The Pain Reporter: More Than Just Physical Shoulder Strain?

A recent Daily Dose highlighted an interesting study linking risk factors for heart disease with an increased likelihood of shoulder problems including joint pain and rotator cuff injury. The Pain Reporter talked to the lead author of the study, Kurt Hegmann, MD, MPH, who is the Center Director of the University of Utah, School of Medicine's Rocky Mountain Center for Occupational and Environmental Health.

Q. What steered you and your team to this research?

A. We noticed an intersection of several previously reported factors. Rotator cuff tears occur in a section of the tendon with a previously known poor blood supply. Risks for rotator cuff problems and shoulder pain were higher in those who smoke. We also noticed a pattern of rotator cuff tears occurring in people with heart disease risk factors. So there was a background question of what is the mechanism of rotator cuff tears that needed answering and the hypothesis we had was impairment of the microvascular blood supply.

Q. Which came first in your research: heart disease risks or shoulder pain? How did you link the two?

A. We had a large study to evaluate risks of common musculoskeletal disorders among working age adults. We were able to design the study to look at simply shoulder joint pain, as well as tendinitis, because we examined all the workers. Because of the prior hypothesis of the cause of the problem, we included assessment of cardiovascular disease risks in our study design. So we had planned this study and its analyses, although the main outcomes for the original study were carpal tunnel syndrome and tennis elbow.

Q. What causes these pathologies to coexist?

A. See above. We know that normal tendons do not rupture. Only abnormal tendons rupture, such as those that are degenerated. As it turns out, nearly everyone's shoulder tendons eventually degenerate. You probably don't want to know that! We would theorize that the cardiovascular disease risk factors impair the microvascular blood supply to the tendon, making it susceptible to degeneration and tearing.

Q. If someone has joint pain or rotator cuff problems, how would you suggest they and their practitioner proceed?

A. The study did not directly test the answers to this question. However, if we were to make reasonable assumptions, the data suggest some additional consideration of cardiovascular disease risks. This would include pre-operative risk assessment--those with heart disease have greater anesthesia risks. It would also seem likely that more aggressive management of cardiovascular risk factors might delay if not prevent tearing of the other shoulder's tendons.

Q. How do you “get the word out” to general practitioners about these findings?

A. The first step is to be willing to help educate people, including talking with reporters. We have already incorporated this information in our Occupational Medicine residency teaching. We are in discussions to get it included in the Internal Medicine residency training and the medical student curriculum. We are teaching this material at regional and national conferences and in CME materials.

Q. What is the next step in your research? Might you do a study with a larger population of patients?

A. We will be testing whether we have predictive ability in the dataset. So, we will test: do the musculoskeletal disorders occur after measurement of the risk factors. That work is underway now.

Q. Do you have an opinion about the current state of pain management in the United States?

A. This is quite a different subject. But we do study this. We are increasingly finding the quality studies are nearly all suggesting we need to move towards a more holistic model and away from a simple medication based treatment model. This includes treatment with specific exercise regimens, fear-avoidant belief training, and cognitive behavioral therapy. Medications should generally be minor supplements, not the mainstays of treatment.

Q. When you’re not working, how do you like to spend your time?

A. Clearly spending time with my wife is #1. After that, I next most enjoy watching children up to our students and residents learn things and achieve. Whether learning knowledge to provide safe and healthy worksites, or skills such as skiing. Beyond that, I would say skiing and gardening.

Q. What is a dream project you hope to work on?

A. I dream of the perfect day when I do not make a single mistake, do not offend someone, do not upset someone, and only put joy on the faces of all. That's the day I look forward to, and getting there is a project(!).

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