Monday, July 22, 2013

Asymptomatic rotator cuff tears - natural history

The Natural History of Asymptomatic Rotator Cuff Tears: A Three-Year Follow-up of Fifty Cases

The authors report on 50 patients with initially asymptomatic full-thickness rotator cuff tears followed clinically, sonographically, and by magnetic resonance imaging over three years.

These patients were part of a prior study by the same authors of 420 asymptomatic volunteers aged between 50 and 79 years. In that study, full-thickness tears of the rotator cuff were detected in 32 subjects (7.6%). The prevalence increased with age as follows: 50 to 59 years, 2.1%; 60 to 69 years, 5.7%; and 70 to 79 years, 15%. The mean size of the tear was less than 3 cm and tear localisation was limited to the supraspinatus tendon in most cases (78%). The strength of flexion was reduced significantly in the group with tears (p = 0.01). The authors concluded that asymptomatic tears of the rotator cuff should be regarded as part of the normal ageing process in the elderly.

In the new study, eighteen of fifty tears developed symptoms during follow-up. There was a significantly larger (11mm) increase in the mean tear size in the newly symptomatic group ( when compared with the still-asymptomatic group (3 mm). The rate of fatty degeneration was significantly higher (35%) in the newly symptomatic group when compared with the still-asymptomatic group (4%). The rate of pathology of the long head of the biceps tendon was significantly higher (33%) in the newly symptomatic group  when compared with the still-asymptomatic group (6%).

During a relatively short-term follow-up, a substantial percentage of asymptomatic rotator cuff tears became symptomatic and underwent anatomic deterioration. Increase in tear size and decrease of muscle quality were correlated to the development of symptoms.

The authors caution that there may not be a direct cause-and-effect relationship between tear progress and the development of symptoms: 3 of 18  newly symptomatic subjects developed symptoms even though the tear did not progress, while 12 of 32 subjects remained asymptomatic although they had deterioration of the rotator cuff.

We would add the caution that the observation that tears progressed with time in some of these patients does not demonstrate that these patients would have fared better if their asymptomatic tears had been surgically repaired.

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