Inordinate attention to minor pathophysiology variations in musculoskeletal research: example of rotator cuff tendinopathy

Christina Nwankpa; Amin Razi; David Ring; Sina Ramtin

doi:10.1016/j.jse.2023.10.008

Inordinate attention to minor pathophysiology variations in musculoskeletal research: example of rotator cuff tendinopathy

J Shoulder Elbow Surg. 2023 Nov 23:S1058-2746(23)00824-8. doi: 10.1016/j.jse.2023.10.008. Online ahead of print.

Authors

Christina Nwankpa¹, Amin Razi¹, David Ring¹, Sina Ramtin²

Affiliations

¹ Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA.
² Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA. Electronic address: Sina.Ramtin@austin.utexas.edu.

PMID: 38000730
DOI: 10.1016/j.jse.2023.10.008

Abstract

Background: Evidence suggests variation in pathophysiology is less relevant to musculoskeletal illness than variation in mental health factors. For diseases such as rotator cuff tendinopathy, attention may be placed on aspects of tendon thinning and suture techniques when studies show that variations in muscle quality and defect size have limited association with comfort and capability compared with variations in thoughts and feelings regarding symptoms. Using rotator cuff tendinopathy as an example, we studied the degree to which research addresses relatively minor degrees of variation in pathophysiology and relatively minor differences in treatments to better understand the relative emphasis on pathophysiology. We asked the following questions: What factors are associated with relative pathophysiology severity in comparative therapeutic studies of musculoskeletal conditions? What factors are associated with relative differences in interventions in comparative therapeutic studies of musculoskeletal conditions?

Methods: We systematically reviewed clinical trials of patients with rotator cuff tendinopathy for the relative severity of pathophysiology (low, moderate, or high) and variation in interventions (minimal, moderate, or large). An example of a relatively minor variation in rotator cuff tendon pathophysiology is bursal- vs. articular-sided thinning of the tendon. An example of a relatively minor variation in treatment is single- vs. double-row defect closure.

Results: Most studies of rotator cuff tendinopathy treatment addressed low (39%) or medium (50%) levels of pathophysiology. Greater relative pathology severity was independently associated with operative treatment (odds ratio, 12 [95% confidence interval, 3.2-45]; P < .001). Of 127 studies, 113 (89%) were rated as comparing treatments with minimal difference.

Conclusion: Despite the evidence of limited variation in comfort and capability due to pathophysiological variations, a large percentage of research on rotator cuff tendinopathy addresses relatively limited severity of pathophysiology and relatively minor variations in treatment. This may be typical of musculoskeletal research and suggests a possibility of focusing, on the one hand, on more impactful interventions such as treatments that can delay or avoid rotator cuff arthropathy and, on the other hand, on management strategies that optimize accommodation of common age-related changes in the rotator cuff tendons.

Keywords: Minor pathophysiology variations; RCT; musculoskeletal research; rotator cuff tendinopathy; severity of pathophysiology; systematic review.

Publication types

Review