Rotator cuff tears (RC) are one of the main causes of shoulder pain and disability worldwide. Damage to the rotator cuff can be caused by degenerative changes, repeated microtraumas, severe traumatic injuries, and secondary functional disorders. Examples of traumatic injuries can include falling on an outstretched hand or pulling an unexpected force. An example of atraumatic causes could be excessive repetitive motion or normal age-related deterioration. The most commonly affected muscle in RC is the supraspinatus.
Learn more about the rotator cuff
RC tears are classified into partial or full thickness tears according to the severity of the disorder of the tendon fibers and the communication between the subacromial and glenohumeral spaces. There is no well-established definition of RC cracks as severity is sometimes expressed by the number of tendons that have been torn and sometimes by the size of the tear. Ladermann et al. Divide RC cracks into 5 categories depending on their location and Cofield divides them into 4 categories depending on the size of the crack and contains the general references cracks with full or partial thickness .
As with the definition of the condition, the optimal treatment is also controversial. This is because surgical treatment often leads to a second tendon failure after repair or surgical complications, and conservative treatment leads to a predisposition to continued irreversible tissue degeneration over time. This degeneration leads to further treatment and poorer results in the long term. There is also no agreed conservative approach to treating RC tears.
There were only a limited number of RCTs that compared the short-term and long-term results of surgical and conservative management. A new systematic review aims to summarize these results and provide new information about which treatment we should recommend to our patients.
Methods
This systematic review followed 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 is shown below. Two reviewers rated the item's inclusion / exclusion criteria, and a third was available in the event of disagreement. Articles published in English, French, Spanish, German and Italian have been included. The risk of bias was rated with the Cochrane tool for the risk of bias and the quality of the articles as GRADE.
("rotator cuff tear" OR "rotator cuff tear" OR "rotator cuff injury" OR "non-traumatic tears" OR "rotator cuff break" OR "rotator cuff disease") AND ("rotator cuff repair") AND ("rotator cuff repair") AND OR "Surgical Interventions" OR "Rotator Cuff Surgery" OR "Arthroscopy" OR "Surgical" OR "Non-Surgical" OR "Conservative" OR "Treatment" OR "Management").
To be included in the analysis, full-thickness rotator cuff tear RCTS, patients 18 years of age and older, and Level I studies based on the Oxford Center of EBM published in peer-reviewed journals had to be performed. If the follow-up time 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 relation to the clinical outcome at different points in time, measured with CMS and VAS (3, 6, 12, 24 and 60 months). The secondary endpoints were the integrity of the repaired tendon as measured by MRI or USS, ROM, simple shoulder test (SST) and American shoulder and elbow surgeon scale (ASES).
After applying the search strategy, the results of five articles were included in the analysis. To make this a bit more difficult, only patient groups from three studies were included, as two studies were follow-up studies of the same patient group.
Results and clinical takeaway
Brief summary of the results
No difference in the Constant Murley score between surgical or conservative repair groups 1 or 2 years after the operation
The surgical group had statistically lower pain values 1 year after the intervention, but was probably not clinically significant
35% of the patients included in the surgical group had a re-crack after a 1 year follow-up examination
27% of the conservatively treated patients had to undergo an operation after 10 years
Overall it can be said that after 1 or 2 years there does not seem to be any significant difference in pain or clinical function between surgical and conservative management. Patients who had their tendons surgically repaired within the first year after treatment showed a slight improvement in the VAS score of 1 point. This is unlikely to represent any significant clinical improvement.
Treatment in the conservative management arms of the RCTs was very different and more an individual approach than a prescribed program, with the main focus of treatment on posture and control and stability of the scapulothoracic and glenohumeral muscles.
The need for an operation a few years after conservative treatment can probably be explained by the fact that the tendons were not repaired after the first tear and continued to deteriorate over many years.
