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H. T. Leong et al.
and shoulder impingement syndrome, requires a battery
of clinical tests and/or a combination of conventional
imaging (3, 19, 20). A recent systematic review of risk
factors related to rotator cuff tears has been reported by
Sayampanathan & Andrew (21); however, their study
included individuals with both symptomatic and asymp-
tomatic rotator cuff tears diagnosed by conventional
imaging or arthroscopic evaluation. Previous studies
have reported poor correlation between symptoms
related to rotator cuff pathologies and structural failure
observed in imaging (22–25). Miniaci et al. (23) reported
that 86% of asymptomatic professional baseball pitchers
have rotator cuff pathology, identified by magnetic re-
sonance imaging (MRI). In addition, Girish et al., (26)
reported that 96% of men without shoulder symptoms
have structural abnormalities identified by ultrasound,
including subacromial bursal thickening, supraspinatus
tendinosis, and supraspinatus tears. Thus, the presence
of structural tissue failure in large numbers of people
without symptoms challenges the validity of imaging
to identify the source of symptoms (2). Noting that the
hallmark characteristics of rotator cuff tendinopathy are
pain and weakness during arm elevation (2), the poten-
tial risk factors of symptomatic rotator cuff tendinopathy
may not be identified in the previous systematic review
(21). The aim of this study was to conduct a systematic
review to identify risk and associated factors under the
umbrella term of symptomatic rotator cuff tendinopathy,
including rotator cuff tendinosis/tendinitis, shoulder
impingement syndrome, and subacromial bursitis.
METHODS
Protocol
A systematic review was performed using a predetermined
protocol in accordance with the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) statement
(27). Our review has been registered with the PROSPERO
database (registration number CRD42017069708) (28).
Search strategy and criteria
An electronic database search of PubMed, CINAHL, and Scopus
was undertaken from inception to June 2017. The keywords used
are shown in Table I. Supplementary searches were carried out by
hand searching the reference lists of the included studies. The search
results were imported into reference-manager software (Endnote
X5; Thomson, New York, USA) to avoid duplication of records.
A study was included if: (i) participants presented with
signs and symptoms suggestive of rotator cuff tendinopathy/
tendinosis/tendinitis, shoulder impingement syndrome, or suba-
cromial bursitis diagnosed by clinical tests and/or conventional
imaging (3, 19, 20); (ii) the study design was cross-sectional,
case-control, prospective, and retrospective analyses; and (iii)
the study report was published in English and full-text articles
prior to June 2017. A study was excluded if: (i) participants were
diagnosed with a rotator cuff full thickness tear or calcified ten-
www.medicaljournals.se/jrm
Table I. Keywords used in the PubMed database
Search terms
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Rotator cuff [MeSH Terms]
Rotator cuff tendon* [All Fields]
Subscapularis [MeSH Terms]
Supraspinatus [MeSH Terms]
Infraspinatus [MeSH Terms]
Teres minor [MeSH Terms]
Subacromial bursa [MeSH Terms]
1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7
Tendinopath* [All Fields]
Tendinitis [All Fields]
Tendinosis [All Fields]
Tendin* [All Fields]
shoulder imping* [All Fields]
subacromial imping* [All Fields]
subacromial bursitis* [All Fields]
9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15
Risk [All Fields]
Associat* [All Fields]
Predict* [All Fields]
Odds [All Fields]
Odds ratio [All Fields]
Probabilit* [All Fields]
17 OR 18 OR 19 OR 20 OR 21 OR 22
8 AND 16 and 23 limited to English language, full text, human studies
dinopathy, and other postsurgical conditions (3, 19, 20); (ii) the
study population involved animal models or cadavers; and (iii)
the study report was published as case studies, reviews (systema-
tic and narrative), editorials, commentaries and opinion-based
papers. Relevant studies were accessed for full-text review prior
to inclusion in the systematic review.
Two reviewers (LHT, HX) independently screened all titles
and/or abstracts and reviewed the studies identified for inclu-
sion. Disagreements were resolved by consensus between the 2
reviewers or by a third reviewer (FSC) when required.
Assessment of methodological quality and risk of bias
Two reviewers (LHT and HX) independently assessed the met-
hodological quality and risk of bias using a modified version of
the Downs and Black (DB) checklist (29). We adapted the 15-
item version of the original DB Checklist, which was previously
used in a review of intrinsic and extrinsic risk factors associated
with heel pain (30) and kinematic variables associated with
anterior cruciate ligament reconstruction (31). The adapted
version was deemed appropriate for this review as it does not
apply questions relating to methodological design validity as-
sociated with an intervention. A total score ≥ 12 indicates high
methodological quality, a score of 10 or 11 indicates moderate
quality, and a score ≤ 9 indicates low quality (31). Disagreements
in scores were resolved by consensus between the 2 reviewers or
by a third reviewer (FSC) when required. Intra-class correlation
coefficient (ICC) 2-way mixed-effects analysis was calculated
using SPSS Version 24 for Windows (SPSS Inc., Chicago,
IL, USA) to measure the interrater agreement between the 2
reviewers for quality assessment.
Data extraction and data synthesis
All data were extracted independently by 2 reviewers (LHT
and HX). Disagreements were resolved by consensus between
the 2 reviewers or a third reviewer (FSC) when required. Data
extraction was based on a standardized form that includes: (i)
the characteristics of the study (authors, years, design and coun-