Should we be in a hurry to operate on atraumatic cuff tears?

Clinical outcomes secondary to time to surgery for atraumatic rotator cuff tears

These authors point out that the time from symptom onset to surgery affects the functional outcomes after repair of traumatic rotator cuff tears (RCTs), but this temporal relationship has not yet been evaluated in patients with atraumatic, degenerative cuff tears.

The aim of their study was to evaluate the relationship between the patient's recollection of the time between symptom onset to surgery and the two year minimum postoperative outcomes in 143 patients with atraumatic RCTs. Patients were divided into 2 cohorts based on the duration between symptom onset and surgery: early (<12 months, n=78, 55%) and delayed (>12 months, n=65, 45%). 

The patient demographics, the tear characteristics and outcomes for the two groups are summarized in the chart below.

The authors concluded that delaying surgical treatment for 1 year or more did not significantly affect postoperative outcomes. 

Comment: In contrast to acute traumatic tears, the time of onset of atraumatic rotator cuff tears cannot be accurately determined. While surgical attention to acute traumatic tears should be strongly considered, for patients with symptomatic atraumatic tears there is an opportunity for non-operative management directed at restoration of flexibility and strengthening of the muscle-tendon units that remain intact (see this link). There appears to be no disadvantage to the patient from a trial of conservative management.

Cuff tear vs cuff wear:

"The rotator cuff is the only tendon structure situated between two bones. Compressed between the acromion and the humerus by every motion of the shoulder, it succumbs to the ravages of attrition long before most other tendons. In youth, it is thick, strong, and elastic and can be disrupted only by great force; after middle age, it has worn thin and often becomes so weak and brittle that it ruptures with ease." McLaughlin 1962


Detachment of the rotator cuff tendons from the greater tuberosity is often described as a rotator cuff tear. The word 'tear' suggests an acute process, such as tear in otherwise great blue jeans that can be easily repaired.

On the other hand, most cuff defects arise in tendons of suboptimal quality without an acute traumatic episode and may be better referred to as cuff wear, similar to defects in worn jeans that defy repair.

We emphasize the distinction in an article on rotator cuff failure in the New England Journal as well as in the text, The Shoulder, where we quote McLauhglin's admonition regarding 'rotten cloth to sew' in an Instructional Course Lecture: "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. [There was complete agreement of the Panel on this point.]" See his 1962 article.

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The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Is rotator cuff repair of value in the treatment of atraumatic rotator cuff tears?

Treatment of Nontraumatic Rotator Cuff Tears - A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up

The authors of this Level I study randomized 180 shoulders (patient age > 55 years, average age 65 ± 6 years) with symptomatic, nontraumatic, isolated supraspinatus tears that had been symptomatic for > 2 years into one of three intervention groups:
*a physiotherapy (PT)-only group (Group 1),
*an acromioplasty, debridement and PT group (Group 2), and
*a rotator cuff repair, acromioplasty, and PT group (Group 3).

The repair technique was arthroscopic single row for tears of ≤10 mm and double row for larger tears followed by sling immobilization for three weeks.

167 shoulders were available for analysis at two years. The Constant score was the primary outcome measure. Secondary outcome measures were visual analog scale for pain, patient satisfaction, rotator cuff integrity by MRI.

Direct cost data were obtained including cost related to transportation, health-care center, hospital, outpatient clinics, physiotherapist visits, laboratory and imaging services, the surgical procedure, length of hospital stay, medications, and lost income during sick leave.

The mean changes in the Constant score were not significantly different among the three groups: 18.4 points for Group 1, 20.5 for Group 2, and 22.6 points for Group 3. The recovery time for Group 3 patients was the slowest. There were no significant differences in visual analog scale for pain scores or patient satisfaction.

In comparison to baseline, at two years, the mean sagittal size of the tendon tear on MRI for Group 1 changed from 9.6 to 10.4 mm, for Group 2 from 9.1 to 11.7 mm and for Group 3 from 8.4 to 4.2 mm (i.e. the average patient having attempted cuff repair had a 4 mm tendon defect at two years in comparison to the average 8 mm defect preoperatively).

At two years, the mean Constant score was 78.4 points in patients with a full-thickness supraspinatus tendon defect and 79.0 points in patients with a healed supraspinatus tendon in all shoulders (Groups 1, 2, and 3). Only 3% of cuff defects randomized to the non-operative group crossed over to having surgery.

The range of motion and the strength for the three groups were virtually identical.

The costs of treatment were € 5,104 for Group 1, € 6,915 for Group 2 and € 9,185 for Group 3.

The costs for the patient were € 2,915 for Group 1, € 2,434 for Group 2 and € 3,674 for Group 3.

The costs for society were € 2,348 for Group 1, € 4,691 for Group 2 and € 5,646 for Group 3.

Considering the value of the different treatments, the treatment cost for a single point increase in the Constant score was € 277.39 for physical therapy, € 337.32 for debridement and € 406.42 for repair.

Comment: The key point about this study is that it concerns atraumatic cuff defects (i.e. the result of cuff wear in contrast to traumatic cuff tears) - see this link. This is the commonest type of cuff defect - the cuff tissue had degenerated to the point where it failed without a specific injury. Attempting to reattach degenerated tendon tissue to bone is expensive on one hand, has a substantial risk of failure on the second hand, and that the clinical results are essentially the same whether the repair attempt heals or not on the third hand.

One might critique this study based on surgical method or period of immobilization after surgery, but until other evidence comes along supporting the surgical treatment of non-traumatic cuff defects, we should strongly consider the authors’ recommendation of: “conservative treatment as the primary initial treatment for nontraumatic, isolated, supraspinatus tears”. As they state, “The wave of operative treatment of nontraumatic rotator cuff tears may cause increasing health-care expenses at no benefit over conservative treatment.”

The results of this study should be compared to that of another Level I study (see this link) with the caveat that the prior study included both traumatic and atraumatic cuff tears.

This article also calls to mind one of the most curious of all publications on rotator cuff surgery which came to a seemingly hyperinflated estimate of the value of cuff surgery (see this link).

We continue to consider the 'smooth and move' procedure (see link) in the management of atraumatic tears.

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Rotator cuff tears: pain does not correlate with tear size

Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear.

The authors studied 393 subjects with an atraumatic symptomatic full-thickness rotator-cuff tears.

48% were female. average age 61 years, dominant shoulder involved in 69%. 

Duration of symptoms was up to three months for 30%, four to six months for 20%, seven to twelve months for 15%, and more than a year for 36%. 

The tear involved only the supraspinatus in 72%; the supraspinatus and infraspinatus in 21%; and only the subscapularis in 7%. 

Tendon retraction was minimal in 48%, midhumeral in 34%, glenohumeral in 13%, and to the glenoid in 5%. 

Humeral head migration was noted in 16%. 

The median baseline VAS pain score was 4.4.

Their analysis indicated that increased comorbidities, lower education level, and race (p = 0.041) were the only significant factors associated with pain on presentation. No measure of rotator cuff tear severity correlated with pain.

Comment: We had the opportunity to provide commentary on this article: Shoulder Pain Does Not Parallel Rotator Cuff Tear Size - What Does That Tell Us? We recalled that the indications for rotator cuff repair surgery remain ambiguous, especially since the clinical outcomes after cuff repair do not differ significantly between the patients who have durable healing of the repair and those who had failure of the repair to endure.

The authors observed that three patient characteristics - comorbidities, lower educational level and race but not tear severity - were associated with the level of pain. It is important to note that none of these three pain associated factors are changed by an attempt at surgical repair. Here are some further thoughts on indications for cuff repair. A complete discussion of cuff tears can be found here.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Rotator cuff tears - getting better without surgery

Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter  prospective cohort study

The authors indicate that 10% of Americans aged over 60 years, or 6 million individuals, have full-thickness rotator cuff tears. Furthermore, only  250,000 rotator cuff repairs are performed each year. As we've pointed out before the average cost of a cuff repair exceeds 10,000, so that the total 'bill' for cuff repair surgery may be $2,500,000,000. As we have also indicated in previous posts, many surgical attempts to repair a rotator cuff defect do not succeed in re-establishing an intact tendon, yet patients may be improved after the surgery and post surgical rehabilitation.

This paper asks the interesting question, 'what if one did the rehabilitation without the surgery?'

They assessed the effectiveness of a specific nonoperative physical therapy program in treating 452 patients with atraumatic full-thickness rotator cuff tears. The average patient age was 63 years and the gender distribution was essentially equal. The authors were careful to exclude the patient with a rotator cuff tear after a major injury, in that most of us believe that an acute traumatic rotator cuff tear, especially in active individuals merits consideration for surgical repair.  The program consisted of simple stretching and gentle strengthening exercises, similar to those shown here, that used no special equipment. Patients were allowed to opt for surgery after 6 weeks if they felt the exercise program was ineffective. Of interest is the observation that almost 25% of the patients had 'had therapy' prior to enrollment in the study. 

70% of the shoulders had supraspinatus only tears. One third had tendon retraction to the mid humeral head.

The authors found that patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months.  Highly statistically significant improvements were seen in the ASES, WORC, SANE and SF12 PCS patient self-assessment scores. Of the 319 patients available for two year followup, only 26% had had surgery.

Another recent article compared formal with home therapy and found essentially no difference in their effectiveness.

While the authors did not report the cost of the rehabilitation program in comparison to the likely cost of treating all of the patients with surgery, it is likely that in this set of 452 individuals over $3 million was saved by avoiding surgery in three out of four patients. Furthermore, the patients with successful non-operative management were spared the risks of surgery and the associated post operative 'down time'. 

This paper presents a strong argument for a trial of at least 6 weeks of simple rehabilitation for individuals with atraumatic rotator cuff tears.

Should the patient elect to proceed with surgery, the rotator cuff may not be securely reparable. For that reason, we present this information to the patient for their preoperative consideration.

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