.

11. Henn RF 3rd, Kang L, Tashjian RZ, Green A. Patients’ preoperative expectations predict the outcome of rotator cuff repair. J Bone Joint Surg Am. 2007;89(9):1913-1919.

12. O’Holleran JD, Kocher MS, Horan MP, Briggs KK, Hawkins RJ. Determinants of patient satisfaction with outcome after rotator cuff surgery. J Bone Joint Surg Am. 2005;87(1):121-126.

13. Namdari S, Donegan RP, Chamberlain AM, Galatz LM, Yamaguchi K, Keener JD. Factors affecting outcome after structural failure of repaired rotator cuff tears. J Bone Joint Surg Am. 2014;96(2):99-105.

14. Nho SJ, Brown BS, Lyman S, Adler RS, Altchek DW, MacGillivray JD. Prospective analysis of arthroscopic rotator cuff repair: prognostic factors affecting clinical and ultrasound outcome. J Shoulder Elbow Surg. 2009;18(1):13-20.

15. Sonnabend DH, Watson EM. Structural factors affecting the outcome of rotator cuff repair. J Shoulder Elbow Surg. 2002;11(3):212-218.

16. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87(6):1229-1240.

17. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg Am. 2007;89(5):953-960.

18. DeFranco MJ, Bershadsky B, Ciccone J, Yum JK, Iannotti JP. Functional outcome of arthroscopic rotator cuff repairs: a correlation of anatomic and clinical results. J Shoulder Elbow Surg. 2007;16(6):759-765.

19. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219-224.

20. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73(7):982-989.

21. Romeo AA, Hang DW, Bach BR Jr, Shott S. Repair of full thickness rotator cuff tears. Gender, age, and other factors affecting outcome. Clin Orthop Relat Res. 1999;(367):243-255.

Patient Preference Before and After Arthroscopic Rotator Cuff Repair: Which Is More Important, Pain Relief or Strength Return?

References

Take-Home Points

Materials and Methods

Pages

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