Received: 20 March 2019 

|
  Revised: 6 August 2019 
|  Accepted: 3 September 2019

DOI: 10.1002/ejp.1482

REVIEW ARTICLE

Incidence of shoulder pain in 40 years old and over and

associated factors: A systematic review

Codjo D. Djade1,2,3  | Teegwendé V. Porgo1,2  | Hervé Tchala Vignon Zomahoun1,2,4,5  |

Gentiane Perrault‐Sullivan   1,2
| Clermont E. Dionne 2,3,6

1
Department of Social and Preventive
Medicine, Université Laval Québec,
Québec, QC, Canada
2
Axe Santé des populations et pratiques
optimales en santé, Centre de recherche du
CHU de Québec‐Université Laval, Hôpital
du Saint‐Sacrement, Québec, QC, Canada
3
Centre d’excellence sur le vieillissement
de Québec (CEVQ), Hôpital du Saint‐
Sacrement, Québec, QC, Canada
4
Population Health and Practice‐Changing
Research Group, Centre de recherche du
CHU de Québec‐Université Laval, Québec,
QC, Canada
5
Health and Social Services
Systems, Knowledge Translation and
Implementation component of the Québec
SPOR‐SUPPORT Unit, Université Laval,
Québec, QC, Canada
6
Department of Rehabilitation, Faculty of
Medicine, Université Laval, Québec, QC,
Canada
Correspondence
Codjo D. Djade, Department of Social
and Preventive Medicine, Université Laval
Québec, QC, Canada.
Email: codjo-djignefa.djade.1@ulaval.ca
Abstract
Background: Shoulder pain is one of the most frequent musculoskeletal complaints,
and its prevalence and consequences increase with age. However, little is known
about the incidence of shoulder pain among aging adults. We conducted this review
to estimate the incidence of shoulder pain in ageing adults and its associated factors.
Databases and data treatment: We conducted a systematic review of cohort stud-
ies in which the incidence of shoulder pain and associated factors were explored in
adults aged 40 years and over. PubMed, Embase, and Web of Science databases were
consulted.
Results: We retrieved 3332 studies and included six, of which five were prospective
cohort studies and one was retrospective. For adults aged 45–64 years, the annual cu-
mulative incidence was 2.4%. The incidence density was estimated at 17.3 per 1,000
person‐years for adults in the 45–64 years age group, at 12.8 per 1000 person‐years
for those in the 65–74 years group and at 6.7 per 1000 person‐years among those
aged 75 years and over. Occupational factors, notably physical demands of work,
were associated with the incidence of shoulder pain. Non‐occupational factors were
also linked to the occurrence of shoulder pain.
Conclusion: Few studies have estimated the incidence of shoulder pain and associ-
ated factors among ageing adults. From this systematic review, we conclude that
studies on the incidence of shoulder pain are scarce, and that both occupational and
non‐occupational factors could be associated with the onset of shoulder pain among
adults 40 years and over. This very limited evidence calls for more studies on this
topic.
Significance: Shoulder pain is one of the most frequent musculoskeletal complaints,
and its prevalence and consequences increase with age. However, since the preva-
lence of a recurring condition is determined by its incidence and the number and
duration of episodes, it is important to have valid incidence estimates and to conduct
aetiological studies on incidence measures to untangle risk factors of the occurrence
of shoulder pain from those affecting the duration and number of episodes . In this
systematic review, we sought to estimate the incidence of shoulder pain in ageing
adults along with its associated factors. This work could lead to better interventions
to prevent shoulder pain in older individuals.

© 2019 European Pain Federation ‐ EFIC®     1

Eur J Pain. 2019;00:1–12. wileyonlinelibrary.com/journal/ejp |
 |
2      DJADE et al.
1  |   BACKGROU N D A N D
O B J EC T IV E
Shoulder pain (SP) is one of the most frequent musculoskel-
etal complaints, affecting between 4.7% and 46.7% of the
adult population each year (Bot et al., 2005; Joud, Petersson,
& Englund, 2012; Luime et al., 2004; Picavet & Schouten,
2003; Urwin et al., 1998; Woolf, 2012), and its prevalence
increases with age (Hsiao et al., 2015; Linsell et al., 2006;
Woolf, 2012). In the United States, SP is responsible for 13%
of sick leaves and 7  billion US dollars in health care costs
per year (Hidalgo‐Lozano et al., 2010), while it represents
26% of occupational injuries in France (Bodin et al., 2017).
However, these figures probably underestimate the impact of
SP, since it is thought that 55% to 67% of people with muscu-
loskeletal pain do not seek medical help (Paloneva, Koskela,
Kautiainen, Vanhala, & Kiviranta, 2013). Moreover, with
ageing populations and longer careers, the burden of SP can
be expected to increase. Therefore, it is more important than
ever to identify the determinants of the occurrence of SP to
better achieve its primary prevention.
SP causes mobility restrictions, functional limitations in
daily activities, sleeping problems, work disability and in-
creased use of health services (Picavet & Schouten, 2003).
While SP may resolve spontaneously, 40% to 76% of affected
individuals have not recovered completely 1–2 years after its
onset (Paloneva et al., 2013). Knowledge of the determinants
of SP is limited; for instance, the most recent systematic review
on musculoskeletal disorders identified three studies focusing
on SP that only examined work‐related risk factors, and none of
them focused on older individuals (da Costa & Vieira, 2010).
Since SP can last for several months and become a recur-
ring condition, prevalence measures reflect indistinctly its
occurrence, average episode duration and average number of
recurrences (Pribicevic, 2012; Von Korff & Parker, 1980).
Studies that have used prevalence figures to identify risk fac-
tors of SP have thus been unable to disentangle risk factors for
occurrence from those for recurrence and episode duration;
this distinction is important to allow to focus on the right expo-
sures according to the level of prevention (primary, secondary,
tertiary) in the natural history of the disease. Most studies that
have examined the determinants of SP used a cross‐sectional
design: for example, a systematic review carried out in 2004
identified only one study that provided information on inci-
dence estimates of SP within the general population (Luime
et al., 2004); all the other 17 studies were cross‐sectional. The
cross‐sectional design is inappropriate to study associations
between potential risk factors and the incidence of SP—i.e. to
identify determinants of the occurrence of SP. Cohort studies
are much better suited for this type of research questions.
The objective of the current study was to systematically
review cohort studies that estimated the occurrence (mea-
sured with cumulative incidence or incidence density) of SP
in adults aged 40  years and over and identified associated
risk factors.
2  |   DATABASES AND DATA
TREATM ENT
We performed a systematic review based on the Cochrane
review methodology (Higgins & Green, 2011) and reported it
according to the Reporting Items for Systematic Reviews and
Meta‐Analyses (PRISMA) (Liberati et al., 2009). This review
has not been registered.
2.1  |  Eligibility criteria
PICOS's approach (Participants, Intervention or exposition,
Comparator, Outcome, Study design) was used to determine
which studies to include. Participants (P)—since SP dispro-
portionately affects ageing adults, we looked at studies that
estimated the incidence of SP in individuals aged 40 years and
over. If the incidence measure was calculated for a broader age
group, we determined what the rate was for our cohort of inter-
est, and the article was retained. Intervention (I)/exposition—
any study on SP, rotator cuff injuries or potential risk factors
was reviewed. Comparator (C)—no restriction; outcome (O)—
we looked at studies that reported cumulative incidence or inci-
dence density measures of SP, rotator cuff injury and measures
of pain and functional limitations; Study (S)—we included only
longitudinal studies, both retrospective cohort and prospective
cohort studies, if they estimated a measure of the incidence of
SP among adults 40 years old and over.
2.2  |  Literature search strategy and
data sources
We consulted the databases PubMed, Embase and Web of
Science from 25 March 2016 to 22 July 2019. The review
was centred around three themes: incidence of SP, rotator
cuff symptoms and associated risk factors. Additionally, we
manually screened the references of eligible studies for fur-
ther leads. No language or publication date restrictions were
applied. We sorted duplicates using EndNote version X7
(Thomson Reuters, 2013).
2.3  |  Study selection and data use
To identify potential studies, two reviewers (CDD and
TVP) independently screened titles, abstracts and then full
texts using the software platform Covidence (Veritas Health
Innovation). Both reviewers used a form to gather informa-
tion on setting, population, SP case definition, estimate of
cumulative incidence or incidence density and potential risk
factors assessed. If a study was not selected, the reason was
DJADE et al.      3
|
documented. Disagreements on study selection and data

% Female
gathered were resolved by consensus.

46.3

53.3

46.2
2.4  |  Assessment of methodological quality

‐
‐
1,410,438
Two reviewers (CDD and GPS) independently conducted

155,534
375,899

35,150
4,919
4,140
quality assessment of included articles using the Risk Of Bias

Na
In Non‐randomized Studies of Interventions (ROBINS‐I) tool
(Sterne et al., 2016) developed by the squad of the Cochrane

1992/1994–1993/1995
1992/1994–1993/1995
Bias Methods Group and the Cochrane Non‐Randomized
studies Methods Group in 2016. The criteria in the list are

Study period
widely used for evaluating observational studies. These in-

1993–1994
2000–2003
2001–2002

1999–2008
clude assessing the risk of bias in seven domains performed
for each study: (a) selection bias, (b) confounding, (c) inter-
vention classification, (d) deviation from intervention, (e)

Neck and upper extremity pain

measurement of outcome, (f) missing data and (g) selection
of reported data. In each domain, risk of bias was ranked

Neck and shoulder pain

“low‐to‐moderate,” “serious,” “critical” or “not enough in-

Musculoskeletal pain
formation to assess risk of bias.” Here again, disagreements
were resolved by consensus.

Shoulder pain
Shoulder pain

Shoulder pain
2.5  |  Data analysis

Topic
A PRISMA flowchart was used to describe the study selec-
tion process. We present the studies included and the popu-

Retrospective cohort study

Prospective cohort study

Prospective cohort study

Prospective cohort study

Prospective cohort study

Prospective cohort study

lation characteristics using descriptive statistics (frequency,
range and median). The results of the quality assessment
were also summarized using a count frequency for both
T A B L E 1   Description of studies that estimated the incidence of SP among adults ≥ 40 years

Study design

specific criteria and the overall assessment. We used the cu-

mulative incidence or incidence density as measures of the
occurrence of SP, and calculated, when data were available,
relative risks (RR) with 95% confidence intervals (95% CI)
to identify risk factors of SP. We did not carry out a formal
Defense Medical Epidemiological

Malmö Shoulder and Neck Study

Malmö Shoulder and Neck Study
Dutch national survey of general

meta‐analysis because the studies were methodologically too

Data from 18 practitioners (11

heterogeneous, and only a few studies covered each risk fac-
tor. However, we carried out a classification of the studied
risk factors and discriminated the ones associated or not with
Mediplus database

the incidence of SP.

Data source

practices)
Database
practice

3  |   R E S U LTS
The search retrieved 3,332 publications, of which 141 full‐
United Kingdom

text articles were assessed for eligibility. In total, six stud-

United States

Netherlands
Netherlands

ies (Bot et al., 2005; Canivet et al., 2008; Hsiao et al., 2015;
Country

Sweden
Sweden

Linsell et al., 2006; Ostergren et al., 2005; van der Windt,

Koes, Jong, & Bouter, 1995), including three that were iden-
tified through manual screening (Bot et al., 2005; Linsell et
Hsiao et al., (2015)
Bot et al., (2005)

al., 2006; van der Windt et al., 1995), were retained (Figure
Patients ≥ 40 years.
van der Windt et
Ostergren et al.,
Canivet et al.,

1).
Linsell et al.,

al., (1995)

Five of the eligible studies were prospective cohort stud-

Authors

(2008)

(2006)

(2005)

ies and one (Hsiao et al., 2015) was retrospective (Table 1).
Two of the studies were conducted in the Netherlands (Bot et
a
 |
4     

T A B L E 2   Definition of the incidence of SP in the included studies

Incidence Risk factors

Cumulative density (ID) in Age Incidence Incidence in and strength of
Outcome incidence (R) 1,000 person‐ group overall defined groups association RRa
Authors Case definition measurement in % year −1 (years) (95% CI) (95% CI) (95% CI)
Bot et al., The incidence density was calculated as the number Physical No Yes ≥ 40 NRc 40–49 years NR
(2005) of patients experiencing a new episode in the study examination ♀ ID = 18.8
year divided by the sum of person‐years. (17.2–20.4)
Patient with the first new episode was considered ♂ ID = 15.7
like that by general practitioners separated from (14.3–17.1)
earlier problems. 50–59 years
Person‐years were calculated on all patients, those ♀ID = 19.3
who did not consult GPb for complaint contributed (17.5–21.1)
one person‐years to the denominator ♂ID = 15.4
(13.8–16.9)
60–69 years
♀ID = 15.9
(14.0–17.9)
♂ ID = 14.5
(12.6–16.4)
70–79 years
♀ID = 17.4
(15.1–19.7)
♂ ID = 12.3
(10.1–14.5)
80 years +
♀ ID = 18.0
(14.9–21.0)
♂ ID = 13.8
(10.0–17.6)
(Continues)
DJADE et al.
T A B L E 2   (Continued)

Incidence Risk factors

DJADE et al.

Cumulative density (ID) in Age Incidence Incidence in and strength of

Outcome incidence (R) 1,000 person‐ group overall defined groups association RRa
Authors Case definition measurement in % year −1 (years) (95% CI) (95% CI) (95% CI)
Canivet et al., Incidence of SP was defined as a new case caused Questionnaire Yes No 45–65 R = 2.4 ♀ R = 2.6 Occupational:
(2008) by sleep disorder or work‐related stress on the total (modified ♂ R = 2.2 Job strain
population followed for 1 year. SNQ)d ♀OR: 1.6
(1.2–2.2)
♂ OR: 1.4
(0.9–2.1)
High mechanical
exposure
♀OR: 1.6
(1.2–2.1)
♂ OR: 1.9
(1.5–2.5)
Non‐occupational:
Sleeping
problems
♀OR: 1.9
(1.4–2.7)
♂ OR: 1.7
(1.1–2.6)
Hsiao et al., Incidence density was calculated by dividing the Physical No Yes ≥ 40 ID = 16.7 NR Not applicable
(2015) total number of injuries observed in a population examination (not
by a measure of exposure (person‐time) standard-
ized);
ID = 15.0
(standard-
ized for
sex, race,
branch of
service
and rank)
(Continues)
|
     5
T A B L E 2   (Continued)
|

Incidence Risk factors

6     

Cumulative density (ID) in Age Incidence Incidence in and strength of

Outcome incidence (R) 1,000 person‐ group overall defined groups association RRa
Authors Case definition measurement in % year −1 (years) (95% CI) (95% CI) (95% CI)
Linsell et al., Incidence was defined as the number of new cases Primary care Yes No ≥ 40 NR 40–49 years NR
(2006) in the year 2000 among the population at risk. database R = 1.5 (1.4–1.6)
50–59 years
R = 1.9 (1.9–2.0)
60–69 years
R = 2.1 (2.0–2.2)
70–79 years
R = 2.1 (1.9–2.2)
+ 80 years
R = 1.9 (1.7–2.1)
Ostergren et ‐ Questionnaire Yes No ≥ 40 R = 7.3 ♀ R = 8.9 Occupational
al., (2005) (modified ♂ R = 5.9 Job strain
SNQ)d ♀ OR = 1.7
(1.3–2.3)
♂ OR = 1.2 (0.8
–1.7)
Mechanical
exposure
♀OR = 1.6
(1.2–2.1)
♂ OR = 2.2
(1.7–2.9)
van der Windt Cases of SP were defined as those presented by pa- Questionnaire No Yes ≥ 45 NR 45–64 years NR
et al., (1995) tients who had not consulted their GP for shoulder on the nature ID = 17.3
complaints in the preceding year. The cumulative and severity (14.0–20.6)
incidence of shoulder complaints of com- 65–74 years
(n/1000/year) was calculated, including the 95% plaints and ID = 12.8
confidence limits. systematic (7.9–17.7)
examination + 75 years
ID = 6.7 (2.3–11.1)
Note: Definition of incidence of shoulder pain in selected study, description of the studies and association measures.
a
RRs for neck and shoulder complaints were adjusted for age (most studies have calculated odds ratios (ORs) that they have interpreted as Risk Ratios (RRs)).
b
GP: General practitioner.
c
NR: Not reported.
d
SNQ: Standardized Nordic Questionnaire.
DJADE et al.
DJADE et al.
al., 2005; van der Windt et al., 1995), two in Sweden (Canivet
et al., 2008; Ostergren et al., 2005), one in the UK (Linsell
et al., 2006) and one in the U.S. (Hsiao et al., 2015). The
data collected spanned a period from 1992 (Ostergren et al.,
2005) to 2008 (Hsiao et al., 2015), and the number of partic-
ipants ranged from 4,140 (Canivet et al., 2008) to 1,410,438
(Hsiao et al., 2015). Two of the studies used data collected
from the same population (Canivet et al., 2008; Ostergren
et al., 2005). To collect data on musculoskeletal symptoms
and estimate the incidence of SP, two of the studies relied
on questionnaires (including the modified version of the
Standardized Nordic Questionnaire—SNQ) (Canivet et al.,
2008; Ostergren et al., 2005), two others relied on physical
examination, one employed both methods and the authors
(Linsell et al., 2006) of the last one collected data through a
primary care database (Table 2).
Three studies focused on SP (Hsiao et al., 2015; Linsell
et al., 2006; van der Windt et al., 1995), two combined data
on neck and shoulder complaints (Bot et al., 2005; Ostergren
et al., 2005) and one examined musculoskeletal pain in gen-
eral (Canivet et al., 2008). Lastly, only two of the six studies
studied risk factors associated with SP (Canivet et al., 2008;
Ostergren et al., 2005) in populations aged 40 years and over.
3.1  |  Quality assessment of included studies
For all quality assessment criteria, confounding domain was
low. In two papers, the risk of bias in the selection bias do-
main was low (Hsiao et al., 2015; Ostergren et al., 2005); it
was moderate in two studies (Bot et al., 2005; Linsell et al.,
2006), and serious in two others due to the low participa-
tion proportion and no clear description of the selection of
patients (Canivet et al., 2008; van der Windt et al., 1995), so
these studies had serious risk of bias for missing data. Bias
domain for intervention classification was low for most stud-
ies (Table 3).
3.2  |  Incidence of shoulder pain
The selected studies did not measure the occurrence of SP all
in the same way. Three of the studies calculated incidence
density (Bot et al., 2005; Hsiao et al., 2015; van der Windt
et al., 1995), and the other three measured cumulative inci-
dence (Canivet et al., 2008; Linsell et al., 2006; Ostergren et
al., 2005). Those that estimated incidence density measured
the number of patients who were diagnosed with the disorder
in a given year (Bot et al., 2005; Hsiao et al., 2015; van der
Windt et al., 1995). The other studies estimated cumulative
incidence and focused on new cases linked to sleep disorders
and work‐related stress (Canivet et al., 2008). They also tar-
geted the annual number of incident cases in groups at risk
(Linsell et al., 2006) in the occupational groups or the general
population (Table 2).
|
     7
3.2.1  |  Incidence density
Only one study provided information on incidence density
of SP stratified by age and sex (Bot et al., 2005). For men
between the ages of 40 and 49 years, the estimate was 15.7
per 1,000 person‐years. In this study, the occurrence of SP
in men decreased with age, declining to 13.8 per 1,000 per-
son‐years among those aged 80 years and older. In contrast,
the incidence density for women was more stable across
age groups: 18.8 per 1,000 person‐years among those aged
40–49 years, 19.3 per 1,000 person‐years among those aged
50–59 years, 15.9 per 1,000 person‐years among those aged
60–69 years, 17.4 per 1,000 person‐years among those aged
70–79  years and 18.0 per 1,000 person‐years among those
aged 80 years and over (van der Windt et al., 1995).
In the Dutch College of General Practitioners' study,
the incidence density was estimated to be 17.3 per 1,000
person‐years among adults 45–64 years old, 12.8 per 1,000
person‐years among those aged 65–74 and 6.7 per 1,000 per-
son‐years among those 75 years old and over (van der Windt
et al., 1995). In another American study that focused on the
U.S. military personnel, when the estimates were standard-
ized for sex, race, branch of service and rank, the incidence
density among those aged 40  years and over was 15.0 per
1,000 person‐years (Hsiao et al., 2015).
3.2.2  |  Cumulative incidence
In the Malmö Shoulder and Neck Study, the annual cumu-
lative incidence among 4,140 adults aged 45–64  years was
2.4% (2.6% among women and 2.2% among men) (Canivet et
al., 2008). In addition, this study provided the following cu-
mulative incidence estimates for different age groups: 1.5%
for 40–49 years; 1.9% for 50–59 years, 2.1% for 60–69 years,
2.1% for 70–79 years and 1.9% for ≥ 80 years (Linsell et al.,
2006).
3.3  |  Risk factors
Two of the selected studies measured the incidence of SP
and assessed potential risk factors (Table 2), using data
collected from the same population (Malmö Shoulder and
Neck Study) (Canivet et al., 2008; Ostergren et al., 2005).
The first study (Canivet et al., 2008) evaluated the effects
of the physical demands of work and psychosocial stressors
at work on the incidence of SP and neck pain; the authors
concluded that the frequency of these occupational factors
and the occurrence of SP were correlated. Specifically, me-
chanical exposure was associated with a higher likelihood
of experiencing SP in both sexes. Furthermore, psychoso-
cial stressors at work (“job strain”) were found to be asso-
ciated with more cases of SP among women. A follow‐up
study was carried out 3 years later on the same cohort and
 |
8      DJADE et al.

it was determined that sleeping problems also predicted SP
(Canivet et al., 2008).
4  |   D IS C U SS ION
In this systematic review, we retrieved and evaluated
studies that estimated the incidence of SP and identified
associated factors in adults aged 40 years and over. Only
six articles were identified, two of which examined occu-
pational and non‐occupational potential risk factors. To
measure the occurrence of SP, the studies calculated ei-
ther the incidence density or the cumulative incidence with
great variation.
Results from the three studies that estimated the cumula-
tive incidence vary widely. For instance, in the Swedish study,

T A B L E 3   Quality assessment results from selected studies

Study Bias domain Risk of bias Justification of risk

Bot et al., Confounding Low Objective of the study was to computes the incidence of pain
(2005) Selection Moderate 8/104 were excluded for missing data but the population characteristics cor-
responded very well to the Dutch population as a whole with respect to age,
sex and the type of health insurance
Intervention Low Intervention status was well defined based on ICPCa
classification
Deviation from No No clear deviation from intervention
intervention information
Missing data Low Less than 10%
Measurement of Low Incidence was well defined, and the first episode of musculoskeletal pain was
outcome determined by a general practitioner
Selection of reported Moderate No clear evidence and comparison with the general population
result
Canivet et al., Confounding Low Took account of age as confounding and all the other factors were tested
2008) Selection Serious Low rate of participation
Intervention Low Exposition status is well defined and based on the instrument for assessing
classification sleeping problems
Deviation from No No clear deviation from intervention
intervention information
Missing data Serious 68% of contextual missing data and 11.2% of accidental missing data, lost at
follow‐up
Measurement of Serious Modified version of the Standardized Nordic Questionnaire (SNQ) (validated
outcome questionnaire) was used but we missed some information on the modifica-
tion on the instrument
Selection of reported Moderate The prevalence of pain was considered low enough (11.8% in men and 14.6%
result in women) to justify the use of OR (Odd Ratio) as a proxy for RR (Relative
Risk). Overestimation of association
Hsiao et al., Confounding Low Different interventions (expositions) were used to examine association with
(2015) shoulder pain
Selection Low The database was all about military staff in the United States
Intervention Low Well‐defined exposure. Information detailing person‐time at risk allows for
classification calculation of incidence density on the entire active‐duty military population
Deviation from No No clear deviation from intervention
intervention information
Missing data Low No missing data mentioned.
Measurement of Low Only first occurrence, primary diagnosis of shoulder impingement and clas-
outcome sification with ICD−9‐CMb was used for shoulder impingement
Selection of reported Moderate Information was well presented by group, but it lacked the characteristics of
result the participants
(Continues)
DJADE et al.      9
|
T A B L E 3   (Continued)

Study Bias domain Risk of bias Justification of risk

Linsell et al., Confounding Low Objective of the study was to estimate the national prevalence and inci-
(2006) dence rates of consultation for shoulder problems using a UK primary care
database
Selection Moderate Data represented the general UK population (with regard to age, sex and
regional distribution), except for Scotland and Northern Ireland, somewhat
under‐represented. Inclusion and exclusion criteria were clear, but there
were no information about excluded patients
Intervention No No information about possible determinants of shoulder pain
classification information
Deviation from No No deviation from intervention
intervention information
Missing data Low No information about missing data
Measurement of Low Lot of codes to make sure many shoulder problems are included. It is well
outcome documented and easy to replicate
Selection of reported Moderate For interest use (prevalence and incidence), there were some mistakes and it
result is not possible to calculate the exact prevalence or incidence figures with the
table
Ostergren et Confounding Low In baseline questionnaire, a significant number of variables associated with
al., (2005) pain and risk factors were collected
Selection Low People were selected at random from the population register.
Intervention Low The instrument for assessing the mechanical exposure index (MEI) was used
classification and psychosocial work exposure was assessed with an instrument developed
by Karasek and Theorell measuring a combination of psychological job
demands and job decision latitude
Deviation from No No information about deviation from intervention
intervention information
Missing data Moderate High participation proportion in follow‐up study (86.6%).
Measurement of Low A modified version of the Standardized Nordic Questionnaire (SNQ) for the
outcome analysis of musculoskeletal symptoms was used but the merging between
shoulder and neck pain is not clear
Selection of reported Serious Wrong measure of association
result
van der Windt Confounding Low Objective of the study was to compute the incidence of pain
et al., (1995) Selection Serious No clear information about selection of patients
Intervention No No information about exposure data
classification information
Deviation from No No information about deviation from intervention
intervention information
Missing data Serious Missing data were estimated by the practitioners themselves (mean proportion
of missed records: 20%)
Measurement of Moderate Before the study, the general practitioners received extra training on the sys-
outcome tematic examination of the cervical spine and shoulder joint according to the
concepts of Cyriax, which is applauded and severely criticized. They do not
explain why they chose this method
Selection of reported Low The results are presented by group
result
Note: Adapted quality assessment of included articles using the Risk Of Bias In Non‐randomized Studies of Interventions (ROBINS‐I)
a
ICPC, International Classification of Primary Care.
b
International Classification of Diseases, Ninth Revision, Clinical Modification.
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10      DJADE et al.

F I G U R E 1   PRISMA diagram
Records identified through
showing the study selection process

Identification
database searching
(n = 3,332)
MEDLINE n = 894
EMBASE n = 1,748
Web of science n = 690

Duplicates excluded
(n = 245)

Titles and abstracts screened

(n = 3,087) Records excluded

Screening
(n = 2,946)

Full-text articles excluded

(n = 124)
• Wrong outcome: 56
• Wrong patient population: 39
• Wrong design: 17
• Conference proceeding only: 5
• Letters: 6
Full-text articles assessed for • Guidelines: 1
eligibility
Eligibility

(n = 141)
Records identified through
bibliographic screening of
eligible studies (n = 3)

Records excluded after reading

full text (due to missing
information on the calculation
of incidence rates)
(n = 14)
Inclusion

Studies included in qualitative

synthesis
(n = 6)

published in 2005, the 1‐year cumulative incidence was 7.3%
(Ostergren et al., 2005); by 2008, it had dropped to 2.4%
(Canivet et al., 2008), and the city of Malmö inhabitants' 1‐
year SP cumulative incidence was similar to the figures found
in the general population (0.9%–2.5% depending on the age
group) (Allander, 1974). Nevertheless, the second study, un-
like the first one, did not include workers who had left their
jobs, which is a group that is more likely to have issues with
SP (they could have been in better health or left work because
of an illness or occupational exposure(s) that impact on the
shoulder) (Rasmussen‐Barr, Grooten, Hallqvist, Holm, &
Skillgate, 2014). This omission could explain why the stud-
ies obtained different estimates and identified different risk
factors. Given the specifics of the population studies to date,
overall, the external validity of most studies is low.
Few studies have looked at the incidence of SP and associ-
ated risk factors among adults aged 40 years and more. While
we stated wanting to pay particular attention to the population
aged 50 and over because it is around this age that degener-
ative diseases occur more often, the scarcity of the studies
forced us to widen our study population. In this study, only two
investigations studied the potential risk factors. Some studies
have looked at the prevalence of SP in the general population
and obtained estimates ranging from 4.7% to 46.7% (Allander,
1974; Luime et al., 2004). According to Luime et al. (Luime et
al., 2004), research on incidence within the general population
is scarce because it is expensive to carry out longitudinal stud-
ies. Cross‐sectional studies are often more feasible because
they do not test any causal hypothesis but rather seek to de-
scribe cases of SP within the population. However, these stud-
ies are poorly suited to aetiologic research or evaluations. For
example, in a systematic review undertaken in 2004, most of
the selected studies did not identify any risk factors, although
one article did find that age was correlated with the likelihood
of experiencing SP (Hsiao et al., 2015). This underscores the
need to carry out longitudinal studies to determine causality.
DJADE et al.
Some authors discussed the difference between incidence and
prevalence measures of pain and indicated that incidence rep-
resents the first time a patient experiences the pain (McBeth &
Jones, 2007). As SP is often a recurring condition, it is diffi-
cult to disentangle risk factors of the onset of SP as such from
those of the duration of a SP “episode” and the number of “ep-
isodes”. Consequently, studies should begin with a clear wash-
out period. Four of the studies did not do so, but rather defined
an incident case as a new case occurring during the follow‐up
(Bot et al., 2005; Hsiao et al., 2015; Linsell et al., 2006) or as
a new case caused by the risk factor under scrutiny (Canivet
et al., 2008). van der Windt et al. (van der Windt et al., 1995)
considered a washout period and defined a new case as having
occurred when a patient who had not consulted a physician for
SP in the preceding year experienced an episode of SP. This
definition of SP incidence is more suitable (although it does
not exclude recurrences), but the van der Windt et al.'s study
did not evaluate the potential risk factors.
In terms of work‐related risk factors of SP, two out of six
studies found that psychosocial stressors and mechanical expo-
sures due to repetitive work, awkward positions and vibrations
were associated with the incidence of SP in large populations
(Herin, Vezina, Thaon, Soulat, & Paris, 2014; Neupane et al.,
2013). Psychosocial stressors and work factors (e.g. job strain)
had a noticeable effect on the incidence of SP only among
women, whereas mechanical exposures were a risk factor for
both sexes (Ostergren et al., 2005). In terms of non‐occupa-
tional factors, one study found that sleeping disorders were
linked to the incidence of SP (Canivet et al., 2008).
Strengths of this systematic review include the wide
search strategy, that is likely to have been highly sensitive,
and the use of the Cochrane tool's quality assessment for non‐
randomized studies (Sterne et al., 2016). The latter allowed
us to objectively evaluate the retained studies and see that
in the six studies included, the risk of bias was minimized.
Our review has also certain limitations. Firstly, there were
few longitudinal studies on the incidence of SP and associ-
ated risk factors, specifically among adults aged 40 years and
over. Secondly, many studies found were cross‐sectional and
evaluated the prevalence of SP within the general population.
Thirdly, the studies conducted in occupational settings often
did not account for survivor bias, which occurs when workers
who develop SP stop working or change jobs (Stock, 1991);
this bias would underestimate the incidence and the strength
of the associations measured. Fourthly, the definitions of the
incidence of SP were heterogeneous in all studies, making it
difficult to validly compare or synthesize the results.
5  |   CO NC LU SION
In summary, very few studies have estimated the inci-
dence of SP and associated risk factors among adults aged
|
     11
40 years and older. Given the very limited number of stud-
ies on the incidence of SP as well as their methodologi-
cal limitations, it does not seem prudent to draw specific
conclusions on the current evidence. Our review found
that the occurrence of SP could be associated with occu-
pational and non‐occupational risk factors. Because most
current knowledge of SP comes from prevalence studies
that have focused on occupational factors, and that preva-
lence reflects not only incidence but also the number and
duration of episodes, more incidence studies considering
occupational and non‐occupational risk factors are needed
in order to develop efficient primary preventive interven-
tions of SP among ageing individuals.
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How to cite this article: Djade CD, Porgo TV,
Zomahoun HTV, Perrault‐Sullivan G, Dionne CE.
Incidence of shoulder pain in 40 years old and over
and associated factors: A systematic review. Eur J
Pain. 2019;00:1–12. https​://doi.org/10.1002/ejp.1482