What is discouraging is the lack of quality evidence in support of treatment for this most common of shoulder disorders:
"1. Full Thickness Tears and Asymptomatic Patients. In the absence of reliable evidence, it is the opinion of the work group that surgery not be performed for asymptomatic, full thickness rotator cuff tears.
Strength of Recommendation: Consensus opinion of the panel
2. Full Thickness Tears and Symptomatic Patients. Rotator cuff repair is an option for patients with chronic, symptomatic full thickness tears.
Strength of Recommendation: Weak
3. a. Rotator Cuff Tears and Exercise a. We cannot recommend for or against exercise programs (supervised or unsupervised) for patients with rotator cuff tears.
Strength of Recommendation: Inconclusive
3. b. Rotator Cuff Tears and Corticosteroid Injections. We cannot recommend for or against subacromial injections for patients with rotator cuff tears.
Strength of Recommendation: Inconclusive
3. c. Rotator Cuff Tears and NSAIDS, Activity Modification, Ice, Heat, Iontophoresis, Massage, T.E.N.S., PEMF, and Phonophoresis. We cannot recommend for or against the use of NSAIDS, activity modification, ice, heat, iontophoresis, massage, Transcutaneous Electrical Nerve Stimulation (TENS), Pulsed Electromagnetic Field (PEMF), or phonophoresis (ultrasound) for nonoperative management of rotator cuff tears.
Strength of Recommendation: Inconclusive
4. a. Rotator Cuff Related Symptoms and Exercise or Nonsteroidal Anti-Inflammatory Medication. We suggest that patients who have rotator cuff-related symptoms in the absence of a full thickness tear be initially treated non-operatively using exercise and/or non-steroidal anti-inflammatory drugs.
Strength of Recommendation: Moderate
4. b. We cannot recommend for or against subacromial corticosteroid injection or Pulsed Electromagnetic Field (PEMF) in the treatment of rotator cuff-related symptoms in the absence of a full thickness tear.
Strength of Recommendation: Inconclusive
4. c. Rotator Cuff Related Symptoms and Iontophoresis, Phonophoresis, Transcutaneous electrical nerve stimulation (TENS), ice, heat, massage or activity modification. We cannot recommend for or against the use of iontophoresis, phonophoresis, transcutaneous Electrical Nerve Stimulation (TENS), ice, heat, massage, or activity modification for patients who have rotator cuff related symptoms in the absence of a full thickness tear.
Strength of Recommendation: Inconclusive
5. Acute Traumatic Rotator Cuff Tears and Surgery Early surgical repair after acute injury is an option for patients with a rotator cuff tear.
Strength of Recommendation: Weak
6. Perioperative Interventions –Corticosteroid Injections/NSAIDS. We cannot recommend for or against the use of perioperative subacromial corticosteroid injections or non-steroidal anti-inflammatory medications in patients undergoing rotator cuff surgery.
Strength of Recommendation: Inconclusive
7. a. Confounding factors – Age, Atrophy/Fatty Degeneration and Worker’s Compensation Status. It is an option for physicians to advise patients that the following factors correlate with less favorable outcomes after rotator cuff surgery: Increasing Age, MRI Tear Characteristics, Worker’s Compensation Status
Strength of Recommendation: Increasing Age: Weak,
7. b. Confounding Factors - Diabetes, Co-morbidities, Smoking, Infection, and Cervical Disease. We cannot recommend for or against advising patients in regard to the following factors related to rotator cuff surgery: Diabetes, Co-morbidities, Smoking, Prior Shoulder Infection, Cervical Disease
Strength of Recommendation: Inconclusive
Strength of Recommendation: Moderate**** See below
9. Surgery – Partial Rotator Cuff Repair, Debridement, or muscle transfers for patients with irreparable rotator cuff tears when surgery is indicated. It is an option to perform partial rotator cuff repair, debridement, or muscle transfers for patients with irreparable rotator cuff tears when surgery is indicated.
Strength of recommendation: Weak
10. a. Surgery – Tendon to Bone Healing. It is an option for surgeons to attempt to achieve tendon to bone healing of the cuff in all patients undergoing rotator cuff repair.
Strength of Recommendation: Weak
10. b. Surgery - Suture Anchors and Bone Tunnels We cannot recommend for or against the preferential use of suture anchors versus bone tunnels for repair of full thickness rotator cuff tears.
Strength of Recommendation: Inconclusive
10. c. We cannot recommend for or against a specific technique (arthroscopic, mini-open or open repair) when surgery is indicated for full thickness rotator cuff tears.
Strength of Recommendation: Inconclusive
11. a. Surgery - Non-Crosslinked, Porcine Small Intestine Submucosal Xenografts. We suggest surgeons not use a non-crosslinked, porcine small intestine submucosal xenograft patch to treat patients with rotator cuff tears.
Strength of Recommendation: Moderate
11. b. Surgery - Allografts and Xenografts. We cannot recommend for or against the use of soft tissue allografts or other xenografts to treat patients with rotator cuff tears.
Strength of Recommendation: Inconclusive
12. Post-Operative Treatment - Cold Therapy. In the absence of reliable evidence, it is the opinion of the work group that local cold therapy is beneficial to relieve pain after rotator cuff surgery.
Strength of Recommendation: Consensus opinion of the panel
13. a. Post-Operative – sling, shoulder immobilizer, abduction pillow, or abduction braceWe cannot recommend for or against the preferential use of an abduction pillow versus a standard sling after rotator cuff repair.
Strength of Recommendation: Inconclusive
13. b. Post-Operative Rehabilitation – Range of Motion Exercises. We cannot recommend for or against a specific time frame of shoulder immobilization without range of motion exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive
13. c. Post-Operative Rehabilitation – Active Resistance Exercises. We cannot recommend for or against a specific time interval prior to initiation of active resistance exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive
13. d. Post-Operative Rehabilitation – Home Based Exercise and Facility Based Rehabilitation. We cannot recommend for or against home-based exercise programs versus facility-based rehabilitation after rotator cuff surgery.
Strength of Recommendation: Inconclusive
14. Post-Operative - Infusion Catheters. We cannot recommend for or against the use of an indwelling subacromial infusion catheter for pain management after rotator cuff repair.
Strength of Recommendation: Inconclusive"
One Level II randomized prospective study89 performed a comparison of 47 patients treated with an arthroscopic rotator cuff repair plus an associated anterior acromioplasty and coracoacromial ligament release with 46 patients who underwent rotator cuff repair alone. All patients had isolated supraspinatus rotator cuff tears with Bigliani type II acromion. The patients were evaluated preoperatively and an average of 15 months postoperatively with the American Shoulder and Elbow Surgeons Score. The authors reported no significant difference between groups of both final ASES scores and improvement from baseline. While these results suggest there was no difference in ASES scores between groups, this study was not sufficiently powered to detect the minimally clinically important improvement.
Another randomized, prospective study81 compared 40 patients treated with an arthroscopic rotator cuff repair, anterior acromioplasty and coracoacromial ligament release with 40 patients who underwent rotator cuff repair alone. All patients had a repairable full thickness tear and either a Bigliani type II or III acromion. At two years postoperatively, the authors reported no significant differences in final Constant-Murley scores or DASH scores. The Constant-Murley scores are suggestive that acromioplasty has no effect on outcome. The work group considered the DASH result a true negative because this study was sufficiently powered to show the nonsignificant result was also not clinically significant. These results suggest that acromioplasty has little or no effect on postoperative clinical outcomes; therefore it is not required for the management of normal acromial bone (including type II and III morphology at the time of rotator cuff repair).
Acromial spurs are independent from normal acromial bone. Spurs have been identified as acquired ossifications of the coracoacromial ligament on the undersurface of the acromion. This ossification is considered in excess of normal acromial bone and may have a pathological role in the process of rotator cuff disease. The work group recognizes that acquired acromial spurs are a topic of interest to many surgeons; however they are beyond the scope of the current guideline."
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