What factors are associated with perceived disease onset in patients with hip and knee osteoarthritis?

Among People Presenting for Musculoskeletal Specialty Care, Is There an Association of Accommodation of Aging and Other Mindset Factors With Levels of Comfort and Capability?

BACKGROUND

Many musculoskeletal symptoms arise from the natural decline of cells and tissues with age (senescence). Among patients seeking care for those conditions, symptom intensity often corresponds more with thoughts and feelings about bodily sensations than with the severity of any pathophysiology. Population studies suggest that a large percentage of people manage to live with (accommodate) symptoms from these conditions without seeking care, and that as people age, healthy attitudes toward sensations from musculoskeletal senescence may help them accommodate these kinds of symptoms; to our knowledge, however, this has not been specifically studied.

QUESTIONS/PURPOSES

In a cross-sectional study of patients presenting for musculoskeletal specialty care, we asked: (1) Are there factors associated with accommodation of aging, including mindsets measured as levels of unhelpful thoughts, feelings of distress, and intolerance of uncertainty? (2) Are there any factors associated with pain intensity, including comfort with aging and mindset measures? (3) Are there any factors associated with level of capability, including comfort with aging and mindset measures?

METHODS

One hundred fifty-six English-speaking adults (age 18 to 89 years) presenting for initial or return specialist evaluation of a musculoskeletal problem (largely an unselected sample of patients with common lower and upper extremity problems) in a single large urban city in the United States agreed to participate. Among the 98% (153) who completed the survey and were analyzed, 57% (87) were women, the mean age was 53 ± 17 years, 69% (105) were non-Hispanic White, and 47% (72) had private insurance. Participants completed an 11-point ordinal measure of pain intensity, a measure of level of capability (a person's perception of the level of difficulty of specific activities, distinct from objective impairment or incapacity), intolerance of uncertainty (that is, a negative regard for uncertainty), unhelpful thoughts (unhealthy misinterpretations) regarding sensations, feelings of distress (worry or despair) regarding sensations, and attitudes toward aging (quantified positive or negative regard for aging), all using instruments with evidence supporting their ability to measure these constructs. Factors associated with levels of accommodation of aging, pain intensity, and incapability were analyzed using multivariable regression models, limiting the models to a single mental health variable because of concerns about collinearity and selecting the best performing model based on the Akaike information criterion. To account for known and anticipated collinearity of the mental health measures, we also performed a k-means cluster analysis to identify statistical groupings of unhelpful thoughts regarding sensations, distress regarding sensations, and intolerance of uncertainty and tested for differences in attitudes toward aging, pain intensity, and capability using analysis of variance.

RESULTS

Accounting for potential confounders such as age, marital status, income status, unhelpful thoughts regarding symptoms, feelings of distress regarding symptoms, and intolerance of uncertainty that were associated in bivariate analysis, we found a small association between lower accommodation of aging and greater feelings of distress regarding symptoms (regression coefficient [RC] -0.17 [95% confidence interval (CI) CI -0.23 to - 0.11]; p < 0.01). Higher pain intensity had a modest association with greater feelings of distress (RC 0.4 [95% CI 0.2 to 0.5]; p < 0.001) and Medicaid insurance (RC 2.2 [95% CI -0.1 to 4.5]; p = 0.04) and a small inverse association with postcollege graduate education (RC -1.7 [95% CI -3.2 to -0.3]; p = 0.02). Higher levels of capability had a large association with less distress (RC -0.8 [95% CI -1.4 to -0.1]; p = 0.001), a small association with younger age (RC -0.2 [95% CI -0.3 to -0.1]; p = 0.005), and a medium association with postcollege graduate education (RC 5.9 [95% CI 0.4 to 11]; p = 0.04). The cluster analysis identified five statistical groupings of levels of unhelpful thoughts, feelings of distress, and intolerance of uncertainty that were associated with greater levels of healthier attitudes toward aging, pain intensity, and levels of capability.

CONCLUSION

The observation that people are less accommodative of aging to the degree that they experience greater intolerance of uncertainty, feelings of distress, and unhelpful thoughts about their body's sensations-and that these factors are also associated with greater levels of discomfort and incapability-points to the importance of cultivating and maintaining a healthy mindset as we age. To help guide patients to a healthier regard for the aging body, musculoskeletal specialists and all clinicians can transition away from concepts of inflammation (tendinitis), injury (tear), or breakdown (bone-on-bone) toward more accurate and healthful words and concepts, such as those that emphasize expected changes in people's bodies, that even painful activities are not off limits, and the importance of evolving one's identity to match one's body.

LEVEL OF EVIDENCE

Level III, prognostic study.

Long Head of Biceps Tendinopathy Is Associated With Age and Cuff Tendinopathy on MRI Obtained for Evaluation of Shoulder Pain

BACKGROUND

Shoulder pain-mostly related to rotator cuff tendinopathy-is the most common reason adults seek upper limb specialty care. Tendinopathy of the long head of the biceps may be part of rotator cuff tendinopathy, which most of us develop as we age. Evidence that these processes are related and that both are part of human shoulder senescence could contribute to a reconceptualization of shoulder tendinopathy as a single set of age-related changes, which are often well-accommodated, sometimes misinterpreted as an injury, and associated with notable nonspecific treatment effects, thus meriting caution regarding the potential for overtreatment.

QUESTIONS/PURPOSES

This study reviewed a consecutive series of MRI scans ordered for the evaluation of shoulder pain and asked: (1) Is long head of the biceps tendinopathy associated with advancing age? (2) Is long head of the biceps tendinopathy associated with concomitant degeneration of the rotator cuff tendons?

METHODS

Five hundred consecutive radiologist interpretations of MRIs of the shoulder obtained between May 2016 and June 2017 for assessment of shoulder pain in adults at a radiology group that provides approximately 80% of the imaging in all practices in our region were reviewed. Patients with bilateral MRIs had one MRI included at random. Patients with fractures, dislocations, previous surgery, and soft tissue masses seen on MRI were excluded, leaving 406 shoulder MRI interpretations for review. The radiology reports were used to identify the presence and severity of rotator cuff and long head of the biceps tendinopathy. Forty-nine percent (197 of 406) were men with a mean ± SD age of 55 ± 14 years, and 54% (220 of 406) were right shoulders. Multivariable analyses accounting for age and gender evaluated the association of long head of the biceps tendinopathy with age and tendinopathy of the rotator cuff tendons.

RESULTS

After controlling for tendinopathy of the other rotator cuff tendons, long head of the biceps tendinopathy was more common with advancing age (OR 1.04 [95% CI 1.02 to 1.06] per year; p < 0.001), meaning the prevalence increases by approximately 4% per year. Among people who were imaged for shoulder pain, everyone 85 years or older had both long head of the biceps and rotator cuff tendinopathy. Any rotator cuff pathophysiology was also notably associated with any long head of the biceps pathophysiology (OR 6.9 [95% CI 2.4 to 20]; p < 0.001). About half (49% [162 of 328]) of long head of the biceps tendons were normal in the presence of any supraspinatus tendinopathy, and 5% (9 of 175) of supraspinatus tendons were normal in the presence of any long head of the biceps tendinopathy.

CONCLUSION

The finding that among people seeking care for shoulder pain, long head of the biceps tendinopathy and rotator cuff tendinopathy occur together and are more common with increasing age (and ubiquitous by the latter half of the ninth decade) suggests that most shoulder pain in adults is associated with expected aging of the shoulder tendons inclusive. In this light, clinicians can guide patients to an understanding of shoulder pain as age-appropriate, safe and sound, and accommodated by a large percentage of people as they age, all of which may be unexpected and counterintuitive. Effective assimilation of this knowledge-which may take time and merits patience-has the potential to both put people at ease and open up possibilities for fewer visits, tests, and treatments addressing tendinopathy, allowing patients to manage on their own (agency) with a set of simple exercises and perhaps occasional use of over-the-counter analgesics.

LEVEL OF EVIDENCE

Level III, prognostic study.

Pain catastrophizing in rheumatic diseases: prevalence, origin, and implications

Pain is a crucial factor in rheumatic disorders, and reducing it is a primary goal of successful treatment. Adaptive pain-coping strategies can enhance this improvement, but maladaptive approaches such as pain catastrophizing may worsen overall patient well-being. This narrative review aims to provide a concise overview of the existing knowledge on pain catastrophizing in the most prevalent specific rheumatic disorders. The objective of this study was to improve understanding of this phenomenon and its implications, as well as to pinpoint potential directions for future research. We conducted searches in the MEDLINE/PubMed, SCOPUS, and DOAJ bibliography databases to identify articles related to pain catastrophizing in rheumatoid arthritis, psoriatic arthritis, axial spondylarthritis, systemic sclerosis, systemic lupus erythematosus, Sjögren's syndrome, juvenile idiopathic arthritis, and osteoarthritis (non-surgical treatment). Data extraction was performed on November 1, 2023. The investigators screened the identified articles to determine their relevance and whether they met the inclusion criteria. Following a bibliography search, which was further expanded by screening of citations and references, we included 156 records in the current review. The full-text analysis centred on pain catastrophizing, encompassing its prevalence, pathogenesis, and impact. The review established the role of catastrophizing in amplifying pain and diminishing various aspects of general well-being. Also, potential treatment approaches were discussed and summarised across the examined disorders. Pain catastrophizing is as a significant factor in rheumatic disorders. Its impact warrants further exploration through prospective controlled trials to enhance global patient outcomes.

Variations in 1-year Trajectories of Levels of Pain and Capability After Shoulder Arthroplasty Are Associated With Baseline Mental Health

BACKGROUND

There is variability in the trajectories of pain intensity and magnitude of incapability after shoulder arthroplasty. A better understanding of the degree to which variation in recovery trajectories relates to aspects of mental health can inform the development of comprehensive biopsychosocial care strategies.

QUESTIONS/PURPOSES

(1) Do pain intensities at baseline and the trajectories during recovery differ between groups when stratified by mental health composite summary score, arthroplasty type, and revision surgery? (2) Do magnitudes of capability at baseline and the trajectories during recovery differ between these groups?

METHODS

We used a registry of 755 patients who underwent shoulder arthroplasty by a single surgeon at a specialized urban orthopaedic hospital that recorded the mental component summary (MCS) score of the Veterans RAND 12, a measure of shoulder-specific comfort and capability (American Shoulder and Elbow Surgeons [ASES] score, which ranges from 0 to 100 points, with a score of 0 indicating worse capability and pain and 100 indicating better capability and pain and a minimum clinically important difference of 6.4), and the VAS for pain intensity (range 0 [representing no pain] to 10 [representing the worst pain possible], with a minimum clinically important difference of 1.4) preoperatively, 2 weeks postoperatively, and 6 weeks, 3 months, 6 months, and 1 year after surgery. Forty-nine percent (368 of 755) of the patients were men, with a mean age of 68 ± 8 years, and 77% (585) were treated with reverse total shoulder arthroplasty (rTSA). Unconditional linear and quadratic growth models were generated to identify the general shape of recovery for both outcomes (linear versus quadratic). We then constructed conditional growth models and curves for pain intensity and the magnitude of capability showing mean baseline scores and the rates of recovery that determine the trajectory, accounting for mental health (MCS) quartiles, primary or revision arthroplasty, and TSA or reverse TSA in separate models. Because pain intensity and capability showed quadratic trends, we created trajectories using the square of time.

RESULTS

Patients in the worst two MCS quartiles had greater pain intensity at baseline than patients in the best quartile (difference in baseline for bottom quartile: 0.93 [95% CI 0.72 to 1.1]; p < 0.01; difference in baseline for next-worst quartile: 0.36 [95% CI 0.16 to 0.57]; p < 0.01). The rates of change in recovery from pain intensity were not different among groups (p > 0.10). Patients with revision surgery had greater baseline pain (difference: 1.1 [95% CI 0.7 to 1.5]; p < 0.01) but no difference in rates of recovery (difference: 0.031 [95% CI 0.035 to 0.097]; p = 0.36). There were no differences in baseline pain intensity and rates of recovery between patients with reverse TSA and those with TSA (baseline pain difference: -0.20 [95% CI -0.38 to -0.03]; p = 0.18; difference in rate of recovery: -0.005 [95% CI -0.035 to 0.025]; p = 0.74). Patients in the worst two MCS quartiles had worse baseline capability than patients in the best quartile (difference in baseline for bottom quartile: -8.9 [95% CI -10 to -7.4]; p < 0.001; difference in baseline for the next-worst quartile: -4.9 [95% CI -6.4 to -3.4]; p < 0.01), with no differences in rates of recovery (p > 0.10). Patients with revision surgery had lower baseline capability (difference in baseline: -13 [95% CI -15 to -9.7]; p < 0.01), with a slower rate of recovery (difference in rate of recovery: -0.56 [95% CI -1.0 to -0.079]; p = 0.021). There were no differences in baseline capability or rates of recovery between TSA and reverse TSA.

CONCLUSION

The observation that preoperative and 1-year comfort and capability are associated with mental health factors and with similar recovery trajectories reminds us that assessment and treatment of mental health is best considered an integral aspect of musculoskeletal care. Future studies can address how prioritization of mental health in musculoskeletal care strategies might reduce variation in the 1-year outcomes of discretionary surgeries such as shoulder arthroplasty.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Time-varying treatment effect modification of oral analgesic effectiveness by depressive symptoms in knee osteoarthritis: an application of structural nested mean models in a prospective cohort

BACKGROUND

Depressive symptoms are common in knee osteoarthritis (OA), exacerbate knee pain severity and may influence outcomes of oral analgesic treatments. The aim was to assess whether oral analgesic effectiveness in knee OA varies by fluctuations in depressive symptoms.

METHODS

The sample included Osteoarthritis Initiative (OAI) participants not treated with oral analgesics at enrolment (n = 1477), with radiographic disease at the first follow-up visit (defined as the index date). Oral analgesic treatment and depressive symptoms, assessed with the Center for Epidemiological Studies Depression [(CES-D) score ≥16] Scale, were measured over three annual visits. Knee pain severity was measured at visits adjacent to treatment and modifier using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale (rescaled range = 0-100). Structural nested mean models (SNMMs) estimated causal mean differences in knee pain severity comparing treatment versus no treatment.

RESULTS

The average causal effects of treated versus not treated for observations without depressive symptoms showed negligible differences in knee pain severity. However, causal mean differences in knee pain severity comparing treatment versus no treatment among observations with depressive symptoms increased over time from -0.10 [95% confidence interval (CI): -9.94, 9.74] to -16.67 (95% CI: -26.33, -7.01). Accordingly, the difference in average causal effects regarding oral analgesic treatment for knee pain severity between person-time with and without depressive symptoms was largest (-16.53; 95% CI: -26.75, -6.31) at the last time point. Cumulative treatment for 2 or 3 years did not yield larger causal mean differences.

CONCLUSIONS

Knee OA patients with persistent depressive symptoms and chronic pain may derive more analgesic treatment benefit than those without depressive symptoms and less pain.

Is Pain in the Uninjured Leg Associated With Unhelpful Thoughts and Distress Regarding Symptoms During Recovery From Lower Extremity Injury?

BACKGROUND

Patients recovering from lower extremity injuries often interpret discomfort associated with increased use of the uninjured leg as a potential indication of harm. If expressed concerns regarding contralateral leg pain are associated with unhelpful thinking regarding symptoms, they can signal orthopaedic surgeons to gently reorient these thoughts to help improve comfort and capability during recovery.

QUESTIONS/PURPOSES

We asked: (1) Among people recovering from isolated traumatic lower extremity injury, is pain intensity in the uninjured leg associated with unhelpful thoughts and feelings of distress regarding symptoms, accounting for other factors? (2) Are pain intensity in the injured leg, magnitude of capability, and accommodation of pain associated with unhelpful thoughts and feelings of distress regarding symptoms?

METHODS

Between February 2020 and February 2022, we enrolled 139 patients presenting for an initial evaluation or return visit for any traumatic lower extremity injury at the offices of one of three musculoskeletal specialists. Patients had the option to decline filling out our surveys, but because of the cross-sectional design, required fields on the electronic survey tools, and monitored completion, there were few declines and few incomplete surveys. The median age of participants was 41 years (IQR 32 to 58), and 48% (67 of 139) were women. Fifty percent (70 of 139) injured their right leg. Sixty-five percent (91 of 139) had operative treatment of their fracture. Patients completed measures of pain intensity in the uninjured leg, pain intensity in the injured leg, lower extremity-specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. Multivariable analysis sought factors independently associated with pain intensity in the uninjured leg, pain intensity in the injured leg, magnitude of capability, and pain accommodation, controlling for other demographic and injury-related factors.

RESULTS

Greater pain intensity in the uninjured leg (regression coefficient [RC] 0.09 [95% CI 0.02 to 0.16]; p < 0.01) was moderately associated with more unhelpful thinking regarding symptoms. This indicates that for every one-unit increase in unhelpful thinking regarding symptoms on the 17-point scale we used to measure pain catastrophizing, pain intensity in the uninjured leg increases by 0.94 points on the 11-point scale that we used to measure pain intensity, holding all other independent variables constant. Greater pain intensity in the injured leg (RC 0.18 [95% CI 0.08 to 0.27]; p < 0.01) was modestly associated with more unhelpful thinking regarding symptoms. Greater pain accommodation (RC -0.25 [95% CI -0.38 to -0.12]; p < 0.01) was modestly associated with less unhelpful thinking regarding symptoms. Greater magnitude of capability was not independently associated with less unhelpful thinking regarding symptoms.

CONCLUSION

A patient's report of concerns regarding pain in the uninjured limb (such as, "I'm overcompensating for the pain in my other leg") can be considered an indicator of unhelpful thinking regarding symptoms. Orthopaedic surgeons can use such reports to recognize unhelpful thinking and begin guiding patients toward healthier thoughts and behaviors.

LEVEL OF EVIDENCE

Level II, prognostic study.

Surgeons Receiving Information About Patient Language Reflecting Unhelpful Thoughts or Distress About Their Symptoms Identify Such Language More Often Than Those Who Do Not Receive This Information

BACKGROUND

Unhelpful thoughts and feelings of distress regarding symptoms account for a large proportion of variation in a patient's symptom intensity and magnitude of capability. Clinicians vary in their awareness of this association, their ability to identify unhelpful thoughts or feelings of distress regarding symptoms, and the skills to help address them. These nontechnical skills are important because they can improve treatment outcomes, increase patient agency, and foster self-efficacy without diminishing patient experience.

QUESTIONS/PURPOSES

In this survey-based study, we asked: (1) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the total number of identified instances of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? (2) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the interobserver reliability of a surgeon's identification of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters?

METHODS

Surgeons from an international collaborative consisting of mostly academic surgeons (Science of Variation Group) were invited to participate in a survey-based experiment. Among approximately 200 surgeons who participate in at least one experiment per year, 127 surgeons reviewed portions of transcripts of actual new musculoskeletal specialty encounters with English-speaking patients (who reported pain and paresthesia as primary symptoms) and were asked to identify language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. The included transcripts were selected based on the rated presence of language reflecting unhelpful thinking as assessed by four independent researchers and confirmed by the senior author. We did not study accuracy because there is no reference standard for language reflecting unhelpful thoughts or feelings of distress regarding symptoms. Observers were randomized 1:1 to receive supportive information or not regarding definitions and examples of unhelpful thoughts or feelings of distress regarding symptoms (referred to herein as "priming") once at the beginning of the survey, and were not aware that this randomization was occurring. By priming, we mean the paragraph was intended to increase awareness of and attunement to these aspects of human illness behavior immediately before participation in the experiment. Most of the participants practiced in the United States (primed: 48% [29 of 60] versus not primed: 46% [31 of 67]) or Europe (33% [20 of 60] versus 36% [24 of 67]) and specialized in hand and wrist surgery (40% [24 of 60] versus 37% [25 of 67]) or fracture surgery (35% [21 of 60] versus 28% [19 of 67]). A multivariable negative binomial regression model was constructed to seek factors associated with the total number of identified instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. To determine the interobserver agreement, Fleiss kappa was calculated with bootstrapped 95% confidence intervals (resamples = 1000) and standard errors.

RESULTS

After controlling for potential confounding factors such as location of practice, years of experience, and subspecialty, we found surgeons who were primed with supportive information and surgeons who had 11 to 20 years of experience (compared with 0 to 5 years) identified slightly more instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms (regression coefficient 0.15 [95% CI 0.020 to 0.28]; p = 0.02 and regression coefficient 0.19 [95% CI 0.017 to 0.37]; p = 0.03). Fracture surgeons identified slightly fewer instances than hand and wrist surgeons did (regression coefficient -0.19 [95% CI -0.35 to -0.017]; p = 0.03). There was limited agreement among surgeons in their ratings of language as indicating unhelpful thoughts or feelings of distress regarding symptoms, and priming surgeons with supportive information had no influence on reliability (kappa primed: 0.25 versus not primed: 0.22; categorically fair agreement).

CONCLUSION

The observation that surgeons with brief exposure to supportive information about language associated with unhelpful thoughts and feelings of distress regarding symptoms identified slightly more instances of such language demonstrates the potential of training and practice to increase attunement to these important aspects of musculoskeletal health. The finding that supportive information did not improve reliability underlines the complexity, relative subjectivity, and imprecision of these mental health concepts.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Association of Unmet Social Needs With Level of Capability in People With Persistent Knee Pain

BACKGROUND

Musculoskeletal providers are increasingly recognizing the importance of social factors and their association with health outcomes as they aim to develop more comprehensive models of care delivery. Such factors may account for some of the unexplained variation between pathophysiology and level of pain intensity and incapability experienced by people with common conditions, such as persistent nontraumatic knee pain secondary to osteoarthritis (OA). Although the association of one's social position (for example, income, employment, or education) with levels of pain and capability are often assessed in OA research, the relationship between aspects of social context (or unmet social needs) and such symptomatic and functional outcomes in persistent knee pain are less clear.

QUESTIONS/PURPOSES

(1) Are unmet social needs associated with the level of capability in patients experiencing persistently painful nontraumatic knee conditions, accounting for sociodemographic factors? (2) Do unmet health-related social needs correlate with self-reported quality of life?

METHODS

We performed a prospective, cross-sectional study between January 2021 and August 2021 at a university academic medical center providing comprehensive care for patients with persistent lower extremity joint pain secondary to nontraumatic conditions such as age-related knee OA. A final 125 patients were included (mean age 62 ± 10 years, 65% [81 of 125] women, 47% [59 of 125] identifying as White race, 36% [45 of 125] as Hispanic or Latino, and 48% [60 of 125] with safety-net insurance or Medicaid). We measured patient-reported outcomes of knee capability (Knee injury and Osteoarthritis Outcome Score for Joint Replacement), quality of life (Patient-Reported Outcome Measure Information System [PROMIS] Global Physical Health and PROMIS Global Mental Health), and unmet social needs (Accountable Health Communities Health-Related Social Needs Survey, accounting for insufficiencies related to housing, food, transportation, utilities, and interpersonal violence), as well as demographic factors.

RESULTS

After controlling for demographic factors such as insurance status, education attained, and household income, we found that reduced knee-specific capability was moderately associated with experiencing unmet social needs (including food insecurity, housing instability, transportation needs, utility needs, or interpersonal safety) (standardized beta regression coefficient [β] = -4.8 [95% confidence interval -7.9 to -1.7]; p = 0.002 and substantially associated with unemployment (β = -13 [95% CI -23 to -3.8]; p = 0.006); better knee-specific capability was substantially associated with having Medicare insurance (β = 12 [95% CI 0.78 to 23]; p = 0.04). After accounting for factors such as insurance status, education attained, and household income, we found that older age was associated with better general mental health (β = 0.20 [95% CI 0.0031 to 0.39]; p = 0.047) and with better physical health (β = 0.004 [95% CI 0.0001 to 0.008]; p = 0.04), but effect sizes were small to negligible, respectively.

CONCLUSION

There is an association of unmet social needs with level of capability and unemployment in patients with persistent nontraumatic knee pain. This finding signals a need for comprehensive care delivery for patients with persistent knee pain that screens for and responds to potentially modifiable social risk factors, including those based on one's social circumstances and context, to achieve better outcomes.

LEVEL OF EVIDENCE

Level II, prognostic study.

Are the Pathologic Features of Enthesopathy, Tendinopathy, and Labral and Articular Disc Disease Related to Mucoid Degeneration? A Systematic Review

BACKGROUND

Tendinopathy, enthesopathy, labral degeneration, and pathologic conditions of the articular disc (knee meniscus and ulnocarpal) are sometimes described in terms of inflammation or damage, while the histopathologic findings are often consistent with mucoid degeneration. A systematic review of the histopathology of these structures at diverse locations might reconceptualize these diseases as expected aspects of human aging. The potential benefits of this evolution might include healthier patient and clinician mindsets as well as a reduced likelihood of overdiagnosis and overtreatment resulting from greater awareness of base rates of pathology.

QUESTION/PURPOSE

In this systematic review of studies of surgical specimens, we asked: Are there are any differences in the histopathologic findings of structural soft tissue conditions (mucoid degeneration, inflammation, and vascularity) by anatomic site (foot, elbow, or knee) or structure (tendon body, muscle or tendon origin or insertion [enthesis], labrum, or articular disc)?

METHODS

Studies between 1980 and 2021 investigating the histopathologic findings of specimens from surgery for trigger digit, de Quervain tendinopathy, plantar fasciitis, lateral and medial elbow enthesopathy, rotator cuff tendinopathy, posterior tibial tendinopathy, patellar tendinopathy, Achilles tendinopathy, or disease of the hip labrum, ulnocarpal articular disc, or knee meniscus were searched for in the PubMed, EMBASE, and CINAHL databases. Inclusion criteria were the prespecified anatomic location or structure being analyzed histologically and any findings described with respect to inflammation, vascularity, or mucoid degeneration. Studies were excluded if they were nonhuman studies or review articles. Search terms included "anatomy," "pathology," and "histopathology." These terms were coupled with anatomic structures or disorders and included "trigger finger," "de Quervain," "fasciitis, plantar," "tennis elbow," "rotator cuff tendinopathy," "elbow tendinopathy," "patellar tendonitis," "posterior tibial tendon," and "triangular fibrocartilage." This resulted in 3196 studies. After applying the inclusion criteria, 559 articles were then assessed for eligibility according to our exclusion criteria, with 52 eventually included. We recorded whether the study identified the following histopathologic findings: inflammatory cells or molecular markers, greater than expected vascularity (categorized as quantitative count, with or without controls; molecular markers; or qualitative judgments), and features of mucoid degeneration (disorganized collagen, increased extracellular matrix, or chondroid metaplasia). In the absence of methods for systematically evaluating the pathophysiology of structural (collagenous) soft tissue structures and rating histopathologic study quality, all studies that interpreted histopathology results were included. The original authors' judgment regarding the presence or absence of inflammation, greater than expected vascularity, and elements of mucoid degeneration was recorded along with the type of data used to reach that conclusion.

RESULTS

Regarding differences in the histopathology of surgical specimens of structural soft tissue conditions by anatomic site, there were no differences in inflammation or mucoid degeneration, and the knee meniscus was less often described as having greater than normal vascularity. There were no differences by anatomic structure. Overall, 20% (10 of 51) of the studies that investigated for inflammation reported it (nine inflammatory cells and one inflammatory marker). Eighty-three percent (43 of 52) interpreted increased vascularity: 40% (17 of 43) using quantitative methods (14 with controls and three without) and 60% (26 of 43) using imprecise criteria. Additionally, 100% (all 52 studies) identified at least one element of mucoid degeneration: 69% (36 of 52) reported an increased extracellular matrix, 71% (37 of 52) reported disorganized collagen, and 33% (17 of 52) reported chondroid metaplasia.

CONCLUSION

Our systematic review of the histopathology of diseases of soft tissue structures (enthesopathy, tendinopathy, and labral and articular disc) identified consistent mucoid degeneration, minimal inflammation, and imprecise assessment of relative vascularity; these findings were consistent across anatomic sites and structures, supporting a reconceptualization of these diseases as related to aging (senescence or degeneration) rather than injury or activity.

CLINICAL RELEVANCE

This reconceptualization supports accommodative mindsets known to be associated with greater comfort and capability. In addition, awareness of the notable base rates of structural soft tissue changes as people age might reduce overdiagnosis and overtreatment of incidental, benign, or inconsequential signal changes and pathophysiology.

The mind and the hand

Symptoms are determined in large part by mindsets. Feelings of distress and unhelpful thoughts (misinterpretations) of symptoms account for much of the variability in comfort and capability with the severity of the underlying pathophysiology making a more limited contribution. Incorporating this experimental evidence into the daily practice of hand surgery will help us find ways to develop healthy mindsets, to prioritize the alleviation of distress and the gentle redirection of unhelpful thoughts, to avoid unnecessary surgery, and to provide better psychological and social support for people recovering from injury and surgery.

Recovery After Musculoskeletal Injury: Mental and Social Health

Recovery from injury involves painful movement and activity, painful stretches and muscle strengthening, and adjustment to permanent impairment. Recovery is facilitated by embracing the concept that painful movement can be healthy, which is easier when one has more hope, less worry, and greater social supports and security. Evolution of one's identity to match the new physical status is a hallmark of a healthy outcome and is largely determined by mental and social health factors. When infection, loss of alignment or fixation, and nerve issues or compartment syndrome are unlikely, greater discomfort and incapability that usual for a given pathology or stage of recovery signal opportunities for improved mental and social health. Surgeons may be the clinicians most qualified to make this discernment. A surgeon who has gained a patient's trust can start to noticed despair, worry, and unhelpful thinking such as fear of painful movement. Reorienting people to greater hope and security and a healthier interpretation of the pains associated with the body's recovery can be initiated by the surgeon and facilitated by social workers, psychologist, and physical, occupational and hand therapists trained in treatments that combine mental and physical therapies.

Persistent Shoulder Pain After Vaccine Administration Is Associated with Common Incidental Pathology: A Systematic Review

BACKGROUND

Claims of shoulder injury now account for half of all claims to the Vaccine Injury Compensation Program. Reports from databases of claims or potential adverse events note a relatively high mean age and high prevalences of rotator cuff tendinopathy and adhesive capsulitis-common shoulder problems that might be incidental to vaccination. Published case reports provide much more detail about individual patients than is available in databases. A review of published cases provides an opportunity for more detailed review of symptoms, diagnoses, pathology, treatment, and prognosis. Such a review can better assess the relative likelihood that pathologies associated with new persistent shoulder symptoms after vaccination are coincidental or unique to and caused by vaccine.

QUESTIONS/PURPOSES

Regarding published case reports addressing persistent shoulder pain after vaccination: (1) In what proportion of patients was a specific diagnosis made? (2) What diagnoses were most common? (3) Among patients treated nonsurgically, what proportion resolved, and over what time span did they resolve?

METHODS

In August 2020, we searched PubMed and Embase between 2006 and 2020 using the following search strategy: Search 1: (shoulder dysfunction OR shoulder pain OR shoulder bursitis OR rotator cuff tendonitis OR adhesive capsulitis OR glenohumeral arthritis AND [vaccine OR vaccination OR immunization]); Search 2: (shoulder injury related to vaccine administration or SIRVA). The search was supplemented by reviewing reference lists of identified studies. Inclusion criteria were any detailed report of three or fewer cases involving shoulder pain after vaccine administration. Twenty published reports of 29 patients were identified and assessed by two reviewers independently. One reported glenohumeral joint infection was excluded because the relationship between this type of relatively uncommon, discrete diagnosis and vaccination raises different considerations. We assumed a high risk of bias, although we are not aware of bias assessment tool for case reports. We recorded and summarized patient demographics, symptoms, examination and imaging findings, surgery findings, diagnoses, treatments, and outcomes. Seventy-five percent (21 of 28) of patients were women, with a mean age of 54 ± 19 years. In search of an underlying pathology, at least one diagnostic study was performed in 82% (23 of 28) of patients including radiographs in seven, ultrasound in seven, and MRI in 16 patients (some patients underwent more than one type of imaging). We distinguished specific pathophysiological diagnosis from shoulder pain and stiffness, counted the most common diagnoses among patients a specific diagnosis, and tracked symptom resolution among patients treated nonoperatively.

RESULTS

A specific diagnosis was made in 57% (16 of 28) of patients. Twelve patients had pain and limitation of motion due to pain but no specific pathological diagnosis. The most common specific diagnoses were rotator cuff tendinopathy (9 of 16) and adhesive capsulitis (4 of 16). Less common specific diagnoses included rotator cuff arthropathy (and rheumatoid arthritis) and suspected septic arthritis with nonspecific synovitis on arthroscopy. One patient had transient MRI signal change in the humeral head, which was interpreted as osteonecrosis that resolved in a manner not typical for that diagnosis. Of the 17 patients treated nonsurgically, 15 reported resolution, and two had incomplete symptom resolution with the mean 6-month evaluation period.

CONCLUSION

The observation that persistent shoulder pain after vaccination overlaps with common shoulder pathology-both in large databases as well as in more detailed reports of specific patients as analyzed in this review-establishes a high probability of a coincidental rather than a causal association. In the absence of high-quality experimental evidence of vaccine-specific shoulder pathology, in our opinion, it seems safest and healthiest to assume that perceived shoulder injury related to vaccine administration (SIRVA) is due to misinterpretation of new symptoms from established pathology rather than a new, vaccine-specific pathology.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Are There Distinct Statistical Groupings of Mental Health Factors and Pathophysiology Severity Among People with Hip and Knee Osteoarthritis Presenting for Specialty Care?

BACKGROUND

There is mounting evidence that objective measures of pathophysiology do not correlate well with symptom intensity. A growing line of inquiry identifies statistical combinations (so-called "phenotypes") of various levels of distress and unhelpful thoughts that are associated with distinct levels of symptom intensity and magnitude of incapability. As a next step, it would be helpful to understand how distress and unhelpful thoughts interact with objective measures of pathologic conditions such as the radiologic severity of osteoarthritis. The ability to identify phenotypes of these factors that are associated with distinct levels of illness could contribute to improved personalized musculoskeletal care in a comprehensive, patient-centered model.

QUESTIONS/PURPOSES

(1) When measures of mental health are paired with radiologic osteoarthritis severity, are there distinct phenotypes among adult patients with hip and knee osteoarthritis? (2) Is there a difference in the degree of capability and pain self-efficacy among the identified mental health and radiologic phenotypes? (3) When capability (Patient-reported Outcomes Measurement Information System Physical Function [PROMIS PF]) is paired with radiographic osteoarthritis severity, are there distinct phenotypes among patients with hip and knee osteoarthritis? (4) Is there a difference in mental health among patients with the identified capability and radiologic phenotypes?

METHODS

We performed a secondary analysis of data from a study of 119 patients who presented for musculoskeletal specialty care for hip or knee osteoarthritis. Sixty-seven percent (80 of 119) of patients were women, with a mean age of 62 ± 10 years. Seventy-six percent (91 of 119) of patients had knee osteoarthritis, and 59% (70 of 119) had an advanced radiographic grade of osteoarthritis (Kellgren-Lawrence grade 3 or higher). This dataset is well-suited for our current experiment because the initial study had broad enrollment criteria, making these data applicable to a diverse population and because patients had sufficient variability in radiographic severity of osteoarthritis. All new and returning patients were screened for eligibility. We do not record the percentage of eligible patients who do not participate in cross-sectional surveys, but the rate is typically high (more than 80%). One hundred forty-eight eligible patients started the questionnaires, and 20% (29 of 148) of patients did not complete at least 60% of the questionnaires and were excluded, leaving 119 patients available for analysis. We measured psychologic distress (Patient Health Questionnaire-2 [PHQ-2] and Generalized Anxiety Disorder-2 questionnaire [GAD-2]), unhelpful thoughts about pain (Pain Catastrophizing Scale-4 [PCS-4]), self-efficacy when in pain (Pain Self-Efficacy Questionnaire-2), and capability (PROMIS PF). One of two arthroplasty fellowship-trained surgeons assigned the Kellgren-Lawrence grade of osteoarthritis based on radiographs in the original study. We used a cluster analysis to generate two sets of phenotypes: (1) measures of mental health (PHQ-2, GAD-2, PCS-4) paired with the Kellgren-Lawrence grade and (2) capability (PROMIS PF) paired with the Kellgren-Lawrence grade. We used one-way ANOVA and Kruskal-Wallis H tests to assess differences in capability and self-efficacy and mental health, respectively.

RESULTS

When pairing measures of psychologic distress (PHQ-2 and GAD-2) and unhelpful thoughts (catastrophic thinking) with the grade of radiographic osteoarthritis, six distinct phenotypes arose. These groups differed in terms of capability and pain self-efficacy (for example, mild pathology/low distress versus average pathology/high distress [PROMIS PF, mean ± standard deviation]: 43 ± 6.3 versus 33 ± 4.8; p = 0.003). When pairing the degree of capability (PROMIS PF) with the Kellgren-Lawrence grade, four distinct phenotypes arose. Patients in three of these did not differ in terms of disease severity but had notable variation in the degree of limitations. Patients with these radiologic and capability phenotypes differed in terms of distress and unhelpful thoughts (for example, moderate pathology/low capability versus mild pathology/high capability [PHQ-2, median and interquartile range]: 3 [1 to 5] versus 0 [0 to 0]; p < 0.001).

CONCLUSION

Statistical groupings ("phenotypes") that include both measures of pathology and mental health are associated with differences in symptom intensity and magnitude of incapability and have the potential to help musculoskeletal specialists discern mental and social health priorities. Future investigations may test whether illness phenotype-specific comprehensive biopsychosocial treatment strategies are more effective than treatment of pathology alone.

LEVEL OF EVIDENCE

Level III, prognostic study.