Saturday, April 6, 2013

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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