By Dr. Geoffrey Modest
And yet another article suggests that we are doing too much surgery. This one is on nontraumatic rotator cuff tears in older patients (see J Bone Joint Surg Am. 2015;97:1729).
Details:
- 160 patients (mean age 64, 50% female, 50% working, mean duration of symptoms 27 months) in Finland with 167 symptomatic, nontraumatic, isolated full-thickness supraspinatus tears were randomized into:
- Group 1: physiotherapy– patients given written info and guidance on home-based exercise program. First six weeks aimed at improving glenohumeral motion and active scapular retraction; then static and dynamic exercises to improve scapular and glenohumeral muscle function until 12 weeks, then increased resistance and strength training until 6 months. Also 10 sessions of PT in outpatient facility to monitor progress.
- Group 2: physiotherapy plus acromioplasty. PT as in group 1, plus arthroscopic acromioplasty (to reduce the friction between the supraspinatus and the acromion).
- Group 3: group 2 plus anatomic repair of the ruptured tendon.
- Primary outcome was Constant score (a combo of 4 scores: pain, ADLs, range of motion, and strength), recorded prior to intervention and after 3, 6, 12 and 24 months). Baseline Constant score was about 60 points. Scores are from 0-100.
- All patients had repeat MRI at 2 years.
Results at 2 years:
- Similar changes in Constant score between the groups at 2 years vs prior to intervention: 18.4 point improvement in group 1, 20.5 points in group 2, and 22.6 points in group 3. These changes not significantly different from each other.
- No significant difference in visual analog scale for pain or patient satisfaction in the 3 groups (high patient satisfaction in all 3 groups: 89% in group 1, 95% in group 2, and 94% in group 3).
- Mean sagittal size of the tendon tear by MRI initially was approx 10.5 mm; at 2 years, tendon tear size was significantly smaller in group 3 (4.2 mm, p<0.01) vs approx 11.0 mm in groups 1 and 2.
- Rotator cuff repair and acromioplasty cost more….
- On review of the Constant subscores:
- Pain and ADL: significantly better in group 2 or 3, beginning at 3 months and continuing for the 2 years, but ROM and strength initially best in group 1 then equalized.
- These differences were on the order of 2 points, where a 10 point difference is considered clinically important.
So,
- Rotator cuff tears are really common, up to 30% of those >60yo. They may be asymptomatic or lead to significant pain/shoulder dysfunction.
- The tear thickness did increase slightly in groups 1 and 2 and decreased in group 3 (who had tendon repair). At 2 years, MRI-documented full thickness tear was found in 80% of groups 1 and 2, but 31% of group 3. Not sure what the clinical significance of this is.
- Though there were statistical differences in the Constant subscores, especially pain and ADL, these numbers were small and the visual-analog scale for pain was no different amongst the groups.
- The finding that there was no difference in these groups is reinforced by the considerable placebo effect of surgery in other studies.
- Bottom line: conservative therapy seems to be a viable option for initial treatment in older patients with non-traumatic rotator cuff tears, though the patients probably would need to be pretty motivated to follow the PT program and have consistent support/guidance.
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