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Management of rotator cuff tears

Authors
Scott David Martin, MD
Tamara L Martin, MD
Section Editor
Karl B Fields, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM

INTRODUCTION

The glenohumeral joint allows for tremendous mobility but is highly susceptible to injury. What is commonly described as the rotator cuff (RC) is a composite of muscles arising from the scapula and inserting onto the humerus. The rotator cuff is crucial to the function and stability of the glenohumeral joint [1-3].

Records of rotator cuff problems extend to the third century BC, when Hippocrates described the relationship of the tendons around the shoulder and noted the injuries associated with these tendons and the variability in their healing [4]. Rotator cuff disease remains a common cause of shoulder pain, accounting for over 4.5 million physician visits per year in the United States alone [5]. While the radiographic imaging, physical therapy, and surgical techniques used to diagnose and manage rotator cuff tears have improved, the indications for surgery remain controversial [6].

The management of rotator cuff tears will be reviewed here. The diagnosis of rotator cuff tears, diagnosis and management of rotator cuff tendinopathy, and the diagnostic approach to shoulder pain are discussed elsewhere. (See "Presentation and diagnosis of rotator cuff tears" and "Rotator cuff tendinopathy" and "Evaluation of the patient with shoulder complaints".)

TREATMENT OPTIONS AND EVIDENCE

The treatment of rotator cuff tears depends upon several factors, including the duration of symptoms, shoulder dominance, the type of tear (partial versus full thickness), and patient factors such as age, comorbidities, and activity level [5,7-11]. Treatment options include surgical repair and nonoperative management. To date, few randomized trials have been performed that directly compare surgical and nonsurgical management of rotator cuff tears [5,7]. Available trials have not demonstrated a clear benefit to surgery [12-14]. Well-controlled, prospective trials are needed to determine the relative risks and benefits of, and appropriate patients for, each approach.

Two systematic reviews of studies evaluating common interventions for the treatment of rotator cuff tears, including studies comparing different surgical approaches and others comparing surgery with physical therapy, found there was insufficient evidence to support one intervention over another and found the quality of many studies to be poor [7,15]. Therefore, our approach to the management of rotator cuff tears, summarized in the accompanying algorithm, is necessarily based upon observational data, animal studies, evidence extrapolated from successful treatment of non-rotator cuff tendon tears, and our clinical experience (algorithm 1) [8,16-20].

               

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Literature review current through: Nov 2016. | This topic last updated: Wed May 04 00:00:00 GMT+00:00 2016.
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References
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  1. Matsen, FA, III, Arntz, CT. Rotator cuff failure. In: The Shoulder, Vol. 2, Rockwood, CA Jr, Matsen, FA III (Eds), WB Saunders, Philadelphia 1990. p.647.
  2. Clark JM, Harryman DT 2nd. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am 1992; 74:713.
  3. Harryman DT 2nd, Sidles JA, Clark JM, et al. Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg Am 1990; 72:1334.
  4. Hippocrates. Hippocrates writings. Trans. Francis Adam. In: The Great Books of the Western World Series, Vol. 10, Adler, MJ (Eds), Encyclopedia Britannica, Chicago 1952. p.197.
  5. Oh LS, Wolf BR, Hall MP, et al. Indications for rotator cuff repair: a systematic review. Clin Orthop Relat Res 2007; 455:52.
  6. Dunn WR, Schackman BR, Walsh C, et al. Variation in orthopaedic surgeons' perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am 2005; 87:1978.
  7. Coghlan JA, Buchbinder R, Green S, et al. Surgery for rotator cuff disease. Cochrane Database Syst Rev 2008; :CD005619.
  8. Sperling JW, Cofield RH, Schleck C. Rotator cuff repair in patients fifty years of age and younger. J Bone Joint Surg Am 2004; 86-A:2212.
  9. Galatz LM, Ball CM, Teefey SA, et al. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 2004; 86-A:219.
  10. Yamaguchi K, Ditsios K, Middleton WD, et al. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am 2006; 88:1699.
  11. Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. J Bone Joint Surg Am 1974; 56:14.
  12. Moosmayer S, Lund G, Seljom US, et al. Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up. J Bone Joint Surg Am 2014; 96:1504.
  13. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of Nontraumatic Rotator Cuff Tears: A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up. J Bone Joint Surg Am 2015; 97:1729.
  14. Lambers Heerspink FO, van Raay JJ, Koorevaar RC, et al. Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. J Shoulder Elbow Surg 2015; 24:1274.
  15. Seida JC, LeBlanc C, Schouten JR, et al. Systematic review: nonoperative and operative treatments for rotator cuff tears. Ann Intern Med 2010; 153:246.
  16. Wolf BR, Dunn WR, Wright RW. Indications for repair of full-thickness rotator cuff tears. Am J Sports Med 2007; 35:1007.
  17. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am 2000; 82:505.
  18. Gerber C, Meyer DC, Schneeberger AG, et al. Effect of tendon release and delayed repair on the structure of the muscles of the rotator cuff: an experimental study in sheep. J Bone Joint Surg Am 2004; 86-A:1973.
  19. Cofield RH, Parvizi J, Hoffmeyer PJ, et al. Surgical repair of chronic rotator cuff tears. A prospective long-term study. J Bone Joint Surg Am 2001; 83-A:71.
  20. Goutallier D, Postel JM, Gleyze P, et al. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg 2003; 12:550.
  21. BROWN JT. Early assessment of supraspinatus tears; procaine infiltration as a guide to treatment. J Bone Joint Surg Br 1949; 31B:423.
  22. Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. Br J Sports Med 2007; 41:200.
  23. Maman E, Harris C, White L, et al. Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging. J Bone Joint Surg Am 2009; 91:1898.
  24. Takagishi, N. Conservative treatment of ruptures of the rotator cuff. J Japanese Orthopedic Association 1978; 52:781.
  25. Jobe FW, Moynes DR. Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. Am J Sports Med 1982; 10:336.
  26. Krabak BJ, Sugar R, McFarland EG. Practical nonoperative management of rotator cuff injuries. Clin J Sport Med 2003; 13:102.
  27. Mall NA, Kim HM, Keener JD, et al. Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and sonographic variables. J Bone Joint Surg Am 2010; 92:2623.
  28. Moosmayer S, Tariq R, Stiris M, Smith HJ. The natural history of asymptomatic rotator cuff tears: a three-year follow-up of fifty cases. J Bone Joint Surg Am 2013; 95:1249.
  29. Yamaguchi K, Tetro AM, Blam O, et al. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg 2001; 10:199.
  30. Moosmayer S, Smith HJ, Tariq R, Larmo A. Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study. J Bone Joint Surg Br 2009; 91:196.
  31. Schibany N, Zehetgruber H, Kainberger F, et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J Radiol 2004; 51:263.
  32. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003; :CD004016.
  33. Blair B, Rokito AS, Cuomo F, et al. Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am 1996; 78:1685.
  34. Alvarez CM, Litchfield R, Jackowski D, et al. A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis. Am J Sports Med 2005; 33:255.
  35. Wei AS, Callaci JJ, Juknelis D, et al. The effect of corticosteroid on collagen expression in injured rotator cuff tendon. J Bone Joint Surg Am 2006; 88:1331.
  36. Wiggins ME, Fadale PD, Ehrlich MG, Walsh WR. Effects of local injection of corticosteroids on the healing of ligaments. A follow-up report. J Bone Joint Surg Am 1995; 77:1682.
  37. Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg 2013; 22:1371.
  38. Keener JD. Surveillance of conservatively treated rotator cuff tears is warranted. Commentary on an article by Stefan Moosmayer, MD, PhD, et al.: "The natural history of asymptomatic rotator cuff tears. a three-year follow-up of fifty cases". J Bone Joint Surg Am 2013; 95:e101 1.
  39. Budoff JE, Nirschl RP, Guidi EJ. Débridement of partial-thickness tears of the rotator cuff without acromioplasty. Long-term follow-up and review of the literature. J Bone Joint Surg Am 1998; 80:733.
  40. Fukuda H. The management of partial-thickness tears of the rotator cuff. J Bone Joint Surg Br 2003; 85:3.
  41. Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med 2007; 35:719.
  42. Safran O, Derwin KA, Powell K, Iannotti JP. Changes in rotator cuff muscle volume, fat content, and passive mechanics after chronic detachment in a canine model. J Bone Joint Surg Am 2005; 87:2662.
  43. Coleman SH, Fealy S, Ehteshami JR, et al. Chronic rotator cuff injury and repair model in sheep. J Bone Joint Surg Am 2003; 85-A:2391.
  44. Goutallier D, Postel JM, Bernageau J, et al. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 1994; :78.
  45. Goutallier D, Postel JM, Lavau L, Bernageau J. [Impact of fatty degeneration of the suparspinatus and infraspinatus msucles on the prognosis of surgical repair of the rotator cuff]. Rev Chir Orthop Reparatrice Appar Mot 1999; 85:668.
  46. Lähteenmäki HE, Virolainen P, Hiltunen A, et al. Results of early operative treatment of rotator cuff tears with acute symptoms. J Shoulder Elbow Surg 2006; 15:148.
  47. Melis B, DeFranco MJ, Chuinard C, Walch G. Natural history of fatty infiltration and atrophy of the supraspinatus muscle in rotator cuff tears. Clin Orthop Relat Res 2010; 468:1498.
  48. Zingg PO, Jost B, Sukthankar A, et al. Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am 2007; 89:1928.
  49. Martin SD, Baumgarten TE, Andrews JR. Arthroscopic resection of the distal aspect of the clavicle with concomitant subacromial decompression. J Bone Joint Surg Am 2001; 83-A:328.
  50. Ozaki J, Fujimoto S, Nakagawa Y, et al. Tears of the rotator cuff of the shoulder associated with pathological changes in the acromion. A study in cadavera. J Bone Joint Surg Am 1988; 70:1224.
  51. Busfield BT, Glousman RE, McGarry MH, et al. A biomechanical comparison of 2 technical variations of double-row rotator cuff fixation: the importance of medial row knots. Am J Sports Med 2008; 36:901.
  52. Frank JB, ElAttrache NS, Dines JS, et al. Repair site integrity after arthroscopic transosseous-equivalent suture-bridge rotator cuff repair. Am J Sports Med 2008; 36:1496.
  53. Park JY, Lhee SH, Choi JH, et al. Comparison of the clinical outcomes of single- and double-row repairs in rotator cuff tears. Am J Sports Med 2008; 36:1310.
  54. Kim SH, Ha KI, Park JH, et al. Arthroscopic versus mini-open salvage repair of the rotator cuff tear: outcome analysis at 2 to 6 years' follow-up. Arthroscopy 2003; 19:746.
  55. Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am 1998; 80:832.
  56. Mohtadi NG, Hollinshead RM, Sasyniuk TM, et al. 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. Am J Sports Med 2008; 36:1043.
  57. Galatz LM, Silva MJ, Rothermich SY, et al. Nicotine delays tendon-to-bone healing in a rat shoulder model. J Bone Joint Surg Am 2006; 88:2027.
  58. Jo CH, Kim JE, Yoon KS, et al. Does platelet-rich plasma accelerate recovery after rotator cuff repair? A prospective cohort study. Am J Sports Med 2011; 39:2082.
  59. Rodeo SA, Delos D, Williams RJ, et al. The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: a prospective, randomized clinical study. Am J Sports Med 2012; 40:1234.
  60. Malavolta EA, Gracitelli ME, Ferreira Neto AA, et al. Platelet-rich plasma in rotator cuff repair: a prospective randomized study. Am J Sports Med 2014; 42:2446.
  61. Jo CH, Shin JS, Shin WH, et al. Platelet-rich plasma for arthroscopic repair of medium to large rotator cuff tears: a randomized controlled trial. Am J Sports Med 2015; 43:2102.
  62. Moraes VY, Lenza M, Tamaoki MJ, et al. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev 2014; :CD010071.
  63. Castricini R, Longo UG, De Benedetto M, et al. Platelet-rich plasma augmentation for arthroscopic rotator cuff repair: a randomized controlled trial. Am J Sports Med 2011; 39:258.
  64. Zhao JG, Zhao L, Jiang YX, et al. Platelet-rich plasma in arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials. Arthroscopy 2015; 31:125.
  65. Keener JD, Galatz LM, Stobbs-Cucchi G, et al. Rehabilitation following arthroscopic rotator cuff repair: a prospective randomized trial of immobilization compared with early motion. J Bone Joint Surg Am 2014; 96:11.
  66. Arndt J, Clavert P, Mielcarek P, et al. Immediate passive motion versus immobilization after endoscopic supraspinatus tendon repair: a prospective randomized study. Orthop Traumatol Surg Res 2012; 98:S131.
  67. Koh KH, Lim TK, Shon MS, et al. Effect of immobilization without passive exercise after rotator cuff repair: randomized clinical trial comparing four and eight weeks of immobilization. J Bone Joint Surg Am 2014; 96:e44.
  68. Kim YS, Chung SW, Kim JY, et al. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med 2012; 40:815.
  69. Chang KV, Hung CY, Han DS, et al. Early Versus Delayed Passive Range of Motion Exercise for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2015; 43:1265.