Journal of Back and Musculoskeletal Rehabilitation 32 (2019) 445–452 445

DOI 10.3233/BMR-170962
IOS Press

Is there a relation between rotator cuff injury

and core stability?
Ali Çağdaş Yörükoğlua,∗ , Raziye Şavkınb , Nihal Bükerb and Khaled Yahya Abdullah Alsayanib
a
Orthopedics and Traumatology Department, Medical Faculty, Pamukkale University, Denizli, Turkey
b
School of Physical Therapy and Rehabilitation, Pamukkale University, Denizli, Turkey

Abstract.
BACKGROUND: Strong core stabilization not only minimizes the load on the vertebral column, but also improves strength and
endurance of peripheral joints, and enables the energy transfer to distal segments. Despite the current interest surrounding core
stability, none of the studies investigated the effect of core stability on the formation of rotator cuff tear or healing after repair.
OBJECTIVE: To determine the relationship between core stability and upper extremity functional performance in patients who
underwent rotator cuff repair surgery and to compare those with healthy subjects of similar age.
METHODS: Patients who underwent rotator cuff repair (RC repair group, n = 58 patient) and healthy subjects of the similar
age group (control group, n = 114) were included in the study. The mean age was 55.03 ± 9.84 years in the RC repair group and
52.71 ± 6.31 years in the control group. The RC repair group took standardized rehabilitation. The rehabilitation program did
not include core strength and stability exercise. Core endurance was assessed with Flexor Endurance, Prone Bridge and Supine
bridge test. Disabilities of the Arm, Shoulder and Hand (DASH), Short Form-36 (SF-36) and the Close Kinetic Chain Upper
Extremity Stability (CKCUES) test were used to evaluate the upper extremity functional performance.
RESULTS: The core endurance (prone and supine bridge test) of the control group was statistically significantly better than the
RC repair group (p 6 0.005). The DASH-T, SF-36 and CKCUES scores of the control group were also statistically significantly
better.
CONCLUSION: The neuromuscular system should be considered as a whole, and addition of the core stabilization exercises to
an effective rehabilitation program after RC repair surgery may be beneficial.

Keywords: Rotator cuff, core stability, upper extremity, quality of life

1. Introduction stantially every year [4,5]. In a recent study, retear after

rotator cuff repair is reported in approximately 20% of
The shoulder joint complex requires the coordinated cases and caused by various factors such as inadequate
movement of many muscle groups and has an impor- repair, biological failure to heal, and inappropriate re-
tant role in daily living activities [1]. Neuromuscular habilitation programs after surgery [6].
control and stability impairments and injuries nega- The relationship between core stability and extrem-
tively affect shoulder function. Neuromuscular control ity performances was generally studied in athletes.
of the shoulder joint is provided by rotator cuff (RC) However, most of the studies focused on its relation-
muscle activation by the management of the nervous ship with lower extremity [7–9]. Core stability is be-
system [2,3]. coming an increasingly popular topic in literature with
RC pathologies and tears affect 30–50% of patients regards to enhanced of extremity functions and pre-
over 50 years of age and surgery rates increase sub- vention of injuries in athletes [10–12]. Although there
is limited evidence supporting the link between core
∗ Correspondingauthor: Ali Çağdaş Yörükoğlu, Orthopedics and
stability and upper extremity injuries and athletic per-
Traumatology Department, Medical Faculty, Pamukkale University, formance amongst athletes who participate in baseball,
Denizli, Turkey. E-mail: alicagdasyorukoglu@gmail.com. football, or swimming, many elite athletes undertake

ISSN 1053-8127/19/$35.00
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446 A.Ç. Yörükoğlu et al. / Rotator cuff injury and core stability

core exercises as part of their training program [12,13]. quently referred to the clinical physical therapist for
The addition of core exercises to the shoulder reha- initiation of rehabilitation (within a range of 2 days
bilitation program in overhead athletes may help to to 15 days post-surgery) and followed the standard-
close the gap between initial rehabilitation exercises ized rehabilitation program. The program did not in-
and later functional rehabilitation exercises [14]. clude exercises on core strength and stability. Individ-
Strong core stabilization not only minimizes the ual home exercises were given at all phases. Each ex-
load on the vertebral column, but also improves ercise session consisted of three sets of 15 repetitions
strength and endurance of peripheral joints, and en- twice a day for 8 weeks. Standardized rehabilitation
ables the energy transfer to distal segments [15,16]. program is as follows:
The relationship between strength and endurance of
core muscles and shoulder problems has become es- 0–2 weeks postoperative: immobilization, cryo-
pecially interesting, and authors suggested that an ef- therapy, pendulum exercises, hand, wrist, and el-
fective rehabilitation program planned for prevention bow active and passive range of motion (ROM),
or treatment should include core stabilization exer- shoulder passive ROM (0–90◦ ) and scapular plane
cises [17–19]. rotation (0–45◦ ).
Despite the current interest surrounding core stabil- 2–4 weeks postoperative: continue the above,
ity, we have not found a study about the effect of core shoulder isometric exercises, Wand exercises and
stability on the formation of RC tear or healing after scapular strengthening.
repair. The purpose of this study is to determine the 4–5 weeks postoperative: continue the above, ac-
relationship between core stability and upper extrem- tive ROM all planes.
ity functional performance in patients who underwent 6–8 weeks postoperative: full active ROM, pro-
RC repair surgery and to compare those with healthy gressive resistive exercises as tolerated.
subjects of similar age.
2.3. Examinations

2. Methods The assessments of the RC repair group were per-

formed one year after the surgery.
2.1. Subjects and allocation of participants Shoulder Pain and Disability Index (SPADI) was de-
veloped by Roach et al. [20]. This is a self-administered
Patients who underwent rotator cuff repair at the Pa- questionnaire that aims to measure shoulder pain and
mukkale University, Department of Orthopedics and disability. The SPADI has been translated into Turkish
Traumatology between August 2014–July 2016 (RC and is a reliable and valid tool for assessing pain and
repair group) and healthy subjects of similar age (con- disability in patients with shoulder pathology [21]. It
trol group) were included in the study. The study was contains 5 items pain scale and 8 items disability scale
approved by the Pamukkale University Non-invasive
which is scored by a numeric rating scale that ranges
Clinical Researches Ethics Committee (60116787-
from 0 (no pain/no difficulty) to 10 (worst pain imag-
020/49572). Written informed consent was obtained
inable/so difficult it required help). A higher score in-
from all participants.
dicates greater pain-related disability [20].
Inclusion criteria for the RC repair group were as
Disabilities of the Arm, Shoulder and Hand (DASH)
follows: patients who underwent RC repair surgery and
questionnaire is a self-administered 30-item upper-
do not have retear and chronic diseases that may ad-
extremity disability/symptom scale introduced by the
versely affect healing. An inclusion criterion for the
“American Academy of Orthopedic Surgeons”, the
control group was: no prior history of shoulder injury
or surgery. Exclusion criteria for both groups were as Council of the “Musculoskeletal Specialty Societies”
follows: having chronic diseases that may adversely af- and the “Institute for Work and Health” [22]. It aims
fect shoulder functions, using corticosteroid, previous to measure disability and symptoms related to upper
spinal, lumbar pathology or surgery, and having lower extremity musculoskeletal disorders. The Turkish ver-
back pain or a neuromuscular disease. sion of the DASH has been published by Duger et al.
The scores range from 0 (no disability) to 100 (most
2.2. Interventions severe disability).
Short Form-36 (SF-36) Health Survey was devel-
The initial RC repair group study sample consisted oped by the Rand Corporation to assess the self-
of 67 patients. After surgery, all patients were subse- perceived health-related quality of life, and the Turk-
 A.Ç. Yörükoğlu et al. / Rotator cuff injury and core stability 447

ish reliability and validity study conducted by Kocyıgıt 2.4. Statistical analysis
et al. It consists eight scaled scores; physical function-
ing, role physical, bodily pain, general health, vitality, The obtained data were analyzed using the Statisti-
social functioning, role emotional, and mental health. cal Package for the Social Sciences (version 21; SPSS
Each scores range from 0 to 100, with higher scores Inc., Chicago, IL, USA). Continuous variables were
representing better self-reported quality of life. described as mean ± standard deviation. Categorical
Western Ontario Rotator Cuff (WORC) index is a variables were presented as absolute number and per-
disease-specific quality of life questionnaire that de- centage. Normality of data distribution was assessed
veloped by Kirkley et al. for patients with disorders of by the Kolmogorov Smirnov test. The Student t-test
the rotator cuff. It has been translated and validated in was used to compare the quantitative variables of the
Turkish [23]. Total percentage scores range from 0 to groups. Pearson Correlation Coefficient was used to
100, with higher scores representing worst quality of determine the relationships between core stability and
life. We conducted this index only RC repair group. upper extremity functional performance variables. In
The Close Kinetic Chain Upper Extremity Stabil- addition, comparisons of continuous variables between
ity Test (CKCUES test) is an objective clinical per- groups were done by analysis of covariance (AN-
formance test which assesses upper extremity function COVA) with adjustment of age. The Significance level
and stability. It can be used to assess subjects with in all the tests was considered as p 6 0.05.
shoulder conditions. The test consists in how many
times, during 15 seconds, the subject assuming a push-
up position is able to touch his/her supporting hand 3. Results
with the swinging hand. The test was performed in a
modified (or kneeling) push position in females, as rec- In RC repair group 9 patient excluded from the study
ommended by the original proposers [24]. because of postoperative infection (n = 1), retear (n =
The Flexor endurance test measures the endurance 2), directed to different treatments due to persistent
of the anterior abdominal wall by asking the person to pain (n = 2), unwilling to come to the assessments
hold a sit-up position as long as they can. The isometric (n = 4). The final study sample consisted of 58 pa-
sit-up position is held at 60◦ from a supine position tients (34 females, 24 males) from RC repair group and
with hips and knees at 90◦ and arms positioned across
114 subjects (55 females, 59 males) from the control
the chest. The test started when the bolster is slid 10 cm
group.
away from the subject’s back and was stopped when
Descriptive characteristics of subjects are provided
the subject back touches the bolster [10].
in Table 1. The mean age was 55.03 ± 9.84 years in the
Prone bridge and Supine bridge test [25] were per-
RC repair group and 52.71 ± 6.31 years in the control
formed for core endurance. For the prone bridge test,
group. The affected upper extremities of the RC repair
subjects began in the prone position propped on the el-
bows. The elbows were spaced shoulder-width apart, group were 48.3% dominant side, 50% non-dominant
and the feet were set with a narrow base, but not touch- side and 1.7% bilateral.
ing. The subject then raised the pelvis from the floor so The comparison of clinical outcome scores of the
that only the forearms and the toes were in contact with RC repair and the control group is shown in Table 2.
the floor. The shoulders, hips and ankles were main- The SPADI (p = 0.000), DASH-T (p = 0.000) and
tained in a straight line. The position was held until fa- physical functioning (p = 0.000), social functioning
tigue prevented maintenance of the test position. The (p = 0.021), role physical (p = 0.000), role emotional
time duration between the assumption of the position (p = 0.000) and pain (p = 0.000) subscale scores of
and the termination of it was counted as the endurance SF-36 and CKCUES test scores (p = 0.000) were sta-
hold duration of the test. For the supine bridge test, the tistically significantly better in control group. Prone
subject began in the supine position with knees flexed (p = 0.028) and supine bridge test (p = 0.000) of
90 degrees and the soles of the feet on the floor with a the control group was statistically significantly better
narrow base, but not touching. The thighs could not be than RC repair group whereas no significance in flexor
in contact. The subject then raised the pelvis from the endurance test (p = 0.159). There were no statisti-
floor so that the shoulders, hips, and knees were main- cally significant between groups in general health per-
tained in a straight line. The position was held until fa- ceptions (p = 0.525), mental health (p = 0.667) and
tigue prevented maintenance of the test position. If the energy/vitality (p = 0.361) subscale scores of SF-36.
subject reached 2 mins, the dominant leg was extended The average WORC percentage score of the RC repair
at the knee, removing one point of support. group was 30.33 ± 25.31.
448 A.Ç. Yörükoğlu et al. / Rotator cuff injury and core stability

Table 1
Descriptive characteristics of subjects
RC repair group (n = 58) Control group (n = 114)
Variables Min-max X ± SD Min-max X ± SD p
Age (y) 38–78 55.03 ± 9.84 45–70 52.71 ± 6.31 0.064
Height (cm) 150–185 162.92 ± 0.09 148–185 165.20 ± 0.08 0.125
Weight (kg) 57–110 74.84 ± 12.41 52–112 79.01 ± 11.26 0.033
BMI (kg/m2 ) 21.67–39.52 28.09 ± 4.16 17.99–46.67 29.09 ± 4.65 0.186
Education (year) 4–18 5.76 ± 3.39 4–18 8.96 ± 5.96 0.004
n % n %
Gender
Female 34 58.6 55 48.2
Male 24 41.4 59 51.8
Dominant extremity
Right 55 94.8 111 97.4
Left 3 5.2 3 2.6
Affected extremity
Dominant side 28 48.3 – –
Non dominant side 29 50.0 – –
Bilateral 1 1.7
Abbreviations: BMI, body mass index; RC, rotator cuff.

Table 2
Comparison of clinical outcome scores of RC repair and control group
Variable RC repair group (n = 58) Control group (n = 114) p
SPADI
Pain 42.60 ± 29.24 12.02 ± 18.58 0.000
Disability 28.18 ± 24.55 6.84 ± 11.25 0.000
Total score 34.38 ± 24.97 8.83 ± 13.60 0.000
DASH-T 27.73 ± 23.26 8.27 ± 10.37 0.000
SF-36
General health perceptions 61.33 ± 24.34 63.46 ± 18.23 0.525
Physical functioning 69.21 ± 29.05 84.62 ± 20.20 0.000
Mental health 66.64 ± 23.61 67.91 ± 14.58 0.667
Social functioning 78.34 ± 27.22 86.95 ± 20.12 0.021
Role physical 49.10 ± 42.63 83.12 ± 32.98 0.000
Role emotional 55.95 ± 45.88 89.58 ± 27.86 0.000
Pain 58.21 ± 29.31 83.42 ± 21.30 0.000
Energy/vitality 57.89 ± 25.90 60.92 ± 16.86 0.361
WORC
Physical symptoms 0.31 ± 0.26 – –
Sports/recreation 0.35 ± 0.29 – –
Work 0.43 ± 0.33 – –
Lifestyle 0.22 ± 0.31 – –
Emotions 0.19 ± 0.22 – –
Total score 30.33 ± 25.31 – –
CKCUES test 8.32 ± 6.08 12.42 ± 4.35 0.000
Core endurance
Flexor endurance test 26.75 ± 17.65 30.96 ± 15.65 0.159
Prone bridge test 24.13 ± 17.86 31.66 ± 21.14 0.028
Supine bridge test 92.97 ± 56.83 159.77 ± 25.73 0.000
Note. Values are mean ± SD. Abbreviations: BMI, body mass index; RC, rotator cuff; SPADI, Shoulder pain and disability index; DASH-T,
Disabilities of the arm, shoulder and hand; SF-36, Short Form-36; CKCUES test, The close kinetic chain upper extremity stability test.

Comparison of means and 95% CI.for clinical out- in Table 4. Flexor endurance test showed a significant
come scores using an ANCOVA model adjusted for positive correlation with general health perceptions
age is shown in Table 3. Adjustment for ‘age’ covariate score of SF-36 (p = 0.019). Prone bridge test showed
has not impact on clinical outcomes. a significant negative correlation with DASH-T (p =
The correlation between core endurance and clini- 0.004) whereas showed a significant positive correla-
cal outcome scores of RC repair group was presented tion with general health perceptions (p = 0.007), and
 A.Ç. Yörükoğlu et al. / Rotator cuff injury and core stability 449

Table 3
Comparison of means and 95% CI for clinical outcome scores using an ANCOVA model adjusted for age
RC repair group (n = 58) Control group (n = 114)
Mean ± Std.Er. (%95 CI) Mean ± Std.Er. (%95 CI) p
SPADI
Pain 43.23 ± 3.21 (36.88–49.59) 11.52 ± 2.55 (6.46–16.57) 0.0001
Disability 26.93 ± 2.42 (22.15–31.72) 6.61 ± 1.92 (2.81–10.41) 0.0001
Total score 33.2 ± 2.58 (28.1–38.3) 8.5 ± 2.05 (4.44–12.55) 0.0001
DASH-T 26.46 ± 2.22 (22.07–30.84) 8.13 ± 1.83 (4.51–11.76) 0.0001
SF-36
General health perceptions 61.26 ± 2.78 (55.77–66.75) 63.38 ± 1.93 (59.58–67.19) 0.533
Physical functioning 70.49 ± 3.23 (64.1–76.88) 83.74 ± 2.67 (78.46–89.02) 0.002
Mental health 66.53 ± 2.46 (61.67–71.39) 67.92 ± 1.7 (64.55–71.28) 0.645
Social functioning 78.71 ± 3.04 (72.71–84.71) 86.59 ± 2.1 (82.43–90.74) 0.035
Role physical 50.46 ± 5.07 (40.42–60.49) 82.5 ± 4.19 (74.2–90.79) 0.0001
Role emotional 58.04 ± 4.9 (48.35–67.74) 88.85 ± 4.05 (80.83–96.86) 0.0001
Pain 57.69 ± 3.27 (51.23–64.14) 83.31 ± 2.26 (78.84–87.78) 0.0001
Energy/vitality 57.73 ± 2.76 (52.27–63.19) 60.98 ± 1.91 (57.2–64.76) 0.337
CKCUES test 8.66 ± 0.71 (7.25–10.06) 12.29 ± 0.45 (11.4–13.18) 0.0001
Core endurance
Flexor endurance test 27.06 ± 2.58 (21.97–32.15) 30.86 ± 1.52 (27.86–33.86) 0.208
Prone bridge test 24.21 ± 3.13 (18.02–30.39) 31.64 ± 1.91 (27.86–35.42) 0.045
Supine bridge test 92.4 ± 5.36 (81.81–102.99) 158.18 ± 3.42 (151.43–164.92) 0.0001
Abbreviations: RC, rotator cuff; SPADI, Shoulder pain and disability index; DASH-T, Disabilities of the arm, shoulder and hand; SF-36, Short
Form-36; CKCUES test, The close kinetic chain upper extremity stability test.

Table 4
The relationship between clinical outcome scores and core endurance in RC repair group
Core endurance CKCUES test
Variable Flexor endurance test Prone bridge test Supine bridge test
SPADI
Pain −0.037 (0.821) −0.361 (0.019) −0.238 (0.112) 0.012 (0.940)
Disability 0.068 (0.678) −0.166 (0.294) −0.043 (0.774) −0.090 (0.557)
Total score 0.026 (0.875) −0.268 (0.087) −0.135 (0.372) −0.051 (0.741)
DASH-T −0.042 (0.799) −0.427 (0.004) −0.171 (0.250) −0.182 (0.225)
SF-36
General health perceptions 0.374 (0.019) 0.408 (0.007) 0.449 (0.002) 0.163 (0.286)
Physical functioning −0.128 (0.438) 0.249 (0.108) 0.343 (0.020) 0.075 (0.625)
Mental health 0.160 (0.330) 0.211 (0.175) 0.141 (0.349) 0.105 (0.491)
Social functioning 0.010 (0.954) 0.227 (0.143) 0.016 (0.918) 0.295 (0.049)
Role physical 0.122 (0.461) 0.248 (0.109) 0.274 (0.065) 0.114 (0.458)
Role emotional −0.003 (0.984) 0.026 (0.870) 0.097 (0.520) 0.200 (0.188)
Pain 0.009 (0.957) 0.293 (0.057) 0.316 (0.033) 0.313 (0.033)
Energy/vitality 0.128 (0.439) 0.351 (0.021) 0.285 (0.055) 0.138 (0.367)
WORC
Physical symptoms −0.183 (0.309) −0.361 (0.031) −0.139 (0.393) 0.074 (0.656)
Sports/recreation −0.082 (0.650) −0.240 (0.159) −0.044 (0.786) −0.072 (0.662)
Work −0.127 (0.482) −0.293 (0.083) −0.024 (0.881) −0.068 (0.680)
Lifestyle −0.069 (0.702) −0.116 (0.501) −0.069 (0.672) −0.177 (0.480)
Emotions −0.092 (0.612) −0.190 (0.266) −0.015 (0.929) −0.092 (0.579)
Total score −0.127 (0.482) −0.277 (0.102) −0.067 (0.681) −0.054 (0.745)
CKCUES test 0.116 (0.481) 0.174 (0.266) 0.269 (0.070) –
Note. Values are, correlation coefficient r and (p). Abbreviations: BMI, body mass index; RC, rotator cuff; SPADI, Shoulder pain and disability
index; DASH-T, Disabilities of the arm, shoulder and hand; SF-36, Short Form-36; CKCUES test, The close kinetic chain upper extremity
stability test.

energy/vitality scores (p = 0.021) of SF-36. Supine correlation with social functioning (p = 0.049) and
bridge test showed a significant positive correlation pain (p = 0.033) scores of SF-36.
with general health perceptions (p = 0.002), physical The relationship between core endurance and clin-
functioning (p = 0.020) and pain (p = 0.033) scores ical outcome scores of the control group is shown in
of SF-36. CKCUES Test showed a significant positive Table 5. Flexor endurance test showed a significant
450 A.Ç. Yörükoğlu et al. / Rotator cuff injury and core stability

Table 5
The relationship between clinical outcome scores and core endurance in the control group
Core endurance CKCUES test
Variable Flexor endurance test Prone bridge test Supine bridge test
SPADI
Pain −0.326 (0.003) −0.354 (0.001) −0.335 (0.002) −0.118 (0.296)
Disability −0.255 (0.023) −0.289 (0.009) −0.270 (0.015) −0.180 (0.110)
Total score −0.301 (0.007) −0.333 (0.003) −0.313 (0.005) −0.115 (0.173)
DASH-T −0.284 (0.011) −0.350 (0.001) −0.295 (0.008) −0.188 (0.094)
SF-36
General health perceptions 0.377 (0.000) 0.513 (0.000) 0.364 (0.000) 0.018 (0.848)
Physical functioning 0.212 (0.058) 0.346 (0.002) 0.369 (0.001) 0.203 (0.071)
Mental health 0.141 (0.131) 0.268 (0.004) 0.045 (0.631) −0.102 (0.278)
Social functioning 0.271 (0.004) 0.348 (0.000) 0.213 (0.023) 0.062 (0.510)
Role physical 0.241 (0.031) 0.340 (0.002) 0.304 (0.006) −0.061 (0.593)
Role emotional 0.134 (0.235) 0.222 (0.048) 0.347 (0.002) 0.092 (0.417)
Pain 0.268 (0.004) 0.277 (0.003) 0.294 (0.002) −0.159 (0.091)
Energy/vitality 0.073 (0.440) 0.267 (0.004) 0.066 (0.077) 0.001 (0.990)
CKCUES test −0.057 (0.545) 0.060 (0.529) −0.080 (0.381) –
Note. Values are, correlation coefficient r and (p). Abbreviations: BMI, body mass index; RC, rotator cuff; SPADI, Shoulder pain and disability
index; DASH-T, Disabilities of the arm, shoulder and hand; SF-36, Short Form-36; CKCUES test, The close kinetic chain upper extremity
stability test.

negative correlation with pain (p = 0.003), disability and symptoms, general health perceptions and pain.
(p = 0.023) and total scores (p = 0.007) of SPADI Furthermore, they are not capable of upper extremity
and DASH-T (p = 0.011) whereas showed a signif- function and quality of life at levels similar to control
icant positive correlation with general health percep- groups one year after surgery.
tions (p = 0.000), social functioning (p = 0.004), role The effectiveness of rehabilitation programs and
physical (p = 0.031) and pain (p = 0.004) scores of contents after rotator cuff surgery has been discussed
SF-36. Prone bridge test showed a significant nega- in recent years [26,27] and some researchers suggest
tive correlation with pain (p = 0.001), disability (p = that core stabilization exercises could be added to re-
0.009) and total scores (p = 0.003) of SPADI and habilitation programs [28]. In our knowledge, none of
DASH-T (p = 0.001) whereas showed a significant the study investigates core stabilization in patients un-
positive correlation with all subscale scores of SF-36. dergoing RC surgery.
Supine bridge test showed a significant negative cor- The healthy neuromuscular system provides a strong
relation with pain (p = 0.002), disability (p = 0.015) core-stability during functional activities and controls
and total scores (p = 0.005) of SPADI and DASH-T the movement and strength of the terminal segments
(p = 0.008) whereas general health perceptions (p = as well as the body position [12]. Neuromuscular con-
0.000), physical functioning (p = 0.001), social func- trol impairments of kinetic chain cause biomechan-
tioning (p = 0.023), role physical (p = 0.006), role ical changes and force imbalances during upper ex-
emotional (p = 0.002) and pain (p = 0.002) scores tremity movements, thus making the shoulder joint
of SF-36. There was no significant correlation between susceptible to injury. The few studies conducted on
SPADI, DASH-T and SF-36 with CKCUES Test. athletes reported that strong core stability maximizes
force production and reduces the load on peripheral
joints [15], while weak core stability increases the risk
4. Discussion of injury [29] by causing shoulder and elbow pain
in the upper extremity of athletes [30]. Therefore the
This study aimed to determine the relationship be- program of preventing [30] or treating [17] shoulder
tween core stability and upper extremity functional injuries should include core stability training. In our
performance in patients with RC repair surgery and to study, there was a significant negative correlation be-
compare with healthy subjects of the similar age. We tween core stabilization and upper extremity function
found that patients who underwent RC repair surgery in the control group, but this relationship was not found
had poor core stability than healthy subjects of the in the RC repair group (Tables 4 and 5). This may be
similar age. There was a relationship between their because the RC repair group may have poor core stabil-
core stability and upper extremity physical functions ity, pain, or upper extremity disability (Table 3). In ad-
 A.Ç. Yörükoğlu et al. / Rotator cuff injury and core stability 451

dition, the effects of shoulder injury and surgical treat- We observed that patients who underwent RC repair
ment may be reflected in the trunk segments (tensegrity surgery had poor core stability than healthy subjects
theorem and myofascial meridian system). of the similar age. Considering previous studies, the
In this study, we evaluated disability with SPADI results of our study may be interpreted in two ways:
and DASH-T. We determined that the functional re- cause or result? The poor core stability may have re-
sults of the RC repair group were notably lower than sulted in RC tears, or RC tear may adversely affect core
the control group. We also determined that there is a stability, and core strength is still insufficient one year
negative correlation between the disability scores and after RC repair surgery.
core endurance. Also, durations of the prone bridge
and supine bridge endurances of the control group
were remarkably higher. We think that the increase 5. Conclusion
in the disability decreases independence of daily life
activities and that is why it causes the decreasing in We think that the neuromuscular system should be
the life quality. Being core area which is called the considered as a whole, and the addition of core stabi-
‘power area’ of the body is powerful, makes truncus lization exercises to an effective rehabilitation program
more stable and powerful. Therefore, it ensures usage after RC repair surgery may be beneficial.
of upper extremity more functional during life activi-
ties of individuals through dissemination of the force.
Furthermore, core endurance scores were found to be Conflict of interest
more correlated with the parameters than the RC re-
pair group and the relationship power was higher in None to report.
the control group. In the framework of the holistic ap-
proach, we think that it should be focused on the trun-
cus with the holistic view and basic area core exercises References
should be included in each treatment program.
[1] Hawkes DH, Alizadehkhaiyat O, Fisher AC, Kemp GJ, Roe-
Nevertheless, some studies have shown that core buck MM, Frostick SP. Normal shoulder muscular activation
stabilization does not affect upper extremity perfor- and co-ordination during a shoulder elevation task based on
mance [31,32]. But reduces compensatory movement activities of daily living: An electromyographic study. J. Or-
thop. Res. [Internet]. 2012; 30: 53–60. Available from: http://
patterns during upper extremity functional activities in
dx.doi.org/10.1016/j.jse.2011.07.022.
the traumatic elbow and wrist injuries [29]. Especially [2] Wilk KE, Arrigo CA, Andrews JR. Current concepts: The sta-
in the early postoperative period, patients present com- bilizing structures of the glenohumeral joint. J. Orthop. Sport.
pensatory movement patterns after RC repair surgery Phys. Ther. [Internet]. 1997; 25: 364–79. Available from: http:
in our clinic. We think that adding core stabiliza- //www.jospt.org/doi/abs/10.2519/jospt.1997.25.6.364.
[3] Ludewig PM, Reynolds JF. The association of scapular kine-
tion exercises to traditional rehabilitation allow to op- matics and glenohumeral joint pathologies. J. Orthop. Sports
timal neuromuscular recovery by avoiding compen- Phys. Ther. 2009; 39: 90–104.
satory movements and prevent to retear caused by ab- [4] Jain NB, Higgins LD, Losina E, Collins J, Blazar PE, Katz JN.
normal motion patterns. Epidemiology of musculoskeletal upper extremity ambulatory
surgery in the United States. BMC Musculoskelet. Disord.
One of the limitations of our study was that we did [Internet]. 2014; 15: 4. Available from: http://www.pubmedc
not have any information about the core stability of entral.nih.gov/articlerender.fcgi?artid=3893587&tool=pmcen
the RC repair group before the injury and subsequent trez&rendertype=abstract.
surgery. In addition to this, with exception of the CK- [5] Motta G da R, Amaral MV, Rezende E, Pitta R, dos Santos
Vieira TC, Duarte MEL, et al. Evidence of genetic variations
CUS test, all our outcome measures were self-reported associated with rotator cuff disease. J. Shoulder Elb. Surg.
questionnaires. It may be more appropriate to measure 2014; 23: 227–35.
the results of the shoulder with objective methods. Fu- [6] Lädermann A, Denard PJ, Burkhart SS. Management of failed
ture studies could include a larger sample size and pa- rotator cuff repair: a systematic review. J. ISAKOS Jt. Disord.
Orthop. Sport. Med. [Internet]. 2016; 1: 32–7. Available from:
tients with varied shoulder problems. Also, researchers http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=
could investigate the role of ipsilateral and contralat- 4849215&tool=pmcentrez&rendertype=abstract.
eral core muscle influence. Clinical studies could be [7] Willson JD, Dougherty CP, Ireland ML, Davis IM. Core Sta-
designed to respond to the following questions: “Is bility and Its Relationship to Lower Injury. J. Am. Acad. Or-
thop. Surg. 2005; 13: 316–25.
core stability affected in upper extremity pathology or [8] Sato K, Mokha M. Does core strength training influence run-
surgery?” and “Does poor core stability lead to upper ning kinetics, lower-extremity stability, and 5000-M perfor-
extremity pathologies?” mance in runners? J. Strength Cond. Res. 2009; 23: 133–40.
452 A.Ç. Yörükoğlu et al. / Rotator cuff injury and core stability

[9] De Blaiser C, Roosen P, Willems T, Danneels L, Vanden [22] Hudak PL, Amadio PC, Bombardier C. Development of an
Bossche L, De Ridder R. Is core stability a risk factor for upper extremity outcome measure: the DASH (disabilities of
lower extremity injuries in an athletic population? A system- the arm, shoulder and hand) [corrected]. The Upper Extremity
atic review. Phys. Ther. Sport. 2018. Collaborative Group (UECG). Am. J. Ind. Med. 1996.
[10] Brumitt J, Matheson JW, Meira EP. Core stabilization exer- [23] El O, Bircan C, Gulbahar S, Demiral Y, Sahin E, Baydar M,
cise prescription, part I: current concepts in assessment and et al. The reliability and validity of the Turkish version of the
intervention. Sports Health [Internet]. 2013; 5: 504–9. Avail- Western Ontario Rotator Cuff Index. Rheumatol. Int. [Inter-
able from: http://www.ncbi.nlm.nih.gov/pubmed/24427424. net]. 2006 [cited 2018 Sep 25]; 26: 1101–8. Available from:
[11] Saeterbakken AH, van den Tillaar R, Seiler S. Effect of core http://www.ncbi.nlm.nih.gov/pubmed/16799776.
stability training on throwing velocity in female handball [24] Goldbeck TG, Davies GJ. Test-Retest Reliability of the
players. J Strength Cond Res. 2011; 25: 712–8. Closed Kinetic Chain Upper Extremity Stability Test: A Clin-
[12] Silfies SP, Ebaugh D, Pontillo M, Butowicz CM. Critical re- ical Field Test. J Sport Rehabil. 2000; 9: 35–45.
view of the impact of core stability on upper extremity ath- [25] Lang JM, Chan KM. A Clinical Tool for Office Assessment
letic injury and performance. Brazilian J. Phys. Ther. 2015; of Lumbar Spine. 86: 380–6.
19: 360–8. [26] Gallagher BP, Bishop ME, Tjoumakaris FP, Freedman KB.
[13] Hibbs AE, Thompson KG, French D, Wrigley A, Spears I. Early versus delayed rehabilitation following arthroscopic ro-
Optimizing performance by improving core stability and core tator cuff repair: A systematic review. Phys. Sportsmed. [In-
strength. Sport. Med. 2008. ternet]. 2015; 43: 178–87. Available from: http://www.ncbi.
[14] Brumitt J, Dale RB. Integrating shoulder and core exercises nlm.nih.gov/pubmed/25797067.
when rehabilitating athletes performing overhead activities. [27] Thomson S, Jukes C, Lewis J. Rehabilitation following surgi-
N. Am. J. Sports Phys. Ther. 2009; 4: 132–8. cal repair of the rotator cuff: a systematic review. Physiother-
[15] Kibler W Ben, Press J, Sciascia A. The Role of Core Stability apy [Internet]. 2016; 102: 20–8. Available from: http://dx.doi.
in Athletic Function. Sport. Med. 2006; 36: 189–98. org/10.1016/j.physio.2015.08.003.
[16] Shinkle J, Nesser TW, Demchak TJ, McMannus DM. Effect [28] Thigpen CA, Shaffer MA, Gaunt BW, Leggin BG, Williams
of Core Strength on the Measure of Power in the Extremities. GR, Wilcox RB. The American Society of Shoulder and El-
J. Strength Cond. Res. [Internet]. 2012; 26: 373–80. Available bow Therapists’ consensus statement on rehabilitation fol-
from: http://apps.webofknowledge.com/full_record.do?produ lowing arthroscopic rotator cuff repair. J. Shoulder Elb. Surg.
ct=UA&search_mode=MarkedList&qid=46&SID=S2yLXY 2016; 25: 521–35.
1v3pb4PyrxBQp&page=1&doc=7&colName=WOS. [29] Ayhan C, Unal E, Yakut Y. Core stabilisation reduces com-
[17] Radwan A, Francis J, Green A, Kahl E, Maciurzynski D, pensatory movement patterns in patients with injury to the
Quartulli A, et al. Is there a relation between shoulder dys- arm: a randomized controlled trial. Clin. Rehabil. [Internet].
function and core instability? Int. J. Sports Phys. Ther. [Inter- 2014; 28: 36–47. Available from: http://www.ncbi.nlm.nih.
net]. 2014; 9: 8–13. Available from: http://www.ncbi.nlm.nih. gov/pubmed/23823711.
gov/pubmed/24567850%5Cnhttp://www.pubmedcentral.nih. [30] Miyake Y, Kobayashi R, Kelepecz D, Nakajima M. Core ex-
gov/articlerender.fcgi?artid=PMC3924603. ercises elevate trunk stability to facilitate skilled motor behav-
[18] Rosemeyer JR, Hayes BT, Switzler CL, Hicks-Little CA. ior of the upper extremities. J. Bodyw. Mov. Ther. 2013; 17:
Effects of Core-Musculature Fatigue on Maximal Shoulder 259–65.
Strength. J. Sport Rehabil. [Internet]. 2015; 24: 384–90. [31] Harrington S, Meisel C, Tate A. A cross-sectional study exam-
Available from: http://journals.humankinetics.com/jsr-current ining shoulder pain and disability in Division I female swim-
-issue/jsr-volume-24-issue-4-november/effects-of-core-musc mers. J Sport Rehabil [Internet]. 2014; 23: 65–75. Available
ulature-fatigue-on-maximal-shoulder-strength. from: https://www.ncbi.nlm.nih.gov/pubmed/23945068.
[19] Wilk KE, Yenchak AJ, Arrigo CA, Andrews JR. The Ad- [32] Tate A, Turner GN, Knab SE, Jorgensen C, Strittmatter A,
vanced Throwers Ten Exercise Program: A New Exercise Se- Michener LA. Risk factors associated with shoulder pain and
ries for Enhanced Dynamic Shoulder Control in the Overhead disability across the lifespan of competitive swimmers. J Athl
Throwing Athlete. Phys. Sportsmed. 2011; 39: 91–3847. Train [Internet]. 2012; 47: 149–58. Available from: http://
[20] Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. www.ncbi.nlm.nih.gov/pubmed/22488280.
Development of a shoulder pain and disability index. Arthritis
Care Res. 1991.
[21] Bumin G, Tüzün EH, Tonga E. The Shoulder Pain and Dis-
ability Index (SPADI): Cross-cultural adaptation, reliability,
and validity of the Turkish version. J. Back Musculoskelet.
Rehabil. [Internet]. 2008 [cited 2018 Sep 25]; 21: 57–62.
Available from: http://www.medra.org/servlet/aliasResolver?
alias=iospress&doi=10.3233/BMR-2008-21108.
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