Evolution of Nonoperatively Treated Symptomatic Isolated Full-Thickness Supraspinatus Tears
Fucentese SF, von Roll AL, Pfirrmann CWA, Gerber C, Jost B. J Bone Joint Surg Am. 2012;94:801-8.
Limited data exists to guide clinicians in prescribing treatment for patients with rotator cuff tears. It is believed that without surgery, rotator cuff tears will progress in size; however, few studies have investigated this theory of tear progression in small (single tendon) rotator cuff tears. In this study, 24 patients (20 male, 4 female; 20 traumatic etiology, 4 degenerative etiology; mean age 52 years, range 39-61 years) who had been diagnosed with a full-thickness supraspinatus tear but declined surgery were reevaluated at a median of forty-two months post-diagnosis using MRI and functional Constant and Murley scoring. Functional scoring included subjective variables (pain, daily living, etc.), objective assessment of shoulder motion, and quantitative measurement of abduction strength. Interestingly, the tear size on average did not increase over time; in 16 of 24 patients, the tear size, measured from MRI images, remained unchanged or even decreased. The initial tear size of patients whose tear did progress was no different from those whose tear did not progress, contrasting the traditional belief that tear size is a predominating factor in predicting tear progression. When examining the supraspinatus muscle, fatty infiltration, measured using an MRI-adapted version of the Goutallier score, did increase and was greatest in larger tears. Functionally, the flexion, abduction, and external rotation angles remained unchanged from initial diagnosis. Correlations were not found between follow-up tear size and pain, abduction strength, or subjective shoulder score. Additionally, there were no correlations between fatty infiltration and abduction strength.
It is commonly believed that all rotator cuff tears are at risk for tear propagation, making surgery the recommended treatment. This is the first clinical study that suggests isolated supraspinatus tears may not always increase in tear size, challenging the recommendation for surgery. The number of traumatic versus degenerative cases studied was skewed towards traumatic etiology. While the authors did not investigate potential differences between these groups (likely due to the low number of degenerative etiology patients), one may question whether an increased sample size would reveal differences that would imply different treatments for traumatic and chronic tears. It is of concern that the fatty infiltration increased over time. This finding indicates that while the tendon tear may not have progressed, muscle degeneration has occurred; however, this did not correlate with abduction strength, and shoulder function did not worsen over time. On the other hand, even with surgical repair, fatty infiltration has been shown to be irreversible. This article is another example of how little is known about rotator cuff tendon tears and both tendon and muscle degeneration. Perhaps not surprisingly, the authors were unable to identify correlations between pain and other parameters that they measured (similar to previous studies), highlighting the need for research in this area. Clinically, have you noticed differences in how patients with tears due to a traumatic event respond to treatment compared to those due to chronic degeneration? Given that fatty infiltration may continue to slightly advance despite the lack of tear progression, would you still recommend conservative (non-surgical) treatment? Overall, what treatment plan do you recommend to your patients with full-thickness, isolated supraspinatus tears?
Written by: Sarah Ilkhani-Pour
Reviewed by: Stephen Thomas
Predictors of Pain and Function in Patients with Symptomatic, Atraumatic Full-thickness Rotator Cuff Tears
American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: Optimizing the Management of Rotator Cuff Problems