Summary

Musculoskeletal impairments of the shoulder are a major problem among the general population and workers in particular. This type of impairment affects the shoulder’s functional status and the quality of life of the individuals involved, and in the case of workers, sometimes leads to problems of absenteeism or losses of productivity. Workers who perform tasks with their arms above shoulder height or repetitive tasks are at higher risk of developing a shoulder impairment, especially an impairment of the rotator cuff (RC). For the 2005‒2007 period, the total costs generated annually by shoulder injuries accepted by the Commission de la santé et de la sécurité du travail (CSST), including the human costs and those associated with losses of productivity, stood at $393,204,738.

Given the magnitude of the problem, an extensive literature review was carried out regarding several aspects of RC impairments. The main objective of the review was to summarize the evidence-based data and make recommendations for diagnostic and clinical evaluation tools, therapeutic interventions, and workplace interventions for workers with an RC impairment. Systematic reviews or meta-analyses of the relevant literature were carried out for each of these themes. A number of stakeholders in the healthcare network contributed to this review, including researchers, collaborators and clinicians.

Based on this literature review, it was possible to asses the diagnostic value of the physical tests performed during clinical examinations of patients. It appears difficult for any single clinical test to be both sensitive and specific. The diagnostic values vary tremendously and do not allow any particular test to be recommended for the purpose of diagnosing RC impairments. In fact, a combination of tests and clinical variables may constitute a good diagnostic tool.

Medical imaging can be used as a complement to a physical examination and would allow for more precise diagnoses (and above all, confirmation) of RC impairments. Ultrasound, magnetic resonance imaging (MRI), and arthrography with magnetic resonance imaging (arthro-MRI) are sensitive and highly specific techniques. They appear to be ideal for confirming RC impairments.

Next, the clinical measurement tools regularly used to evaluate the shoulder’s muscle strength, range of joint motion, and scapular position and movement generally have good measurement properties. However, they must be used in combination with other tools such as self-evaluation questionnaires.

Lastly, self-evaluation questionnaires have excellent measurement properties for the clinical evaluation of patients with RC impairments. The Western Ontario Rotator Cuff (WORC) questionnaire is one of the most sensitive to change. Some of these questionnaires, including the popular Disability of the Arm, Shoulder and Hand (DASH) questionnaire, have a French version and are available free of charge. Mixed tools combining questionnaires and performance tests also appear to be valid for clinical use. However, there is a lack of data on their sensitivity to change.

No treatment algorithm exists to guide professionals in treating RC tendinopathy. However, based on the results of this literature review, some interventions can be recommended for managing tendinopathy or full-thickness tears of the RC.

For RC tendinopathy, taking nonsteroidal anti-inflammatory drugs (NSAIDs) for a short period of time appears useful for alleviating pain. An exercise program has also demonstrated positive outcomes in study populations of adults and workers. Particularly in workers, a therapeutic exercise program can reduce pain, improve shoulder function, and speed up the return to work. Some studies have shown similar efficacy between an exercise program and acromioplasty-type surgery for RC tendinopathy. Conservative treatment is therefore recommended initially for adults with this condition. If it fails, surgery can then be envisaged. A comparison of different types of surgery revealed similar efficacy between arthroscopic and open acromioplasty.

For a full-thickness tear of the RC, repair surgeries performed on the RC have proven effective, whether arthroscopic or open procedures are used. Single-row and double-row suture repair surgeries have yielded similar outcomes. Adding acromioplasty to RC repair does not produce any additional benefits and therefore is not recommended.

The predictive factors for absenteeism and return to work (RTW) were also explored. This literature review confirmed the ambiguity surrounding the factors associated with these two issues. Numerous factors actually emerged from the review, but with no consensus. Based on the determinants explored for joints other than the shoulder, psychosocial or environmental factors as well as the employer’s role appear to be key factors in the success of the RTW.