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 ad monition 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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