Okafor et al. (2023)

Rotator cuff prognosis for varying tear sizes: does tear size matter?

This study compared patients with varying tear severity to assess the differences in rotator cuff prognosis

There appears to be one factor that was moderately predictive of shoulder pain and function

The results are not generalizable to all rotator cuff tears, as this study only included participants already scheduled to receive arthroscopic repair


A striking finding with rotator cuff tendon tears is the lack of correlation between the size and type of tear that goes along with the pain and functional deficits that a patient can experience. Sometimes massive tears give little to no complaints, while small tears can result in significant disability and pain. The biopsychosocial context may play a large role in the pain experience, as shown in earlier studies. This study examined whether psychological distress is associated with shoulder pain and function in patients with all sorts of rotator cuff tear severities. By doing so, rotator cuff prognosis was assessed for partial tears, small to medium-thickness tears, and large-to-massive full-thickness tears.



In this retrospective cross-sectional study, participants who were scheduled to receive arthroscopic rotator cuff repair were included. They completed the 11-item OSPRO questionnaire at baseline. This tool provides an assessment of psychosocial factors that present as yellow flags. It is intended for use by orthopedic physiotherapists who want to estimate several individual psychological questionnaire scores (for example the Patient Health Questionnaire and the Fear-Avoidance Beliefs Questionnaire) without putting the patient through the trouble of completing each whole instrument.

The association between the OSPRO questionnaire and patient-reported VAS, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) was studied. Patients were then stratified based on their rotator cuff tear severity into partial-thickness tears, small to medium-thickness tears, and large to massive full-thickness tears.



A total of 84 participants with rotator cuff tears were included in the study. Thirty-nine had a partial-thickness tear, 20% a small to medium full-thickness tear, and 41% a large to massive full-thickness tear.

rotator cuff prognosis
From: Okafor et al., JSES International (2023)


At baseline, there were no differences in patient-reported outcomes scores, OSPRO scores, nor between the 3 stratifications of tear severity. The results revealed several weak to very weak correlations, except for fear avoidance beliefs for physical activity and the ASES score. This negative correlation means that higher levels of fear avoidance for physical activity result in lower, and thus worse ASES scores.

rotator cuff prognosis
From: Okafor et al., JSES International (2023)


Questions and thoughts

The authors used the OSPRO questionnaire to identify the level of distress participants experienced. But, the relationship between the OSPRO scores and shoulder pain and function is not yet understood. The OSPRO comes in 3 forms: 17 items, 10 items, and 7 items with a minimum of 85%, 81%, and 75% accuracy, respectively, for identifying yellow flags. The authors of this study mentioned completing the 11-item questionnaire. I guess this would be the 10-item version of the OSPRO. This gives a 75% accuracy for identifying yellow flags. I only wonder why they haven’t completed the 17-item version, as filling in 6 more questions leads to more confidence in the results.

What was interesting about this study is that there were no significant differences in patient-reported outcome scores among the 3 stratifications of tear severity. Even more interesting was that the study found no significant differences in pain-associated psychological distress (measured by the OSPRO) among the 3 stratifications of tear severity.

The authors state that preoperative psychological distress was a stronger predictor of poor shoulder function and pain than the rotator cuff tear severity in patients undergoing arthroscopic rotator cuff repairs. It should, however, be noted that it is a strong predictor of shoulder function and pain experienced before the arthroscopy, as the ASES questionnaire was filled out preoperatively. This study can thus give no prediction about the postoperative results.

What is the influence of the affected shoulder? For example, a self-employed construction worker with a dominant sided-tear could experience more psychological distress due to the burden it places on the ability to do his job.


Talk nerdy to me

With the cross-sectional nature of the study, this study cannot answer the question of whether psychological distress is the reason for pain and reduced shoulder function in those with a rotator cuff tear. It gives no causal explanation, but it can capture relevant information which can then be investigated further. For example, with the results of this study, we now know that the severity of the rotator cuff tear alone may not be the best predictor of the extent of pain someone is having. Rather, considering the person with a rotator cuff tear as a whole should give a more accurate prediction of their level of shoulder pain and function, than just the tear itself.

The study design was a retrospective cross-sectional study. Retrospective studies may lack important information and give some bias in the results. Cross-sectional studies on the other hand are using information from one specific moment in time, and cannot study the influence of confounding variables such as age, personal background, or study setting. It gives a snapshot of the people who were scheduled to receive arthroscopic surgery at that time, at the given location. Information that was lacking for me was the reason to choose arthroscopic repair. Did they get operated on because of diminished shoulder function, pain, or just because they had a tear? I would certainly understand that some of these patients would be distressed knowing they will receive surgery.

Importantly, patients had to fill out the questionnaires before they saw the surgeon. This may have led to overestimated responses. The study found that patients seeking arthroscopic repair appear to have elements of negative mood or low confidence in rehabilitation. As such, they may report higher levels of disability and pain. Yet, the confidence in rehabilitation was not measured directly, so I would rather be cautious while using this statement.

Importantly, the results are not generalizable to all rotator cuff tears, as this study only included participants already scheduled to receive arthroscopic repair.


Take home messages

Bearing in mind that more than just the severity of a torn rotator cuff tendon alone may predict someone’s shoulder pain and functional impairments, it would be interesting to objectify how distressed someone is. This can give an idea about the prognosis of patients undergoing arthroscopy for their torn rotator cuff. This study found that higher levels of fear avoidance were correlated with a lower ASES score, which means, more pain and disability. Psychological distress encompasses more than just fear avoidance, but in this study, this was the only factor that was moderately related to the patient-reported outcome questionnaire ASES.



Okafor, C., Levin, J. M., Boadi, P., Cook, C., George, S., Klifto, C., & Anakwenze, O. (2023). Pain associated psychological distress is more strongly associated with shoulder pain and function than tear severity in patients undergoing rotator cuff repair. JSES International, 7(4), 544-549. 



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