Epidemiology of Shoulder Pain

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Introduction[edit | edit source]

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[edit | edit source]

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[edit | edit source]

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]

Rates of recurrence and chronicity of shoulder pain are moderate. Many people with shoulder pain do not experience a complete resolution of symptoms, with between 40% and 50% of those who experience shoulder pain reporting 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.

Risk Factors[edit | edit source]

Risk factors for shoulder pain share many similarities with other musculoskeletal conditions such as genetics, psycho-social pathology (eg, depression, anxiety, poor coping skills, somatisation), sleep disorders, smoking, and sedentary lifestyle.[5][13] genetics (Harvie et al. , 2004), hormonal influences (Magnusson et al. , 2007), lifestyle factors such as smoking (Baumgarten et al. , 2010) alcohol consumption (Passaretti et al. , 2015), comorbidities and level of education (Dunn et al. , 2014), biochemical, patho-anatomical, peripheral and central sensitisation, sensory-motor cortex changes (Lewis et al. , 2015a) and a raft of psychosocial factors (Dean and Söderlund, 2015) have the potential to contribute to RCRSP, excessive and mal-adaptive load imposed on the tissues appears to be a major influence (Cook et al. , 2015, McCreesh and Lewis, 2013).

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]

Economic Burden[edit | edit source]

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.[20]

Relevance to Physiotherapy[edit | edit source]

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][21][22][23] 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.

References[edit | edit source]

  1. ↑ Kooijman MK, Swinkels ICS, Leemrijse CJ, de Bakker DH, Veenhof C. National Information Service of Allied Health Care. 2011.
  2. ↑ 2.0 2.1 Barrett E. Examining the Role of Thoracic Kyphosis in Shoulder Pain [Phd Thesis]. Limerick: University of Limerick. 2016.
  3. ↑ 3.0 3.1 3.2 Pope DP, Croft PR, Pritchard CM, Silman AJ. Prevalence of Shoulder Pain in the Community: The Influence of Case Definition. Annals of the Rheumatic Diseases. 1997 May 1;56(5):308-12.
  4. ↑ 4.0 4.1 4.2 Murphy RJ, Carr AJ. Shoulder Pain. BMJ clinical evidence. 2010;2010.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Pribicevic M. The Epidemiology of Shoulder Pain: A Narrative Review of the Literature. InPain in Perspective 2012. InTech.
  6. ↑ Miniaci A, Mascia AT, Salonen DC, Becker EJ. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. American Journal of Sports Medicine 2002; 30(1): 66-73.
  7. ↑ Connor PM, Banks DM, Tyson AB, Coumas JS, D’Alessandro DF. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. American Journal of Sports Medicine 2003; 31(5): 724-727.
  8. ↑ Templehof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. Journal of Shoulder and Elbow Surgery 1999; 8: 296-299.
  9. ↑ Worland R, Lee D, Orozco C, Sozarex F, Keenan J. Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. Journal of the Southern Orthopaedic Association 2003; 12(1): 23-26.
  10. ↑ Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, Kobayashi T. Prevalence and risk factors of a rotator cuff tear in the general population. Journal of Shoulder and Elbow Surgery 2010; 19(1): 116-120.
  11. ↑ 11.0 11.1 Greving K, Dorrestijn O, Winters JC, Groenhof F, Van der Meer K, Stevens M, Diercks RL. Incidence, prevalence, and consultation rates of shoulder complaints in general practice. Scandinavian journal of rheumatology. 2012 Mar 1;41(2):150-5.
  12. ↑ Brownson, P., Donaldson, O., Fox, M., Rees, J. L., Rangan, A., Jaggi, A., et al. (2015). BESS/BOA Patient Care Pathways. Shoulder & Elbow, 7(3), 214–226. http://doi.org/10.1177/1758573215585656
  13. ↑ 13.0 13.1 13.2 13.3 Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, Verhaar JA. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scandinavian journal of rheumatology. 2004 Mar 1;33(2):73-81.
  14. ↑ Struyf, F., & Meeus, M. (2013). Current evidence on physical therapy in patients with adhesive capsulitis: what are we missing? Clinical Rheumatology, 33(5), 593–600. http://doi.org/10.1007/s10067-013-2464-3
  15. ↑ 15.0 15.1 Kelley, M. J., Shaffer, M. A., Kuhn, J. E., Michener, L. A., Seitz, A. L., Uhl, T. L., et al. (2013). Shoulder Pain and Mobility Deficits: Adhesive Capsulitis. Journal of Orthopaedic & Sports Physical Therapy, 43(5), A1–A31. http://doi.org/10.2519/jospt.2013.0302
  16. ↑ MD, T. T., BSc, B. L., BSc, B. T. R., & PhD, D. R. M. (2014). A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. Journal of Shoulder and Elbow Surgery, 23(12), 1913–1921. http://doi.org/10.1016/j.jse.2014.08.001
  17. ↑ Picavet HS, Schouten JS.Musculoskeletal Pain in the Netherlands: Prevalence’s, Consequences and Risk Groups, the DMC(3)-Study. Pain 2003167178
  18. ↑ Kooijman MK, Swinkels ICS, Leemrijse CJ, de Bakker DH, Veenhof C. National Information Service of Allied Health Care. 2011.
  19. ↑ May S. An Outcome Audit for Musculoskeletal Patients in Primary Care. Physiotherapy Theory and Practice 2003; 19: 189-198.
  20. ↑ Littlewood, C. (2013). Contractile dysfunction of the shoulder (rotator cuff tendinopathy): an overview. Journal of Manual & Manipulative Therapy, 20(4), 209–213. http://doi.org/10.1179/2042618612Y.0000000005
  21. ↑ Winters JC, Sobel JS, Groenier KH, Arendzen JH, Meyboom de Jong B. The long-term course of shoulder complaints: a prospective study in general practice. Rheumatology 1999; 38: 160-163.
  22. ↑ van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics and management. Annals of Rheumatic Diseases 1995; 54(12): 959-964.
  23. ↑ Croft P, Pope D, Silman A. The clinical course of shoulder pain: case series in primary care. British Medical Journal 1996; 313: 601-612.
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