INTRODUCTION
New symptoms are often misperceived as new pathophysiology [1-5]. New pain is often misperceived as an injury [1,3,4]. As a demonstration of this phenomenon, a study of bilateral magnetic resonance imaging (MRI) for claims of work injury based on new knee or shoulder symptoms demonstrated age-related pathophysiology on the asymptomatic side that was equal to or worse than the pathophysiology on the symptomatic side [4]. There are several heuristics (mental shortcuts used by human intelligence to make pressing judgments) and cognitive biases (systematic errors in thinking that result from these shortcuts) that lead to misinterpretation of new pain from established pathophysiology as damage. One is the post hoc ergo propter hoc fallacy, which is when a person notes the absence of symptoms prior to the event and concludes the symptoms must be related to the event. The presence of asymptomatic disease in the opposite, asymptomatic limb establishes this as faulty thinking. Another is the framing heuristic: if the event seems injurious or is plausibly so, one may be more likely to find the sense of damage more convincing. Anchoring bias posits that it can be difficult for the human mind to move away from its initial theories, while confirmation bias describes the way the human mind tends to pay selective attention to factors that prove rather than disprove the theory of injury. There are many other cognitive biases contributing to the erroneous interpretation of new pain at work as an injury when it is actually from degeneration of the rotator cuff.
Such misperceptions are particularly important among claims of work injury in the state of Texas, where workers’ compensation requires that such claims must establish the presence of new pathophysiology (“…damage or harm to the physical structure of the body…”) and “does not include an ordinary disease of life” [6]. In other words, new symptoms from established pathophysiology such as age-appropriate rotator cuff tendinopathy [7] are not covered. This is particularly true when an employer chooses not to participate in the Texas state workers’ compensation system, in which case they can specify that degenerative and pre-existing conditions are not covered [8].
When people perceive injury and relate that “something popped,” the clinician may be drawn into the misperception of an injury. In the setting of a work injury claim, an independent physician may be asked to review a work claim due to a prolonged duration of work limitations or requests for seemingly unrelated tests, treatments, or referrals, which is often a consequence of misperception of a gradual-onset, degenerative problem as a new pathophysiology or an injury. The prevalence of misperception and misinterpretation of bodily sensations may be an underappreciated aspect of health and care. Anticipation of faulty thinking as a consequence of normal human intelligence can become integral to all patient evaluations.
Some people whose claim underwent further review reported hearing or feeling a pop exhibited no rupture or corresponding pathophysiology on MRI. If analysis of a sizable cohort of peer-reviewed claims confirms that patient perception of a pop is not associated with new pathophysiology, such as rupture of the long head of biceps or rotator cuff, that knowledge might help ameliorate the patient and clinician sense of injury associated with a popping sensation that can contribute to misdiagnosis and mistreatment of a degenerative condition.
As a first step to investigate these considerations, among work claims for new shoulder symptoms brought to peer review—a setting where routine bilateral MRI is performed as a routine part of the evaluation of a shoulder claim—we measured the concordance of a popping sensation with new pathophysiology in the form of an attritional rupture of the long head of the biceps tendon or a probable acute traumatic rupture of the rotator cuff tendons.
Specifically, we asked: Are there any factors, including perception of a pop, that correspond with an attritional rupture of the long head of the biceps or an acute traumatic rupture of the rotator cuff tendons?
METHODS
Study Design and Setting
In an institutional review board-approved study (University of Texas at Austin, No. STUDY00003454), a repository of work claims under peer review was securely maintained using a password-controlled and Health Insurance Portability and Accountability Act (HIPAA)-compliant system with deidentified data. The work claim repository was obtained from a third-party administrator that oversees the care of claimants in a large number of statewide occupational medicine offices from May 10, 2021 to February 23, 2022. Data were accessed for research purposes in February 2023. Need for consent was waived by the institutional review board because no protected health information (PHI) was collected in the dataset and the PHI was kept in password protected HIPAA compliant servers.
Peer review is triggered by one of the following occurrences under the care of occupational medicine clinicians: (1) duration of work limitations and remaining in care inconsistent with the diagnosed injury (e.g., strain or sprain); (2) discomfort or incapability disproportionate to the diagnosed injury; or (3) request for tests, treatments, or specialty referral inconsistent with the diagnosed injury. In other words, these patients are not representative of the average patient with shoulder pain in a work claim. This is a subset of claims that are identified as stalled and potentially benefitting from additional oversight. Shoulder pain that resolved within a few weeks or months with closed claims would not be flagged and is not represented. People having an MRI or considering surgery are represented. The following were recorded: age, sex, mental health comorbidities, patient reports of feeling or hearing a pop, and patient reports of numbness or tingling in the hand.
All 11 (9%) long head of biceps ruptures diagnosed on MRI were assumed to be new. The rationale for this was to be as permissive as possible and create a “worst case scenario” for the sensation of a pop being a sign of acute tendon rupture. Five (4%) potentially acute rotator cuff ruptures were diagnosed based on a tendon defect larger than 10 mm with no muscle atrophy or fat replacement. The same “worst case” rationale was used. Muscle edema was considered supportive of acute tendon rupture.
Study Subjects
One hundred and eighteen work claims were analyzed including 55% (n=65) women with a mean age of 54 (standard deviation, 10 years; range, 20–84 years). One quarter of the claimants (n=29) reported feeling or hearing a “pop” in their shoulder (Table 1).
Statistical Analysis
We conducted descriptive statistical analyses of the data, reporting numbers and percentages in parentheses for all discrete variables. For continuous variables, we reported the mean and standard deviation. We performed chi-square and Fisher exact tests to analyze categorical variables, and t-tests to analyze continuous variables as appropriate (Table 2). Variables with associated P-values below 0.10 were included in multivariable analysis. It is important to use this approach when analyzing small cohorts to limit potential for model overfitting during multivariable analysis. Logistic regression analysis was employed to identify factors associated with the new pathophysiology. We considered P-values below 0.05 to be statistically significant.
RESULTS
Accounting for confounding variables using logistic regression, possible acute rotator cuff rupture or long head of biceps rupture were associated with older age (odds ratio [OR], 1.10; 95% CI, 1.02–1.18) and the presence of a degenerative rotator cuff defect (OR, 6.0; 95% CI, 1.5–24) (Table 3). The perception or sensation of a pop (recorded in 29 of the 118 records; 25%) was not associated with rotator cuff defect or biceps rupture (Table 2).
DISCUSSION
Patient and clinician misperceptions of new pain as representing an injury have the potential to contribute to over-testing, over-treatment, and unnecessary restrictions. When a patient reports experiencing a “pop,” this may indicate that the patient is misperceiving the problem as damage to the body. When a patient reports concerns about injury, there is potential for a parallel misconception in the clinician through emotional contagion. The finding in this dataset that a “pop” was not associated with a tendon rupture or any other type of new pathology is helpful to patients and clinicians. It directs both towards accurate diagnosis of symptoms from degenerative conditions rather than injury, reorientation of common misperceptions, and alleviation of worry and despair.
Limitations
Readers should keep in mind that we studied a subset of work claims that came under scrutiny and that sensing a pop could correspond more or less with a tendon rupture in the setting of the average work claim or outside of workers’ compensation. This is a very specific setting that might not be generalizable to the care of shoulder pain in general. On the other hand, based on the near-universal prevalence of rotator cuff tendinopathy among claimants and evidence of comparable pathophysiology in both symptomatic and asymptomatic shoulders, our opinion is that the misinterpretation of new pain as an injury is likely in patients with rotator cuff tendinopathy in general [4]. It is also possible that some of the rotator cuff defects that were classified as acute ruptures were degenerative in nature. A sensitivity analysis of long head of biceps tendon ruptures alone did not alter the results. We initially collected information on mental health comorbidities but the rate of such comorbidities was inordinately low and we lost confidence that these were accurately recorded in the medical record in an occupational health setting. Occupational medicine notes are known for overdiagnosis of damage, under-documentation and underdiagnosis of symptoms of distress and unhelpful thinking, and provide limited information about comorbidities in general. The low number of possible acute rotator cuff traumatic defects (n=5) and long head of biceps ruptures (n=11) may seem to limit the statistical power of the study. That makes the regression model less stable as seen in the wide confidence interval of the odds ratio. It is possible, and even likely, that all of the tendon defects and ruptures were degenerative and pre-existing. Therefore, the focus should be on the prevalence of a sensation of a pop (29 patients, 25%), which was notable and discordant from any type of tendon defect, including both new and pre-existing. We used a “worst case” interpretation of the MRI, assuming that all biceps ruptures and appropriate rotator cuff defects were new ruptures. Even within this “worst case” framing, there was no relationship between sensation of a pop and tendon defect or rupture.
The observation that patient reports of feeling or hearing a pop were not associated with long head of biceps rupture or suspected acute ruptures of the rotator cuff tendons directs patients and clinicians not to overvalue these perceptions. Clinicians that treat people involved in work claims can be attuned to the fact that new pain from established pathophysiology is often misinterpreted as new pathophysiology [2,3] or an injury [1,3,4]. Clinicians can critically evaluate the injury mechanism. They can discern when the injury mechanism is inconsistent with a strain or sprain. They can also identify when a strain or sprain is possible, but the symptoms do not improve over days to weeks as expected for a strain or sprain [9]. All of the claims evaluated were characterized by minimal to no improvement of symptoms in spite of diagnosis with a self-limiting condition such as a sprain or strain. In these situations, the clinician can make a diagnosis of degenerative rotator cuff tendinopathy, which is an important cause of symptoms in anyone aged 30 or over among people claiming work injury. Clinicians should also be attentive for glenohumeral arthritis, another degenerative source of symptoms in this cohort. The finding that long head of biceps rupture was associated with more advanced rotator cuff tendinopathy in older people is consistent with the current best evidence regarding rotator cuff tendinopathy, which suggests that tendinopathy of the long head of biceps tendon is associated with rotator cuff tendinopathy [10] and that both are aspects of human senescence [7,11] .
CONCLUSIONS
In this cohort, the perception of a “pop” did not correspond with new pathophysiology consistent with tendon rupture. It is important that patients and clinicians not anchor on injury when there is the perception of a pop, as that could lead to misdiagnosis, overdiagnosis, and overtreatment. In both workers’ compensation and other settings, future studies should address whether the perception of a pop is associated with measurable aspects of unhelpful/faulty thinking such as catastrophic thinking, kinesiophobia, or negative pain thoughts. In the meantime, patients and clinicians can be reassured that patient perception of a pop is not associated with tendon rupture or any type of concerning pathophysiology.
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