Could the diagnostic labels 'subacromial impingement' and 'rotator cuff tear' be harmful?Aug 23, 2021
In this blog post, I address the important topic of diagnostic labels for shoulder pain. I hope it prompts some thought and reflection.
The 'words matter' movement has been around a while now, a decade at least, however whether anything has materially changed in clinical practice is questionable. What are the possible consequences of this lethargy towards change? Keep reading.
This blog is a review of a recent paper by Zadro et al 2021, titled:
Diagnostic labels for rotator cuff disease can increase people’s perceived need for shoulder surgery: an online randomized controlled experiment (ref)
Background and objective:
The clinical presentation of non-traumatic shoulder pain is a diagnostic conundrum. Traditionally, pathoanatomical labels such as subacromial impingement syndrome, rotator cuff tear and tendonitis/tendinopathy have been the preferred diagnostic terms. However, accumulating evidence has challenged the accuracy and utility of these terms [1,2,6]. As such, alternative options have been suggested, including rotator cuff-related shoulder pain (RCRSP)  and subacromial shoulder pain. To date, there is no consensus diagnostic label across countries and settings.
Diagnostic labels can influence people’s management preferences; however, this has not been experimentally verified for rotator cuff disease. This randomized controlled trial primarily set out to answer the question “do different diagnostic labels for rotator cuff disease influence peoples perceived need for surgery”?
This was a 6-arm online randomized controlled trial. Participants were recruited via an online market research company.
Participants were given a standardized vignette to read about their hypothetical shoulder pain. The vignette was written in an optimistic style, avoiding potential fear-inducing rhetoric and constructed to convey their symptoms would most likely improve over time. After reading the vignette, participants were randomized in to one of 6 diagnostic labels:
- Subacromial impingement syndrome
- Rotator cuff tear
- Rotator cuff-related shoulder pain
- Shoulder sprain
- Episode of shoulder pain (control label)
The primary outcome was ‘perceived need for surgery’ after being assigned to one of the above diagnostic labels. Secondary outcomes were the perceived need for imaging, an injection, a second opinion and to see a specialist.
1626 participants were randomized to one of the 6 groups. 318 participants did not complete the outcome measures, leaving 1308 participants included in the analysis.
Participants were recruited from 5 countries (Australia, NZ, Canada, USA, UK). The mean age was 40.3 years and 59.1% were women. 46% had a university education and 61% were employed.
Overall the perceived need for surgery was low in all groups. People allocated to the rotator cuff tear group had the highest perceived need for surgery when compared to those allocated to the bursitis label.
Perceived need for imaging was moderate across all groups and highest in those allocated to rotator cuff tear and subacromial impingement groups when compared to those allocated to the bursitis label. There were no between groups differences for all other outcomes.
Words have power. They can save, cure, uplift, devastate, deflate, and kill. Robert Sapolsky (Behave, 2017).
The most important limitation of this RCT is its online methodology. It remains to be seen if these results are replicable in real life.
The positive message of the vignette in this RCT may not be indicative of the common narrative describing rotator cuff disease in everyday clinical practice.
Potentially key diagnostic labels were not investigated, including subacromial shoulder pain, subacromial pain syndrome and non-specific shoulder pain.
This was a well-constructed clinical trial, yielding actionable information. The core message is classic diagnostic labels of rotator cuff disease, including rotator cuff tear and subacromial impingement, marginally increase a patient’s perceived need for surgery and imaging, which may drive unnecessary usage of health resources. Whilst the overall difference between the groups in this trial was small, this could compound substantially when applied at a population level. Rotator cuff disease is prevalent in the general population and is the 3rd most common reason people seek care for musculoskeletal pain and dysfunction. It is reported that every year 2% of adults in the UK seek care for new-onset shoulder pain, which equates to roughly 1 million people each year . Simple mathematical modelling suggests there would be tens of millions of people worldwide diagnosed with rotator cuff disease each year. A small difference amongst 1000 trial participants may scale up significantly amongst 10 million. Crucially, there is no impenetrable barrier to modifying our diagnostic terminology, just tradition and habit. It’s not easy to break a habit or form a new one, but there is precedence in musculoskeletal health care with diagnostic labels, including non-specific low back pain and tendinopathy, having been mostly integrated into clinical practice somewhat recently.
Crucially, there is no impenetrable barrier to modifying our diagnostic terminology, just tradition and habit. Jared Powell (2021)
The positive messaging of the vignette warrants discussion. It is doubtful the clinical diagnosis of rotator cuff tear is routinely accompanied by such an optimistic message as used in this RCT. Unfortunately, it is likely the diagnosis is delivered within a biomedical-centric framework, making it logical for a patient to assume that their tear must be ‘fixed’ for their pain to improve . As such, the problem may be bigger than depicted in this experiment.
In summary, language probably matters for rotator cuff disease, even when accompanied by positive clinical messaging. In a time when low-value healthcare is a global problem, we should be willing to explore various strategies to curtail its growth and diagnostic labels may be one strategy.
- The diagnostic labels ‘rotator cuff tear’ and ‘subacromial impingement result in a small but significant increased perceived need for surgery and imaging in this clinical trial, despite being accompanied by positive and non-threatening clinical messaging.
- Small between group differences in this trial may become more substantial when applied at a population level.
- Implementing a modification to diagnostic labels for rotator cuff disease is a scalable, simple and no-cost intervention.
- Further research is required to reveal a consensus term for rotator cuff disease that is valid, accurate and doesn’t have a nocebo effect.
What do I think we should call the diagnosis 'subacomial impingement'? I discuss this at length in my online course. Check it out HERE.
- Barreto, R. P. G., Braman, J. P., Ludewig, P. M., Ribeiro, L. P., & Camargo, P. R. (2019). Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow Surg, 28(9), 1699-1706. doi:10.1016/j.jse.2019.04.001
- Cuff, A., & Littlewood, C. (2018). Subacromial impingement syndrome - What does this mean to and for the patient? A qualitative study. Musculoskelet Sci Pract, 33, 24-28. doi:10.1016/j.msksp.2017.10.008
- Lähdeoja, T., Karjalainen, T., Jokihaara, J., Salamh, P., Kavaja, L., Agarwal, A., Winters, M., Buchbinder, R., Guyatt, G., Vandvik, P.O., Ardern, C.L. (2020). Subacromial decompression surgery for adults with shoulder pain: a systematic review with metaanalysis. Br J Sports Med, 54, 665-673. doi:10.1136/bjsports-2018-100486
- Lewis, J. (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther, 23, 57-68. doi:10.1016/j.math.2016.03.009
- Malliaras, P., Rathi, S., Burstein, F., Watt, L., Ridgway, J., King, C., & Warren, N. (2021). 'Physio's not going to repair a torn tendon': patient decision-making related to surgery for rotator cuff related shoulder pain. Disabil Rehabil, 1-8. doi:10.1080/09638288.2021.1879945 Vandvik, P. O., Lahdeoja, T., Ardern, C., Buchbinder, R., Moro, J., Brox, J. I., . . . Poolman, R. W. (2019). Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ, 364, l294. doi:10.1136/bmj.l294
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