Epidemiology of Shoulder Pain

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Rachael Lowe and Fasuba Ayobami  

Introduction

Shoulder pain is a common musculoskeletal condition that is is recognised as a disabling problem and can be associated with substantial economic burden. The pain and disability associated with shoulder pain can have a large impact on individuals and their families, communities, and healthcare systems affecting daily functioning, and ability to work. It is the third most common musculoskeletal complaint presenting to physiotherapy. [1][2]

The definition of shoulder pain is not so clear cut and in epidemiological studies defining shoulder pain symptoms presents a number of difficulties secondary to the complex interrelations between the shoulder and adjacent areas and the frequent occurrence of referred pain which make clinical case definition problematic. The aetiology of shoulder pain is diverse and includes pathology originating locally from the shoulder such as the glenohumeral joint, acromioclavicular joint, sternoclavicular joint, rotator cuff, and other soft tissues within the shoulder complex but can also be referred from other structures, such as the neck, or other visceral organs. [3][4][5] The extent of tissue damage observed on clinical imaging does not correlate with shoulder pain intensity, thus the relevance of diagnosing structural pathology in people with shoulder pain has been challenged by many in research and clinical practice.[6][2][7] Similarily it has been shown that in the general population anywhere from 20 - 40% of individuals have asymptomatic rotator cuff tears, which suggests that structural pathology may not fully explain the perception of shoulder pain and highlights the potential for diagnostic labels to mislead treatment.In practice, therefore, ‘shoulder pain’ has been applied as an all encompassing term in many of the epidemiological studies available.[8][9][10]

Here we will review some findings from the literature with regards to the incidence and prevalence of shoulder pain in the general population, age distribution, occupational and psychosocial risk factors associated with the onset of shoulder-related pain symptoms. [5]

Incidence

Incidence figures ranged from 0.9-2.5% with average incidence of 29.3 per 1000 person-years over a period of 9 years, with specific incidences of [11];

  • 32.2 for women
  • 26.2 for men

Mean incidence per 1000 person-years over a period of 9 years [11];

  • 22.2 in 18- 44 year olds
  • 40.2 in 45 - 64 year olds
  • 37.1 in 65+ year olds

Incidence of Specific Conditions;

  • Rotator Cuff Tendinopathy incidence ranges from 0.3%to5.5%
  • Traumatic dislocation of the Glenohumeral Joint is the most common joint dislocation with an incidence of 8.2 to 23.9 per 100,000 per year [12]

Prevalence

There is  substantial variances in the estimated prevalence of shoulder pain, ranging anywhere from 1% up to 66% [3] [13].  This can in part be as a result of the complex structure of the shoulder and close functional biomechanical association with adjacent areas, including the spine. Some further causes of variability in reporting relate to that fact that the shoulder may be a primary or secondary source of pain, so many authors and clinicians tend to summarise such a presentation simply as shoulder pain syndrome.[3] [4]

As a point of reference, epidemiological studies have reported: [5][13]

Prevalence related to Specific Conditions:

  • Primary Adhesive Capsuitis reported prevalence from 2 % to 5.3 %, mainly affecting women, with sedentary jobs, non-dominant shoulder, over 40 years old [14][15]
  • Secondary Adhesive Capsulitis related to Diabetes Mellitus and Thyroid Disease reported prevalence from 4.3% and 38% [15]
  • Rotator Cuff Related Abnormalities reported prevalence ranged from 9.7% - 62% [16]

Prevalence is generally higher in women (15% - 26%) than in men (13 - 18%), with a greater number of women presenting to Primary Care. [5] 

Prevalence increased linearly with age while incidence peaked at around 50 years then remained static at around 2%. Most prevalent in middle age (45 - 64 years, from 21 - 55%), which may be attributed to the normal aging process of shoulder structures including the rotator cuff but is also common in the younger age group (adolescents aged 12 - 18 years, from 12 - 57%), which can be attributed to a postural relationship associated with increased periods of sitting, and increased technology use. [5] 

Shoulder was the second most commonly affected site for musculoskeletal pain behind low back pain in the Netherlands. Some other interesting findings from that study include that 30% described continuous pain, while 55% had recurrent pain with mild pain more common (70%) than severe pain (15%). [17] While Koojman et al suggest that shoulder pain is the third most common musculoskeletal complaint presenting to physiotherapy [18], representing 14% of annual referrals to physiotherapy outpatient services in the UK.[19]

Risk Factors

Risk factors for shoulder pain share many similarities with other musculoskeletal conditions such as genetics[20], hormonal influences[21], lifestyle factors such as smoking[22], alcohol consumption[23], comorbidities, level of education[24] and sedentary lifestyle [5], sleep disorders [5][13], biochemical, patho-anatomical, peripheral and central sensitisation and sensory-motor cortex changes [25] and a raft of psychosocial factors such as depression, anxiety, poor coping skills, somatisation [26]. In particular excessive and mal-adaptive load imposed on the tissues appears to be a major influence in certain disorders of the shoulder such as Rotator Cuff Related Shoulder Pain [27][28].

Work-related risk factors associated with the onset of shoulder pain cited in the literature include repetitive work in particular overhead activities or working above should, high force demand and vibration, work-related posture, computer work and psychosocial factors including stress, job pressure, social support and job satisfaction.[4][5][13]

When we look at specific shoulder conditions rotator cuff disorders are associated with excessive overloading, instability of the glenohumeral and acromioclavicular joints, muscle imbalance, adverse anatomical features, age related rotator cuff degeneration, ischaemia, and musculoskeletal diseases that result in rotator cuff atrophy. [29][30][31][32] Adhesive Capsulitis risk factors include being female, older age, history of shoulder trauma, surgery, diabetes, cardiorespiratory disorders, cerebrovascular events, thyroid disease, and hemiplegia.[5][33][34][35]

Prognosis

Approximately 50% of new episodes of shoulder pain resolve in eight to twelve weeks, but as many as 40% of cases persist for longer than one year with rates of recurrence and chronicity of shoulder pain rated as moderate to high. [13] Many people with shoulder pain do not experience a complete resolution of symptoms, and between 40% to 50% of those who experience shoulder pain report recurrence within 1 to 5 years later. While up to 13.6% were still attending medical services with a shoulder problem during the third year of follow-up. In a 2003 study of Danish workers with shoulder tendinopathy, average symptom duration was 10 months or less, with 25% of workers continuing to experience symptoms at 22 months. [36]

Poor prognosis is associated with increasing age, female sex, severe or recurrent symptoms at presentation and associated neck pain. In particular high baseline pain and previous episodes of shoulder pain are associated with an unfavourable outcome.[5][37] A favourable prognosis is associated with mild trauma or overuse before onset of pain, early presentation and acute onset.[4][8][36]

Research shows that associations between prognostic factors and outcome are often inconsistent, which may be due to type II error or heterogeneity on a number of levels including treatment selection, adherence or outcome measure. Only two baseline prognostic factors consistently demonstrated anassociation with outcome in two or more studies; duration of shoulder pain and baseline function. [38]

Economic Burden

The economic burden due to disorders of the shoulder is high, and includes costs of treatment, and lost wages. One study in the UK reported approximately 1% of adults in the UK consult their medical practitioner with estimated costs of £310 million in the first 6 months, additional surgical costs for procedures were estimated at approximately £30 million/year, with up yo 50% of these costs related to sick leave from paid employment.[39]

Relevance to Physiotherapy

Although some acute episodes of shoulder pain resolve spontaneously, as many as 50% of all new episodes of shoulder pain still continue to show symptoms or recurrences at 6 months.with as many as 40% still with symptoms at 1 year.[5][40][41][42] For managing shoulder pain the strongest evidence currently is for exercise. Physiotherapists have a detailed understanding of the shoulder complex, related pain mechanisms and exercise prescription which makes them well placed to be the experts to help individuals with shoulder pain return to normal function, therefore reducing burden of shoulder pain.[15][36][41]

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