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Musculoskeletal Science and Practice

journal homepage: https://www.journals.elsevier.com/musculoskeletal-
science-and-practice

Original article

Rotator cuff-related pain: Patients' understanding and experiences

Melissa A. Gillespie, BPhty(Hons) a, b, Aleksandra Ma˛cznik, MPhy, PhD a,
Craig A. Wassinger, PT, PhD c, Gisela Sole, BSc(Physio), MSc(Med)Exercise Science, PhD a, *
a
Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand
b
Advance Wellness Centre, Hamilton, New Zealand
c
Department of Physical Therapy, East Tennessee State University, Johnson City, TN, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Persistent musculoskeletal pain is a multi-factorial entity, influenced by biological, genetic
Received 13 March 2017 and psychosocial factors. Psychosocial factors, such as individuals' beliefs and experiences, need to be
Received in revised form considered in the management of such pain. While extensive research has explored beliefs of individuals
22 May 2017
with spinal pain, less is known about individuals' beliefs regarding shoulder pain.
Accepted 25 May 2017
Objectives: To explore beliefs about the cause of pain in individuals with persistent rotator cuff-related
pain, as well as the experiences of the effect of pain on their daily lives.
Keywords:
Design: A mixed methods design, using semi-structured interviews and validated outcome
Shoulder pain
Rotator cuff
questionnaires.
Subacromial pain Method: Five men and five women, aged 47e68 years, with shoulder pain for at least three months were
Beliefs recruited. Individual semi-structured interviews were audio-recorded, transcribed verbatim and ana-
Qualitative research lysed using the general inductive approach.
Results/findings: Four key themes emerged. The cause of pain, ‘Understanding the pain’, was described in
terms of anatomical factors within the context of the participants' lives. The pain impacted all areas of
life, creating another theme, ‘It affects everything’. Participants responded to their pain by adopting
certain, ‘Pain-associated behaviours’ and sought information for diagnosis, general management and
exercise prescription, ‘Emotional responses and the future’.
Conclusions: The participants with rotator cuff-related pain believed the cause of their pain to be local to
the shoulder region. However, they also described various stressors in their work-, sports- and family-
related lives. Rehabilitation may need to include educating the individual, expanding their under-
standing regarding pain mechanisms and appropriate interventions, based on individual goal-setting.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction of these potential sources towards the patients' pain (Hegedus

Shoulder disorders are the third most common musculoskeletal
complaint seen in general practice (Urwin et al., 1998) and rotator
cuff-related pain contributes to over two-thirds of these cases
(Murphy and Carr, 2010). Shoulder pain related to structures of the
subacromial space is commonly thought to be due to a variety of
pathoanatomical sources, such as bursitis, tendinopathy, and par-
tial or full-thickness tendon tears (Lewis, 2010; Murphy and Carr,
2010). However, partly due to low accuracy of physical examina-
tion tests for the shoulder, it is difficult to differentiate contribution
* Corresponding author. Centre for Health, Activity and Rehabilitation Research,
School of Physiotherapy, University of Otago, Box 56, Dunedin, 9054, New Zealand.
E-mail address: Gisela.sole@otago.ac.nz (G. Sole).
et al., 2015; Magarey et al., 2016). A clear diagnostic label for such
pain remains challenging, and various entities have been sug-
gested, such as rotator cuff-related pain, subacromial pain syn-
drome, subacromial impingement syndrome or non-specific
shoulder pain (Cools and Michener, 2016; Lewis, 2016). For the
purpose of this study, the label rotator cuff-related pain (RCRP) was
chosen, as this is still a commonly-used clinical entity (Lewis, 2016).
Besides potential pathoanatomical structures, neurophysiolog-
ical processes also contribute towards the patients' pain experi-
ences. Following tissue damage, peripheral sensitisation of
nociceptors occurs, increasing the sensitivity of nerve endings (Nijs
et al., 2015). In patients with persistent shoulder pain, evidence of
central sensitisation or hyperexcitability of the central nervous
system has also been shown (Borstad and Woeste, 2015; Gwilym

http://dx.doi.org/10.1016/j.msksp.2017.05.009
2468-7812/© 2017 Elsevier Ltd. All rights reserved.
 M.A. Gillespie et al. / Musculoskeletal Science and Practice 30 (2017) 64e71
et al., 2011; Nijs et al., 2015). Management of shoulder disorders can
be further challenging as only 50% of new episodes presenting in
primary care recover within six months, with just 60% recovered at
one year (Kuijpers et al., 2004). Prognostic factors for persistent
shoulder pain include pain intensity, concurrent neck pain and
longer duration of complaints (Kooijman et al., 2015).
Persistent musculoskeletal pain is a multi-factorial entity that is
influenced by biological and psychosocial factors (George et al.,
2014). In terms of psychosocial factors, patients' attitudes and be-
liefs can influence their pain perceptions, response to and satis-
faction with rehabilitation (Hush et al., 2011; Main et al., Nijs et al.,
2013), however, only few studies have explored perspectives of
patients with RCRP. Using focus groups, Nyman et al. (2012)
explored experiences of patients diagnosed with supraspinatus
tendinitis prior to and following physiotherapy or surgery. Simi-
larly, Minns Lowe et al. (2014) conducted individual interviews
with patients with full-thickness rotator cuff tears to explore their
experiences. The patients appeared to have a mechanistic (patho-
anatomical) view of the cause of the pain, expecting a clear diag-
nosis and an intervention that would solve the pain (Nyman et al.,
2012). Both studies highlighted the multi-dimensional effects of
the shoulder pain on the patients' lives in various domains,
including psychological, functional and occupational (Minns Lowe
et al., 2014; Nyman et al., 2012).
In other musculoskeletal conditions with persistent pain,
neuroscience education has been incorporated into rehabilitation
(Louw et al., 2016). The education explained pain physiology and
was tailored to address individuals' pain perceptions (Nijs et al.,
2011). It is possible that such pain education may also be used to
optimise outcomes of treatment of patients with RCRP. To facilitate
development of pain education resources for people with RCRP,
enhanced understanding of such patients' beliefs of the causes of
their pain and their understanding of contributing factors towards
their pain is needed, adding towards a patient-centred approach to
rehabilitation. This report is part of a larger project to develop re-
sources for pain education specifically for patients with RCRP. As
the first step, this study aims to explore such individuals' beliefs
about the cause of their shoulder pain, and their experiences of the
effect of pain on their daily lives.
2. Methods
2.1. Study design
This mixed methods study included semi-structured interviews
and validated outcome questionnaires. Researchers bracketed their
perceptions around the topic prior to the study. The University of
Otago Human Ethics Committee (Health) granted ethical approval
for this research.
2.2. Participants
Participants were recruited from the local community via
newspaper advertisements, flyers placed in physiotherapy and
general practitioner clinics, sports and fitness centres, and posts on
Facebook. The inclusion criteria were: (i) men and women
aged
40 years; (ii) complaining of shoulder pain with/without
referral in the upper limb for more than three months (Andersson,
2004); (iii) range of motion largely preserved and; (iv) able to
provoke shoulder pain consistently with resisted contractions into
abduction and/or lateral rotation (Littlewood et al., 2014). In-
dividuals were excluded according to the following criteria: (i)
shoulder surgery in the last six months; (ii) known systemic in-
flammatory disorders; (iii) repeated cervical movement testing
affecting shoulder pain and/or range of movement and; (iv) pain or
65
injuries of the arm other than the shoulder that limited function in
the past three months.
Potential participants contacted a research administrator via
telephone or e-mail and were screened for inclusion factors (i and
ii) and exclusion factors (i and ii). Thirty-one volunteers expressed
interest in the study, however, nine of these did not meet the
telephonic screen. Those who met the telephonic screen criteria
were then contacted by the senior researcher (GS) to schedule the
interview, and to provide a link to an electronic questionnaire,
completed before the interview. After being informed of the pur-
pose of the study and providing written, informed consent, the
participants were fully screened by the senior researcher. Sampling
ensured that the first five men and five women meeting the full
screen were included in the study. Eleven participants underwent
the physical screen, one of which did not meet the criteria
(shoulder pain reproduced during cervical movement testing).
When the 10 interviews were completed and data saturation was
deemed to have been reached, the remaining eleven volunteers
who met the telephonic screen criteria were thanked and informed
that no further participants were required.
2.3. Data collection
Interviews took place in the School of Physiotherapy, the first
and tenth conducted by GS, a female musculoskeletal physiother-
apist with a PhD and over thirty years of clinical and academic
experience. All other interviews were conducted by MG, a female
Honours physiotherapy student. Both researchers attended all in-
terviews, except the final, where only GS attended. An interview
guide (Table 1) with questions and prompts was developed, based
on the study aims and previous qualitative studies regarding pa-
tients' pain experiences (Darlow et al., 2013; Minns Lowe et al.,
2014). After interview four, the guide was adapted to include a
question that emanated from those initial interviews (Table 1).
Although the guide provided a framework, the sequence and
questions were not fixed. Open-ended questions were used to
facilitate in-depth narrative descriptions (Dicicco-Bloom and
Crabtree, 2006). Interviews were audio-taped and interviewer
field notes were taken throughout. The interviews did not cause
obvious distress and no repeat interviews were undertaken.
Prior to attending the interview participants were sent a link
and asked to complete an online survey using Qualitrics software
(Version July 2016 of Qualtrics, Provo, Utah, USA), including the
following:
 Shoulder Pain and Disability Index, SPADI (Breckenridge and
McAuley, 2011)
 The shortened Disabilities of the Arm, Shoulder and Hand Score,
QuickDASH (Mintken et al., 2009)
 Fear-Avoidance Beliefs Questionnaire, FABQ (Mintken et al.,
2010)
 Pain Catastrophising Scale, PCS (Sullivan et al., 1995)
 General health: EQ-5D™ (The EuroQol Group, 1990).
2.4. Data analysis
The quantitative data were downloaded into a Microsoft Excel®
spreadsheet and the median and ranges were calculated for the key
variables. All data and interviews were anonymised (Stuckey, 2014)
and participants were each assigned a pseudonym. Interviews were
transcribed verbatim by MG for the first interview and an inde-
pendent professional transcriber for the remaining nine. After the
initial interview transcription, data analysis began using the gen-
eral inductive approach, allowing frequent or significant themes to
66 M.A. Gillespie et al. / Musculoskeletal Science and Practice 30 (2017) 64e71

Table 1
Semi-structure interview guide.

1. Please could you tell us more about yourself: what you do in terms of work, hobbies, sports?
2. Who do you live with or like spending time with?
3. Can you please tell us about your shoulder pain?
Prompts: How did it start? What happened at that time? How long ago?
4. How does your pain affect your life, for example in terms of your family, friends, work, sports, etc?
5. Could you tell us what your thoughts were at the time when the pain started as to what was causing the pain, or why you had the pain?
6. Have you had the shoulder assessed by a health professional, and what did they say about what was causing the pain?
7. If you have had treatment by the health professional, what was this treatment and how did it this help you?
8. What information from the health professionals has been useful for you and why?
9. Where else have you looked for information?
10. Is there any specific information you think would be helpful for you, or that you are seeking?a
11. Were there any specific aspects of your rehabilitation that you think worked well for you?
12. What do you think were the challenges during your rehabilitation and were you able to overcome these?
13. What else have you done or considered that has been helpful?
14. Are there any particular concerns or expectations about your shoulder pain, about what may happen in future?
a
Question added after the fourth interview.

arise (Thomas, 2006). Transcripts were read several times, creating Table 2
familiarity, before inductive coding identified codes emerging from Results of patient-related outcomes (PRO) questionnaires.

text segments reflecting the research aims (Thomas, 2006). These Tool Components Median (range)
codes were named and written in the transcript margins to SPADI Pain (/100) 39.0 (22.0e72.0)
accompany text segments. As each transcript was analysed, previ- Disability (/100) 25.0 (6.3e81.3)
ous transcripts were re-read, to identify any new codes that were Total (/100) 36.9 (12.3e77.7)
found in the subsequent transcripts, using an iterative process. QuickDASH Disability/Symptom Score (/100) 28.1 (18.8e56.3)
Work (/100, n ¼ 8) 28.1 (18.8e56.3)
The codes and supporting pseudonyms were tabulated into a
Sports (/100, n ¼ 7) 50.0 (18.8e100)
word processing document throughout the analysis. MG analysed FABQ Physical Activity (/24) 12 (1e20)
all interviews, while GS independently analysed the first and the Work (/42, n ¼ 9) 17 (0e36)
subsequent alternative interviews (total five), as a form of consis- PCS Rumination (/16, percentiles) 2 (0e8)
Magnification (/12, percentiles) 2 (1e7)
tency checking (Thomas, 2006). Relevant text segments with
Helplessness (/24, percentiles) 5 (0e7)
pseudonyms were listed under the appropriate code/s in a separate Total (/52, percentiles) 9.4 (1e19)
document (Thomas, 2006). Following analysis of all transcripts, EQ-5D General Health Status 83 (62e90)
coding was discussed, then codes were combined to reduce overlap
SPADI: Shoulder Pain and Disability Index: outcome expressed as a percentage from
and redundancy, before being merged into main themes. Themes 0% (‘no pain’ and ‘no disability’) to 100% (‘worst pain imaginable’ and ‘so difficult it
were compared back to the raw data, to ensure correct interpre- requires help’).
tation (Thomas, 2006). The emerging themes and model were QuickDASH: The Disabilities of the Arm, Shoulder and Hand Score: components
ranging from 0 to 100 (‘least’ to ‘most disability’). Two participants did not complete
discussed and ratified within the research team. Participants
the Work section as they were retired or studying respectively; three participants
receive a summary of results which gave them an opportunity to did not complete the Sports section as they did not consider their physical activities
confirm whether or not the content reflected their beliefs and ex- to be “sport (n ¼ 2) or as they did not undertake any sport (n ¼ 1).
periences, or to offer additional information (Thomas, 2006). FABQ: Fear-Avoidance Beliefs Questionnaire: total scores for physical activity ¼ 24
and work ¼ 42. Higher scores (>15 for physical activity and >34 for work) indicate
fear-avoidance beliefs.
3. Results PCS: Pain Catastrophising Scale: total combined score ranging from 0 to 52. Scores
are given a percentile relative to normative data, a score of 52 ¼ 100th percentile
catastrophiser. Rumination score
11, magnification score
5; helplessness score
3.1. Participant characteristics
13, and a total score
30, correspond to clinically relevant levels of catastroph-
ising.
The interviews ranged from 10 to 34 min (average ¼ 23 min). EQ-5D: Health-related quality of life, with 100% indicating high quality.
The participants were all New Zealand European, with a median
(range) age of 58 (47e68) years, complaining of shoulder pain for a
median (range) of 11 (4e240) months. One participant was retired, (Tom) had a magnification score considered clinically relevant (5/
four were office workers, and the occupation of the remaining five
12) (Sullivan, 2009).
entailed upper body work (farmer, gardener, plastic fabricator,
nurse, handyman). Leisure and sports activities included gardening,
golf, gym fitness training, tramping, walking, running and fishing. 3.2. Emergent themes
Based on the SPADI, participants had mild-moderate levels of
pain (median 39%), and they scored minimal difficulty (25%) in Four main themes emerged from the interviews: (1) Under-
their perceived level of disability during certain tasks. Question- standing the pain; (2) It affects everything; (3) Pain-associated
naire data from the QuickDASH revealed participants had greater behaviours and; (4) Emotional responses and the future. The
difficulty carrying out sports than work (Table 2). The median FABQ resulting model indicated a ripple effect of the persistent RCRP on
scores indicated no fear-avoidance beliefs, however, three partici- the participants' lives (Fig. 1). Two participants responded to the
pants had a FABQ-Physical activity >15, indicating fear avoidance results summary, confirming that it reflected their beliefs and ex-
during activity while the FABQ-Work was <34 for all, indicating periences. Full-sentence quotes supporting the themes and sub-
little evidence for avoidance related to work (Williamson, 2006). themes are presented in Table 3 and additional relevant quotes
None of the participants had a total PCS >30, considered to indicate are displayed in the Supplementary File. An em dash () was used
clinically-relevant pain catastrophizing, however, one participant to indicate a pause, an ellipsis (…) the removal of some text that did
 M.A. Gillespie et al. / Musculoskeletal Science and Practice 30 (2017) 64e71
Fig. 1. Model of the participants' experiences of their rotator cuff-related pain.
not alter the meaning of the quote, and square brackets [ ] to
indicate the addition of text to clarify meaning.
3.2.1. Understanding the pain
Participants described the cause of their pain from an anatom-
ical perspective within the context of their lives and two sub-
themes emerged.
3.2.1.1. What I think is happening. Participants thought their pain
was due to “pulled” or “tight” muscles (Tom), “torn muscles” (Peter),
“sore muscles”, “inflamed tendons” (Lynne) and “pulled tendons”
(Max). Some participants (4/10) described impingement-type
mechanisms (Quotes 1, 2).
Others (4/10) described malposition of the shoulder, “it's - like
it's in the wrong position, or screwed up in a ball or something”
(Anne). Muscles located in the arm (biceps brachii and deltoid)
were also described by participants (5/10) as contributing to their
pain, “the actual pain is down (…) there [at the deltoid]- Yeah, right in
there it gets sore” (Jack). Three participants were unsure what was
causing the pain, “whatever goes on, I don't really know” (Peter).
Five participants consulted the internet or literature for infor-
mation regarding their pain, however, found it, “quite hard to pick
what you think you've got …” (Jack) due to the vast amount of, often
perceived conflicting, information, “I can look at books and things
but it doesn't really tell you much” (Jane). Information from health
professionals appeared to influence individuals' beliefs about the
pain (Quote 3). However, there was also confusion when being told
67
by health professionals that a pathoanatomical lesion was not
visible with imaging, yet the individual experienced pain (Quote 4).
3.2.1.2. How it happened. The participants also made sense of their
pain by relating it to the context of their lives, in terms of ‘how it
happened’, half of them (5/10) recalling the pain-provoking event
(Quote 5, 6).
The other half (5/10) reported it was a “grey area when [the
shoulder pain] started” (David), “[the shoulder] just really came up a
bit sore” (Jack). Two participants believed stress to contribute,
“stress at work, over the desk all day writing … a fairly stressful time,
you're always in tension” (Tom) while five “just put it down to age”
(Anne), “you accept that you're getting older” (Jack).
3.2.2. It affects everything
Participants reported their pain to “affect most aspects of what I
would do” (Lynne), “it affects everything” (Jane). Different levels of
pain and its influence on function were described, also reflected in
the range for SPADI-Pain (22.0e77.0%), and SPADI-Disability
(6.3e61.3%, Table 2). For some, “it was never really a debilitating
thing, it was more … an annoying pain” (David), for others, “it was
hurting a lot” (Max). Nonetheless, the pain was “unpredictable”
(Peter) and fluctuated, “you have good days and bad days” (Tom).
The influences were described within four sub-themes.
3.2.2.1. Activities of daily living. All participants reported their pain
to affect activities of daily living, such as dressing, showering,
hanging washing, cooking, shopping, lifting, and driving, often
68 M.A. Gillespie et al. / Musculoskeletal Science and Practice 30 (2017) 64e71

Table 3
Themes, sub-themes and supporting narrative.

Theme Sub- Supporting narrative

theme
Quote Participant Quote
number

Understanding the pain

‘What I think is happening’
1 Lynne To my way of thinking, the tendon gets stuck under the bone (…) because it was inflamed, it wouldn't slide under and gets stuck”
2 Jane “What I thought was happening was that [a muscle] was getting squashed.”
3 Lynne I had a scan and X-ray … she said there was a bit of bursitis? The vessel was inflamed ….
4 Max “[The doctors] were a little bit more, ‘oh you don't seem to be having trouble … holding the positions' … they did X-rays and she
made it plain … she said ‘oh there is not much wrong with you basically’. I come out and I sort of thought ‘why?’ You know, ‘why
is this hurting so much?
‘How it happened’
5 Max I was fishing (…), there was a rough bit that had (…) hidden hollows. (…) I fell down one and put my arm out and fell quite heavily
on it.
6 Peter To this day [I] don't really know what the actual [cause of the pain is], other than the fact that I know (…) where the instances
occurred.
It affects everything
Activities of Daily Living
7 Max Anything above my head was the worst, getting dressed is tough.
8 Tom Putting the washing out was quite an effort (…) holding your hand up (..). So prolonged [activities] in one position gets it after a
while.
Occupation, sports and leisure activities
9 Jane I can't lift the [grand]children. I don't walk my dogs for fear of that (…) pulling.
Sleep
10 Lynne [Sleep] was alright at the beginning. It seemed to gradually get worse all the time, that's why I went to the doctors.”
Cognition
11 Tom The worst thing it does is make you always wonder, ‘could I be better at what I am doing?’ (Tom).
12 Jane One night, two nights I can do, three nights I'm starting to get really tired (…) my energy levels drop, (…) memory getting really
ditsy at work.
Pain-associated behaviours
Avoidance and adaptation
13 Lynne I just made sure I didn't do that same movement [that caused my pain] again.
14 Peter I have developed a little bit of a technique (…). I've found (…) work procedures to make things slightly different working with the
animals.
Seeking professional help
15 Sue Once I found I had been declined for [b the medical funder] I didn't go back [to the physiotherapist] because I actually fairly just
couldn't afford it and I didn't feel that I was benefiting that much.
Life continues
16 David You try and just blank it out (…) and not let it stop you doing anything.
17 Kate I've managed to do everything I need to (…) sometimes you've just got to suck it up.
18 Jack I still do everything anyway really. You just do things slightly different, maybe at times, but you still do it yeah.
Emotional responses and the future
Emotional responses
19 Kate [The pain] would annoy me more than anything, rather than worry me. Because I get frustrated if I can't do everything
20 Sue [The pain makes me feel] frustrated and old.”
21 Peter Losing your complete career was far worse than (…) losing the ability to play tennis (…) in the big scale of things, that's that and
this is (…) completely manageable.
Concerns and goals for the future
22 Max If [the shoulder] hurts it is doing something, it is hurting for a reason you know, so … no one sort of managed to say anything
about that.
23 Jane What would I be seeking. How [the shoulder] actually works, like some sort of dynamic sense of what it is doing, rather than just
the picture itself … would be more useful [than online information].
24 Kate I'd be interested to know whether I'm doing more harm (…). Because really I want to carry on doing exactly what I do.

tasks requiring holding the arm of the affected shoulder in one
position (Quotes 7, 8).
3.2.2.2. Occupation, sports and leisure activities. Although the
SPADI-Work indicated that work was only minimally affected for
the group, most participants (9/10) reported the pain interference
at varying levels. With prolonged sitting at a desk, the painful
shoulder could “drag, [and] you just can't concentrate the same …”
(Tom). Physical work was also affected, “hammering - that jarring
really does aggravate it big time.” (Tom). Most participants (9/10)
also reported the pain to impact sports/leisure activities, ultimately
resulting in the cessation of some activities (Quote 9).
However, participants' pain experiences related to exercising
differed. One reported the shoulder was “perfectly okay” (Peter)
during a gym workout, while another only felt the pain during
certain gym exercises, “I notice it above the head stuff with weight.”
(Anne), and a third participant could not undertake her usual gym
exercise due to the pain (QuickDASH Sport 100%, Jane). Similarly,
one participant reported the pain to have no effect on golf being
“such a relief” (Peter), while another felt the pain decreased his
golfing performance “probably 50%” (Max).
3.2.2.3. Sleep. Most participants (9/10) reported the pain to affect
their sleep. Three experienced minimal “discomfort” (Peter) at
night, while others (4/10) reported sleep was “a big issue” (Jane).
The pain interrupted sleep, causing one participant to wake “five,
six, seven times” (Max) a night. Pain during sleep could be the
driving factor for seeking help (Quote 10).
3.2.2.4. Cognition. Two participants reported the pain affected
their cognition and, thereby, their work-related performance and
energy (Quotes 11, 12).
 M.A. Gillespie et al. / Musculoskeletal Science and Practice 30 (2017) 64e71
3.2.3. Pain-associated behaviours
Pain-associated behaviours or strategies were evident, which
could be divided into three sub-themes.
3.2.3.1. Avoidance and adaptation. Many participants (6/10) learnt
to avoid movements that aggravated the pain (Quote 13) related to
activities of daily leaving (ADL), sports and occupation (Quote 14).
All participants adapted their lives, “you just do things slightly
differently … but you still do it” (Jack), such as “… for putting on a
shirt type thing I put [the sore arm] in first” (Sue). During sleep,
participants reported to hang an arm “right over the edge of the bed”
(Max) or “sleep more on my shoulder blade …” (Lynne).
An office worker adapted by “trying to do it with the other hand”
(Kate), while a gardener stated, “you always do things close to your
body … you can't pull things out of the ground … you have to get a
spade and dig” (Jack). One participant was “more right-hand domi-
nant” (Tom) during golf. Leisure activities were also adapted, “in the
garden … the shoulder] felt sore … I was very conscious that I was
using more of my left hand than my right” (Kate).
3.2.3.2. Seeking professional help. Five participants reported having
sought health professional help, including physiotherapists, oste-
opaths, massage therapists and medical practitioners prior to
participating in this study. Three other participants only used
painkillers or non-steroidal anti-inflammatories. The remaining
two participants did not use any form of treatment, with severity of
injury and expense being the reasons, “mainly because (..). I don't
think [the shoulder is] bad enough, and money” (Anne). One partic-
ipant who had sought physiotherapy reported that she had dis-
continued mainly due to the financial cost of treatment, but also
due to lack of sufficient improvement (Quote 15).
3.2.3.3. Life continues on. Most participants (8/10) suggested that
despite pain, they tried to “carry on as normal” (Lynne), and also
demonstrate resilience: “… I'll live with it if I have to” (Anne)
(Quotes 16e18). Being self-employed or the only individual trained
in a particular role at work may leave an individual with no other
choice, “there's nobody [at work] that would be able to do my job”
(Kate).
3.2.4. Emotional responses and the future
Participants reported the pain impacted their lives emotionally
and contributed to thoughts about the future.
3.2.4.1. Emotional responses. While the PCS did not indicate
clinically-relevant pain catastrophizing (Table 2), most participants
(7/10) expressed frustration and/or annoyance to a certain extent
(Quotes 19, 20). Coping was facilitated by putting the pain into
perspective, such as career changes (Quote 21) and other health
conditions they had had.
3.2.4.2. Concerns and goals for the future. Many participants (8/10)
expressed concerns for future, such as whether their activities may
cause “permanent damage” (Max), “does the mobility get worse as
age goes on?” (Peter) or whether the pain “will it ever go” (Max).
However, hope was also expressed by five participants, such as “I
hope it comes right. That's my biggest hope” (Lynne).
Some participants (3/10) reported having task-specific goals for
their shoulder, to “sleep well” (Max), and “to carry the groceries in
from the car” (Jane). Other participants (3/10) reported impairment-
related goals, “get rid of some pain and make [the shoulder] move”
while “hoping to build muscle up” (Tom).
Information that was sought included knowledge about un-
derlying causative factors contributing towards the shoulders pain
(Quote 22), and function of the shoulder (Quote 23). Three of the
69
participants sought specific exercises to strengthen the shoulder
and to improve flexibility. Other participants were specifically
wanting advice regarding decreasing risk for progressive harm
(“damaging my body irreparably”, Anne) and strategies to remain
active (Quote 24). Thus, overall, they were interested in the prog-
nosis of their pain and self-management strategies, seeking re-
assurance for not creating further damage.
4. Discussion
This study explored beliefs and experiences of the pain of in-
dividuals with RCRP. Participants believed that predominantly
anatomical factors local to the shoulder caused their persistent
RCRP, with half of them having sought advice from health practi-
tioners. Our findings indicate that RCRP can impact life extensively
which supports findings of previous studies (Minns Lowe et al.,
2014; Nyman et al., 2012). A recent qualitative study of in-
dividuals with frozen shoulder reported hidden suffering by those
individuals as the impact of the pain and disability was not always
visible to others (Jones et al., 2013). Although frozen shoulder may
be associated with higher levels of pain and disability than those
reported in the current study [e.g. SPADI-total above 60% (Sharma
et al., 2009)], the hidden, invisible influence of the pain on the
participants was also evident. These participants reported devel-
oping strategies to avoid painful movements or postures, and to
persevere in daily life and occupations. Nevertheless, a number of
functional limitations and impairments were described, including
those that were related to ADL, occupation, sports and leisure.
While they had high levels of general health, the interference of
their pain on the quality of their lives was sufficient to motivate
them to participate in this study, seeking information, specifically,
as to causes of the pain, function of the shoulder, similar to previous
report of patients with ‘supraspinatus tendinitis’ (Nyman et al.,
2012).
Further ‘invisible’ impairments were disturbed sleep and
thereby, cognition and concentration, albeit to varying degrees,
similar to reports from Nyman et al. (2012) and Minns Lowe et al.
(2014). Emotional responses such as frustration and annoyance
were also voiced, yet not the profound emotional impact described
by Minns Lowe et al. (2014) for participants with full thickness
rotator cuff tears. However, on deeper analysis of the data, concern
and worry was evident, questioning whether the pain, weakness
and stiffness would progress over time, and/or if the effects were
permanent.
4.1. Methodological considerations
A strength of this study is the mixed methods approach, with
quantitative data providing a greater breadth and the qualitative
data greater depth, strengthening inferences (Teddlie, 2009). No
new codes emerged from the data after six interview, indicating
that data saturation had been reached (Guest et al., 2006). Inde-
pendent coding, involving co-analysis of five interviews was
another strength (Thomas, 2006), as little difference was found
between coding from the two researchers, indicating credibility in
the codes. Trustworthiness is also evident by discussing and con-
firming the themes and evolving model within the research team,
and by providing additional quotes in the supplementary file. Un-
like previous research (Minns Lowe et al., 2014; Nyman et al., 2012),
this study did not limit the inclusion criteria to those who had
received or were seeking treatment, thus allowing a broader scope
of perspectives to be explored.
Lack of diagnostic imaging may be considered as a weakness,
however, signs and symptoms of RCRP are not always reflective of
anatomical pathology (Magarey et al., 2016) and, at primary care
70 M.A. Gillespie et al. / Musculoskeletal Science and Practice 30 (2017) 64e71
level, management is guided by a clinical examination (Lewis et al.,
2015). Clear inclusion/exclusion criteria were used and all partici-
pants were screened by the senior researcher. Despite aiming to
recruit widely, the participants were all New Zealand European,
therefore, these findings may not apply to other cultural groups. As
is common in qualitative research studies, the small sample size
restricts the generalisability of the results, however, allowed
greater depth of the data analysis.
4.2. Clinical implications
Participants' beliefs overwhelmingly indicated a biomedical or
pathoanatomical view of shoulder pain. Furthermore, half the
participants believed their pain was due to ‘getting old’ and they
appeared to have little understanding that common age-related
changes often remain asymptomatic (Yamamoto et al., 2011).
Although psychosocial factors can contribute to persistent pain
(Linton and Boersma, 2003), the participants rarely considered
these. The PCS and FABQ indicated low levels of catastrophizing and
fear-avoidance behaviour. Yet on deeper questioning, life stressors
(work, health and family issues) were mentioned. Educational re-
sources explaining pain physiology have been recommended for
patients with various persistent musculoskeletal pain (such as Nijs
et al., 2011). Similar resources may also be relevant for individuals
with persistent RCRP, supplementing tailored physiotherapy
treatment, based on individuals' beliefs, experiences and goals. The
participants sought exercises to strengthen the shoulder and
expressed concerns regarding worsening shoulder mobility, on-
going pain and potential further damage through continued use.
Therefore, such resources should also address these concerns,
providing reassurance and strategies to enhance self-efficacy and
self-management. Additionally, clinicians should provide in-
dividuals with information regarding possible contributing factors
towards the pain and address these, through a biopsychosocial
approach to management (Alonso, 2004). Furthermore, pain
reduction and tendon load management, in the form of unloading
and reloading, should be considered (Lewis, 2010). This sample was
largely active and their ‘life continues on’ approach may have
resulted in shoulder overload in some of the participants. Thus,
perhaps physical load modification should be emphasised, collab-
oratively exploring safe and progressive margins of shoulder
loading in terms of their physical activity and occupation.
5. Conclusion
The participants with rotator cuff-related pain focused on
structures of the shoulder when describing the cause of their pain,
yet such causal factors may not always result in pain. While they
reported that the pain affected most of their activities, participants
adapted their lives, continuing in their occupational, sporting and
social involvements. Clinicians should question individuals about
psychosocial stressors in their lives, as this sample placed little
emphasis on these contributing to their pain. In addition, pain
physiology education should supplement physiotherapy treatment,
all of which needs to be tailored, considering individuals' unique
experiences and goals.
Acknolwedgements
This study was supported by grants from the New Zealand
Manipulative Physiotherapists Association and Physiotherapy New
Zealand.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.msksp.2017.05.009.
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