Management of degenerative rotator cuff tears: a review and treatment strategy
© Clement et al.; licensee BioMed Central Ltd. 2012
Received: 17 December 2011
Accepted: 5 December 2012
Published: 14 December 2012
The aim of this review was to present an over view of degenerative rotator cuff tears and a suggested management protocol based upon current evidence. Degenerative rotator cuff tears are common and are a major cause of pain and shoulder dysfunction. The management of these tears is controversial, as to whether they should be managed non-operatively or operatively. In addition when operative intervention is undertaken, there is question as to what technique of repair should be used. This review describes the epidemiology and natural history of degenerative rotator cuff tears. The management options, and the evidence to support these, are reviewed. We also present our preferred management protocol and method, if applicable, for surgical fixation of degenerative rotator cuff tears.
The earliest published description of a rotator cuff tear was by Alexander Munro some 220 years ago in 1788, describing a “hole with ragged edges in the capsular ligament of the humerus” . Since this description there has been little agreement amongst orthopaedic surgeons regarding the exact indications for surgical repair of a torn degenerative rotator cuff . The purpose of this review was to present an overview of degenerative rotator cuff tears and a suggested management protocol based upon current evidence.
The prevalence of rotator cuff disease increases with age, with 4% of asymptomatic patients aged less than 40 years and 54% of patients aged 60 years or over, having partial or complete tears of the rotator cuff on magnetic resonance scanning . Ultrasound scanning has demonstrated that 13% of the population in the fifth decade, 20% in the sixth decade and 31% in the seventh decade of life have a rotator cuff tear . Yamaguchi et al.  demonstrated that more than half of asymptomatic rotator cuff tears become symptomatic within 3 years and progressed in size during this time period.
Evaluation and diagnosis
Degenerative rotator cuff tears tend to occur in older patients (>50 years old) and often have no history of trauma, presenting with progressive shoulder pain and/or dysfunction . Examination may reveal atrophy around the shoulder girdle secondary to chronic disuse, typically in the supraspinatus and infraspinatus fosse . Range of movement should be assessed, where active movement may be limited but generally passive is full . Neers sign and Hawkins signs can be used to assess for impingement of the rotator cuff . More specifically horn blowers sign, Jobe’s and Gerber’s belly press tests assess specific rotator cuff muscles; teres minor, supraspinatous, and subscapularis respectively . Multiple imaging modalities are available to assess the status of the rotator cuff. Plain radiographs enable assessment of the acromiohumeral space (normally 7 to 14mm), acromial morphology, and the glenohumeral joint, which can be used to grade the rotator cuff arthropathy . Ultrasound allows dynamic assessment of the rotator cuff with no radiation exposure, however magnetic resonance imaging (MRI) remains the gold standard in the radiographic assessment of the rotator cuff .
The natural history of a rotator cuff tear
The management of a rotator cuff tear is multifaceted. Conservative management includes analgesia and anti-inflammatory medications, physical therapy, activity modification and subacromial injections of local anaesthetic and/or steroid. Injection of hyaluronate is advocated by some authors for complete rotator cuff tears, but a randomized control trial found it to be no more effective than a steroid injection . More recently however Chou et al. demonstrated a significant improvement in shoulder function at 6 weeks following injection with hyaluronate compare with placebo for partial tears . Operative interventions include arthroscopic debridement of the tear or repair of the torn rotator cuff, with or without subacromial decompression. Most reports in the literature are procedure oriented, consisting of retrospective single surgeon series with limited numbers of patients. A Cochrane review performed in 2004 analysed interventions for rotator cuff tears and concluded that there is little evidence to support or refute the efficacy of commonly used treatment methods .
A suggested approach to management of a rotator cuff tear
The aim in managing a rotator cuff tear is to reduce pain and improve function. The evidence for conservative management of a rotator cuff tear dictates an initial period, of at least 6 weeks to 3 months, of non-operative treatment unless there is evidence of an acute tear in a younger patient [25–27]. Prolonged conservative management in symptomatic patients can have negative consequences. These include increase in tear size, tear retraction, increased difficulty of repair [28, 29] and muscle atrophy with fatty infiltration, all of which can result in a diminished outcome [29–32].
Despite limited evidence, physiotherapy is the mainstay of conservative management of rotator cuff tears. An ultrasound or MRI scan may be obtained for patients with persistent symptoms that have not improved after 2 to 3 months of conservative management. There is no good evidence for or against steroid injection in the management of rotator cuff tears, although empirically these do seem to have a positive effect in some patients. Multiple injections should be avoided however, especially if there is a diagnosed rotator cuff tear that is potentially repairable.
Initial radiographic assessment includes an anteroposterior, scapulolateral, and axillary view. If a rotator cuff tear is suspected based on clinical assessment, an ultrasound or MRI scan can be obtained. An ultrasound scan offers dynamic assessment of the rotator cuff with less expense, relative to a MRI scan, but it is operator dependent. A MRI scan can also evaluate tear size and retraction, but in addition the rotator cuff muscles can be assessed for fatty atrophy which predicts outcome after repair.
Symptomatic rotator cuff tears treated conservatively can give a baseline to which the outcome after surgical intervention can be compared. Bartolozzi et al.  in a study of 136 patients managed conservatively with symptomatic rotator cuff disease identified that full-thickness tears greater than 1cm2, symptoms persisting more than 1 year, and functional impairment and weakness were associated with a worse outcome. They recommended that surgery be considered in these patients with those risk factors. In contrast however, they found no association between age and functional outcome . Itoi and Tabata  reported 62 cuff tears in 54 patients that were treated conservatively and found that 72% of patients had good or excellent results at an average of 3.4 years. This however was a selected cohort of patients presenting with mild pain and minimal functional deficit. Bokor et al.  reported that 74% of patients with confirmed rotator cuff tears managed conservatively had minimal or no pain at 7 years and 86% were satisfied with their result. In this study, patients who failed conservative treatment and went on to have surgery were excluded, which introduces an obvious selection bias. Samilson and Binder  report the largest series of conservatively managed full-thickness rotator cuff tears (n=292), demonstrating that 72% of shoulders had more than 150º of abduction after treatment but 40% were rated as having a fair or poor outcome. Hawkins and Dunlop  reported a smaller series of 33 patients managed conservatively. No patients were excluded and unsatisfactory results occurred in 14 of 33 (42%) with 12 patients eventually undergoing surgery. Patients with an insurance claim were less likely to be satisfied.
Repair of a torn rotator cuff has been shown to give predictable pain relief and functional improvement, with good overall patient satisfaction . The results of open, mini-open and arthroscopic rotator cuff repair have all generally been favourable, but approximately 38% of patients suffer a post-operative complication . Re-rupture rates of 13%  to 68%  have been reported after rotator cuff repair, however patients suffering a re-rupture still have significant improvement in pain and function . The re-rupture rate, as assessed by MRI is 20% to 39% [40–42] and in larger tears the rate at 2 years is nearly double this (41% to 94%) [43–45]. Patients with an intact repair have significantly better outcomes [41, 44]. The outcome of revision surgery for symptomatic failed primary repairs is inferior to successful primary repair, with only 69% of patients being satisfied . Despite the risk of complications and tendon re-rupture, rotator cuff repair predictably reduces pain and improves strength and function in symptomatic patients .
Most of the guiding principles used for decision-making in treating rotator cuff disease are based on limited evidence and minimal science. Factors that seem to be important include duration of symptoms, weakness, size of the tear, and muscle atrophy. If surgery is performed, either by a mini-open or arthroscopic technique, a double row bridging repair seems to be biomechanically stronger, provided this can be performed in a tension-free environment. At this point in time there is no functional evidence to support double row repair over single row repair, however the re-rupture rate is diminished after a double row repair.
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