Saturday, January 11, 2014

Do patients with long standing symptoms have more severe rotator cuff disease?

The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears

The intent of this study was to determine whether the duration of symptoms correlated with more advanced findings of rotator cuff tear severity on magnetic resonance imaging, worse shoulder outcome scores, more pain, decreased range of motion, and less strength. This was not a prospective study, however, it was a cross-sectional study so it does not necessarily inform our understanding of the natural history of this condition. They found that a longer duration of symptoms did not correlate with more severe rotator cuff disease, the amount of weakness weakness, limitations in range of motion, tear size, fatty atrophy, or patient-reported outcome measures.

As we've pointed out in prior posts, the amount of pain does not correlate with the magnitude of the cuff tear - complete tears of the cuff may, like complete tears of the Achilles tendon, be painless. In fact, smaller, partial tears may be more painful than complete tears, again as in the case of the Achilles tendon. Also, as is shown in prior posts, the complaint of shoulder pain may have more to do with socioeconomic and other patient factors than with factors pertaining to the shoulder. Finally, it is not necessarily the case that cuff tears with long standing symptoms are bigger than less chronic tears. 

It appears that the guidelines for treating rotator cuff tears are becoming clearer:
(1) Acute traumatic tears in otherwise healthy individuals merit strong consideration for prompt repair before the bone, tendon and muscle deteriorate.

(2) Chronic, atraumatic tears may present as pain, stiffness, weakness, and instability. By dint of their chronicity, the surgeon has time to consider the best option and to explore non-repair alternatives. If pain is the overwhelming symptom, surgery may not be the ideal solution.  If stiffness is the main symptom and not responsive to stretching exercises, an attempt a surgical repair of a retracted tendon may risk further tightening and limiting the range of motion; thus a smooth and move many be a better option.  If weakness is the primary problem and not responsive to strengthening exercises, the surgeon needs to determine whether a durable repair is achievable; if not, the substantial down time to protect a tenuous repair may not be in the best interest of the patient.  If instability is the issue, something more that a cuff repair attempt may be needed, such as a reverse total shoulder. 

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