Shoulder pain due to rotator cuff disease is a common reason for patients to see an orthopaedic surgeon. However, making clinical recommendations based on high-level evidence is difficult. Controversy continues over the benefits of conservative or surgical options in the management of known atraumatic rotator cuff tears (RCTs).
The goal of treatment is to resolve pain, restore function, and provide lasting durable relief that will not deteriorate with time. Imaging studies (MRI and ultrasound) have shown a high prevalence of asymptomatic RCTs in patients older than age 60, suggesting that most RCT patients in this age category do not require any treatment, let alone surgery. However, patients who complain of shoulder pain with an associated RCT do not, by definition, have an “asymptomatic RCT.”
Although the clinical results of surgical management of RCTs are highly successful, the surgical repair often fails, especially if the patient is older than age 60. Pain relief in patients with rotator cuff repair failure often does not differ significantly from that in patients with an intact cuff, raising the question of the real source of pain. The clinician must seek more definitive guidelines in managing the patient with a painful RCT.
The Academy’s clinical practice guidelines on “Optimizing the Management of Rotator Cuff Problems” found a lack of definitive evidence. The working group could issue only four moderate-grade recommendations, including a statement that exercise and nonsteroidal anti-inflammatory medications may be useful in the management of rotator cuff symptoms in the absence of a full-thickness RCT.
A consensus opinion was reached that surgery should not be performed for asymptomatic RCTs, but no studies were found that addressed this recommendation. Only weak evidence (one Level 3 and multiple Level 4 studies) exists to support the recommendation of surgical repair for patients with chronic symptomatic full-thickness RCTs. The study group concluded that “given the clinical importance of rotator cuff disease, the absence of good evidence represents a serious knowledge deficit.” As a result, clinicians are guided primarily by Level 4 evidence and their own personal experiences in managing this common clinical problem.
Multiple recent studies related to the progression of rotator cuff disease as well as the results of surgical and nonsurgical management have revealed new insights that may assist the physician with treatment recommendations. These studies do not totally clarify the decision-making process but do highlight the challenges of each treatment modality.
The MOON (Multicenter Orthopaedic Outcomes Network) shoulder group includes 16 fellowship-trained orthopaedic surgeons and research personnel from nine geographically dispersed sites in the United States. Established to conduct large multicenter studies on conditions of the shoulder, the MOON investigators have been studying the correlation of duration and severity of symptoms to tear severity, as well as the effectiveness of physical therapy in the management of atraumatic RCTs.
According to John E. Kuhn, MD, Vanderbilt University, only about 4.4 percent of U.S. patients with RCTs will actually undergo surgery. The MOON studies have shown that the relationship between pain and rotator cuff disease is not robust; RCT severity has not been found to correlate with pain severity, duration of symptoms, or activity level.
One prospective study followed a group of 450 patients with atraumatic, painful, full-thickness RCTs treated with an evidence-based exercise program. At 2-year follow-up, nonsurgical treatment was effective in more than 80 percent of patients. The patients from the study who required surgery did so primarily within the first 3 months of treatment.
Dr. Kuhn contends that the informed consent for rotator cuff surgery should cover the following points:
- 6 million Americans have atraumatic RCTs, but less than 5 percent will undergo surgery for it.
- If pain is the predominant symptom, an exercise program has about an 85 percent chance of improving symptoms for up to 2 years.
- If weakness is the main problem, patients considering surgery should know that repairs fail about 35 percent of the time.
- Patients who elect nonsurgical management should contact their physicians if symptoms worsen.
- If and when the tear will progress or to what level of symptoms cannot be predicted.
Based on their Level 3 multicenter study, the MOON group believes that conservative nonsurgical treatment is the best option for most patients with painful atraumatic RCTs.
A very different line of research is being pursued at Washington University in St. Louis where Ken Yamaguchi, MD, and coworkers have used serial ultrasounds of the shoulder to track the natural evolution of atraumatic RCTs. They have been following a group of 390 patients with either full- or partial-thickness RCTs with yearly ultrasound evaluations to determine the rate of tear progression, among other things.
A subgroup of 196 patients with asymptomatic tears in the contralateral shoulder were identified and followed prospectively for an average of 3 years. Patients were monitored for pain development as well as changes in tear size, fatty degeneration, changes in glenohumeral kinematics, and shoulder function. The results of this Level 1 study (prospective study for outcome of disease) showed that 49 percent of RCTs increased in size and that larger tears progressed faster. Pain development was associated with tear size progression, although this was not always the case. These researchers concluded that a substantial proportion of patients with asymptomatic RCTs will eventually become symptomatic.
Dr. Yamaguchi notes that several other studies have demonstrated tear progression with time as well. The literature shows that patients with partial tears are, on average, in their 40s, those with full-thickness tears are in their 50s, and those with bilateral tears are in their late 60s. These data also suggest that RCTs gradually progress.
Dr. Yamaguchi also contends that the success of surgical repair is related to tear size and patient age. The smaller the tear, the more likely it will heal following surgical repair. In studies evaluating the results of surgical RCT repair, the average age of patients with a healed repair is in the early 50s, while the average age of patients whose repair did not heal is in the early to mid 60s. Patients in their early 50s with small tears who undergo surgical repair have a much higher chance of successful healing compared to patients in their mid 60s with larger tears.
If nonsurgical treatment simply delays surgery until patients are in their 60s, does it potentially decrease the patient’s ability to heal and negatively affect the care of those patients? If the need for surgery is inevitable in a significant number of patients and delay in treatment affects prognosis, why not offer surgery sooner? This issue is primarily focused on younger patients with smaller tears who have more to lose if conservative treatment fails and who may experience more risk with nonsurgical treatment.
Although Dr. Yamaguchi states that his research cannot fully predict which patients will respond to conservative treatment and never require surgery in the future, he believes it is important to note that the literature reports only short-term (2-year) success with nonsurgical treatment and certainly cannot be used to predict continued success over a lifetime. Based on his studies, he and his colleagues recommend surgery for patients younger than age 60 who have small- and medium-sized tears, as well as for patients with acute tears of any size.
How to decide?
So the challenge remains for the practicing orthopaedic surgeon who must weigh multiple factors in the decision-making process. A generally recommended treatment algorithm for the management of patients with rotator cuff inflammation consists of an initial conservative program to calm down inflammation, reestablish range of motion, and regain balanced strength around the shoulder girdle.
Patients who reach these goals and whose pain is resolved within a reasonable period of time (6 to 12 weeks) typically do not receive MRIs but are treated with further exercises and observation. Some of these patients undoubtedly have undiagnosed full-thickness RCTs. Thus, even surgeons who are strong proponents of surgical management are probably already treating some patients nonsurgically.
The factors associated with tear progression have not yet been fully elucidated. The patient at most risk is one whose tear progresses with minimal symptoms and does not become significantly symptomatic until it is irreparable. An understanding of which patients are more likely to have tear progression and which are not will help target the patients who can be best managed by each treatment modality.
On the one hand, patients who will do well long-term with nonsurgical management should not be subject to the risks of surgery. On the other hand, allowing a treatable tear with a good prognosis to progress to an irreparable tear with more limited treatment options and a worse overall prognosis should not occur.
These new studies demonstrate that a large proportion of atraumatic RCTs will respond to an exercise program for at least 2 years. Although duration and degree of symptoms do not necessarily correlate with tear size, tear progression is often (but not always) accompanied with increased symptoms. Because a substantial number of patients will experience progression in the size of their tears and surgery is more successful when performed earlier and on smaller tears, surgeons must monitor these patients carefully and use good clinical judgment in recommending surgical or nonsurgical management.
Xavier A. Duralde, MD, is an orthopaedic surgeon at Peachtree Orthopaedic Clinic in Atlanta and lead orthopaedist for the Atlanta Braves Major League Baseball team.
- Optimal treatment for asymptomatic RCTs—surgical or nonsurgical—has not been determined.
- Studies demonstrate that a large proportion of atraumatic RCTs will respond to an exercise program for at least 2 years.
- Recent high-quality studies are adding to the evidence base and providing surgeons with additional information for decision-making.
- Because RCTs may become larger over time and surgery is less effective in treating large tears, younger patients with smaller tears have more to lose if conservative treatment fails.
CPG: Optimizing the Management of Rotator Cuff Problems
- Keener JD, Steger-May K, Stobbs G, Yamaguchi K. Asymptomatic rotator cuff tears: Patient demographics and baseline shoulder function. J Shoulder Elbow Surg 2010;19:1191–1198.
- Dunn WR,Kuhn JE, Sanders R et al: Symptoms of Pain Do Not Correlate with Rotator Cuff Tear Severity: A cross-sectional study of 393 patients with a symptomatic atruamatic full-thickness rotator cuff tear. J Bone Joint Surg 2014;96:793–800.