Psychosocial factors play a greater role in preoperative symptoms for patients with atraumatic shoulder instability: data from the MOON-Shoulder Instability group

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Background: Previous studies have demonstrated that psychosocial factors and comorbid depression are associated with worse preoperative baseline measures, clinical outcomes, and recovery in patients undergoing shoulder surgery. It is unknown whether this potential link would differ between those with traumatic vs. atraumatic shoulder instability, as symptoms may persist longer in atraumatic instability prior to surgical intervention. The purpose of this study was to determine if psychosocial factors and/or comorbid depression more heavily influence preoperative symptoms for patients with traumatic vs. atraumatic shoulder instability. Methods: Prospective baseline data from 1552 patients in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were analyzed based on mechanism of injury while controlling for age, sex, and direction of instability. Multivariable linear regressions were performed to determine whether psychological factors (RAND 36 Mental Component Score [MCS], depression diagnosis, Personality Assessment Screener–22) were predictive of preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Western Ontario Shoulder Instability Index (WOSI) scores in the atraumatic group. The same model was repeated for the traumatic instability group, and the model fit was compared between groups, with P < .05 considered statistically significant. Results: Female sex and lower MCS were significantly associated with worse preoperative ASES and WOSI scores for the group with atraumatic instability (ASES R2 = 0.15, P < .001; WOSI R2 = 0.17, P < .001). The same model performed significantly worse (P < .05) for both ASES and WOSI scores in the group with traumatic instability (ASES R2 = 0.07, WOSI R2 = 0.08). Conclusions: Worse preoperative psychosocial factors were found to be more strongly associated with shoulder-related pain and function for patients with atraumatic instability. Across multiple orthopedic conditions, depression and emotional well-being have been associated with worse preoperative symptoms and inferior postoperative patient-reported outcomes. Despite the stronger and significant association in atraumatic patients, worse psychosocial factors did not have as large an impact as has been seen in other, more chronic conditions such as osteoarthritis or rotator cuff tears. In addition to medically optimizing patients prior to surgery, the current findings identify a subset of shoulder instability patients that may benefit from a behavioral health intervention either prior to surgery or early in the postoperative period to potentially improve postoperative outcomes.

Original languageEnglish
Pages (from-to)533-538
Number of pages6
JournalJournal of Shoulder and Elbow Surgery
Issue number3
StatePublished - Mar 2023

Bibliographical note

Funding Information:
Funding: This study was supported, in part, by research grants from the Orthopaedic Research & Education Fund and by the National Center for Advancing Translational Sciences through grant UL1TR001998 , as well as through the University of Kentucky ’s PSMRF program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the University of Kentucky.

Funding Information:
Conflicts of interest: Cale A. Jacobs reports a grant from Smith and Nephew and personal fees from Flexion Therapeutics, all outside the submitted work. Scott D. Mair reports receiving consulting fees from Smith and Nephew, outside the submitted work. Keith M. Baumgarten reports consulting fees from Wright Medical, and personal fees from Arthrex, Micah, and Stryker, all outside the submitted work. Jonathan T. Bravman reports consulting for Smith and Nephew, consulting for DJO, and consulting and receiving royalties from Shukla Medical, all outside the submitted work. Brian T. Feeley reports NIH grant funding, consulting for Kaliber, is on the Board of Directors for Bioniks, and is an Associate Editor for the Journal of Shoulder and Elbow Surgery and an Editor for Current Reviews in Musculoskeletal Medicine, all outside the submitted work. John A. Grant reports a grant and personal fees from JRF Ortho, a grant and educational support from Arthrex, a grant from Aesculap Biologics, personal fees from ConMed, consulting fees from Vericel, all outside the submitted work. Drew A. Lansdown reports educational support from Evolution Surgical/Arthrex, consulting fees from Vericel and AlloSource, and a research grant form AOSSM, all outside the submitted work. Robert G. Marx reports personal fees (Deputy Editor) from the Journal of Bone and Joint Surgery, personal fees as an Associate Editor from JBJS Evidence-Based Orthopedics, royalties from books published from Springer and Demos Health, and equity compensation for seat on science advisory board from MEND Nutrition Inc., all outside the submitted work. Adam J. Seidl reports personal fees (consulting) form DJO, outside the submitted work. Matthew V. Smith reports grant (collaborator) from National Science Foundation, personal fees (educational speaker) from Elite Orthopedics (Arthrex), personal fees (consultant) from Flexion Therapeutics and grant (site-principal investigator) from PCORI, all outside submitted work. Brian R. Wolf reports personal fees from UnitedHealth Care and consulting fees and royalties from ConMed, all outside the submitted work. Rick W. Wright reports a research grant from NIH, NIAMS, book royalties from Wolters Kluwer Lippincott, Williams & Wilkins, and royalties from Responsive Arthroscopy, all outside the submitted work. Alan L. Zhang reports consulting fees from Stryker and from DePuy-Mitek, all outside the submitted work. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Publisher Copyright:
© 2022 Journal of Shoulder and Elbow Surgery Board of Trustees


  • Level III
  • MOON Shoulder Instability
  • PROs
  • Prognosis Study
  • Retrospective Cohort Comparison
  • atraumatic
  • psychosocial factors
  • traumatic

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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