Rotator cuff (RC) tears are one of the leading causes of shoulder pain and disability worldwide. The damage to the rotator cuff can be caused by degenerative changes, repetitive micro-trauma, severe traumatic injuries as well as secondary dysfunction. Examples of traumatic injury can be falling on an outstretched hand or by pulling an unexpected force, an example of atraumatic causes can be excessive repetitive movements or normal age related deterioration. The most commonly affected muscle in the RC is supraspinatus.
RC tears are classified in partial or full-thickness tears according to the severity of the tendon fibres disruption and the communication between the subacromial and glenohumeral space. There is no exact agreed upon definition of RC tears as sometimes the severity is expressed by the number of tendons which are torn and sometimes the size of tear. Ladermann et al divide RC tears into 5 categories depending on location and Cofield divide them into 4 categories depending on size of tear and includes the commonly references full or partial thickness tears.
As with the definition of the condition the optimal treatment is equally disputed. This is because with surgical treatment often leads to a second failure of the tendon after repair or exposure to surgical complications and conservative management leads to predisposure to continued irreversible tissue degeneration over time. This degeneration leads to further treatment and worse results over the long term. There is also no agreed conservative approach to treating RC tears.
There have only been a limited number of RCTs which have compared the short and long term outcomes of surgical and conservative management. A new systematic review has aimed to pool these results together and provide new insights into which treatment we should recommend to our patients.
This systematic review adhered to PRISMA and searched 5 databases including CENTRAL, MEDLINE, EMBASE, CINAHL and Google Scholar as well as reference lists. The search string is published in full and can be seen below. Two reviewers assessed the inclusion of the article based on the inclusion / exclusion criteria and a third was available if there was disagreement. Articles published in English, French, Spanish, German and Italian were included. Risk of bias was assessed using the Cochrane risk of bias tool and quality of articles was assessed using GRADE.
(“rotator cuff” OR “rotator cuff tear” OR “rotator cuff injury” OR “non-traumatic tears” OR “rotator cuff rupture” OR “rotator cuff disease”) AND (“rotator cuff repair” OR “surgical procedures” OR “rotator cuff surgery” OR “arthroscopy” OR “operative” OR “non operative” OR “conservative” OR “treatment” OR “management”).
To be included within the analysis articles had to be RCTS involving full-thickness rotator cuff tears, involve patients who were 18 years or older and level-I studies based on the Oxford Centre of EBM published in peer review journals. If the follow up period was less than 1 year after shoulder surgery the article was excluded from analysis.
The primary outcome measure was the effectiveness of each treatment in terms of clinical outcome at different time points measured using CMS and VAS (3, 6, 12, 24 and 60 months). The secondary outcome measures were the integrity of repaired tendon measured by MRI or USS, ROM, simple shoulder test (SST) and American shoulder and elbow surgeons scale (ASES).
After applying the search strategy the results from five articles were included in the analysis. To complicate this somewhat only patient groups from three studies were included as two studies were follow up studies from the same group of patients.
Results and Clinical Take Home
Overall it can be said that there appears to be no significant difference in pain or clinical function at 1 or 2 years between surgical and conservative management. There is a marginal improvement of 1 point in VAS scoring in those who have had a surgical repair of their tendon within the first year after treatment this is unlikely to represent significant clinical improvements.
The treatment involved in the conservative management arms of the RCTs varied greatly and was more of an individual approach than a prescribed programme with most of the focus of treatment being on posture and scapulothoracic and glenohumeral muscular control and stability.
The need for surgery several years after conservative management can likely be explained by the fact that the tendons have not been repaired after the initial tear and continue to deteriorate over many years.