Rev. bras. ortop. vol.52 número5

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Review

Article

Outcome

assessment

in

the

treatment

of

rotator

cuff

tear:

what

is

utilized

in

Brazil?

夽

Jorge

Henrique

Assunc¸ão

∗

_,

_Eduardo

_Angeli

_Malavolta,

_Vitor

_Rodrigues

_Domingues,

Mauro

Emilio

Conforto

Gracitelli,

Arnaldo

Amado

Ferreira

Neto

UniversidadedeSãoPaulo,FaculdadedeMedicina,HospitaldasClínicas,InstitutodeOrtopediaeTraumatologia,SãoPaulo,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received16June2016 Accepted26July2016

Availableonline1September2017

Keywords: Shoulder

Evaluationofresultsoftherapeutic interventions

Rotatorcuff

a

b

s

t

r

a

c

t

Thisreviewevaluatedtheoutcomesusedinclinicalstudiesinvolvingrotatorcufftear pub-lishedinthelastdecadeinthetwoleadingBrazilianorthopedicjournals.Aliteraturereview wasperformed usingthe journals RevistaBrasileira de OrtopediaandActaOrtopédica Brasileira.Itincludedalloriginalclinicalarticlesdescribingatleastoneoutcomemeasured beforeorafteranyclinicalorsurgicalinterventionrelatedtorotatorcufftear,published between2006and2015.Theauthorsevaluatedrangeofmotion,musclestrength,patient satisfaction,andtendonintegrityandfunctionaloutcomesscores.Therewere25clinical studiespublishedaboutrotatorcuffinthetwoprincipalBrazilianorthopedicjournalsinthe lastdecade,20caseseries(80%),onecase–control(4%),andfourcohorts(16%).Objective measuressuchasmusclestrength,patientsatisfaction,andevaluationoftendonintegrity werelittleused.Rangeofmotionmeasurementswereperformedin52%ofthearticles. Evaluationsofmusclestrengthandpatientsatisfactionwerereportedby28%and16%of thestudies,respectively.Only28%ofthearticlesevaluatedtendonintegrityaftersurgery. Ofthese,16%didsobymagneticresonanceimagingand12%byultrasonography.Themost usedscalewastheUCLA,presentin92%ofthearticles,whiletheConstant–Murleyappeared in20%.Scalesdeemedreliable,withhighinternalconsistencyandgoodresponsiveness, wererarelyused.

夽

PaperdevelopedatUniversidadedeSãoPaulo,FaculdadedeMedicina,HospitaldasClínicas,InstitutodeOrtopediaeTraumatologia, GrupodeOmbroeCotovelo,SãoPaulo,SP,Brazil.

∗ _{Corresponding}_author.

E-mail:[email protected](J.H.Assunc¸ão).

http://dx.doi.org/10.1016/j.rboe.2017.08.013

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Avaliac¸ão

dos

desfechos

no

tratamento

da

rotura

do

manguito

rotador:

o

que

usamos

no

Brasil?

Palavras-chave: Ombro

Avaliac¸ãoderesultadode intervenc¸õesterapêuticas Manguitorotador

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e

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o

Avaliamososdesfechosusadosnosestudosclínicosqueenvolvemroturadomanguito rota-dorpublicadosnaúltimadécadanosdoisprincipaisperiódicosortopédicosbrasileiros.Foi feitaumarevisãodaliteraturanosperiódicosRevistaBrasileiradeOrtopediaeActaOrtopédica Brasileira.Foramincluídos todosos artigosclínicos originaisquedescreviam aomenos umamedidadedesfechoantesouapósalgumaintervençãoclínicaoucirúrgicareferente aomanguitorotadorpublicadosentre2006e2015.Osdesfechosavaliadosforamarcode movimento,forçamuscular,satisfação,integridadetendíneaeescalasclínicas.Foram publi-cados25estudosclínicossobremanguitorotadornosdoisprincipaisperiódicosortopédicos brasileirosnaúltimadécada,20sériesdecasos(80%),umestudotipocaso-controle(4%) equatrocoortes(16%).Medidasobjetivascomoforçamuscular,satisfaçãodopacientee avaliaçãodaintegridadetendíneaforampoucoempregadas.Asmedidasdoarcode movi-mentoforamdescritasem52%dosartigos.Aavaliaçãodaforçamusculareasatisfação dopaciente foramdescritas em28% e16%dos estudos,respectivamente. Apenas28% dosartigosavaliaramaintegridadetendíneaapósacirurgia.Desses,16%ofizeramcom aressonânciamagnéticae12%comaultrassonografia.AescalamaisusadafoiadaUCLA, presenteem92%dosartigos,enquantoadeConstant-Murleyfoiusadaem20%.Escalas consideradasconfiáveis,comgrandeconsistênciainternaeboaresponsividade,raramente foramusadas.

Introduction

Shoulderpainhasahighprevalenceinthepopulation,ranging from7to26%.1_Rotator_cuff_conditions,_the_main_cause_of_pain

intheshouldergirdle,affect20%ofthegeneralpopulationand upto50%ofpatientsover80years.2

Standardizedclinicalassessmentisessentialtodetermine theefficacyofatreatmentandalsotocomparetheresultsof differentstudies;itiscrucialinclinicalresearch.3,4_Methods

forevaluatingtheresultsoforthopedictreatmenthavebeen modifiedinrecentyears.5,6 _Previously, _measurements_were

based on physicalexamination, byexamining joint mobil-ityandmusclestrength.However,questionnairesorclinical scaleshavebeendevelopedthathaveimprovedtheevaluation ofresults.7,8 _However,_there_is_a_wide_variation_in_the

mea-surementtools.9_More_than₄₀_scales_are_described_to_assess

shoulderpainandfunction.10_In_addition,_the_measurement

oftherangeofmotionandstrength,andthedescriptionofthe imagingfindingsalsodonothaveaconsensus.9

Makhnietal.9_recently_published_a_review_involving_the_six

leadinginternationalorthopedicjournals,anddescribedthe toolsusedtoassessoutcomeinrotatorcuffdisorders.Wedo nothaveasurveyshowingthemaintypesofclinical evalu-ationinBrazil.Mostinstruments havebeendevelopedand evaluatedintheEnglishlanguage.10_For_these_instruments_to

beusedinBrazil,translation,culturaladaptation,aswellas teststhatevaluatemeasurementpropertiesofthese instru-ments,suchasinternalconsistency,reproducibility,validity andresponsivenessarerecommended.5

Theobjective ofthisstudy wastoevaluatetheoutcome usedinclinical studiesinvolvingtherotator cuffpublished

in the last decade in the two main Brazilian orthopedic journals.

Methods

Design

A literaturereviewwas performedin thetwo main Brazil-ianorthopedicjournals,RevistaBrasileiradeOrtopedia(RBO) and Acta Ortopédica Brasileira. The period covered was one decade (January 2006 to December 2015). This study was approved bythe local Ethics Committeewith number 1197.

Searchstrategy

Thesearchstrategyinitiallyincludedthereadingofalltitles ofthearticlesbyoneoftheauthors(JHA),usingthejournals’ tableofcontents.Incasesofdoubtwiththereadingofthetitle, theabstractwasevaluated.Thisway,allarticlesthatdidnot involvetheshoulderjointwereexcluded.Thentheabstracts werereadbythreeauthors(JHA,EAMandVRD)and,if neces-sary,thefulltext,todetermineifthearticlefittheselection criteria.Incaseofdisagreementintheselectionofaparticular articleamongthethreeauthors,whetherincludingitornot wasdefinedbyconsensus.

Selectioncriteria

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one outcome measure before or aftera certain clinical or surgical intervention for the rotator cuff were included. Casereports, description ofsurgical technique, articles on diagnostic methods accuracy, anatomical studies, articles involvinganimalsorcadavers,basicscienceorreviewswere excluded.

Outcomes

Dataregardingthestudytitle,yearandvolumeofthe publi-cation,casuistry,minimumfollow-up,regularfollow-upand levelofevidencewere tabulated.Inaddition, the following outcomeswereassessed:

Rangeofmotion

Theevaluationoftherangeofmotionwasinvestigated:frontal flexion,elevation,abduction,lateralrotation(withthearmat thesideofthebodyorabduction)andmedialrotation(with thehandtowardthebackorwiththearminabduction).The measureinanyoftheaforementionedpositionswaslisted. Datawereonlyconsideredifquantitativelydescribedinthe resultssection.Thepositionofthepatient(supine,sittingor inaorthostaticposition)andtheuse ofagoniometerwere alsoevaluated.

Musclestrength

Thepositioninwhichstrength wasevaluatedwasstudied: frontalflexion,elevation,abduction,lateralrotation(withthe armatthesideofthebodyorabduction)andmedialrotation (withthe handtoward thebackor withthearmin abduc-tion).Themeasureinanyofthepositionswaslisted.Data wereonlyconsideredifquantitativelydescribedintheresults section.Thepositionofthe patient (supine, sitting orin a orthostaticposition)andtheuseofdynamometerwerealso evaluated.Manual evaluationdata(graduationfrom0to5) werecomputed.Dataonasubdomainofaclinicalscalewere alsoreported.

Tendonintegrity

The imaging method used (magnetic resonance with or withoutcontrast,computedtomographywithorwithout con-trast orultrasonography) was evaluated. Radiographs were notanalyzed.Theperiodicityand timinginwhichthetest was performed were reported. The use of some integrity assessmentscales,orcategoricalevaluationinrupturedand intact tendons has been described. We also describe the presenceorabsence ofdata relatedtothe acquisition and analysis of imaging tests: device used, evaluators, images obtained.

Satisfaction

Any data regarding patient satisfaction was studied. This included questions regarding treatment satisfaction or whether thepatient wouldrecommend the procedureto a thirdpartyor if theywould havesurgeryagain. Data on a subdomainofaclinicalscalewerealsoreported.

Evaluationscalesandquestionnaires

Thefunctionalscalesandtheevaluationquestionnairesused bytheauthorswereevaluated.Wealsoreportedstudiesthat usedvisualanaloguescale(VAS)forpainorfunction.

Statisticalanalysis

Datawereexposedinadescriptiveway,bymeansofabsolute numbersandpercentage.

Results

Intheperiodevaluated,712originalarticleswerepublished in the Brazilian Journal of Orthopedics and 588 in Acta OrtopédicaBrasileira,or1300publications.Amongthese,84 (6.7%ofthetotal)wereclinicalarticlesonshoulderdiseases; 25publications(1.9%ofthetotal)11–35 _evaluated_the_clinical

results of treatment ofrotator cuff tears (Table 1); twenty studies(80%)werecaseseries(levelofevidenceIV),one(4%) case–controlstudy(levelofevidenceIII)andfour(16%)cohorts (levelofevidenceII).Norandomizedstudywaspublishedin theperiod.Westudied1651shoulders,66.1±50.3shoulders perstudy.Eightarticles(32%)hadfollow-uptimeofpatients greater thantwoyears andonlytwo(8%) followedupwith standardizedassessment time.The mean ofthe evaluated outcomewas2.2±1.1(Fig.1).

Rangeofmotion

Among the studies evaluated, 12 (48%) did not report the measurementoftherangeofmotioninanypositioninthe postoperative period. Nine articles (36%) presentedmedial rotation,11(44%)evaluatedthelateralrotation,samenumber foundofpublicationsthatevaluatedthepatients’elevation. Threepublications(12%)evaluatedonlyonepositionofthe rangeofmotion,one(4%)evaluatedtwopositionsandnine (36%)presentedthemeasurementsoftherangeofmotionin threepositions(Fig.2).Themethodologyappliedinthe mea-surementoftherangeofmotionwasreportedinseven(28%) articles,theothersdidnotreporttheuseofgoniometer,the measurementtechniqueorthepatientposition.

Musclestrength

Musclestrengthafterrotatorcuffrepairwasreportedinseven studies(28%).Inthreestudies(12%)itwaspresentedasa sub-domainofafunctionalscale,andintwoarticles(8%)itwas reportedcategoricallywiththeuseofthecontralateralside asareference.Twostudies(8%)usedquantitative measure-mentofmusclestrengthusingadynamometerandreported the patient’s position (orthostatic).Six studies(24%) evalu-atedonlyonepositionmovement(elevationorabduction),one study15_evaluated_the_elevation_and_lateral_rotation.

Tendonintegrity

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Table1–Publicationsontreatmentofrotatorcufftearsbetween2006and2015.

Author(s) Title Journal Year Volume

(number)

Pages

Pecoraetal. Prognosticfactorsfortheclinicaloutcomefollowingrotator cuffrepair

ActaOrtopédica Brasileira

2015 23(3) 146–149

Portoetal. Evaluationofpatientsundergoingrotatorcuffsuturewiththe modifiedMason-Allentechnique

ActaOrtopédica Brasileira

2013 21(3) 167–169

Ramosetal. Resultsofarthroscopictreatmentofrotatorcufftears ActaOrtopédica Brasileira

2010 18(1) 15–18

Checchiaetal. Isolatedtearofthesubscapulartendon ActaOrtopédica Brasileira

2009 17(1) 26–30

Veadoetal. Rotatorcufftearinpatientsover65years:evaluationof function,integrityandstrength

RevistaBrasileirade Ortopedia

2015 50(3) 318–323

Miyazakietal. Evaluationofresultsofarthroscopicsurgicaltreatmentof rotatorcufftearsinpatients≥65years

2015 50(3) 305–311

Godinhoetal. Long-termfunctionalevaluationofvideoarthroscopic treatmentofpartialtearsoftherotatorcuff

2015 50(2) 200–205

Godinhoetal. Resultofarthroscopicsurgicaltreatmentofretearsofthe shoulderrotatorcuff

2015 50(1) 89–93

Almeidaetal. Comparativeanalysisofarthroscopicsutureoflargeand extensivetearsoftherotatorcuffrelatedtothelevelof osteopenia

2015 50(1) 83–88

Miyazakietal. Functionalevaluationofarthroscopicrepairoftherotatorcuff tearsinpseudoparalysispatients

2014 49(2) 178–182

Ikemotoetal. Evaluationoftheclinical-functionalresultsoftherepairof extensiverotatorcufftearwithinclusionofthetendonofthe longheadofthebiceps

2013 48(2) 165–169

Malavoltaetal. Platelet-richplasmainthearthroscopicrepairofcomplete tearsoftherotatorcuff

2012 47(6) 741–747

Ikemotoetal. Arthroscopicrepairofsmallandmediumtearsofthe supraspinalmuscletendon:evaluationofclinical-functional resultsaftertwoyearsoffollow-up

2012 47(4) 436–440

Godinhoetal. Resultsofthearthroscopicrepairofisolatedtearsofthe subscapularmuscletendon

2012 47(3) 330–336

Veadoetal. Prospectiveandcomparativestudyofthefunctionalresults aftertheopenandarthroscopicrepairofrotatorcufftears

2011 46(5) 546–552

Miyazakietal. Evaluationofresultsofthearthroscopicrepairofrotatorcuff tearsinpatientsupto50yearsofage

2011 46(3) 276–280

Almeidaetal. Comparativeanalysisoftheresultofarthroscopicsutureofthe rotatorcuffinsmokingandnon-smokingpatients

2011 46(2) 172–175

Miyazakietal. Evaluationofresultsofreoperationsofpatientswithrotator cufftears

2011 46(1) 45–50

Veadoetal. Functionalevaluationofpatientsundergoingarthroscopic debridementforthetreatmentofextensiveandirreparable tearsoftherotatorcuff

2010 45(5) 426–431

Godinhoetal. Evaluationoftheanatomicalintegritythroughultrasoundand functionalintegritythroughConstant&Murleyindexofthe rotatorcuffafterarthroscopicrepair

2010 45(2) 174–180

Miyazakietal. Extensivetearsoftherotatorcuff:evaluationofresultsofthe arthroscopicrepair

2009 44(2) 148–152

Veadoetal. Functionalevaluationofthearthroscopicrepairofcomplete tearsoftherotatorcuffassociatedwithacromyoplasty

2008 43(11/12) 505–512

Balsinietal. Arthroscopicrepairofcompleteisolatedtearsofthe subescapular

2008 43(11/12) 497–504

Veadoetal. Functionalandstructuralanalysisofrotatorcuffextensive tearsrepair

2006 41(8) 294–301

Veadoetal. Efficacyofarthroscopicdebridementinpartialrotatorcuff tears

2006 41(1/2) 22–28

publications(16%) usednon-enhancedmagneticresonance

imagingtocheckfortendonintegrity,andinthree(12%)an ultrasoundexamwasused.Allstudiesusedonlya categori-calevaluation,completeorrupturedrepair.Onlythreestudies (12%)mentionthenumberofevaluatorsandintwo(8%)the specificationsofthedeviceusedarereported.Nostudy men-tionsimageacquisitionprotocols.Thetestsweredoneonce

inallstudies,andonlyonestudyperformedtheexamona regularbasis(12months).22

Satisfaction

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50

40

30

20

10

0

1 2

Number of outcomes evaluated

Percentage of studies

3 4

4 8

20 44

24

5

Fig.1–Percentagedistributionofnumberofoutcomes analyzedperstudy.

50

40

30

20

10

0

0 1

Range of motion position evaluated

2 4 12

36 48

3

Fig.2–Percentagedistributionofnumberofrangeof motionpositionsevaluatedperstudy.

agree to undergo treatment again, and two (8%) assessed satisfactionthrough asimplequestion withtwocategories (satisfied/dissatisfied).

Evaluationscalesandquestionnaires

Of the 25 studies included, 23 (92%) used the University of California, Los Angeles Shoulder Rating Scale (UCLA),36

five papers (20%) used the Constant–Murley evaluation questionnaire,37 _two_(8%)_evaluated_the_results_through_the

Simple Shoulder Test (SST)38 _and _one _(4%) _through _the

questionnaireAmericanShoulderandElbowSurgeons Stan-dardized Shoulder Assessment Form (ASES)39 ₍_Fig. ₃_); ₂₀

publications(80%)usedonlyonescale,four(16%)madethe evaluationthrough twoscales and one study (4%)through threequestionnaires.Infourarticles(16%)VASwasusedto quantifypainbeforeandaftertreatment.

Discussion

Rotatorcufftearisthemaincauseofshoulderpain2_and_the

repairofthe rotatorcuffisthe mostcommonlyperformed surgeryofthisjoint.40_However,_in_the_period_evaluated,_only

100

75 92

20

UCLA Constant-Murley SST ASES

Clinical scales used

8

4 50

25

0

Fig.3– Percentageofstudiesusingclinicalscales.

25publicationswerefoundthatevaluatedtheclinicalresults ofthetreatmentofrotatorcufftearsinthetwomain Brazil-ianjournalsoforthopedicsandtraumatology.Thenational average was 2.5 articles per year. Between 2010 and 2014, an average of4.8and 8.8articles per year were published inthetwomajorcomprehensiveorthopedicjournals,Journal ofBone&JointSurgeryandTheAmericanJournalofSports Medicine,respectively.

TheBrazilianstudiesevaluatedtheresultswithameanof 2.2outcomesperarticle,anumber thatwassimilartothat observedininternationalstudies.9_However,_only_32%_of_the

studieshadpatients’follow-upofmorethantwoyears,and 8%had afollow-up withstandardizedevaluationtime.We alsofoundthatnationalpublicationsonthistopichavealow levelofevidence,80%werecaseseries,andwedidnotfind anarticlewithlevelIevidence,unlikethemainforeign jour-nals,whichreport13%ofstudieswithlevelI,17%withlevel II,26%withlevelIII,andonly43%withlevelIV.9_The

predom-inanceofcaseseriesisacharacteristicofBrazilianorthopedic publications.41

ThemostusedevaluationquestionnaireforBrazilian stud-ieswastheUCLAscale,usedin92%ofthepublications.This numberisfarsuperiortothatofMakhnietal.,9_who_found

that it had been usedonly in35% of articles, the thirdin prevalence. This scale was initially developed for patients undergoingtotalshoulderarthroplasty.42_Ellman_et_al.43_were

thefirstauthorstoapplythistooltoevaluatetheresultsofthe treatmentofrotatorcufftears;sincethen,ithasbeenused inseveralpublications.However,therearenostudiesto vali-dateitsdevelopmentandtheapplicationofthisinstrument inthesepatients. Itisconsidered ascale withlow reliabil-ityandvalidity,andhasseverallimitationsinthecollection ofinformation.44 _A_recent_systematic_review_comparing_the

assessmentscalesforshoulderdiseasesfoundthatthebest are the ASES, SST and OxfordShoulder Scorescales. They areconsideredreliable,withgreatinternalconsistency,good responsivity, and were previouslyvalidated.45 _In _our_study,

onlyonepublication(4%)18_used_the_ASES_scale,_and_two

stud-ies (8%)15,32 _used_SST_for_evaluation._On_their_turn,_Makhni

etal.9_observed_that_the_publications_of_the_six_major

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consideredmorereliable;ASESquestionnairewasusedin59%, andtheSSTin28%.

TheConstant–Murleyscale37 _was_the_second_most_used,

obsrvedinfivearticles(20%).Thisscaleisthemostusedin internationallypublishedstudies(61%ofpublications).This toolhasasmainlimitationthedifficultyandvariabilityforthe evaluationoftheabductionstrength,whichrepresents25% ofits totalscore.Severalauthorsreportits inconsistency,46

depending on the dynamometer used,47 _on _the _degree _of

shoulderabductionandrotation,48_and_on_strength _relative

toageandgender.49_Only_recently_has_this_scale_been

trans-lated and culturally adaptedto the Portugueselanguage.37

Indexesofnormalityareavailableforsomecountriesbuthave notbeenvalidatedinBrazil.49_We_believe_that_the_use_of_the

Constant–MurleyIndividualRelativeScale,whencomparedto thecontralateralshoulderwhenitisasymptomatic,theuseof digitaldynamometers,andscaletrainingreducedbiasinthe useofthisinstrument.50–52

IntheBrazilianjournals,only28%ofstudiesevaluate tendi-nousintegrityaftersurgery. Ofthese,16% dosowithMRI, and12%withultrasound.Thesevaluesarelowerthanthose reportedininternationaljournals,inwhich65%ofthestudies useimaginginthepostoperativeperiod,MRIiscitedin38%, ultrasoundin31%,andarthrotomographyin8%.9_In_addition,

noneofthe articlesevaluating integritythroughMRIuse a scaleofevaluation,onlythestratificationintointactand rup-tured.Exceptforthedeterminationofthesimpleabsenceor presenceofatear,theclassificationproposedbySugayaetal.53

isthemostusedandreliable,citedin33studiesinarecent meta-analysis.54

Ourresultsshowthatthedescriptionofmeasuresofthe rangeofmotionismadein52%ofthearticles,afigureslightly lowerthanthe63%reportedinforeignjournals.9 _The_same

occursregardingevaluationofstrength,describedin28%of nationalstudies,and38%ofinternationalones.9_{Satisfaction,}

initsturn,isevaluatedinonly16%ofthestudies,considerably lessthanthe54%foundininternationalstudies.9 _However,

fewarticleshavereportedthemethodologyusedtoevaluate thesemeasuresclearlyandreproducibly.Itshouldbenoted thatnoneofthenationalstudiesusedtoolstomeasurequality oflife, unlikeinternational journals, whichcite these out-comesinmorethan15%ofcases.9

Ourstudy hassomelimitations.Itincluded all typesof clinical studies,thus havinglevel IVofevidence. However, thegreaterpossibilityofbiasinarticlesoflowerlevelof evi-dencedidnotinfluenceourresults,sinceweevaluatedthe toolsused,nottheoutcomesthemselves.Inaddition,wehave reviewedthe articlesofonly onedecade and two national journals.Theaimofthisapproachwastoplotthenational pictureinarelativelyrecentperiod.Finally,oursearch strat-egymayhaveincludedarticlesbyforeignauthorspublished innationaljournals,anddidnotincludearticlesbyBrazilian authorspublishedininternationaljournals.

Webelievethat themembers ofthe BrazilianSocietyof ShoulderandElbowSurgeryshouldinitiate adiscussionto standardize the evaluation tools. Attitudes such as these, already takenbyUS55 _and _Japan56 _societies,_facilitate _data

comparison amongthe studies, allow for more consistent exposureofresults, and increase the possibilitiesofciting nationalarticles.ASESandSSTscale,alreadyvalidatedforthe

Portugueselanguage,andwithgoodreliability,38,57_should_be

prioritized,alongwiththeConstant–Murleyscaleadjustedfor genderandage;normalityindicesshouldbeobtainedforthe Brazilianpopulation. Inaddition,qualityoflifeassessment shouldbeencouraged.Likewise,theassessmentofstrength andamplitudecouldbeinlinewiththatusedininternational studies.Theassessmentoftendinousintegrityaftersurgery shouldbeencouragedandwhenMRIisused,itshouldbemade throughtheclassificationbySugayaetal.53

Final

considerations

Twenty-fiveclinicalstudiesonrotatorcuffwerepublishedin thetwomainBrazilianorthopedicjournalsinthelastdecade. ThemostusedscalewasUCLA,presentin92%ofthearticles. Scalesconsideredreliable,withgreatinternalconsistencyand good responsiveness, were rarelyused.Objective measures suchasmusclestrength,patientsatisfactionandevaluation oftendonintegritywerepoorlyused.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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