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 . 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) . 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 , 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 . 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 .
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 . 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 surgical repair. Therefore, it would seem reasonable to manage degenerative rotator cuff tears without surgery, but the evidence is less clear for traumatic tears.
Is subacromial decompression alone adequate for treatment of rotator cuff tears?
A number of studies have looked at arthroscopic procedures that do not involve tendon repair [2,5]. It would appear that arthroscopic subacromial decompression alone is good for pain relief in the presence of rotator cuff tears in elderly patients with low functional demand, on a limited goals basis, where restoration of strength is not the key aim.
When to repair rotator cuff tears?
The key surgical step in rotator cuff surgery has been to attach the torn tendon to the original attachment. There are no clear indications on when to proceed from non-operative care to surgery based on the evidence thus far. Kuhn et al. , in post-hoc analysis, found that in atraumatic rotator cuff tear subjects who did not believe therapy would be successful, conservative therapy failed the majority of the time. Classically, some of the clinical indicators to proceed to surgery include traumatic tear, symptomatic full-thickness tear in patients who have failed conservative therapy for at least six weeks and physiologically young patients. The best available evidence suggests earlier surgical intervention may be indicated in patients with traumatic cuff tears with functional disability and weakness . The time from injury to surgery may affect the reparability and outcome, but this is not conclusively demonstrated in the literature .
While the majority of rotator cuff tears develop in a chronic degenerative fashion, there is a subset of patients who develop rotator cuff tears following an injury. It is thought that even such tears may develop on a background of tendinopathy (diseased tendon) that varies depending on the patient’s age. Acute tears have better outcomes following early surgery .
Arthroscopic versus open surgery
Arthroscopic surgery for the shoulder has led to one of the greatest advancements in the surgical management of rotator cuff tear. These techniques allow for minimal tissue damage, lower wound complications, and quicker recovery. At the forefront of this development are technical advances allowing detailed visualisation of the joint. The first ingredient has been development of fluid management systems that are key to maintaining content pressure and minimising turbulence during surgery. Secondly, the development of radio frequency devices for tissue ablation and bleeding control allow resection of the reactive and inflamed tissue that is commonly seen in rotator cuff surgery. The next major advance has been the development of anchors, which have been shown to improve healing and also allow a complex pattern of repairs while minimising complications . Finally, good quality arthroscopic shavers and hand instruments allow for technical steps with minimal collateral damage. Such advances have helped achieve outcomes comparable to open techniques, even in the hands of a wider surgical community .
What are the results of rotator cuff repair?
The published results of rotator cuff repairs have been variable. This may be related to patient selection, differing techniques, bias and differing outcome measures. Most studies have only reported the size of the cuff tear and patient age in relation to the results; however, our understanding of the importance of the rotator cuff muscle quality (atrophy and fatty infiltration) in relation to repair results is now clearer.
We also appreciate the relevance of the broad insertion area of the rotator cuff on the humerus, known as the footprint area. We now attempt to recreate this with our repair techniques. Progressive degenerative cuff tears have poorer tendon quality than traumatic tears in good tendon tissue and are more likely to fail and we need to look at alternative methods to manage these patients.
There are many new techniques for reconstructing larger tears, such as superior capsular reconstruction and new technologies, such as the InSpace Balloon. Biological enhancement technologies, using stem cells, growth factors and promoters of net-vascularisation are currently being investigated . The role of these is still being defined and will be clearer in the next decade.
So, should we repair rotator cuff tears?
In summary, based on our understanding of the published literature and experience – yes!
But this does depend on a number of factors, not all of which are easy to quantify objectively. A traumatic rotator cuff tear in a young, active patient would be an indicator for early repair. An atraumatic, degenerate tear in an elderly, low-demand patient would not be a good candidate for repair. The grey zone between those two extremes is less clear and it is best to apply principles of shared decision-making. In fact, one of the key advances of modern medical practice, in the current era of internet-based information, is such shared decision-making between the surgeon and the patient. Patients must be involved in decisions regarding their health, especially when it comes to surgical treatment. Therefore, decisions to proceed with rotator cuff repair are best supported with evidence-based discussions regarding management options, complications, recovery times and anticipated outcomes.
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Lennard Funk and Puneet Monga are consultant shoulder surgeons at Wrightington Hospital.