{"id":910,"date":"2015-12-03T15:35:42","date_gmt":"2015-12-03T15:35:42","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=910"},"modified":"2017-08-21T11:15:42","modified_gmt":"2017-08-21T11:15:42","slug":"primary-care-corner-with-geoffrey-modest-md-rotator-cuff-repair-in-the-older-people","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/12\/03\/primary-care-corner-with-geoffrey-modest-md-rotator-cuff-repair-in-the-older-people\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Rotator Cuff Repair in the Older People?"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>And yet another article suggests that we are doing too much surgery. This one is on nontraumatic rotator cuff tears in older patients\u00a0(see\u00a0J Bone Joint Surg Am. 2015;97:1729).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>160 patients (mean age 64, 50% female, 50% working, mean duration of symptoms 27 months)\u00a0in\u00a0Finland with 167 symptomatic, nontraumatic, isolated\u00a0full-thickness supraspinatus tears were randomized into:\n<ul>\n<li>Group 1:\u00a0physiotherapy&#8211; 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\u00a0and\u00a0dynamic exercises to improve scapular and glenohumeral muscle function\u00a0until 12\u00a0weeks, then increased resistance and strength training until 6 months. Also 10 sessions of PT in outpatient facility to monitor progress.<\/li>\n<li>Group 2: physiotherapy plus acromioplasty. PT\u00a0as in group 1, plus arthroscopic acromioplasty (to reduce the friction between the supraspinatus and the acromion).<\/li>\n<li>Group 3: group 2 plus anatomic repair of the ruptured tendon.<\/li>\n<\/ul>\n<\/li>\n<li>Primary outcome was Constant score (a combo of 4 scores: pain, ADLs, range of\u00a0motion, and strength), recorded prior to intervention and after\u00a03,\u00a06,\u00a012 and 24 months). Baseline Constant score was about 60 points. Scores are from 0-100.<\/li>\n<li>All patients had repeat MRI at 2 years.<\/li>\n<\/ul>\n<p>Results at 2 years:<\/p>\n<ul>\n<li>Similar\u00a0changes in Constant score between the groups at 2 years vs prior to intervention: 18.4 point\u00a0improvement\u00a0in group 1, 20.5 points in group 2, and 22.6 points in group 3. These\u00a0changes not significantly different from each other.<\/li>\n<li>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\u00a0group 1, 95% in group 2, and 94% in group 3\u200b).<\/li>\n<li>Mean sagittal size\u00a0of the tendon\u00a0tear\u00a0by MRI initially was\u00a0approx 10.5 mm;\u00a0at 2 years, \u00a0tendon tear size was significantly\u00a0smaller in group 3 (4.2 mm, p&lt;0.01) vs approx\u00a011.0 mm in groups 1 and 2.<\/li>\n<li>Rotator cuff repair and acromioplasty cost more&#8230;.<\/li>\n<li>On review of the Constant subscores:\n<ul>\n<li>Pain and ADL:\u00a0significantly better in group 2 or 3, beginning at 3 months and continuing for the 2 years, but ROM and strength\u00a0initially best in group 1 then equalized.<\/li>\n<li>\u200bThese differences were on the order of 2 points, where a 10 point difference is considered clinically important.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>So,<\/p>\n<ul>\n<li>Rotator cuff tears are really common, up to 30% of those &gt;60yo. They may be asymptomatic\u00a0or lead to significant pain\/shoulder dysfunction.<\/li>\n<li>The tear thickness did increase slightly in groups 1 and 2 and\u00a0decreased in group 3 (who had\u00a0tendon repair).\u00a0At 2 years, MRI-documented full thickness tear was found in 80% of groups 1 and 2, but 31% of group 3.\u00a0Not sure what the clinical significance of this is.<\/li>\n<li>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.<\/li>\n<li>The finding\u00a0that there was no difference in these groups is reinforced by the considerable placebo effect of surgery in other studies.<\/li>\n<li>Bottom line:\u00a0conservative therapy seems to\u00a0be a viable option for initial treatment in older\u00a0patients 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.\u200b<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Rotator Cuff Repair in the Older People? [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/12\/03\/primary-care-corner-with-geoffrey-modest-md-rotator-cuff-repair-in-the-older-people\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-910","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/910","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=910"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/910\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=910"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=910"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=910"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}