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Smoking Predisposes to Rotator Cuff Pathology and Shoulder Dysfunction: A Systematic Review

PainSci » bibliography » Bishop et al 2015
Tags: treatment, shoulder, strain, tendinosis, head/neck, injury, pain problems, muscle, overuse injury

Two articles on PainSci cite Bishop 2015: 1. Smoking and Chronic Pain2. Complete Guide to Frozen Shoulder

PainSci commentary on Bishop 2015: ?This page is one of thousands in the bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

Smoking is strongly linked to more shoulder pain and injuries (like rotator cuff tears, and probably frozen shoulder as well), which is weird. This seems to be excellent evidence of two principles:

  1. There doesn’t seem to be anything that smoking will not make worse.
  2. Musculoskeletal pain/injury that seems “mechanical” is often more about subtle biological vulnerability.

This review considered thirteen studies of shoulder trouble in about 6000 smokers out of 16,000 patients. The studies showed clear links between smoking and rotator cuff tears: more tears and worse tears, with more degenerative signs later on. That is, the “cuff” of muscles around the shoulder joint is apparently more fragile in smokers. They also found a link with unexplained chronic shoulder pain and dysfunction. One experimental study showed that nicotine made rat shoulder tendons stiffer.

Smoking is bad for your shoulders! Who knew.

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

PURPOSE: To investigate the association of smoking with rotator cuff (RTC) disease and shoulder dysfunction, defined as poor scores on shoulder rating scales.

METHODS: A systematic review was performed using a search strategy based on "shoulder AND [smoke OR smoking OR nicotine OR tobacco]." English-language clinical or basic science studies testing the association of smoking and shoulder dysfunction on shoulder rating scales or disease of the soft tissue of the shoulder were included. Level V evidence studies and articles reporting only on surgery outcomes, subjective symptoms, adhesive capsulitis, or presence of fracture or oncologic mass were excluded.

RESULTS: Thirteen studies were included, comprising a total of 16,172 patients, of whom 6,081 were smokers. All 4 clinical studies addressing the association between smoking and patient-reported shoulder symptoms and dysfunction in terms of poor scores on shoulder rating scales (i.e., Simple Shoulder Test; University of California, Los Angeles shoulder scale; and self-reported surveys) confirmed this correlation with 6,678 patients, of whom 1,723 were smokers. Two of four studies documenting provider-reported RTC disease comprised 8,461 patients, of whom 4,082 were smokers, and found a time- and dose-dependent relation of smoking with RTC tears and a correlation of smoking with impingement syndrome. Smoking was also reported in 4 other articles to be associated with the prevalence of larger RTC tears or tears with pronounced degenerative changes in 1,033 patients, of whom 276 were smokers, and may accelerate RTC degeneration, which could result in tears at a younger age. In addition, 1 basic science study showed that nicotine increased stiffness of the supraspinatus tendon in a rat model.

CONCLUSIONS: Smoking is associated with RTC tears, shoulder dysfunction, and shoulder symptoms. Smoking may also accelerate RTC degeneration and increase the prevalence of larger RTC tears. These correlations suggest that smoking may increase the risk of symptomatic RTC disease, which could consequently increase the need for surgical interventions.

LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

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