A previous post (see this link) discussed the management of traumatic rotator cuff tears in individuals with an average age of 60 years. By contrast this study discusses the management of atraumatic rotator cuff tears in individuals with an average age of 71.
180 shoulders with symptomatic, non-traumatic supraspinatus tears were randomly assigned to one of the three treatment groups: physiotherapy (Group 1), acromioplasty and physiotherapy (Group 2) and rotator cuff repair, acromioplasty and physiotherapy (Group 3).
150 shoulders (mean age 71) were available for analysis after a mean follow-up of 6.2 years.
The mean sagittal tear size of the supraspinatus tendon tear was at baseline 10 mm in all groups.
Eight shoulders in Group 1 and two shoulders in Group 2 crossed over to rotator cuff repair during the follow-up.
There were no significant differences in the mean change of the Constant score.
There were also no statistically significant differences in the change of visual analog scale for pain and patient satisfaction.
Preoperatively there was no or mild radiographic evidence of osteoarthritis At follow-up moderate or severe osteoarthritis was detected in 7 (19%), 14 (40%), and 13 (35%) shoulders in Groups 1, 2, and 3 respectively (p=0.124). Despite non-significant between group differences, there was a statistically significant mean progression in the grading of osteoarthritis from baseline to follow-up in the overall study group.
From this study, the authors concluded that
(1) operative treatment was not better than non-operative treatment of small non-traumatic single tendon supraspinatus tears in patients over 55 years of age.
(2) operative treatment did not protect against degeneration of the glenohumeral joint or cuff tear arthropathy.
(3) non-operative treatment is a reasonable option for the primary initial treatment for these tears.
Readers may be interested in a recent Cochrane analysis, Does repair of torn rotator cuff tendons work?, that concluded, "As compared with non-operative treatment, moderate-certainty evidence (downgraded due to risk of bias) indicates that surgery (rotator cuff repair with or without subacromial decompression) probably provides little or no benefit in pain and low-certainty evidence indicates that it may provide little or no improvement in function, participant-rated global treatment success or overall quality of life (downgraded due to bias and imprecision) in people with rotator cuff tears." The AAOS practice guidelines for the management of cuff tears can be found at this link.
Comment: Rotator cuff repair is a surgical procedure that can be associated with increased costs, substantial postoperative discomfort and a prolonged "down time" to protect the repair during the time of anticipated healing. In this light, surgical repair should be reserved for cases in which the procedure offers a definite benefit to the patient in comparison to non-operative treatment.
An example of "right sizing" treatment is shown in the case below of a degenerative supraspinatus cuff tear.
With a simple stretching and strengthening rehabilitation program (see this link), durable full, comfortable function was achieved.
