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251C OPYRIGHT Ó 2016BYT HE J OURNALOFB ONEAND J OINTS URGERY, I NCORPORATEDA commentary by Michael Khazzam, MD, islinked to the online version of this article atjbjs.org.Mental Health Has a Stronger Associationwith Patient-Reported Shoulder Pain andFunction Than Tear Size in Patients withFull-Thickness Rotator Cuff TearsJames D. Wylie, MD, MHS, Thomas Suter, MD, Michael Q. Potter, MD, Erin K. Granger, MPH, and Robert Z. Tashjian, MDInvestigation performed at the Department of Orthopaedics, University of Utah, Salt Lake City, UtahBackground: Patient-reported outcome measures have increasingly accompanied objective examination findings in theevaluation of orthopaedic interventions. Our objective was to determine whether a validated measure of mental health (ShortForm-36 Mental Component Summary [SF-36 MCS]) or measures of tear severity on magnetic resonance imaging were morestrongly associated with self-assessed shoulder pain and function in patients with symptomatic full-thickness rotator cuff tears.Methods: One hundred and sixty-nine patients with full-thickness rotator cuff tears were prospectively enrolled. Patientscompleted the Short Form-36, visual analog scales for shoulder pain and function, the Simple Shoulder Test (SST), and theAmerican Shoulder and Elbow Surgeons (ASES) instrument at the time of diagnosis. Shoulder magnetic resonance imagingexaminations were reviewed to document the number of tendons involved, tear size, tendon retraction, and tear surface area. Age,sex, body mass index, number of medical comorbidities, smoking status, and Workers’ Compensation status were recorded.Bivariate correlations and multivariate regression models were calculated to identify associations with baseline shoulder scores.Results: The SF-36 MCS had the strongest correlation with the visual analog scale for shoulder pain (Pearson correlationcoefficient, 20.48; p 0.001), the visual analog scale for shoulder function (Pearson correlation coefficient, 20.33; p 0.001), the SST (Pearson correlation coefficient, 0.37; p 0.001), and the ASES score (Pearson correlation coefficient,0.51; p 0.001). Tear severity only correlated with the visual analog scale for shoulder function; the Pearson correlationcoefficient was 0.19 for tear size (p 0.018), 0.18 for tendon retraction (p 0.025), 0.18 for tear area (p 0.022), and0.20 for the number of tendons involved (p 0.011). Tear severity did not correlate with other scores in bivariatecorrelations (all p 0.05). In all multivariate models, the SF-36 MCS had the strongest association with the visual analogscale for shoulder pain, the visual analog scale for shoulder function, the SST, and the ASES score (all p 0.001).Conclusions: Patient mental health may play an influential role in patient-reported pain and function in patients with full-thicknessrotator cuff tears. Further studies are needed to determine its effect on the outcome of the treatment of rotator cuff disease.Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewedby an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication.Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party insupport of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six monthsprior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is writtenin this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or havethe potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are alwaysprovided with the online version of the article.J Bone Joint Surg Am. 44

252TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RGV O L U M E 98-A N U M B E R 4 F E B R UA R Y 17, 2 016ddOdver the past twenty years, the evaluation of clinicalresults after surgical intervention has trended awayfrom using only clinician-centered objective measuresand toward including patient-reported outcome scales; currently,there are more than twenty patient-reported questionnaires formeasuring shoulder pain, function, and shoulder-specific healthrelated quality of life1. With many questionnaires from which tochoose, investigators must determine which is most appropriatefor their chosen research question. Given the movement towardpatient-reported outcomes to evaluate the results of shouldersurgical procedures, it is important to understand how psychosocial factors and objective clinical measures of pathology relateto and influence patients’ self-assessment of pain, function, anddisability.Multiple measures of mental health have been shown tonegatively correlate with patient-reported shoulder pain andfunction. Patients with shoulder pathology and high scoreson the Distress Risk Assessment Method (DRAM)2, HospitalAnxiety and Depression Scale (HADS)3, or Center for Epidemiological Studies Depression scale (CESD) questionnaires4report worse shoulder pain on a visual analog scale (VAS) andinferior Simple Shoulder Test (SST), Disabilities of the Arm,Shoulder and Hand (DASH) questionnaire, and AmericanShoulder and Elbow Surgeons (ASES) scores compared withnon-distressed patients. Similarly, an inferior Short Form-36Mental Component Summary (SF-36 MCS) score has beenshown to be a significant negative predictor of the PennsylvaniaShoulder Score in patients with rotator cuff tears or shoulderarthritis5.Commonly used measures of rotator cuff tear severityinclude the size of the tear from anterior to posterior, thenumber of tendons involved in the tear, the distance thatthe tendon edge has retracted, and the degree of atrophy of theinvolved muscles. However, the correlation of these measureswith patient self-assessment of shoulder pain and functionis variable. For patients with full-thickness rotator cuff tears,Dunn et al. found that tear severity did not correlate with painat preoperative evaluation6. Similarly, tear size and tendon retraction did not correlate with preoperative ASES or WesternOntario Rotator Cuff Index scores in other studies. Patientswith massive tears (defined as three-tendon involvement) didreport lower ASES scores than patients with isolated supraspinatus tears7. By contrast, a number of patient characteristics other than tear morphology, including sex, level ofeducation, shoulder range of motion, number of medicalcomorbidities, and body mass index (BMI), have been shownto influence preoperative shoulder health-related quality-oflife measures5,7-10.Given the uncertain relationship among objective pathology, mental health, and self-reported shoulder outcomescores, we aimed to determine which factors are associated withpreoperative VAS for shoulder pain and function and SST andASES scores for patients with full-thickness rotator cuff tears.We hypothesized that mental health as assessed by the SF-36MCS would show a stronger association with patient-reportedshoulder measures than tear morphology on magnetic resonanceM E N TA L H E A LT H A N D P AT I E N T - R E P O R T E D S H O U L D E R P A I NF U N C T I O N I N R O TAT O R C U F F T E A R SANDimaging (MRI). We also hypothesized that morphological tearseverity would be more highly correlated with patient-assessedVAS for shoulder function than with the VAS for pain, SST score,or ASES score.Materials and MethodsStudy DesignPatients diagnosed with symptomatic full-thickness rotator cuff tears onshoulder MRI were prospectively enrolled. Our institutional review boardapproved the study before enrollment commenced. All patients were enrolledby a single surgeon (R.Z.T.) between September 2009 and July 2014. The studywas compliant with the Health Insurance Portability and Accountability Act(HIPAA). Inclusion criteria were patient age of eighteen years or older, an MRIconfirmed full-thickness rotator cuff tear, and documentation of a completepre-treatment evaluation. Exclusion criteria were patient age of younger thaneighteen years, partial-thickness rotator cuff tears on MRI, pregnancy, Spanishas the primary language, a diagnosis of rotator cuff tear arthropathy, or anincomplete patient evaluation as described below.Patient EvaluationOn enrollment, patients completed SF-36, VAS for shoulder pain, VAS forshoulder function, SST, and ASES evaluation forms. The SF-36 measures eightspecific domains of general health-related quality of life and two compositescores, the Physical Component Summary (PCS) and the MCS. The mean score(and standard deviation) in the general non-patient population is 50 1011,12points. Higher scores correspond to better health-related quality of life. TheMCS was chosen as a validated measure of patients’ mental health that couldimpact shoulder-specific health-related quality of life.The VAS for pain measures pain from the affected shoulder from 0 to 10points, with 0 points representing no pain at all and 10 points representing painas bad as it can be. The VAS for shoulder function measures the function of theaffected shoulder on a scale from 0 to 10 points, with 0 points indicating thatthe patient can use the shoulder easily and 10 points indicating that the patientcannot use the shoulder at all. The SST is a patient-reported outcome measurethat asks the patient ten yes-or-no questions about the ability to performfunctions with the shoulder and activities of daily living and two questionsabout the comfort (pain) level in the shoulder. Each response of yes is given131 point, with higher scores representing better shoulder function . The ASESTABLE I Distribution of Patient-Reported Shoulder Measuresand Measures of Rotator Cuff Tear Severity*Patient-Reported Outcome MeasureResult†VAS pain (points)4.8 2.8 (0 to 10)VAS function (points)5.6 2.5 (0 to 10)SST score (points)4.4 3.1 (0 to 12)ASES score (points)47.5 21.6 (5 to 98.3)SF-36 MCS score (points)48.2 12.2 (17 to 72)MRI measures of tear severityTear size (cm)2.7 1.4 (0.7 to 7.5)Tendon retraction (cm)2.4 1.3 (0.2 to 6.0)Tear area (cm2)7.7 7.5 (0.3 to 33.2)*The mean number of tendons torn was 1.6; 91 patients (54%) hadone torn tendon, 62 patients (37%) had two torn tendons, and 16patients (9%) had three torn tendons. †The values are given as themean and the standard deviation, with the range in parentheses.