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Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and
semantic analyses of recommendations
Patrick Doiron-Cadrin, PT, M.Sc., Simon Lafrance, PT, M.Sc, Marie Saulnier, PT,
M.Sc., Émie Cournoyer, B.Sc., Jean-Sébastien Roy, PT, Ph.D., Joseph-Omer
Dyer, PT, Ph.D., Pierre Frémont, MD, Ph.D., Clermont Dionne, OT, Ph.D., Joy C.
MacDermid, PT, Ph.D., Michel Tousignant, PT, Ph.D., Annie Rochette, OT, Ph.D.,
Véronique Lowry, PT, M.Sc., Nathalie J. Bureau, MD, M.Sc., Martin Lamontagne, MD,
Marie-France Coutu psy, Ph.D., Patrick Lavigne, MD, François Desmeules, PT, Ph.D.
PII: S0003-9993(20)30030-7
DOI: https://doi.org/10.1016/j.apmr.2019.12.017
Reference: YAPMR 57759
To appear in: ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 10 December 2019
Accepted Date: 12 December 2019
Please cite this article as: Doiron-Cadrin P, Lafrance S, Saulnier M, Cournoyer É, Roy J-S, Dyer J-O,
Frémont P, Dionne C, MacDermid JC, Tousignant M, Rochette A, Lowry V, Bureau NJ, Lamontagne M,
Coutu psy M-F, Lavigne P, Desmeules F, Shoulder rotator cuff disorders: a systematic review of clinical
practice guidelines and semantic analyses of recommendations, ARCHIVES OF PHYSICAL MEDICINE
AND REHABILITATION (2020), doi: https://doi.org/10.1016/j.apmr.2019.12.017.
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© 2020 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine
RC DISORDERS GUIDELINES SYSTEMATIC REVIEW
Shoulder rotator cuff disorders: a systematic review of clinical

practice guidelines and semantic analyses of recommendations
Patrick Doiron-Cadrin PT, M.Sc.1, Simon Lafrance PT, M.Sc.1, Marie Saulnier, PT, M.Sc.1, Émie Cournoyer
B.Sc.1, Jean-Sébastien Roy PT, Ph.D.2, 3, Joseph-Omer Dyer PT, Ph.D.4, Pierre Frémont MD, Ph.D.2,
Clermont Dionne OT, Ph.D. 2, 5, Joy C. MacDermid PT, Ph.D.6, Michel Tousignant PT, Ph.D.7, Annie
Rochette OT, Ph.D.4, 8, Véronique Lowry PT, M.Sc.1, Nathalie J. Bureau MD, M.Sc.9, 10, Martin
Lamontagne MD11, Marie-France Coutu psy, Ph.D.13, Patrick Lavigne, MD 1, 14, François Desmeules PT,
Ph.D.1, 4
1. Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada
2. Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
3. Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Quebec City, Quebec, Canada
4. School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
5. Centre de recherche du CHU de Québec - Université Laval, Quebec City, Quebec, Canada
6. School of Physical Therapy, Western University, London, Ontario, Canada
7. School of Rehabilitation, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada
8. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, Quebec, Canada
9. Department of Radiology, Oncology and Nuclear Medicine, Faculty of Medicine, University of Montreal, Montreal, Quebec,
Canada
10. University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
11. Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
12. School of Public Health, University of Montreal, Montreal, Quebec, Canada
13. Centre for Work Disability Prevention and Rehabilitation (CAPRIT), Charles-Le Moyne Hospital Research Centre affiliated with
Université de Sherbrooke, Longueuil, Canada
14. Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
Corresponding author: François Desmeules, PT, Ph. D.

University of Montreal
Maisonneuve-Rosemont Research Centre
5415, boulevard de l’Assomption
Montréal (Québec) H1T 2M4
Canada : f.desmeules@umontreal.ca
FUNDING:
This project was financially supported by the Institut de recherche Robert-Sauvé en santé et en
sécurité du travail (# 2016-0029). The funding source had no involvement in study design; in the
collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit
the article for publication.
2019-12-08 1
1 Shoulder rotator cuff disorders: a systematic review of clinical

2 practice guidelines and semantic analyses of
3 recommendations
4
5 ABSTRACT
6
7 Objectives: To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of
8 specific clinical recommendations for the management of rotator cuff disorders in adults.
9
10 Data sources: A systematic bibliographic search was conducted up until May 2018 in Medline, Embase
11 and PeDro databases, in addition to twelve clinical guidelines search engines listed on the AGREE Thrust
12 website.
13
14 Study selection: Nine CPGs on the management of rotator cuff disorders in adults and/or workers,
15 available in English or French and published from January 2008 onward, were included and screened by
16 two independent reviewers.
17
18 Data extraction: CPGs methodology was assessed with the AGREE II tool. A semantic analysis was
19 performed to compare the strength of similar recommendations based on their formulation. The
20 recommendations were categorized in a standardized manner considering the following four levels:
21 “Essential”, “Recommended”, “May be recommended” and “Not recommended”.
22
23 Data synthesis: Methodological quality was considered high for three CPGs and low for six. All CPGs
24 recommended active treatment modalities, such as an exercise program in the management of rotator
25 cuff disorders. Acetaminophen and/or NSAIDs prescription and corticosteroid injections were presented
26 as modalities that may be recommended to decrease pain. Recommendations related to medical
27 imagery and surgical opinion varied among the guidelines. The most commonly recommended return to
28 work strategies included intervening early, use of a multidisciplinary approach and adaptation of work
29 organization.
30
31 Conclusions: Only three CPGs were of high quality. The development of more rigorous CPGs is
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32 warranted.
33
34 KEYWORDS
35 Rotator Cuff, Evaluation, Treatment, Tendinopathy, Tendon Tear, Return-to-Work, Systematic Review,
36 Qualitative Analysis, Shoulder Impingement Syndrome, Shoulder pain
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37 LIST OF ABBREVIATION
38 CPGs: Clinical practice guidelines
39 GRADE: Grading of Recommendations Assessment, Development, and Evaluation
40 MRI: Magnetic resonance imaging
41 NSAID: Nonsteroidal anti-inflammatory drug
42 NHMRC: National Health and Medical Research Council
43 RC: Rotator cuff
44 RTW: Return to work
45 SIGN: Scottish Intercollegiate Guidelines Network
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46 Rotator cuff (RC) disorders are the most frequent group of pathologies affecting the shoulder
47 and represent 50% to 85% of shoulder conditions treated by health professionals (1). This group of
48 pathology includes tendinopathies, partial tears and full-thickness tears of one or more tendons of the
49 rotator cuff (2).
50 The point prevalence of shoulder pain varies from 6.9 to 26% in the general population and
51 increases with aging (3). The prevalence of RC abnormalities in the general population increase with
52 aging, reaching an estimate of 31% in adults between 60 and 69 years old and 65% in adults overs 80
53 years old (4). Without appropriate care, individuals with rotator cuff disorders are subject to persistent
54 pain over time (5). This situation highlights the importance of establishing a rapid and valid diagnosis,
55 while offering the best available evidence-based care to individuals of working age presenting with such
56 conditions.
57 Clinical practice guidelines (CPGs) have been developed for the treatment of rotator cuff
58 disorders in adults (6-14). CPGs are generally referred as “systematically developed statements to assist
59 practitioner decisions about appropriate health care for specific clinical circumstances” (15). While CPGs
60 offer a convenient way to transfer scientific knowledge into clinical practice for healthcare practitioners,
61 adherence to their content and recommendations remains suboptimal (16, 17).
62 Barriers to the uptake of clinical recommendations include, the use of weak or conflicting
63 evidence, the lack of applicability and ambiguous formulation have already been identified (18). In
64 addition, the methodological quality of clinical guidelines has been shown to vary widely from an
65 organization to another (19, 20) and conflicting recommendations on a same topic can be a source of
66 confusion for health-care providers, patients and stakeholders (21-23). Nonetheless, multiple systems to
67 grade evidence are currently used by authoring organizations to classify the strength and/or the level-of-
68 evidence underlying clinical recommendations, while other institutions simply do not present grading
69 scales at all (24). Comparing clinical recommendations from different publications can thus represent a
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70 challenge. Qualitative thematic analysis of recommendations, based on the choice of semantic fields for
71 the formulation of recommendations rather than on a specific scale, can be helpful to overcome this
72 obstacle (25).
73 The aim is therefore to systematically review and critically appraise recent CPGs developed for
74 the management of rotator cuff disorders in adult, including evaluation, conservative and surgical
75 treatments as well as return to work strategies and to synthesize, through a semantic analysis current
76 evidence regarding the most consensual recommendations for rotator cuff disorders in adults.
77
78 METHODS
79 Identification, Selection of Guidelines and Quality Appraisal
80 A systematic bibliographic search was conducted up until May 2018, in Medline, Embase and
81 PeDro databases, in addition to twelve clinical guidelines search engines listed on the AGREE Thrust
82 website (see Figure 1). The keywords “shoulder”, “tendinopathy”, “rotator cuff”, “shoulder girdle”,
83 “upper limb” and “guidelines” were used to identify clinical guidelines (exact search is presented in
84 supplementary material). A manual search was also conducted through the identified guidelines
85 reference lists. Inclusion criteria for the clinical guidelines were: 1-containing recommendations on the
86 evaluation, treatment and/or return-to-work of adults or workers presenting a rotator cuff disorder; 2-
87 published recently (from January 2008 onward); 3- available in English or French. Clinical guidelines with
88 an exclusive scope on other shoulder pathologies such as adhesive capsulitis, shoulder fractures, labral
89 tears, arthritis or other shoulder disorders were excluded.
90 References were retrieved from databases and duplicates were removed. Two reviewers (PDC
91 and MS) screened titles and abstracts from the reference list in order to assess eligibility for inclusion.
92 Full texts were retrieved and assessed (PDC and MS). Reference lists from full-text documents were
93 checked for relevant citations. In case of disagreement, a consensus was reached between the pair of
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94 reviewers at all stages process. When two or more guidelines from the same organization and the same
95 committee were identified, only the most recent was included.
96 Clinical guidelines characteristics were extracted by two reviewers (PDC and SL), using a
97 standardized form documenting titles, organizations, year of publication, reported objectives and
98 presence of recommendations specifically targeted to injured workers. Methodological elements such as
99 the professional groups involved, the presence of a systematic review of the literature, the declaration of
100 competing interests, the description of the methods to formulate the recommendations, the presence of
101 an explicit link between the scientific evidence and the recommendations, and the presence of an
102 external revision process were also compiled.
103 Clinical guidelines methodological quality was assessed by pairs of reviewers (PDC, EC, MS, SL)
104 based on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The AGREE II
105 appraisal tool comprises 23 key items rated on a 7-point scale (1—Strongly disagree to 7—Strongly
106 agree). The items are summarized in six domains (Scope and Purpose, Stakeholder involvement, Rigour
107 of Development, Clarity of Presentation, Applicability, and Editorial Independence). This validated tool
108 has been widely used to evaluate the methodology quality of clinical guidelines worldwide (26). The final
109 score for each clinical guideline was obtained by means between pairs of reviewers as recommended by
110 the AGREE instrument methodology (27).
111
112 Semantic Analysis and Synthesis of Recommendations
113 Clinical recommendations were extracted from the clinical guidelines, coded and pooled by a
114 reviewer (PDC) into nine categories: clinical evaluation, medical imaging, medication for RC
115 tendinopathy, medication for RC full-thickness tears, rehabilitation modalities for RC tendinopathy,
116 rehabilitation modalities for RC full-thickness tears, surgical interventions for RC tendinopathy, surgical
117 interventions for RC full-thickness tears and return-to-work strategies for all RC disorders. The categories
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118 were then refined and confirmed by a second reviewer (SL).
119 A semantic analysis was performed to compare the strength of similar recommendations based
120 on their formulation (28, 29). The recommendations were categorized according to their strength in a
121 standardized manner considering the following four levels: “Essential”, “Recommended”, “May be
122 recommended” and “Not recommended” (see Table 1). The analysis was based on the semantic fields for
123 the terms “obligation”, “recommendation” and “possibility” for the recommended activities, modalities
124 or strategies (30, 31). All the non-recommended activities, modalities or strategies were categorized as
125 “not recommended” (Table 1).
126 All recommendations presented in the included CPGs, as well as the accompanying explanations,
127 were subject to the semantic analysis and a second reviewer (SL) validated data results. A consensus was
128 needed between reviewers; a third reviewer was available to discuss any disagreement.
129
130 RESULTS
131 Included Guidelines Characteristics
132 Ten clinical guidelines were identified during the systematic review (6, 7, 9, 11, 14, 32-36). One
133 guideline was later excluded because the complete version was only available in Danish (36). Data were
134 extracted from the remaining nine guidelines (Figure 1). All the guidelines were published between 2008
135 and 2015 in English, seven guidelines covered clinical evaluation activities or strategies (7, 9, 11, 14, 32-
136 34), eight guidelines covered medical imaging prescriptions (7, 9, 11, 14, 32-35), seven guidelines
137 covered medication prescriptions, rehabilitation modalities and surgery or surgical techniques (6, 7, 9,
138 11, 14, 32, 35), and six guidelines contained recommendations on return to work strategies (7, 9, 11, 14,
139 32, 35).
140 The CPGs characteristics and AGREE II composite domain scores are presented in table 2. Three
141 CPGs were considered of high methodological quality (6, 9, 33) while six were considered of lower
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142 methodological quality (7, 11, 14, 32, 34, 35). A systematic review of the relevant literature was involved
143 in the development of seven guidelines (6, 7, 9, 14, 32, 33, 35). An explicit link between the scientific
144 evidence and the recommendations was present in four guidelines (6, 7, 9, 33). Three guidelines included
145 a declaration of conflicting interests, involved a systematic consultation of stakeholders and explicitly
146 stated that an external revision process was performed (6, 9, 33).
147
148 Assessment of Shoulder Pain
149 Thirteen clinical evaluation activities or strategies were identified in seven guidelines (9, 11, 14,
150 32-35). Taking a medical history, performing a physical examination, identifying red and yellow flags,
151 measuring shoulder range of motion and strength and using validated questionnaires to assess patient’s
152 condition were considered essential elements or were recommended in all guidelines. Using shoulder
153 specific clinical tests and contacting an interpreter if needed were either “recommended” or “may be
154 recommended”, while performing a functional capacity evaluation and use of local anesthetic injections
155 in the subacromial space for diagnostic purpose were considered as “may be recommended”, when the
156 subject was covered.
157
158 Medical Imaging for Rotator Cuff Disorders
159 Prescribing radiography for the initial assessment or during the follow-up of patients, diagnostic
160 ultrasound, magnetic resonance (MRI) and magnetic resonance arthrography (MRA) were considered as
161 “may be recommended”, when the subject was covered. Radiography was indicated at initial
162 consultation in the presence of a history of trauma (14, 32, 33) or if a diagnosis other than a RC disorder
163 was suspected after the clinical evaluation (9, 11, 14). At the follow-up, conventional radiography was
164 “recommended” in the absence of improvement after an adequate conservative treatment when
165 reviewed (7, 9, 11, 32, 33, 35). Diagnostic ultrasound was “recommended” in the absence of
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166 improvement after conservative care (7, 11, 32, 33, 35), if there is a “lack of access to MRI” (9) or to
167 “rule-out a RC tear” in one guideline (32). MRI was “recommended” in the absence of improvement after
168 conservative care (9, 11, 32, 33), prolonged refractory or unexplained pain (34), significant weakness on
169 shoulder elevation or rotation (35), suspected RC tear (14) or if diagnostic ultrasound was inconclusive
170 (7). MRA was recommended to investigate a possible intra-articular lesion or an associated
171 glenohumeral instability (7, 11, 34, 35), for suspected partial RC tear (7, 34) or if the diagnosis was not
172 identified with standard imagery techniques (35).
173
174 Medication for Rotator Cuff Tendinopathy
175 Thirteen activities related to medication prescriptions for RC tendinopathy were identified
176 among a total of seven guidelines (6, 7, 9, 11, 14, 32, 35). Four guidelines did cover the prescription of
177 acetaminophen, which was “recommended” for mild or moderate pain in two guidelines (9, 11) and
178 “may be recommended” without specific indications in two others (14, 35). Seven guidelines covered
179 and considered the prescription of NSAIDS as “may be recommended” for the treatment of shoulder
180 pain without specific indications (6, 7, 9, 11, 14, 32, 35).
181 Corticosteroids injections were considered as “may be recommended” in all guidelines, when
182 reviewed, but indications varied substantially: in the presence of persistent pain after a conservative
183 treatment (7, 9), if there is a “positive response” to a diagnostic analgesic injection (11), in the absence
184 of response to “manual methods” (32) or was considered as “may be recommended” without any
185 specific indications in two guidelines (14, 35). Patient education regarding the prescribed medication was
186 recommended in three guidelines, but the content of the information to provide was not specified (7, 11,
187 35).
188
189 Medication for Rotator Cuff Full-Thickness Tear
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190 Eleven activities related to medication prescriptions for RC full-thickness tears were identified
191 among a total of six guidelines (6, 9, 11, 14, 32, 35). Acetaminophen prescription was “recommended” in
192 two guidelines (9, 11) and as “may be recommended” without further details in two others (14, 35).
193 Indications for various medications varied substantially from a publication to another. Tramadol
194 was as “may be recommended” for “patients without prior opioid addiction” in one guideline (35) and if
195 there is “no response to manual methods” in another one (11). Opioids were as “may be recommended”
196 if regular assessments are possible, in one guideline (9), and in the presence of severe upper extremity
197 pain, in another one (35). Hypnotics were considered as “may be recommended” in case of sleep
198 disorders in two guidelines (11, 35)}. Muscle relaxant and anti-anxiety medications were covered in two
199 guidelines and subject to conflicting recommendations (not recommended vs. may be recommended)
200 (11, 35). Patient education regarding the prescribed medication was “recommended” in two guidelines,
201 but the content of the information to be provided was not specified (11, 35).
202 Corticosteroids injections were considered as “may be indicated” in a case of persistent pain
203 after an adequate conservative treatment (9) and in the “absence of response to manual methods” (32).
204
205 Rehabilitation Modalities for Rotator Cuff Tendinopathy
206 Sixteen rehabilitation modalities or treatment approaches were identified among a total of
207 seven guidelines and exercise prescription was recommended in all of them (6, 7, 9, 11, 14, 32, 35).
208 Manual therapy modalities and psychosocial interventions were “recommended” or “may be
209 recommended” in a total of six guidelines (7, 9, 11, 14, 32, 35). Heat or cold applications, acupuncture,
210 TENS and using a multidisciplinary approach were reviewed in a total of six guidelines and defined as
211 “may be recommended” in all of them (6, 7, 9, 11, 32, 35). Taping, microwave diathermy and laser were
212 “not recommended” and reviewed in two guidelines (11, 35).
213
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214 Rehabilitation Modalities for Full-Thickness Rotator Cuff Tear
215 Fourteen rehabilitation modalities or treatment approaches were identified among a total of five
216 guidelines. Exercise prescription was “recommended” in three guidelines (9, 11, 14) and as “may be
217 recommended” in another one (35). Manual therapy modalities were “recommended” in one guideline
218 (14) and were as “may be recommended” in three others (9, 11, 35). Heat or cold applications,
219 acupuncture, therapeutic ultrasound, TENS, psychosocial interventions and using a multidisciplinary
220 approach were classified as “may be recommended” in three guidelines (9, 11, 35).
221
222 Interventions Related to Surgery or Other Medical Interventions for Rotator Cuff
223 Tendinopathy
224 Seven interventions related to surgery and surgical approaches were identified among a total of
225 six guidelines (7, 9, 11, 14, 32, 35). Referring for a surgical opinion was “recommended” in five
226 guidelines in varied circumstances: in the presence of a “significant activity limitation, participation
227 restriction and/or persistent pain after a nonsurgical treatment of three months” (9), in the “absence of
228 improvement after a three to six-month rehabilitation program” (35), if “pain is worsening after three to
229 six weeks or in the presence of inadequate improvement at 7-8 weeks” (32), if “no improvement with 6
230 weeks of conservative intervention and rehabilitation program” (11) and if “no improvement with
231 conservative intervention and rehabilitation program” (14). Acromioplasty was considered as an
232 intervention that may be indicated after an active rehabilitation program in three guidelines (11, 14, 35).
233 Recommendations for percutaneous lavage were present in four guidelines and were “may be indicated”
234 in the absence of improvement after conservative care in three guidelines (9, 14, 35), and without
235 additional details in another one (7). Both open and arthroscopic surgery approaches for the treatment
236 of RC tendinopathy were “recommended” in all four guidelines covering the subject (7, 9, 32, 35).
237 Platelet-rich plasma injections in the treatment of RC tendinopathy were considered as “may be
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238 recommended” in one guideline (35) and were “not recommended” as a treatment in another one (32).
239
240 Interventions Related to Surgery for Rotator Cuff Full-Thickness Tear
241 Ten interventions related to surgery and surgical approaches were identified among a total of six
242 guidelines (7, 9, 11, 14, 32, 35). Referring for a surgical opinion was “recommended” in all six guidelines,
243 but in various circumstances: “in the presence of a full-thickness tear” (6, 9, 11), in the presence of an
244 “acute full-thickness RC tear of >1 cm or no response to a conservative treatment for tears <1 cm” (35), if
245 a RC tear is suspected with no response to four to six weeks of “manual methods” (32) and in the
246 presence of a symptomatic full-thickness RC tear or after a conservative treatment in the presence of a
247 chronic tear and for patients of 65 years and older (14). Performing an acromioplasty in conjunction with
248 a RC repair was “not recommended” in all three guidelines covering the subject (6, 14, 35). Performing a
249 RC repair by single vs. double rows, or by open surgery vs. arthroscopy were equally recommended in
250 three guidelines (9, 14, 35). Performing a graft was also “not recommended” based on recommendations
251 in two guidelines (14, 35).
252
253 Return-to-Work Strategies for Rotator Cuff Disorders
254 Eleven interventions or strategies related to return to work (RTW) were identified among a total
255 of six guidelines (7, 9, 11, 14, 32, 35). The most commonly recommended return to work strategies
256 included intervening early, use of a multidisciplinary approach and adaptation of work organization.
257 Intervening early, establishing a RTW plan using shared decision-making process, maintaining
258 communication between the worker and the employer, establishing realistic goals for RTW were
259 “recommended” or considered “essential” in all guidelines that covered the subject (9, 11, 14, 35). All
260 other interventions or strategies were either “recommended”, or “may be recommended”, when
261 covered and details of these interventions are presented in the Supplementary Material (7, 9, 11, 14, 32,
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262 35).
263
264 DISCUSSION
265 The aim of this systematic review was to systematically review and critically appraise recent CPGs
266 developed for the management of rotator cuff disorders in adults, including evaluation, conservative and
267 surgical treatments. To our knowledge, this review is the first to use a semantic analysis approach to
268 synthesize the published recommendations for this population.
269 Among the guidelines identified through our systematic search, publications from three
270 organizations stood out for their methodological quality: the University of New South Wales (9), the
271 American Academy of Orthopaedic Surgeons (6) and the National University of Health Sciences (33)
272 guidelines. The development process for those clinical guidelines included systematic reviews and
273 consultation of the stakeholders, presented a statement on conflicts of interests and explicit methods for
274 formulating the recommendations, in addition to an external review. Those three guidelines also
275 systematically tended to score higher for all the other AGREE II domains. Some of the AGREE domains,
276 like “Applicability”, “Development” and “Independence”, systematically presented very low scores
277 among the other guides.
278 Concerns about the overall methodological quality of clinical guidelines have been raised before
279 (37). This review tends to demonstrate that improvements in clinical guideline development and
280 publication process are still to be expected nowadays for the guidelines covering the evaluation, the
281 treatment and the return-to-work of adults presenting a RC disorder.
282 The qualitative analysis presented in this systematic review underlines that many of the currently
283 published recommendations covering evaluation, treatment or return-to-work strategies with adults
284 presenting a RC disorder are often inconsistent. Some interventions were, however, recommended on a
285 more consensual basis, such as all clinical evaluation activities, which were either considered “Essential”,
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286 “Recommended” or “May be recommended”, although the exact content of a valid physical examination
287 was not precisely defined. Prescribing exercise for the treatment of RC tendinopathy and RC full-
288 thickness tear was universally recommended among the guidelines covering this subject. Manual therapy
289 was either considered “recommended” or “may be recommended”, theses recommendations are in line
290 with the results of a systematic review published by Desjardins-Charbonneau et al., (38) which concluded
291 that manual therapy may decrease pain in adults with RC tendinopathy. In the same order of ideas, a
292 Cochrane review reported that the effect of manual therapy and exercise may be similar to those of
293 corticosteroid injections and subacromial decompression surgery, but may not lead to clinically
294 important effect when compared to a placebo (39). In all guidelines, prescribing acetaminophen, NSAIDS
295 and corticosteroid injections were presented as “may be recommended” options for the treatment RC
296 tendinopathy and RC full-thickness tear. The effect of platelet-rich plasma injections in the treatment of
297 RC tendinopathy remained unclear. A meta-analysis reported that platelet-rich plasma injections
298 significantly reduce pain and disability when compared to a placebo injection or to dry needling (40).
299 However, this review only included two RCTs on RC tendinopathy and could not conclude if the effect
300 was clinically important or not.
301 Regarding surgical interventions, performing an acromioplasty for the treatment of RC
302 tendinopathy was presented as a treatment option after the failure of conservative treatments,
303 however, it is important to highlight that these CPGs were published before two RCTs that report no
304 benefit of arthroscopic subacromial decompression compared to a placebo surgery and no clinically
305 important difference when compared to no intervention or exercise therapy (41, 42). Routine
306 acromioplasty during a RC repair was universally not recommended. Single row sutures, double row
307 sutures, open approach and arthroscopy were presented as equally effective in all guidelines for the
308 reparation of RC full-thickness tears. All the identified return-to work strategies were either
309 “Recommended” or “May be recommended” in all guidelines that covered the subject.
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310 On the other hand, other recommendations were subject to high heterogeneity across the
311 retrieved guidelines. For instance, indications for medical imaging tests like radiography, diagnostic
312 ultrasound, MRI and MRA varied among CPGs. This could be explained by comparable diagnostic
313 capabilities among diagnostic ultrasound, MRI and MRA for RC tear, with slightly higher sensitivity and
314 sensibility for MRA (43). Indications to refer for a surgical opinion also varied among the CPGs, which
315 could be explained by a lack of evidence regarding surgical indications for RC disorders (44-46).
316 Therapeutic ultrasounds were “may be recommended” for the treatment of RC tendinopathy in some
317 guidelines, and “not recommended” in others. Those conflicting recommendations can render the
318 clinical decision-making process rather difficult for the healthcare professionals.
319 Another issue is the use of multiple scales to appraise the quality of the evidence and the
320 strength of recommendations such as National Health and Medical Research Council (NHMRC),
321 Scottish Intercollegiate Guidelines Network (SIGN), or Grading of Recommendations Assessment,
322 Development, and Evaluation (GRADE) scales. This situation clearly represents a challenge even if several
323 guidelines gave adequate information on the utilization of the appraisal scales. Still, four of the retrieved
324 guidelines in this review do not explicitly state a standardized appraisal scale (11, 14, 32, 34). This
325 impediment has been encountered by authors of other clinical guidelines systematic reviews and
326 creative approaches, such as creating a new scale or converting the recommendations to a unified level
327 of evidence grading scale, have been employed (19, 22). The qualitative thematic analysis presented in
328 this systematic review allowed a comparison between the complete set of currently published
329 recommendations, which would not have been possible otherwise. Similar approaches to ours, based on
330 an analysis of the formulation rather than a strength-of-recommendation or level-of-evidence scale, has
331 been used in previous clinical guidelines systematic reviews (47, 48).
332 Those findings thus underline an urge for standardizing and simplifying the formulation of clinical
333 recommendations among authoring organizations. While clinical guidelines aim to “assist practitioner
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334 and patient decisions about appropriate healthcare for specific clinical circumstances” (15), an explicit
335 link between scientific evidence and recommendations remains essential to allow clinicians, stakeholders
336 and consumers to evolve in an evidence-based practice framework (49). Furthermore, ambiguous
337 recommendation formulations, such as “It is recommended that by using patient feedback and response
338 as a guide, increasing grades of amplitude may be applied” (32), were present in several guidelines and
339 could be confusing for the reader. It has been demonstrated that recommendations formulated in a
340 simple manner are associated with a better uptake by clinicians (50). Clinical recommendations should
341 thus be formulated in that sense.
342 Furthermore, most of the identified guidelines were based on a biomedical model. Several
343 studies and systematic reviews have recognized the effectiveness and cost-effectiveness of
344 interdisciplinary interventions that included support during return to work (51-55). Work disability field
345 literature also highlights the importance of communication between patients and healthcare
346 professionals, as it can influence the recovery trajectory for injured workers (56). Surprisingly, such
347 interventions were scarcely covered and discussed in the retrieved guidelines.
348 This review presents many strengths, among which an extensive systematic search in three
349 major scientific databases, in addition to twelve other guideline databases and medical societies’
350 websites. The validated AGREE II appraisal instrument was also used to compare the methodological
351 quality between the guidelines. Since no cut-off score has been identified for the AGREE II instrument,
352 methodological items were extracted from the different domains to allow an objective comparison of
353 the identified guidelines.
354 Our review also presents some limits. Since only guidelines published in English or French were
355 retained, other relevant publications could have been missed. The excluded guideline by the Danish
356 Authority is an example of this limitation (36). The fact that only two reviewers appraised the
357 methodological quality of the guidelines could also potentially impact the results, since concerns about
2019-06-03 16
358 inter-reviewer fidelity have been raised for the AGREE instrument (24). Likewise, no verification upon the
359 quality or the sources for the scientific evidence underlying the clinical recommendations was sought.
360 Variations in the evidence could explain some discrepancies between the recommendations presented in
361 the included guidelines, but those analyses would not have been possible for all of them due to a lack of
362 methodological information and transparency.
363
364 CONCLUSIONS
365 In this systematic review, a qualitative thematic analysis was used to compare recommendations
366 from nine clinical guidelines on the evaluation, treatment and the return-to-work of adults presenting a
367 shoulder RC disorder. Three clinical guidelines were considered of high methodological quality, while six
368 were considered of lower methodological quality. Prescribing exercise for the treatment of RC
369 tendinopathy was universally recommended. All identified clinical evaluation activities and all return-to-
370 work strategies were presented as modalities that may be recommended for that population. Indication
371 for medical imagery (radiography, diagnostic ultrasounds and MRI) and surgical opinion varied among
372 the guidelines. Since this can be confusing for healthcare professionals there is a need to standardize the
373 way clinical recommendations are formulated. The same applies to the reporting for strength and level
374 of evidence among guidelines. Enhancing the clinical guideline development process regarding the
375 applicability, the development and the declaration of competing interests are mandatory in order to
376 allow the health-care professionals to fully appraise and uptake their content.
377
378
379 AUTHORS’ CONTRIBUTIONS:
380 PDC designed the study protocol, performed the literature search, selected the articles of interest,
2019-06-03 17
381 performed the risk-of-bias analysis, extracted the data, led the interpretation of results, and wrote the
382 manuscript. SL participated in the selection of the articles, risk-of-bias analysis, data extraction, results
383 interpretation and writing the manuscript. MS and EC participated in risk-of-bias analysis, data extraction
384 and writing of the manuscript. JSR, JOD, PF, CD, MT, AR, VL, NJB, ML, MFC participated in the protocol
385 design, interpretation of results and reviewed the article. JCM participated in the protocol design and
386 reviewed the article. PL participated in the interpretation of results and reviewed the article. FD
387 participated in the design, interpretation of results, writing of the manuscript, managed the project and
388 is the corresponding author.
389
390
391 COMPETING INTERESTS
392 The authors declare that they have no competing interests.
393
394
395 WORD COUNT: 4181 words
2019-06-03 18
396 TABLES AND FIGURES
397 Figure 1: Flow diagram for the systematic review selection progress
398
399 Table 1: Thematic classification for the clinical recommendations in the included guidelines
400 Table 2: Clinical guidelines characteristics
401
402 Supplementary material 1: Clinical guidelines recommendations summary
403 Supplementary material 2: Complete AGREE II scores for the retrieved guidelines
404 Supplementary material 3: Systematic review search strategies for scientific databases
405
406
2019-06-03 19
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2019-06-03 23
Records identified through Records identified through medical societies and guidelines
scientific databases databases proposed by the AGREE thrust
Medline (n=288)
Embase (n=358) National Guideline Clearinghouse (n=90)
Pedro (n=24) National Institute for Health and Care Excellence (n=250)
Canadian Medical Association (n=3)
Identification
Scottish Intercollegiate Guideline Network (n=57)

National Health and Medical Research Council (n=2)
eGuidelines (MGD Ltd.) (n=1)
Guidelines-International-Network (n=312)
TRIP database (n=362)
Royal Dutch Society for Physical Therapy (n=15)
Ministry of Health – New Zealand (n=0)
Records after duplicates American Academy of Orthopaedic Surgeons (n=27)
removed GuidelineCentral (n= 67 566 results, research stopped after 4
n=495 pages of results)
Records after title and Records retained after title and abstract screening
abstract screening n=11
Sceening
n=2
Records after duplicate records removed

n=10
Full-text publications assessed for eligibility Records identified

n=10 through manual
searching
n=0
Elligibility
Excluded
Complete guide unavailable in English (n=1)
Included
Publications included in qualitative synthesis

n=9
Table 1: Thematic classification for the clinical recommendations in the included guidelines
Industrial
American Colorado New York State Washington State
The University of Insurance
National University of Academy of Department of American College of Dutch Orthopaedic Worker's Department of
Organization New South Wales Chiropractic
Health Sciences (2008) Orthopaedic Labor and Radiology (2015) Association (2014) Compensations Labor and industries
(2013)
Surgeons (2010) Employment (2015) Advisory Board (2013) (2013)
Committee (2014))
" […] requires",
"there must be", "[…] is essential", "[…]
"Must or must be "The provider must "Must or must be "[...] is required",
Essential "the clinician must is the most important "[…] must be" "[…] is mandatory" ____
[...]" […]" [...]" "clinicians will [...]",
[...]", "clinicians will feature"
[...]"
"The working group

"Should implement
recommends […]",
[…]", "Is "[...] is
"[...] has the best "The clinician should
recommended", recommended",
"We recommend chance of success", [...]”, “[…] should be
"The clinician should "Indicated", "[…] is "should incorporate "should consider "Should or should be
[...]", "we suggest "Primary indications "[...] should be recommended",
Recommended [...]", "[…] should be indicated before other […]", "[…] should be [...]", "should […]", "[...] is strongly
that […]"," […] is are […]", "should be" used", "[…] is "[...] are typically
recommended" […]" considered", include", "this is preferred"
beneficial" advised", "[...] can sufficient", "[...] is
"strongly consider considered best
be considered", "[...] indicated"
[…]", "[…] is practice to […]"
is indicated", "it is
generally accepted"
preferable to [...]"
"[…] may be "[…] may be

[...] may be used,
recommended", helpful", "[…] may
"Not initially "[...] may be
"[…] may be be beneficial", "[…] "May be used", "It
"May include", indicated", "not "May be indicated", offered", "[...] will
indicated", "[…] is "[…] may be used", is useful in some may be of value to
May be "may consider or routinely indicated", "may be useful", be considered if",
"[...] is an option" not necessary if", "[...] can or may be circumstances", "[…] [...]", "it may be
recommended may be […]" , "can "special "may use", "can be "[…] should be used
"may include […]", considered" should be useful", "can or can
or can be [...]" investigation", "[…] is used" if", "[…] is a
"[…] is not considered if", be [...]"
typically not useful" treatment option if",
necessarily "[…] may be
"[...] is reasonable if"
contraindicated" indicated"
"[…] should not",

"[...] is not "[…] not be "Not "[…] do not appear "[…] should not", "[…] should not",
"[...] is not
indicated", "should performed", "we recommended", to add benefits", "it "[...] is not "[...] is not
Not recommended ____ ____ indicated", "will not
not", "should refrain suggest surgeons "may not be is recommended not indicated"," […] is indicated", "will not
[...]", "[...] is not
from using [...]" not use […]" pertinent" to use […]" not recommended" [...]"
recommended"
"No clinical "We can not
No
recommendations ____ recommend for or ____ ____ ____ ____ ____ ____
recommendation
were made" against […]"
Table 2: Clinical practice guidelines characteristics
Development
Population Declaration Presence of an
Development involved a Methods for
of injured of explicit link
involved a systematic formulating the Externally
Organization Title workers competing between the
systematic consultation recommendation reviewed
specifically interests evidence and the
review of are described
covered mentioned recommendations
stakeholders
Clinical practice
guidelines for the
The University management of
of New South rotator cuff Yes Yes Yes Yes Yes Yes Yes
Wales (2013) syndrome in the
workplace
Diagnostic
imaging guideline
National for
University of musculoskeletal
No Yes Yes Yes Yes Yes Yes
Health Sciences complaints in
(2008) adults – an
evidence-based
approach
Optimizing the
American management of
Academy of rotator cuff
No Yes Yes Yes Yes Yes Yes
Orthopaedic problems
Surgeons (2010) guideline and
evidence report
Colorado
Shoulder Injury
Department of
Medical
Labor and Yes Yes Not specified No No Not specified Not specified
Treatment
Employment
Guidelines
(2015)
Practice
parameter for
the performance
American and
College of interpretation of No Not specified Not specified No No No Not specified
Radiology (2015) magnetic
resonance
imaging (MRI) of
the shoulder
Guideline for
diagnosis and
treatment of
Dutch subacromial pain
Orthopaedic syndrome: a
No Yes Not specified No Yes Yes Not specified
Association multidisciplinary
(2014) review by the
Dutch
Orthopaedic
Association
Industrial Conservative
Insurance Care Options for
Chiropractic Work-Related
Yes Yes Not specified No No No Not specified
Advisory Mechanical
Committee Shoulder
(2014) Conditions
New York
New York State
Shoulder Injury
Worker's
Medical Yes No Not specified No No No Not specified
Compensations
Treatment
Board (2013)
Guidelines
Washington
State Medical
Department of Treatment
Yes Yes Not specified No No No Not specified
Labor and Guidelines
industries
(2013)
Evaluation, treatment and return to work for shoulder rotator cuff disorders:
a systematic review of clinical practice guidelines and semantic analyses of recommendations
Evaluation, treatment and return to work for shoulder rotator cuff disorders:
a systematic review of clinical practice guidelines and semantic analyses of recommendations

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To appear in: ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 10 December 2019

Accepted Date: 12 December 2019

Shoulder rotator cuff disorders: a systematic review of clinical

Corresponding author: François Desmeules, PT, Ph. D.

1 Shoulder rotator cuff disorders: a systematic review of clinical

49 rotator cuff (2).

61 adherence to their content and recommendations remains suboptimal (16, 17).

79 Identification, Selection of Guidelines and Quality Appraisal

89 tears, arthritis or other shoulder disorders were excluded.

95 committee were identified, only the most recent was included.

98 presence of recommendations specifically targeted to injured workers. Methodological elements such as

102 external revision process were also compiled.

110 the AGREE instrument methodology (27).

112 Semantic Analysis and Synthesis of Recommendations

118 were then refined and confirmed by a second reviewer (SL).

125 “not recommended” (Table 1).

131 Included Guidelines Characteristics

139 32, 35).

148 Assessment of Shoulder Pain

156 subject was covered.

158 Medical Imaging for Rotator Cuff Disorders

172 identified with standard imagery techniques (35).

174 Medication for Rotator Cuff Tendinopathy

189 Medication for Rotator Cuff Full-Thickness Tear

205 Rehabilitation Modalities for Rotator Cuff Tendinopathy

212 “not recommended” and reviewed in two guidelines (11, 35).

214 Rehabilitation Modalities for Full-Thickness Rotator Cuff Tear

240 Interventions Related to Surgery for Rotator Cuff Full-Thickness Tear

251 in two guidelines (14, 35).

253 Return-to-Work Strategies for Rotator Cuff Disorders

268 synthesize the published recommendations for this population.

277 among the other guides.

281 treatment and the return-to-work of adults presenting a RC disorder.

300 was clinically important or not.

301 Regarding surgical interventions, performing an acromioplasty for the treatment of RC

321 Scottish Intercollegiate Guidelines Network (SIGN), or Grading of Recommendations Assessment,

341 thus be formulated in that sense.

353 the identified guidelines.

362 methodological information and transparency.

379 AUTHORS’ CONTRIBUTIONS:

388 is the corresponding author.

391 COMPETING INTERESTS

392 The authors declare that they have no competing interests.

395 WORD COUNT: 4181 words

396 TABLES AND FIGURES

1. Tekavec E, Jöud A, Rittner R, Mikoczy Z, Nordander C, Petersson IF, et al. Population-

BMJ Quality & Safety. 2005;14(5):367-70.

Scottish Intercollegiate Guideline Network (n=57)

Records after duplicate records removed

Full-text publications assessed for eligibility Records identified

Publications included in qualitative synthesis

"The working group

"[…] may be "[…] may be

"[…] should not",

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