Rotator Cuff Tears

The classic explanation for how a rotator cuff can tear without traumatic injury has been that the supraspinatus tendon impinges on the acromion,1 but more recently, authors have emphasised the role of intrinsic tendon degeneration.2-4 These types of tears are especially prevalent among patients age 60+, with prevalence estimates ranging from 20% to 30%.5 Both physiotherapy and surgery have been considered among first-line treatments, but there has been little research on how to identify the patients most likely to benefit from physiotherapy as a first-line treatment. This past September, Ian Lo, of the University of Calgary’s Department of Surgery, and fellow researchers helped answer this need for information.6  They followed 76 patients with uncomplicated, partial-thickness rotator cuff tears. Patients received conservative treatment from doctors and physiotherapy.

Physiotherapy programs included posterior capsular stretching, rotator cuff and parascapular muscle strengthening, and other treatments as individually indicated. Conservative physician treatment was individually determined but included pain medications, anti-inflammatories, and/or subacromial steroid injections. Ian Lo and colleagues considered conservative treatment a failure if patients elected surgery within 4.4 years and a success if patients did not elect surgery, although this definition of “failure” merits some examination. 
 
Overall, conservative treatment resulted in improved clinical outcomes, but regression analysis did reveal characteristics that predicted success. These were dominant shoulder, tear thickness, and traumatic status. The most dramatic difference was in traumatic vs. atraumatic onset (16% and 84% success rates of conservative treatment respectively). Tears of less than 50% thickness had a 65% success rate. Success proved slightly more likely with nondominant shoulders (51% vs 49%).  

The success/failure dichotomy set up in this study is useful for easy examination of the outcomes, but we should be careful of overinterpreting the term “failure.” Kim et al has previously found that delaying surgery for a course of conservative treatment in partial thickness tears improved functional results of surgery at six months.7 Even patients who elect surgery after conservative treatment likely benefit from the pre-surgical physiotherapy.
 
The findings of the current study are consistent with a growing body of evidence showing that physiotherapy can be considered a worthwhile first-line treatment.8-11 Orthopaedic surgeon J. Kukkonen found that for non-traumatic rotator cuff tears the results of physiotherapy as firstline treatment were not inferior to the results of surgery.8

Similarly, the multi-center trial of Kuhn et al found a 90% success rate from physiotherapy for chronic, atraumatic, fullthickness rotator cuff tears.9 The current body of research suggests that the majority of patients will be satisfied with the improvements achieved through conservative treatment alone when the tear is atraumatic and it is either full-thickness or less than 50% thickness. However, monitoring for tear progression may be indicated. For patients with traumatic rotator cuff tears and/or partial tears of greater than 50% thickness, surgery seems likely, but a pre-surgical course of physiotherapy may improve the outcomes of surgical repair.  

References
 
1. Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983; 173:70-77.
2. Operatively treated traumatic versus non-traumatic rotator cuff ruptures: a registry study. Ups J Med Sci. 2013; 118: 29-34.
3. Kim H, Dahiya N, Teefey S, et al. Location and initiation of degenerative rotator cuff tears: an analysis of three hundred and sixtyy shoulders. J Bone Joint Surg [Am]. 2010; 92-A: 1088-1096.
4. Moosmayer S, Tariq R, Stiris M, Smith H. MRI of symptomatic and asymptomatic full-thickness cuff tears: a comparison of findings in 100 subjects. Acta Orthop. 2010; 81: 361-366.
5. Fehringer E, Sun J, VanOveren L, et al. Full-thickness rotator cuff tear prevalence and correlation with function and co-morbidities in patients sixty-five years and older. J Shoulder Elbow Surg. 2008; 17: 881885.
6.  Lo IK, Denkers MR, More KD, Nelson AA, Thornton GM, Boorman RS. Partial-thickness rotator cuff tears: clinical and imaging outcomes and prognostic factors of successful nonoperative treatment. Open Access Journal of Sports Medicine. 2018;9:191.
7. Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. The American Journal of Sports Medicine. 2018 Apr;46(5):1091-6.
8. Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Äärimaa V. Treatment of nontraumatic rotator cuff tears: a randomized controlled trial with two years of clinical and imaging follow-up. JBJS. 2015 Nov 4;97(21):1729-37.
9. Kuhn JE, Dunn WR, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL, Holloway BG, Jones GL, Ma CB. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. Journal of Shoulder and Elbow Surgery. 2013 Oct 1;22(10):13719.
10. Mathiasen R, Hogrefe C. Evaluation and management of rotator cuff tears: A primary care perspective. Current Reviews in Musculoskeletal Medicine. 2018 Mar 1;11(1):72-6.
11. Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. Exercise rehabilitation in the non-operative management of rotator cuff tears: a review of the literature. International Journal of Sports Physical Therapy. 2016 Apr;11(2):279.
 
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