Thursday, September 18, 2014

Which is better physical therapy or surgical repair for rotator cuff tears of 3 cm or less

Tendon Repair Compared with Physiotherapy in the Treatment of Rotator Cuff Tears

These authors have performed a remarkable Level I intention to treat analysis of 103 cases of small acute or chronic cuff tears (3 cm or less) confirmed by both MRI and sonography that did not have stiffness or substantial muscle atrophy. Cases were block randomized to either (a) repair (with or without biceps surgery) or (b) supervised physical therapy (PT) with the possibility of secondary repair. Secondary surgery was offered to patients in the PT group if symptoms persisted after 15 PT visits. Clinical and sonographic followup was 98% at 5 years.

The authors selected the Constant Score as the primary outcome of interest. This score was only slightly better for the group having surgical repair: 79.8 ± 15.0 as compared to 74.2 ± 20.3 for the PT group. P = .05.

The failure rates in the two groups were comparable:
(1) Over 14 of the tears treated with PT had progression of the tear size > 5mm, some related to trauma. It is not possible to know if repair of these tears would have been successful. Twelve nonoperative patients reported an insufficient treatment effect and desired surgical treatment.

(2) For the surgical patients, a re-tear (or non-healing) was diagnosed 15 patients. The recurrent defect was full-thickness in eight patients (13%) and a partial-thickness in seven patients (12%). These are essentially the same results as found in the classic article by Harryman et al reported over two decades ago.  There was no mention of whether complications occurred in the surgery group. It is not stated if the re-tears required repeat surgery.

A biceps tenodesis was performed in over one third of cases in the primary tendon repair group; no biceps tenodeses were performed in the physical therapy group. Thus, if over 1/3 of patients in this series had biceps tendon pathology, this pathology went untreated in the PT group.   One could wonder if such untreated pathology might have accounted for the small difference in the two outcomes.

Comment: Our approach to rotator cuff tears remains unaltered: acute tears resulting in a substantial change of shoulder function deserve strong consideration for prompt surgical repair if the patient is healthy and active as long as there is no reason to believe the tendon is of poor quantity or quality (i.e. patient is elderly, a smoker, has had steroid injections, has atrophy, massive tear, retraction).

Chronic tears deserve a good try at non operative management. If non-operative management is not successful, consideration can be given to a smooth and move or a repair depending on the quantity and quality of the tissue encountered at surgery.

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