Rotator cuff pathology can be asymptomatic

Effects of asymptomatic rotator cuff pathology on in vivo shoulder motion and clinical outcomes

These authors suggest that the incidence of asymptomatic rotator cuff tears in population ranges from 15% to 39%. They assessed the effects of asymptomatic rotator cuff pathology on shoulder kinematics, strength, and patient-reported outcomes. They recruited 46 asymptomatic volunteers (age: 60.3± 7.5 years) with normal shoulder function and used ultrasound to document the condition of their rotator cuff. 70% of these asymptomatic patients had cuff pathology!

Shoulder motion was measured with a biplane x-ray imaging system, strength was assessed with a Biodex,, and patient-reported outcomes were assessed using the Western Ontario Rotator Cuff Index and visual analog scale pain scores.

While patients with rotator cuff pathology had somewhat less abduction and elevation strength, 

the authors found no significant differences in the Western Ontario Rotator Cuff Index, visual analog scale, or range of motion.

For shoulders with cuff pathology, the humerus was positioned more inferiorly on the glenoid (P = .018), and the glenohumeral contact path length was longer (P = .007). 

Comment: We do not know the extent of the cuff pathology in these volunteers - the authors only classified them as normal or pathological. Yet it is remarkable that 70% of individuals who felt they had normal function turned out to have rotator cuff pathology on ultrasound. While sophisticated testing could differentiate the two groups, the patients had similar comfort and function. 

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Progression of asymptomatic degenerative rotator cuff tears - is the 'cable' relevant?

Patterns of tear progression for asymptomatic degenerative rotator cuff tears

These authors studied 139  full-thickness rotator cuff tears with a mean subject age of 63.3 years and follow-up duration of 6.0 years/

Ninety-six (69.1%) of the tears demonstrated integrity of the anterior 3 mm of the supraspinatus tendon (the 'cable').

Fifty (52.1%) of the tears with intact anterior 3 mm of the supraspinatus tendon showed >5mm progression of tear width at a median of 3.2 years from enrollment. 

Twenty nine (67.4%) of tears with disruption of anterior 3 mm of the supraspinatus tendon showed >5mm progression of tear width at a median of 2.2 years from enrollment.

They concluded that the integrity of the anterior 3 mm of the supraspinatus had no effect on the magnitude of enlargement.

Comment: It is not surprising that degenerative cuff tears continue to degenerate. The significance of the 'anterior rotator cuff cable' remains undefined. 

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Atraumatic cuff tears: an intrinsic age-related degenerative process

The authors of Research Zeroes in on Pathogenesis of Rotator Cuff Disease received the 2014 Ann Doner Vaughan Kappa Delta Award.

These authors observed that non-traumatic rotator cuff tears result from degenerative changes in the tendon that progress in size over time in association with fatty degeneration of the attached muscle. At a certain stage, these changes become irreversible.

They conducted a longitudinal, prospective follow-up study of a cohort of 262 patients with asymptomatic full or partial thickness rotator cuff tears that were incidentally discovered contralateral to a symptomatic cuff tear by routine ultrasound examination.

The findings indicated that rotator cuff disease develops in an age-related, bilateral, degenerative way; approximately 40 percent of rotator cuff tears increase in size over as few as three years due to an intrinsic, degenerative process, rather than the previously held belief that tears develop due to acromial “impingement”.

In this study, tears commonly started about 1.5 cm posterior to the biceps tendon—and then propagated in both posterior and anterior directions. Loss of the anterior supraspinatus tendon attachment correlated with fatty degeneration. Proximal migration of the humeral head was much more likely to occur once the tear reached a specific threshold: tears wider than 1.5 cm at the humeral insertion were more likely to have superior migration, tears that extended to the bicipital groove and through the anterior supraspinatus tendon were more likely to have altered kinematics.

The authors recommend that patients younger than 60 years with small or medium-sized tears that are significantly painful should be given strong consideration for early surgical intervention in hopes of preventing progression in tear size and development of fatty degeneration. They noted that rotator cuff repair is much less likely to lead to tendon healing in patients who are 63 years and older; early surgical intervention does not provide much clinical advantage in these patients for which there is concern for healing.

Comment: The recognition that cuff tearing is an intrinsic progressive degenerative process, rather than related to subacromial ‘impingement’ is important. This recognition is consistent with the lack of evidence that acromioplasty is an important part of treatment of rotator cuff disease. Furthermore the recognition that cuff failure is a degenerative process suggests that at some point the tendon and associated muscle will degenerate to the point that attempting surgical reattachment of the degenerated tendon to bone is unlikely to result in a durable repair.

What remains to be established is whether reattachment of a tendon early in the process of degeneration will reverse the degenerative process.
As H.L.McLaughlin stated in 1962, "the wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis."
It has yet to be demonstrated that suturing degenerated tendon results in improvement in the quality of the tendon.
Bottom line: it matters if the cuff fails because of tear or wear

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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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