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Shoulder disorders in the elderlyA community survey.

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BRIEF REPORT
SHOULDER DISORDERS IN THE ELDERLY: A COMMUNITY SURVEY
M. D. CHARD, R. HAZLEMAN, B. L. HAZLEMAN, R. H. KING, and B. B, REISS
A community survey of identifiable symptomatic
shoulder disorders in a sample of 644 elderly people over
age 70 (318 male and 326 female) revealed a prevalence
of 21%. Shoulder disorders were more common in
women (25%, versus 17% in men). Approximately 70%
of the cases of shoulder pain involved the rotator cuff.
Fewer than 40% of the subjects sought medical attention
for these symptoms. Increased medical awareness is
needed, since the elderly often do not volunteer information about such symptoms.
Hospital-based studies have suggested that
nontraumatic symptomatic shoulder disorders, although common in middle-aged adults, are relatively
rare in the elderly (1-3). One community survey found
a less marked difference in prevalence, but the maximum age of the study subjects was only 74 years (4).
These findings contrast with those of pathologic studies, which have suggested that there is progressive
degeneration of the rotator cuff with age (5-7), with
tendon rupture being found in 20% or more of shoulders from patients of all ages, examined postmortem
(8-10). One study suggested that there was no true
From the Rheumatology Research Unit, Addenbrooke’s
Hospital, and East Barnwell Health Centre, Cambridge, United
Kingdom.
M. D. Chard, MB, MRCP: Senior Registrar in Rheumatology, Addenbrooke’s Hospital; R. Hazleman, RGN: Research
Nurse, Addenbrooke’s Hospital; B. L. Hazleman, MA, MB, FRCP:
Consultant Rheumatologist, Addenbrooke’s Hospital; R. H. King,
MB, MRCP, MRCGP, East Barnwell Health Centre; B. B. Reiss,
OBE, MRCP, FRCGP: East Barnwell Health Centre.
Address reprint requests to B. L. Hazleman, MA, MB,
FKCP, Rheumatology Research Unit, Addenbrooke’s HospitalUnit E6, Hills Road, Cambridge, CB5 8SP, UK.
Submitted for publication June 4, 1990; accepted in revised
form December 3 1, 1990.
Arthritis and Rheumatism, Vol. 34, No. 6 (June 1991)
relationship between clinical symptoms and pathologic
changes (1 I).
It was considered that physically fit middleaged people were more likely than the elderly to stress
their tendons and, hence, produce symptoms. However, a recent hospital study of elderly patients (over
age 70) who were admitted to an acute-care geriatric
unit found that 21 of the 100 surveyed had a symptomatic shoulder disorder, mostly related to the rotator
cuff (12). Not only was the frequency greater than
might have been expected, but only 3 of these subjects
had sought medical treatment for those symptoms. It
could be argued that although these patients had been
admitted for acute conditions, the patients might, as a
group, be physically more infirm than elderly persons
living in the community. Therefore, they might have
been more predisposed to the development of shoulder
disease. To try to discover the true prevalence of
symptomatic shoulder disorders in the elderly population, a community-based prevalence study was undertaken.
Patients and methods. It was decided to assess a
similar number of males and females in order to be
able to compare the findings with those in other
populations of different sex ratios. In our hospital
study, 26% of females and 16% of males were affected
(12). Based on an expectation of some reduction in
frequency among people in the community, it was
estimated that at least 600 persons (300 males and 300
females) would need to be surveyed to produce statistically meaningful epidemiologic prevalence data.
A random sample of male and female patients
aged 70 years and over was derived from age and sex
registry lists from 2 general medicine group practices.
The patients were predominantly Caucasian, from
BRIEF REPORTS
middle- and working-class backgrounds (socioeconomic classes 111-V). Persons who were too physically
or mentally infirm to successfully participate were
excluded from study. The study sample was made up
of 644 persons (318 male and 326 female subjects) who
had been successfully contacted and screened.
A structured screening interview was administered by one of us (RH), a research nurse, when the
patient was either at a medical visit or, more commonly, at home. The interview sought to elicit current
shoulder pain and disability and any treatments that
had been prescribed by the physician or undertaken on
the patient's own initiative. Persons found to have
shoulder symptoms were subsequently examined by
one of us (MDC), a rheumatologist. A general physical
examination, with careful examination of the neck and
shoulder, was performed,
Shoulder examination included documentation
of muscle wasting, weakness, deformity, or tenderness, and the presence of a painful arc of motion and
pain on resisted abduction, external rotation, and
internal rotation. Active and passive shoulder movements were measured with a pendulum goniometer (13).
Rotator cuff tendinitis was diagnosed according
to the criteria of Cyriax (14), i.e., shoulder pain
exacerbated by movement against resistance in 1 or
more of the following motions: abduction, external
rotation, o r internal rotation. Although active range of
motion of the shoulder was normally limited by pain,
passive range of motion remained approximately normal. A diagnosis of frozen shoulder was made if there
was marked restriction of all active and passive movements, with external rotation reduced by at least 50%
of normal in the absence of bony restriction.
Chronic rotator cuff rupture was diagnosed if
there was marked difficulty initiating abduction, with
weakness and limitation of movement. Pain was usually experienced toward the end of the active range of
movement. Rotator cuff impingement alone was considered to be present when there was a painful arc on
abduction above So", often with the inability to overcome it, and some limitation of passive as well as
active abduction but without features of the other
shoulder conditions described above.
Acromioclavicular joint arthritis was diagnosed
in the presence of localized pain and tenderness in the
region of the acromioclavicularjoint, with a high arc of
pain on abduction and with localized pain on jointstressing maneuver (3).
Involvement of the glenohumeral joint was recorded as due to rheumatoid arthritis or glenohumeral
767
50
-
40
30
m
O
20
s1
0
4
10
0
mlalor CuH
lenms
w"
,uplure
ACJ
OA
rolalor cull
mpln~emem
w\
on
frozen
Milwaukee
Shouldor
Should01
Condition
Figure 1. The relative frequency of specific shoulder disorders in a
random sample of elderly patients over age 70 (see Patients and
Methods for details). ACJ = acrornioclavicular joint; OA = osteoarthritis; RA = rheumatoid arthritis.
osteoarthritis. In addition, Milwaukee shoulder syndrome (apatite-related shoulder arthropathy) was diagnosed when there was a large, cool, shoulder effusion and combined features of rotator cuff rupture and
glenohumeral arthritis (15). Shoulder pain that did not
result from identifiable shoulder pathology or shoulder
pain that represented referred pain was diagnosed
accordingly.
Results. A positive report of current shoulder
pain was found in 170 subjects (26%). An identifiable
shoulder disorder was present in 136 members of the
study population (21%). This included 55 males (17%
of all male study subjects; age range 70-88 years) and
81 females (25% of all female study subjects; age range
70-92 years).
Of the 34 other subjects with current shoulder
pain (5% of the study population), 12 had referred pain
from cervical spondylosis. Six patients refused to be
examined. One subject died suddenly prior to the
scheduled examination, and 1 subject moved away.
The other patients had miscellaneous conditions that
resulted in pain around the shoulder. In 2, there had
been a previous humeral shaft fracture with trauma to
surrounding tissues in the upper arm. Two subjects
had soft tissue scarring: 1 from implantation of a
cardiac pacemaker and the other from mastectomy.
The remaining 10 subjects had ill-defined postural and
periscapular shoulder girdle pain.
The relative frequency of the shoulder disorders found in the study group is shown in Figure 1. At
least 70% of the shoulder disorders primarily involved
the rotator cuff. Twenty-three patients had more than
one shoulder condition, either bilateral tendinitis or
tendinitis with impingement or with frank signs of
rupture in the other shoulder. The duration of current
BRIEF REPORTS
768
shoulder pain varied from 1 month to many years, with
the longest history in those whose rotator cuff had
ruptured. The mean duration of pain, according to the
major diagnostic groups, was rotator cuff tendinitis 19
months (range 1-84 months), acromioclavicular joint
arthritis 43 months (range 2-120 months), rotator cuff
impingement 47 months (range 1-120 months), and
rotator cuff rupture 50 months (range 1-120 months).
Those with rheumatoid arthritis had a mean duration
of pain of 33 months (range 12-60 months).
The level of pain experienced during shoulder
movement was mild in 52 subjects, moderate in 54,
and severe in 30. Pain at night was a problem in 93
patients, and pain at rest occurred in 65. Disability
experienced by the patients due to the shoulder condition included washing and personal care in 83,
household chores in 73, and difficulty with lifting and
doing tasks above shoulder height in 108.
There were no other features of the medical
history or general state of health that distinguished
those with shoulder pain from the rest of the study
population. Thirty-seven percent of those with shoulder disorders used a device to help with walking,
compared with 20% of the rest of the study group.
Except for the patients with rotator cuff tendinitis, all patients with shoulder pain had restricted
shoulder movements on the affected side or restricted
range of motion in those affected bilaterally. Subjects
with rotator cuff rupture, frozen shoulder, and glenohumeral arthritis were affected the most; for example,
the range of abduction was 10-90", depending on the
severity of the condition. In 1 of the 4 patients with a
frozen shoulder, the condition was related to a previous stroke, with stiffness persisting despite mild residual weakness in the limb and a relatively mild increase
in muscle tone.
In all patients whose shoulder pain was caused
by rheumatoid arthritis, the condition had been properly diagnosed, although 1 subject thought his shoulder problem had not been assessed specifically, independently of the known rheumatoid arthritis. Only
35% of the remaining patients had told their primary
care physician about their shoulder pain (Figure 2).
Only 40% of these patients reported having been given
any treatment for the pain, either analgesics, nonsteroidal antiinflammatory drugs, or pain-relieving exercises.
Discussion. Symptomatic shoulder disorders
were common in subjects of this community survey,
occurring in 1 in 5 of this group of elderly persons.
This prevalence rate is similar to that found in our
50
-
40
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a
c,
30
c
0
k
20
0
5
=
10
0
rotator cun
rotator cun
tenams
rupture
ACJ
OA
~9
lmplngcment
pitrnav
OA
tmen
Shoulder
M,hYaukee
Shouldel
Condition
Figure 2. Number of elderly persons with shoulder pain who presented for medical assessment, grouped according to shoulder
disorder. See Figure 1 for explanations of abbreviations.
previous hospital study (12). In the present study, a
greater percentage of those with shoulder pain had
consulted their general practitioner about it (-40%)
than did those in the hospital study (14%). However,
more than 50% of those with shoulder pain had previously undocumented shoulder lesions.
Since this survey was conducted in the community, all diagnoses were based on clinical features.
Without supportive investigations, particularly radiography and arthrography, it is not possible to be
absolutely certain of the underlying pathology. In
particular, some patients with tendinitis or impingement due to degeneration may have had a small
rupture of the rotator cuff, but this is difficult to
diagnose clinically. This does not, however, detract
from the high level of disability recorded.
The potential disability and unmet need caused
by shoulder disorders in elderly persons living within
the community would appear to be considerable. The
institution of new contractural responsibilities of primary care physicians in the United Kingdom for the
monitoring and care of the elderly in the community
(16) increases the importance of conducting surveys
such as this, to improve awareness of the impact of
musculoskeletal disorders in the elderly.
Detailed assessment of the extent of disability
caused by shoulder disorders in the elderly is needed,
as is investigation of the effectiveness of treatment
modalities, such as local injections of corticosteroids.
Such studies are currently being conducted.
Acknowledgments. We acknowledge the assistance of
our primary care physician colleagues at the East Barnwell
and 125 Newmarket Road Health Centres in Cambridge for
allowing the assessment of patients under their care, and Dr.
Alan Silman, Director of the Arthritis and Rheumatism
Council Epidemiology Research Unit, University of
BRIEF REPORTS
Manchester Medical School. for invaluable advice concerning epidemiologic issues
REFERENCES
1. Hazleman BL: The painful stiff shoulder. Rheumatol
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2. Wright V , Haq AMMM: Periarthritis of the shoulder:
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3. Kessell L , Watson M: The painful arc syndrome: clinical
classification as a guide to management. J Bone Joint
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4. Allander E: Prevalence, incidence and remission rates of
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J Rheumatol 3: 145-153, 1974
5 . Skinner HA: Anatomical considerations relative to rupture of the supraspinatus tendon. J Bone Joint Surg
19A:137-151, 1937
6. Lindblom K: On the pathogenesis of rupture of the
tendon aponeurosis of the shoulder joint. Acta Radio1
20563-577, 1937
7. Wilson CL, Duff GL: Pathological study of degeneration
and rupture of the supraspinatus tendon. Arch Surg
47:121-135, 1943
8. Codman EA, Akerson IB: The pathology associated
with rupture of the supraspinatus tendon. Ann Surg
93:348-359, 1939
769
9. Fowler E: Stiff painful shoulders exclusive of tuberculosis and other infections. JAMA 101:210~2108,1933
10. Keyes EL: Anatomical observations on senile changes
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11. Olsson 0: Degenerative changes in the shoulder joint
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12. Chard MD, Hazleman BL: Shoulder disorders in the
elderly (a hospital study). Ann Rheum Dis 46:684-687,
1987
13. Binder AI, Parr G , Hazleman BL, Fitton-Jackson S:
Pulsed electromagnetic field therapy of persistent rotator cuff tendinitis: a double-blind controlled assessment.
Lancet I:695-698, 1984
14. Cyriax J , editor. Diagnosis of soft tissue lesions, Textbook of Orthopaedic Medicine. London, Balliere Tindall, 1971
15. McCarty DJ, Halverson PB, Carrera GF, Brewer BJ,
Kozin F: “Milwaukee shoulder”-association of microspheroids containing hydroxyapatite crystals, active collagenase, and neutral protease with rotator cuff defects.
I. Clinical aspects. Arthritis Rheum 24:464-473, 1981
16. Secretary of State for Health, Social Security for England, Wales and Scotland: A New Contract. Her Majesty’s Stationery Office, London, 1989
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