Risk factors for degenerative, symptomatic rotator cuff tears: a case-control study.

BACKGROUND: Despite the considerable public health burden of rotator cuff tears, there is no consensus on risk factors associated with symptomatic rotator cuff tears. In this study, a large data source was used to identify factors associated with symptomatic rotator cuff tears. We defined cases of rotator cuff tears as those verified by imaging or operative reports and controls as symptomatic shoulders without rotator cuff tears as verified by imaging or operative reports. METHODS: We performed a case-control study of patients with and without symptomatic rotator cuff tears by use of the Vanderbilt University Medical Center de-identified electronic medical record system, the Synthetic Derivative, with records on >2.5 million patients from 1998 to 2017. Cases and controls were confirmed by individual chart review and review of imaging and/or operative notes. A final set of 11 variables were analyzed as potential risk factors for cuff tears: age, sex, body mass index (BMI), race, smoking history, hypertension, depression/anxiety, dyslipidemia, carpal tunnel syndrome, overhead activity, and affected side. Multivariable logistic regression was used to estimate the association between predictor variables and the risk of having a rotator cuff tear. RESULTS: A total of 2738 patients were selected from the Synthetic Derivative, which included 1731 patients with rotator cuff tears and 1007 patients without rotator cuff tears. Compared with individuals without tears, those with rotator cuff tears were more likely to be older (odds ratio [OR], 2.44; 95% confidence interval [CI], 2.12-2.89), to have a higher BMI (OR, 1.45; 95% CI, 1.24-1.69), to be of male sex (OR, 1.56; 95% CI, 1.32-1.85), and to have carpal tunnel syndrome (OR, 1.41; 95% CI, 1.03-1.93). Patients with rotator cuff tears were less likely to have left shoulder symptoms (OR, 0.68; 95% CI, 0.57-0.82) and to have depression/anxiety (OR, 0.77; 95% CI, 0.62-0.95) compared with the control group, which had symptomatic shoulder pain without rotator cuff tears. CONCLUSIONS: In a large imaging and operative report-verified case-control study, we identified advancing age, male sex, higher BMI, and diagnosis of carpal tunnel syndrome as risk factors significantly associated with an increased risk of rotator cuff tears. Left shoulder symptoms and depression/anxiety were less likely to be associated with rotator cuff tears compared with symptomatic shoulders without rotator cuff tears. Contrary to some prior reports in the literature, smoking was not associated with rotator cuff tears.

Characteristics of ambulatory spine care visits in the United States, 2009-2016.

BACKGROUND: Back pain is a leading reason for seeking care in the United States (US), and is a major cause of morbidity. OBJECTIVE: To analyze demographic, patient, and visit characteristics of adult ambulatory spine clinic visits in the United States from 2009-2016. METHODS: Data from the National Ambulatory Medical Care Survey from 2009-2016 were used and were sample weighted. RESULTS: Most patients presenting for ambulatory spine care were 45-64 years (45%), were most commonly female (56.8%), and private insurance (45%) and Medicare (26%) were most common payors. The percentage of visits for spine care done at a primary care setting was 50.1% in 2009-2010 and 48.3% in 2014-2015. Approximately 15.5% were seen in orthopedic surgery clinics in 2009-2010 and 7.3% in 2015-2016. MRI was utilized in 11.7% in 2009-2010 and 11.0% in 2015-2016. Physical therapy was prescribed in 13.2% and narcotic analgesic medications were prescribed in 36.2% of patients in 2015-2016. CONCLUSIONS: MRI was used more frequently than guidelines recommended, and physical therapy was less frequently utilized despite evidence. A relatively high use of opiates in treatment of back pain was reported and is concerning. Although back pain represents a substantial public health burden in the United States, the delivery of care is not evidence-based.

Factors Associated With Symptomatic Rotator Cuff Tears: The Rotator Cuff Outcomes Workgroup Cohort Study.

OBJECTIVE: Although rotator cuff tear is one of the most common musculoskeletal disorders, its etiology is poorly understood. We assessed factors associated with the presence of rotator cuff tears in a cohort of patients with shoulder pain. DESIGN: From February 2011 to July 2016, a longitudinal cohort of patients with shoulder pain was recruited. Patients completed a detailed questionnaire in addition to a magnetic resonance imaging scan and a clinical shoulder evaluation. The association of multiple factors associated with rotator cuff tears was assessed using multivariate logistic regression. RESULTS: In our cohort of 266 patients, 61.3% of patients had a rotator cuff tear. Older age (per 1 yr: odds ratio = 1.03, 95% confidence interval = 1.02-1.07), involvement of the dominant shoulder (odds ratio = 2.02, 95% confidence interval = 1.16-3.52), and a higher body mass index (per 1 kg/m2: odds ratio = 1.06, 95% confidence interval = 1.03-1.12) were independently associated with rotator cuff tears. Sex, depression, smoking status, shoulder use at work, hypertension, and diabetes were not significantly associated with rotator cuff tear. CONCLUSIONS: In a cohort of patients with shoulder pain, we identified older age, involvement of the dominant shoulder, and a higher body mass index to be independently associated with rotator cuff tear. The mechanism of how these factors possibly lead to rotator cuff tears needs further research. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Identify factors associated with an increased risk of developing rotator cuff tears in adults; (2) Describe the current epidemiological trends of rotator cuff tears in the United States; and (3) Discuss the pathophysiological role of aging in the development of nontraumatic rotator cuff tears. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Characteristics of Non-Spine Musculoskeletal Ambulatory Care Visits in the United States, 2009-2016.

BACKGROUND: Despite the enormous economic and societal impact of musculoskeletal disorders, detailed data on the patient demographics and visit characteristics of nonspine musculoskeletal ambulatory care are sparse. Such data are essential to inform policymakers on population health needs and to justify health care resource allocation. OBJECTIVE: To determine the demographic, patient, and visit characteristics of adult musculoskeletal ambulatory clinic visits, with the exception of spine visits, in the United States. DESIGN: Survey/registry. SETTING: National Ambulatory Medical Care Survey (NAMCS), Centers for Disease Control and Prevention (CDC) 2009 to 2016. PATIENTS: The NAMCS was designed to capture information regarding the provision and use of ambulatory medical care services in the United States. Nonfederally employed office-based physicians reported data for this survey from 2009 to 2016. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Average annual estimated number (in 100 000s), Average annual estimated rate of ambulatory care musculoskeletal visits per 100 U.S. adults. RESULTS: During 2009 to 2016, the leading cause of musculoskeletal visits was knee symptoms (15.3 million annually from 2009 to 2010, 14.0 million annually from 2011 to 2012, 12.5 million annually from 2013 to 2014, and 12.4 million annually from 2015 to 2016). Musculoskeletal visits were most frequent in patients that were 45 to 64 years of age (40.4% to 43.6% of visits were for patients 45 to 64 years of age depending on body region). Orthopedic surgeons conducted more musculoskeletal visits than any other physician specialty for all body regions. Among body regions, magnetic resonance imaging (MRI) studies were ordered most commonly for patients with shoulder (total visits in 100 000 ± standard error [SE] 47.00 ± 0.21; 12.5% of total visits for shoulders) and knee symptoms (61.85 ± 0.15; 11.4% of total visits for knees). Opioid and opioid analgesic combinations (9.2% to 14.8% of visits) were most commonly prescribed in visits related to hip complaints. CONCLUSIONS: Visits were most frequent for knee symptoms and in patients of working age groups, which likely affects work productivity. Orthopedic surgeons were the most common provider specialty. Opioid medications were prescribed most commonly for patients with hip symptoms, which may highlight an area for potential intervention given the ongoing opioid crisis.

Comparative Time to Improvement in Nonoperative and Operative Treatment of Rotator Cuff Tears.

BACKGROUND: Comparative time to recovery after operative and nonoperative treatment for rotator cuff tears is an important consideration for patients. Hence, we compared the time to achieve clinically meaningful reduction in shoulder pain and function after treatment. METHODS: From February 2011 to June 2015, a multicenter cohort of patients with rotator cuff tears undergoing operative or nonoperative treatment was recruited. After propensity score weighting, the Kaplan-Meier method was used to estimate the time to achieve a minimal clinically important difference (MCID), >30% reduction, and >50% reduction in the Shoulder Pain and Disability Index (SPADI) and the American Shoulder and Elbow Surgeons (ASES) scores. (In our analysis, both ASES and SPADI were coded such that a lower number corresponded to a better outcome; thus, the word "reduction" was used to indicate improvement in both ASES and SPADI scores.) A 2-stage test was conducted to detect a difference between the 2 groups. RESULTS: In this cohort, 96 patients underwent nonoperative treatment and 73 patients underwent a surgical procedure. The surgical treatment group and the nonoperative treatment group were significantly different with respect to SPADI and ASES scores (p < 0.05). The maximum difference between groups in achievement of the MCID for the SPADI scores was at 3.25 months, favoring the nonoperative treatment group. The probability to achieve the MCID was 0.06 (95% confidence interval [CI], 0.00 to 0.12) for the surgical treatment group compared with 0.40 (95% CI, 0.29 to 0.50) for the nonoperative treatment group. The surgical treatment group had a greater probability of achieving >50% reduction in SPADI scores at 15.49 months (0.20 [95% CI, 0.12 to 0.29] for the surgical treatment group compared with 0.04 [95% CI, 0.00 to 0.09] for the nonoperative treatment group). The surgical treatment group had a greater probability of achieving >50% reduction in ASES scores at 24.74 months (0.96 [95% CI, 0.84 to 0.99] for the surgical treatment group compared with 0.66 [95% CI, 0.53 to 0.75] for the nonoperative treatment group). The differences for >30% reduction in SPADI and ASES scores and the MCID for ASES scores were not significant. CONCLUSIONS: Patients undergoing nonoperative treatment had significantly better outcomes in the initial follow-up period compared with patients undergoing a surgical procedure, but this trend reversed in the longer term. These data can be used to inform expectations for nonoperative and operative treatments for rotator cuff tears. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

US Geographical Variation in Rates of Shoulder and Knee Arthroscopy and Association With Orthopedist Density.

Importance: Although rates of arthroscopy have substantially increased, recent data question its comparative effectiveness. Objectives: To assess time trends and geographical variations among several US states in arthroscopy rates and to assess the association of orthopedist density with arthroscopy rates. Design, Setting, and Participants: In this cross-sectional study, procedure rates were calculated for knee arthroscopy, shoulder arthroscopy, and arthroscopic rotator cuff repair using data from the State Ambulatory Surgery and Services Databases for 2006 to 2016 (as available) for the states of California, Colorado, Florida, Iowa, Kentucky, Maryland, Maine, Michigan, Minnesota, North Carolina, Nebraska, New Jersey, Nevada, New York, Oregon, Utah, Vermont, and Wisconsin. Data were analyzed from June 2017 to October 2019. Main Outcomes and Measures: Rates of knee arthroscopy, shoulder arthroscopy, and arthroscopic rotator cuff repair. Results: The combined data sets included 4 856 385 records with 2 530 840 female patients (47%); mean (SD) patient age was 49.13 (16.34) years. Rates per 100 000 persons showed large geographical variations for knee arthroscopy (from 63.31 [95% CI, 5.92-198.95] to 721.72 [95% CI, 633.41-806.20]), shoulder arthroscopy (from 53.02 [95% CI, 2.80-164.36] to 438.25 [95% CI, 399.00-476.78]), and arthroscopic rotator cuff repair (from 11.94 [95% CI, 1.30-56.98] to 185.35 [95% CI, 143.84-226.20]) across US states and years. There were significant downward time trends in knee arthroscopy rates in California, Florida, Iowa, Maryland, Michigan, Nebraska, and New Jersey and upward trends for arthroscopic rotator cuff repair in Colorado, Florida, Kentucky, Maine, and North Carolina. Orthopedist density was not associated with knee arthroscopy rates (slope = 3.07; 95% CI, -9.88 to 16.03; P = .54), shoulder arthroscopy rates (slope = 2.74; 95% CI, -6.53 to 12.01; P = .47), or rates of arthroscopic rotator cuff repair (slope = 1.15; 95% CI, -2.77 to 5.05; P = .49). Conclusions and Relevance: There is large geographical variation in arthroscopy rates despite the questionable comparative effectiveness of these procedures. The reasons for increasing rates of rotator cuff surgery should be further examined.

Glenohumeral corticosteroid injections in adhesive capsulitis: a systematic search and review.

OBJECTIVE: To assess the literature on outcomes of corticosteroid injections for adhesive capsulitis, and, in particular, image-guided corticosteroid injections. TYPE: Systematic search and review. LITERATURE SURVEY: The databases used were PubMed (1966-present), EMBASE (1947-present), Web of Science (1900-present), and the Cochrane Central Register of Controlled Trials. Upon reviewing full-text articles of these studies, a total of 25 studies were identified for inclusion. The final yield included 7 prospective studies, 16 randomized trials, and 2 retrospective studies. METHODOLOGY: This systematic review was formatted by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study criteria were limited to clinical trials, prospective studies, and retrospective studies that specifically evaluated intra-articular corticosteroid injections, both alone and in combination with other treatment modalities, for shoulder adhesive capsulitis. We included studies that were not randomized control trials because our review was not a meta-analysis. Data items extracted from each study included the following: study design, study population, mean patient age, duration of study, duration of symptoms, intervention, single or multiple injections, location of injections, control population, follow-up duration, and outcome measurements. A percentage change in outcome measurements was calculated when corresponding data were available. Risk of bias in individual studies was assessed when appropriate. SYNTHESIS: All the studies involved at least 1 corticosteroid injection intended for placement in the glenohumeral joint, but only 8 studies used image guidance for all injections. Seven of these studies reported statistically significant improvements in range of motion at or before 12 weeks of follow-up. Ninety-two percent of all the studies documented a greater improvement in either visual analog pain scores or range of motion after corticosteroid injections in the first 1-6 weeks compared with the control or comparison group. CONCLUSIONS: Corticosteroid injections offer rapid pain relief in the short-term (particularly in the first 6 weeks) for adhesive capsulitis. Long-term outcomes seem to be similar to other treatments, including placebo. The added benefit of image-guided corticosteroid injections in improving shoulder outcomes needs further assessment.

Outcomes of Ultrasound-guided Glen Humeral Corticosteroid Injections in Adhesive Capsulitis.

AIMS: To assess short and longer-term outcomes of ultrasound-guided glenohumeral corticosteroid injections for adhesive capsulitis. STUDY DESIGN: A mixed prospective and retrospective study design. PLACE AND DURATION OF STUDY: Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Department of Orthopaedic Surgery, Brigham and Women's Hospital, between June 2011 and July 2012. METHODOLOGY: Using medical records, we first retrospectively identified patients who had received ultrasound-guided injections of lidocaine and triamcinolone for adhesive capsulitis We then assessed short-term follow-up outcomes (within 3 months of procedure) using medical record review and phone interviews. Longer-term follow-up (at least 3 months from the procedure) outcomes were determined by mailings and phone calls. Average and worst shoulder pain scores were measured on a visual analog scale. Shoulder ROM was measured in forward flexion, isolated abduction, and external rotation. RESULTS: Patients presented an average of 5.1 (SD=4.1) months after onset of symptoms. Within three months of the injection, 55.9% (95% CI: 39.2%, 72.6%) of patients reported greater than 75% pain relief and 44.1% (95% CI: 27.4%, 60.8%) of patients reported greater than 75% ROM improvement. The percentage of patients who improved increased with increased duration of follow-up. At short-term follow-up (mean=2.1 months, SD=2.7), average pain decreased from 5.6 (SD=2.2) to 3.0 (SD=1.8) (p ≤ .001) and worst pain decreased from 7.8 (SD=1.2) to 4.3 (SD=3.2) (p ≤ .001). At longer-term follow-up (mean =10.4 months, SD=3.7), average pain decreased to 1.9 (SD=1.9) (p ≤ .001) and worst pain decreased to 2.9 (SD=2.3) (p ≤ .001). CONCLUSION: A majority of patients had significant pain reduction and functional improvement after an ultrasound guided glenohumeral corticosteroid injection for adhesive capsulitis. Our patients experience the majority of their pain and functional relief within the first three months after an ultrasound-guided corticosteroid injection with continued increase in relief in the longer-term.

Electron microscopy of biotinylated protein complexes bound to streptavidin monolayer crystals.

Chemical biotinylation of protein complexes followed by binding to two-dimensional (monolayer) crystals of streptavidin is shown to be an effective way to prepare cryo-EM specimens from samples at low protein concentration. Three different multiprotein complexes are used to demonstrate the generality of this method. In addition, native thermosomes, purified from Sulfolobus solfataricus P2, are used to demonstrate that a uniform distribution of Euler angles is produced, even though this particle is known to adopt a preferred orientation when other methods of cryo-EM specimen preparation are used.