Rotator cuff tears: to operate or not?

 In Upper Limb

The shoulder joint is a very common area of injury (7). It is prone to pain or injury due to its ability to move in many directions and its involvement in many day-to-day activities (7). To ensure stability at the shoulder, a group of muscles called the rotator cuff play a vital role. The rotator cuff is a group of four muscles that control rotation of the shoulder and is very important in keeping your arm (humeral head) attached to your shoulder blade (glenoid) (6).

Rotator Tear

Tears of the rotator cuff are a common cause of shoulder injuries in both younger and older generations (1)(3). The prevalence of rotator cuff tear is 25% in those over 50 years old and 20% in those over 20 (2). Interestingly, only 1/3 of these tears cause pain (2). Of those painful tears only 20% seek physiotherapy – resulting in 1/15 of those with a rotator cuff tear (symptomatic or asymptomatic) receiving physiotherapeutic treatment (2).

The two most common causes are following a shoulder dislocation, repetitive overhead trauma during sports (typically younger population) or tendon degeneration due to age (typically older population) (2). If not managed correctly, rotator cuff tears can be a source of persistent pain, dysfunction, instability of the affected limb and further degeneration to the shoulder joint (3).

Following a rotator cuff tear there are two primary pathways of management; conservative management or surgical repair. Research has been conducted in an attempt to determine if one of these options were more superior or if both options had outcomes that were much the same (3).

Rotator Tear

Following a rotator cuff tear there are two primary pathways of management; conservative management or surgical repair. #physiowithafinishline @pogophysio Click To Tweet

Conservative Management

Conservative management has been shown to be effective in 73-80% of patients with a full-thickness rotator cuff tear (2). To eliminate pain experienced by clients, the use of non-steroidal anti-inflammatory medication (NSAIDs) and/or steroid injections into the shoulder joint or shoulder bursa have been effective (2). Icing the shoulder in the acute phase as well as rest are important to reduce inflammation and pain (6). Other modalities such as heat, stretching, range of movement exercises and muscle activation and/or strengthening are also useful in reducing symptoms (2). Particular focus of this management surrounds the use of passive stretching, particularly to the muscles behind the shoulder (posterior capsule) (6). Strengthening exercises for the shoulder (rotator cuff muscles) and shoulder blade (scapula stabilisers) as well as giving both postural and technique advice to avoid further or future irritation (6).

Surgical Management

According to the American Academy of Orthopaedic Surgeons (AAOS) the indications for rotator cuff repair surgery are as follows:

  • Symptoms > 6-12 months
  • Rotator cuff tear > 3 cm, or those at risk of re-tears
  • Significant weakness and loss of function
  • Acute tears (7)

A combination of the AAOS guidelines and research surrounding the topic conclude that those with poor outcomes post surgery typically involve:

  • Very large tears
  • Significant comorbidities
  • Elderly clients
  • Labour-intensive occupations
  • Non-dominant arm
  • Fear avoidant behaviours or beliefs (8)

Rotator Tear

There are numerous approaches surgeons can use when repair a rotator cuff tear. These include arthroscopic, mini-open and open with either a single or double row fixation (5). Research suggests that there is little difference has been found between the approaches long term (1-2 years) (4). However, the mini-open approach was superior in the short term (3 months) (4). The approach is also important for a physiotherapist to know when a rehabilitation program is being devised following surgery (4).

Post-operative management

Rehabilitation following a rotator cuff repair can be broken down into three main phases:

Rotator TearPhase 1

Aim: prevent stiffness and scar tissue adherence while allowing tendon/bone healing

Duration: weeks 1-6 (begins with arm sling)

Examples: light activities, passive exercises (using other arm to lift operated arm), gentle scapula exercises

Phase 2

Aim: shift from passive to active movements, beginning of using shoulder muscles again

Duration: weeks 7-12

Examples: progressive scapula exercises, active movement (using affected shoulder muscles), isometric exercises and brain retraining (neuromuscular), aquatic therapy, closed chain exercise

Rotator TearPhase 3

Aim: muscles to begin working against resistance then introducing the operated shoulder to functional activities

Duration: weeks 12+

Examples: resistive exercises (elastic band), functional lifting, return to sport/work (5).

Note: The speed at which a client would move through these phases is dependent on a wide range of factors (5).

Conservative vs Surgical

A number of studies have looked at and compared the outcomes of both management options. Some results showed that those who underwent surgery had better pain scores, improved function, lower recurrence rate and higher patient satisfaction (1). In contrast to this, other research observed insignificant differences between surgical and conservative managements outcomes 1 year after treatment (3). However, they reported small differences between the two in regards to pain scores and disabilities in favour of the surgical intervention (3). The research also stated that the best outcomes observed were the surgically treated clients that had intact rotator-cuffs post-operatively (3).

So which option is best for me?

Which option is best is dependent upon a wide range of factors, as stated earlier. To ensure you select the most appropriate option – a thorough assessment by health professionals must be undertaken.

When comparing surgical vs conservative treatment for a rotator cuff tear – it can be summarised that the conservative approach should be the initial method chosen or should be used if surgical intervention is not an option for the client (8).

 

Alec Lablache
POGO Physiotherapist

Featured in the Top 50 Physical Therapy Blog

References

  1. Gomberawalla, M. M., & Sekiya, J. K. (2014). Rotator cuff tear and glenohumeral instability: A systematic review. Clinical Orthopaedics and Related Research, 472(8), 2448-2456. doi:10.1007/s11999-013-3290-2
  2. Itoi, E. (2013). Rotator cuff tear: Physical examination and conservative treatment. Journal of Orthopaedic Science, 18(2), 197-204. doi:10.1007/s00776-012-0345-2
  3. Lambers Heerspink, Frederik O., MD, van Raay, Jos J.A.M., MD, PhD, Koorevaar, R. C. T., MD, van Eerden, Pepijn J.M., MD, Westerbeek, R. E., MD, van ‘t Riet, Esther, PhD, . . . Diercks, Ronald L., MD, PhD. (2015). Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: A randomized controlled trial. Journal of Shoulder and Elbow Surgery, 24(8), 1274-1281. doi:10.1016/j.jse.2015.05.040
  4. Mohtadi, N. G., Hollinshead, R. M., Sasyniuk, T. M., Fletcher, J. A., Chan, D. S., & Li, F. X. (2008). A randomized clinical trial comparing open to arthroscopic acromioplasty with mini-open rotator cuff repair for full-thickness rotator cuff tears: Disease-specific quality of life outcome at an average 2-year follow-up. The American Journal of Sports Medicine, 36(6), 1043-1051. doi:10.1177/0363546508314409
  5. Rotator Cuff. (2015). In The Editors of the American Heritage Dictionaries (Ed.), The American Heritage Dictionary of Medicine (2nd ed.). Boston, MA: Houghton Mifflin. Retrieved from https://elibrary.jcu.edu.au/login?url=https://search.credoreference.com/content/entry/hmmedicaldict/rotator_cuff/0?institutionId=429
  6. Ryder, S., & Maloney, M. D. (2003). Diagnosis and management of rotator cuff tears: Symptoms usually can be resolved with appropriate conservative treatment. The Journal of Musculoskeletal Medicine, 20(2), 87.
  7. Trackactive.co. (2017). Exercises. Retrieved from https://app.trackactive.co/practices/1011/exercise
  8. Upright Health. (2017). Is surgery my only option for my rotator cuff tear. Retrieved from https://uprighthealth.com/is-surgery-my-only-option-for-my-rotator-cuff-tear/

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