Since my six weeks studying with Dr. Neer in 1975, I’ve been trying to put the rotator cuff literature (>10,340 articles at this writing) together along with what I’ve personally seen work and fail over the last 43 years of shoulder practice, I’ve come to the following opinions.
(1) In a large number of people, the rotator cuff degenerates with age. In many of these individuals, the progression of cuff pathology is well accommodated by the shoulder, allowing them to continue to lead functional lives without medical intervention (I am one of these). A small percentage of individuals with cuff tears come to see shoulder surgeons (I am not one of these). Most of our ‘knowledge’ about cuff tears comes from this disproportionately small sample.
(2) While some surgeons have tried to associate various morphologic features of the acromion with cuff disease, evidence that surgical modification of the acromion changes the natural history of cuff disease or improves the outcome of cuff repair is lacking. Furthermore it is evident that acromioplasty increases the risk of pseudoparalysis and anterosuperior escape in patients with cuff deficiency.
(3) For young individuals with acute small cuff tears, surgical repair may be the procedure of choice. There is no evident difference among the different repair approaches.
(4) For individuals with chronic cuff pathology, there is no rush for intervening surgically. In many cases gentle range of motion and strengthening exercises can improve the patient’s comfort and function without the risks, cost and inconvenience of surgery.
(5) When considering surgery for a chronic cuff tear, it is important to assess the shoulder for active and passive range, crepitance, stability, and glenohumeral arthritis. Patients having chronic cuff tears without arthritis, with good active range of motion and with refractory stiffness and crepitance can receive substantial benefit by a smooth and move procedure – a procedure that encourages early active use of the shoulder without the downtime associated with cuff repair. Patients with a preserved coracoacromial arch, retained active motion in the presence of cuff deficiency and arthritis – especially those wishing to avoid the risks and complications of a reverse total shoulder – can consider a hemiarthroplasty with a cuff tear arthropathy humeral head. Finally, patients with cuff deficiency, along with instability, pseudoparalysis and/or anterosuperior escape can consider a reverse total shoulder.
This is what I teach and how I practice.
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