ORIGINAL ARTICLE

The effects of rotator cuff tears, including shoulders without pain,on activities of daily living in the general population

Daisuke Nakajima • Atsushi Yamamoto • Tsutomu Kobayashi •

Toshihisa Osawa • Hitoshi Shitara • Tsuyoshi Ichinose •

Eiji Takasawa • Kenji Takagishi

Received: 2 August 2011 / Accepted: 9 December 2011 / Published online: 17 January 2012

� The Japanese Orthopaedic Association 2012

Abstract

Background Few reports have so far evaluated the pos-

sible restrictions of activities of daily living (ADL) in

patients with asymptomatic rotator cuff tears (RCTs). The

purpose of this study was to examine the effects of RCTs,

including shoulders without pain, on ADL in the general

population.

Methods We performed medical checkups on 462 indi-

viduals (924 shoulders). All participants completed a

questionnaire regarding their background and medical

history. We then assessed their shoulder functions with the

Simple Shoulder Test (SST) and performed US (US)

examinations of both shoulders to diagnose RCTs. We

divided participants into tear and nontear groups and per-

formed statistical analysis to compare total SST scores and

each SST item between groups. Furthermore, we per-

formed the same examinations for participants identified as

having shoulders without pain.

Results Among participants, those in the tear group

showed significantly lower total SST scores than those in

the nontear group. After examining each SST item, a sig-

nificant difference was observed regarding the ability to

sleep comfortably and to lift 3.6 kg to shoulder level. In

shoulders without pain, the tear group showed significantly

lower total SST scores than the nontear group. A significant

difference was observed only regarding the ability to lift

3.6 kg to shoulder level.

Conclusions In the general population, ADL were

restricted in participants with RCTs; they experienced

night pain in the shoulder and muscle weakness during

shoulder elevation. Furthermore, participants with RCTs,

even if the condition itself did not induce any pain, tended

to experience muscle weakness during shoulder elevation,

thus resulting in restrictions of ADL.

Introduction

A rotator cuff tear (RCT) is one of the most common

disorders affecting the shoulder and cause pain and dys-

function. However, recent studies have found that there are

cases of asymptomatic RCTs in which the patient exhibits

no shoulder symptoms [1–10]. It is evident that patients

with symptomatic RCTs tend to demonstrate restrictions in

activities of daily living (ADL); however, few reports have

so far evaluated the possible restrictions of ADL in patients

with asymptomatic RCTs. We found no published reports

examining what effects RCTs might have on ADL in the

general population.

There are several methods to evaluate the effects of

shoulder joint disorders on ADL. The Simple Shoulder

Test (SST) as proposed by Lippitt et al. [11] is a self-

assessment tool that evaluates 12 common shoulder func-

tions; participants answer by circling ‘‘Yes’’ or ‘‘No’’.

These 12 questions are listed in Table 1. The SST is fre-

quently used to evaluate ADL in cases of shoulder joint

disorders because it is easy to perform but also sensitively

reflects shoulder dysfunction attributed to shoulder joint

D. Nakajima (&) � A. Yamamoto � T. Kobayashi � H. Shitara �T. Ichinose � E. Takasawa � K. Takagishi

Department of Orthopaedic Surgery, Gunma University

Graduate School of Medicine, 3-39-22, Showa-machi,

Maebashi, Gunma 371-8511, Japan

e-mail: di0623sk@orange.plala.or.jp

T. Osawa

Department of Orthopaedic Surgery, National Hospital

Organization Takasaki Hospital, 36, Takamatsu-machi,

Takasaki, Gunma 370-8537, Japan

123

J Orthop Sci (2012) 17:136–140

DOI 10.1007/s00776-011-0186-4

disorders. It does not bias the examiner into a particular

direction, and it has excellent reproducibility [11–21].

The purpose of this study was to examine the effects of

RCTs on ADL in the general population, including shoul-

ders without pain, using the SST.

Materials and methods

This cross-sectional study was approved by the institutional

review board of our institution. A medical checkup, which

was intended to help prevent the occurrence of lifestyle-

related disease and promote early detection of cancer, was

conducted for the residents of a mountain village, where

agriculture, forestry, and tourism remain the most impor-

tant sources of income. Consent was obtained from 544

individuals participating in the study. First, all participants

filled out a questionnaire regarding age, gender, presence

of shoulder pain at the present time, history of shoulder

joint trauma, history of surgery, history of outpatient hos-

pital care, and then the range of motion of active and

passive forward elevation of the shoulder joint was mea-

sured. We then assessed shoulder functions with the SST.

We also conducted ultrasonographic (US) examinations of

both shoulders in order to diagnose RCTs. US examina-

tions were performed with the technique described by

Middleton et al. [22] using LOGIQ e (GE Health Care,

USA) with linear-array probes at 12 MHz. To avoid

interobserver variation, all US examinations were

performed by one experienced shoulder joint surgeon who

was blinded to the other items in the evaluation. In

accordance with the report by Takagishi et al. [23], dis-

continuity and thinning of the rotator cuff were considered

to be indications of full-thickness RCTs. Any suspected

cases of partial-thickness RCTs were considered to be

nontears. According to the US findings prior to surgery on

58 shoulders, which were performed by the shoulder joint

surgeon who conducted the US examinations in this study,

in cases that underwent arthroscopic rotator cuff repair in

our institute from January 2010 to August 2011 after being

diagnosed with RCTs, outcomes of 91.8% sensitivity,

77.8% specificity, 95.7% positive predictive value, 63.6%

negative predictive value, and 89.7% accuracy were

obtained (unpublished data).

Participants were selected based on the following

criteria:

1. All target evaluation items could be obtained;

2. individuals with both an active and/or passive forward

elevation C100�, with the purpose here being to exclude

any cases of shoulder joint contracture, such as frozen

shoulders, with the limit angle selected based on reports

by Bunker et al. [24] and Zuckerman et al. [25];

3. No history of trauma and surgery to the shoulder

joints;

4. No treatment on the shoulders at the time of this

survey.

Based on these inclusion criteria, 52 patients lacking all

evaluation items, five observed with a limited range of

motion, 11 with a history of trauma and surgery to the

shoulder joints, and 14 undergoing treatment for shoulder

pain during the investigation were excluded. With regard to

the five patients in whom a limited range of motion was

observed, no RCT was observed on US examinations, so

they were not considered to be cases demonstrating a

secondary contracture accompanying an RCT. Moreover,

there were two patients with an active forward elevation of

B100� and a passive forward elevation of C100�, and an

RCT was observed in both patients based on US examin-

ations. These 2 cases were diagnosed as pseudoparalysis

accompanied by an RCT and were thus included in this

study because they had normal elbow flexion strength and

demonstrated no neurological abnormalities due to a sus-

picion of either cervical spine disease or a central nervous

system disorder. Therefore, the study comprised 462 par-

ticipants with 924 shoulders; 171 were men and 291 were

women, with a mean age of 61.3 (28–87) years.

As a statistical analysis, we first divided all participants

into a tear and a nontear group, depending on the existence

of an RCT, and conducted a comparative examination

using the Mann–Whitney U test to ascertain that a differ-

ence existed between the two groups in the total SST score.

Table 1 Simple Shoulder Test

1. Is your shoulder comfortable with your arm at rest by your side?

2. Does your shoulder allow you to sleep comfortably?

3. Can you reach the small of your back to tuck in your shirt with

your hand?

4. Can you place your hand behind your head with the elbow

straight out to the side?

5. Can you place a coin on a shelf at the level of your shoulder

without bending your elbow?

6. Can you lift 1 pound (0.5 kg) to the level of your shoulder

without bending your elbow?

7. Can you lift 8 pounds (3.6 kg) to the level of your shoulder

without bending your elbow?

8. Can you carry 20 pounds (9.1 kg) at your side with the affected

extremity?

9. Do you think you can toss a softball underhand 10 yards (9.1 m)

with the affected extremity?

10. Do you think you can toss a softball overhand 20 yards

(18.3 m) with the affected extremity?

11. Can you wash the back of your opposite shoulder with the

affected extremity?

12. Would your shoulder allow you to work full time at your

regular job?

The effects of RCTs on the ADL 137

123

In addition, to examine factors that determined the two

groups with respect to each SST item, we performed a

logistic regression analysis using the existence of a tear as

an objective variable and each SST item as an explanatory

variable. It is known that the prevalence of RCTs increases

with age [3, 4, 6, 7, 9, 10, 12]; therefore, age was used as a

regulator in the examination, and the effect of age on ADL

was excluded.

Next, the participants who had no present pain in the

shoulder joint, including pain on motion according to the

questionnaire findings, and who also answered ‘‘Yes’’ to

both SST items of question 1: ‘‘Is your shoulder comfort-

able at rest?,’’ which evaluates the presence of pain at rest;

and question 2: ‘‘Does your shoulder allow you to sleep

comfortably?,’’ which evaluates the presence of pain at

night, were thus defined as having ‘‘shoulders without

pain.’’ These participants were then examined in the pre-

viously described manner with respect to the total SST

score and each item. Statistical analysis was carried out

using the IBM SPSS Statistics 19 (IBM Japan, Ltd., Tokyo,

Japan), and the critical values for significance were set at

\5%.

Results

Examination of all participants

Of the 924 shoulders, 99 belonged to the tear group [mean

age 70.5 (46–87) years] and 825 to the nontear group

[mean age 60.2 (28–86) years]. Total SST score was 10.6

(3–12) in the tear group and 11.3 (5–12) in the nontear

group, with the total SST score in the tear group being

significantly lower (P \ 0.001) (Fig. 1). Upon examination

of each SST item, there was a significant difference with

respect to two items: question 2 ‘‘ability to sleep com-

fortably’’ [odds ratio (OR) 0.41, 95% confidence interval

(CI) 0.19–0.88, P = 0.022], and question 7 ‘‘lift 3.6 kg to

shoulder level’’ (OR 4.21, 95% CI 2.25–7.88, P \ 0.001).

Examination of shoulders without pain

A total of 708 shoulders had no pain, 57 of which belonged

to the tear group [mean age 71.1 (56–87) years] and 651 to

the nontear group [mean age 60.5 (28–86) years]. The total

score for SST questions 3 through 12 (maximum score 10

points) was 9.0 (3–10) in the tear group and 9.5 (5–10) in

the nontear group, with the total SST score in the tear

group being significantly lower (P \ 0.001) (Fig. 2). There

was a significant difference among the questions only in

respect to question 7, ‘‘lift 3.6 kg to shoulder level’’ (OR

4.60, 95% CI 1.91–11.09, P = 0.001).

Discussion

Several published reports have evaluated the SST score for

ADL in patients with RCTs. Lippitt et al. [11] studied 50

shoulders with RCTs and reported that the patients had an

impaired ability to sleep comfortably, lift 3.6 kg to shoul-

der level, and throw a ball 18.3 m overhand. Duckworth

et al. [26] studied 123 shoulders with full-thickness RCTs

and reported that the total SST score was 5 points on

average and that many restrictions were found with respect

to the ability to sleep comfortably, lift 3.6 kg to shoulder

level, throw a ball 18.3 m overhand, wash the back of the

opposite shoulder, and do regular work. Harryman et al.

[27] studied 333 shoulders with full-thickness RCTs and

reported that the total SST score was 4.4 points and that

many restrictions were found in respect to the ability to

sleep comfortably, lift 3.6 kg to shoulder level, and throw a

ball 18.3 m overhand. The results of these studies agreed

on the fact that RCTs restrict ADL. However, all of these

studies examined symptomatic RCTs and did not evaluate

RCTs in their entirety, including asymptomatic RCTs.

Fig. 1 Comparison of Simple Shoulder Test (SST) total scores

between all shoulders. SST score was significantly lower in the tear

group (*P \ 0.001)

Fig. 2 Comparison of Simple Shoulder Test (SST) total scores

between shoulders without pain. SST score was significantly lower in

the tear group (*P \ 0.001)

138 D. Nakajima et al.

123

A few previous reports studied the effects of asymp-

tomatic RCTs on ADL. Schibany et al. [5] studied 212

asymptomatic shoulders and reported that, although full-

thickness RCTs were detected in 6% of the shoulders by

US, there was no difference between the tear and nontear

groups with respect to ADL evaluation. However, that

study limited its participants to volunteers who had no

shoulder symptoms, and the method of ADL evaluation

was measured only by the constant subscores. Therefore,

no detailed evaluation of ADL limitations that includes all

RCTs has yet been published. Keener et al. [15] studied

196 participants with asymptomatic RCTs and 54 with an

intact rotator cuff presenting with a painful RCT in the

contralateral shoulder. The authors stated that participants

with an intact rotator cuff had greater but clinically insig-

nificant SST scores than those with an asymptomatic tear.

However, it was not a population-based study intended for

the general population, and therefore the individual SST

items were not considered in detail. In our study, we

considered each SST item in the investigated group of

participants to be representative of the general population.

The results of the overall examination confirmed ADL to

be restricted in participants with RCTs; specifically, par-

ticipants were prone to suffer night pain in the shoulder

joint and muscle weakness during shoulder elevation. In

addition, in the examination of shoulders without pain,

detailed evaluations by SST confirmed that when there was

a RCT, ADLs were restricted; specifically, participants

were prone to suffer muscle weakness when engaging in

shoulder elevation motions. These are the first-ever results

from an inclusive study on RCTs in the general population

to identify how RCTs affect ADL, regardless of whether or

not participants exhibit any symptoms. Tashjian et al. [21],

however, reported that patients with rotator cuff disease

who are treated without surgery and had a 2-point change

in the SST score experienced a clinically important change

in self-assessed outcome. In our study, we found ADL to be

restricted by evaluating each SST item, but further studies

will be required to confirm whether any clinically impor-

tant difference actually exists when evaluating participants

by the total SST score.

Regarding the relationship between asymptomatic RCT

and muscular strength, Moosmayer et al. [4] studied 420

shoulders of asymptomatic volunteers aged between 50 and

79 years and reported that the strength of flexion signifi-

cantly decreased in the group with RCTs. Kim et al. [1]

also studied 237 asymptomatic shoulders and reported the

abduction strength to significantly decrease in shoulders

with a large to massive full-thickness RCT. The ADL

restriction identified in our study with respect to shoulders

without pain was the inability to lift 3.6 kg to shoulder

level. It is believed that this restriction can be attributed to

muscle weakness during shoulder elevation motions, and as

a consequence, no inconsistency is considered to exist

between these reports and our study.

Our study has several limitations. The first is that this

study was not conducted with an examination of tear size,

and we did not determine which tendons were involved.

Yamaguchi et al. [9] noted that RCT size appeared to be an

important factor in symptom development. As mentioned

previously, Kim et al. [1] reported that abduction strength

significantly decreased in shoulders with a large to massive

full-thickness RCT. Harryman et al. [27] also demonstrated

that patients who had an infraspinatus as well as a supra-

spinatus tendon tear tended to have a significantly wors-

ened ability to use the arm overhead compared with those

who had only a supraspinatus tear. It is therefore possible

that ADL restrictions may differ depending on the size and

extent of the tear. Second, ADL evaluation was done only

by SST in this study. Some other evaluation methods on

ADL in cases of shoulder joint disorder have been reported.

In this study, evaluation was done by the STT in view of

the fact that it allows evaluation of ADL in a larger number

of participants within limited time constraints. The third

point concerns the diagnosis of partial-thickness RCTs

using US, the diagnostic criteria for which remain con-

troversial. Therefore, in this study, partial-thickness RCTs

were considered to be nontears. Fourth, with regard to the

selection criteria, we excluded any participants who had

restrictions in both active and passive forward elevation so

as to exclude patients with other potential causes of

shoulder pain, such as osteoarthritis. However, no other

type of diagnostic imaging was conducted other than US,

and thus we could not exclude such patients completely.

Fifth, this was a cross-sectional study, and a longitudinal

examination was not conducted. Yamaguchi et al. reported

that about 50% of asymptomatic shoulders with RCTs

became symptomatic within an average of 2.8 years [8].

Mall et al. [2] also reported that larger tears are more likely

to develop pain in the short term than are smaller tears, so it

is possible that observations over time may reveal changes

in the degree of ADL restriction.

Until now, the purpose of conservative treatment for

RCTs was to maintain a painless condition even in the

presence of a tear. However, results of this study demon-

strate that RCTs cause restriction in ADL, even if the

condition itself does not induce pain. In the case of RCTs

without pain, the individual might not visit a medical

institution, thinking that the restriction in ADL is merely

the result of the normal aging process. We therefore con-

sider that it is necessary to explain to such individuals the

possibility that their RCTs, which cause no pain, may

nevertheless eventually result in restriction in ADL. In

addition, specialists who treat RCTs should be mindful of

this phenomenon and try to provide optimal treatment to

improve the quality of life for such patients.

The effects of RCTs on the ADL 139

123

In conclusion, we evaluated the effects on ADL caused

by RCTs using the SST in a general population. Total SST

score was significantly lower when participants had RCTs,

which thus led to the onset of various types of dysfunc-

tions: ‘‘sleep disturbances due to shoulder pain’’ and an

‘‘inability to lift 3.6 kg to shoulder level.’’ Total SST score

was also significantly lower in shoulders without pain when

there was an RCT, thus leading to the occurrence of a

dysfunction; namely, an ‘‘inability to lift 3.6 kg to shoulder

level.’’

Conflict of interest The authors did not receive and will not receive

any benefits or funding from any commercial party related directly or

indirectly to the subject of this article.

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