Lennard Funk and Puneet Monga discuss the management and treatment of rotator cuff tears
Rotator cuff disease is very common. There is as much enthusiastic discussion and debate on its management as there was 80 years ago when Codman first described the pathology and surgical management [1]. There is great variation among surgeons as to the management of rotator cuff tears, biased by experience and their understanding of the literature, skills levels and regional variations. There has been a lot of research into the pathology, non-operative and operative treatments over the past twenty years, and over the last decade there have been massive strides in the development of new surgical techniques and technologies; however, despite these advances, there remains as much discussion and debate!
Are cuff tears normal?
There is an old adage among orthopaedic surgeons that “grey hair equals cuff tear” and the general teaching has been that cuff tears are a normal part of the ageing process. Sher et al. in 1995 looked at asymptomatic patients using magnetic resonance imaging (MRI) [15]. They found that 54 per cent of asymptomatic shoulders in patients over the age of 60 had evidence of a rotator cuff tear; 28 per cent of those were full thickness tears, and 26 per cent were partial thickness tears.
Such conventional wisdom has been challenged recently. In a large study of 4629 shoulders, Reilly et al. revealed that full thickness tears are only present in about 11 per cent of cadavers [14], while an ultrasound scanning study published last year suggests that such a prevalence in asymptomatic individuals may actually be as low as 2.3 per cent [13]. Therefore, the true incidence of asymptomatic degenerate tears of the rotator cuff is perhaps not as high as previously thought.
What is the natural history of rotator cuff tears?
Yamanaka and Matsumoto followed 40 partial articular surface cuff tears over 14 months and found that during the period of observation 10 per cent had healed, 10 per cent had decreased in size and 80 per cent enlarged to become full thickness tears [16].
Yamaguchi and colleagues longitudinally followed asymptomatic rotator cuff tears over a five-year period to assess the risk for development of symptoms and tear progression using ultrasound scans and clinical assessments [17]. They found that 50 per cent of the study group developed symptomatic cuff tears during the five-year period; 50 per cent of the entire group’s tears increased in size; no patient had a decrease in size of tear; and only 22 per cent of the remaining asymptomatic patients had progression of their tears. Thus, even without tear progression, 78 per cent developed symptomatic tears.
Therefore, it would appear that articular surface partial tears generally progress to full thickness tears. The full thickness tears are at risk of progressing and are likely to become symptomatic. The progression of tears is, however, not linear. Although the contributions from individual factors are poorly understood in an individual case, it is widely understood to be multifactorial in nature. Factors such as extrinsic compression from the acromion, trauma, age, degeneration, genetic factors and vascular changes play a part in progression. In fact, only a small proportion of massive cuff tears go on to develop arthritis, reminding us of the non-linear progression of such tears.
What is the role of non-operative treatment?
Symptomatic rotator cuff tears can often be managed without surgery and the use of painkillers, injection and rehabilitation are well established. Surgery is usually indicated when non-operative measures fail. There are many studies reporting good results of treating rotator cuff tears with rehabilitation methods, but only two studies comparing rotator cuff repair with non-operative treatment [3,4]. These show a trend towards better outcomes with surgical repair, but no significant difference in the short term. Kukkonen et al. limited their study to atraumatic (degenerative) rotator cuff tears, highlighting the difference between traumatic and degenerative mechanisms. Moosmayer et al. had 24 per cent of the non-operative group crossing over to s