Why Surgery for Rotator Cuff Tears Deserves a Closer Look

Bruce S. Miller, MD, MS serves as the Chief of Sports Medicine, Medical Director for MedSport, Professor of Orthopaedic Surgery, and Head Orthopaedic Team Physician for University of Michigan Athletics. A graduate of Harvard Medical School, Dr. Miller was himself an All-American student-athlete during his time at Harvard.

In addition to an active clinical research program on sports injuries and shoulder and knee disorders, Dr. Miller specializes in all disorders of the shoulder, including shoulder replacement surgery, rotator cuff surgery, and fractures. His research in the field of rotator cuff tears has been frequently recognized and honored, and he has authored numerous articles, chapters, and peer-reviewed publications on shoulder and knee injuries.

In this brief but in-depth, approximately 17-minute lecture from NEJM Journal Watch Audio General Medicine, Dr. Miller takes a critical look at surgery for symptomatic rotator cuff tears, including the management of full-thickness rotator cuff tears. Dr. Miller also addresses the practice of managing rotator cuff tears via a non-surgical treatment method. This approach typically includes a blend of physical therapy, exercise therapy, steroid injections, and NSAID pain relievers.

On this often “controversial” topic, randomized trials have consistently yielded conflicting results. In one study in the Journal of Bone and Joint Surgery, orthopaedic surgeons compared surgical repair and non-surgical management of symptomatic, full-thickness rotator cuff tears. The study’s authors used data from a Michigan-based shoulder surgery registry, drawing from more than 400 registry patients treated by experienced shoulder surgeons.

A group of 100 surgical patients recovered from their injury somewhat more than the group of 100 non-surgical patients who were assessed in the study. However, during two years of follow-up, scores on two standardized rotator cuff tests incorporating pain, activity, and function substantially improved—in both groups.

Full-thickness rotator cuff tear: what is it?

Consisting of the supraspinatus, subscapularis, teres minor, and infraspinatus muscles, the rotator cuff contributes to both stability and movement of the glenohumeral joint—and is critical to the proper functioning of the upper limb. A full-thickness rotator cuff tear is defined by the complete removal of the tendon from the bone. This includes large tears (3-5 cm) and massive tears (5 cm or more).

Rotator cuff tear management.

Taken on the whole, rotator cuff tear management aims to relieve pain, restore movement, and enhance overall function and mobility of the shoulder. Management of rotator cuff tears can broadly be divided into surgical and non-surgical treatment methods. Surgical treatments encompass arthroscopic repairs, open repairs, mini-open repairs, tendon reconstruction, and reverse shoulder arthroplasty. Non-surgical treatments, on the other hand, consist of physiotherapy or injection—with physiotherapy interventions typically involving stretching and strengthening exercises. Physiotherapy can also include electrotherapy and other physical modalities including ultrasound, moist heat, and laser therapy. Injection treatment in recent studies has included the introduction of corticosteroids, hyaluronic acid, and platelet-rich plasma to the injured area.

Rotator cuff tears and younger patients.

In younger patients, many full-thickness rotator cuff tears are a result of intense athletic competition. Younger patients who suffer from so-called “traumatic” rotator cuff injuries, rather than degenerative tears that develop over time, are typically treated with a surgical approach from the very outset. Not all rotator cuff tears must be treated with surgery, however. Many such injuries can be managed well via physical therapy, exercise therapy, steroid injections, and NSAID pain relievers.

“Rotator cuff tears in the younger patients very often reflect a traumatic rather than a degenerative etiology,” states Dr. Miller in his lecture. “And in our younger patients, again 40s and 50s, in the setting of known trauma in a previously asymptomatic shoulder, we very often go right to surgical management. It’s a very different biology and etiology.”

Rotator cuff tears among elderly patients.

Then there’s the matter of full-thickness rotator cuff tears in our elderly patient population. The most ideal treatment option for alleviation of pain and restored shoulder function in the elderly patient population is still being debated.

While rotator cuff tear injuries among this age demographic aren’t typically “traumatic” in nature, more active adults who participate in sports such as tennis, softball, golf, jogging, or even swimming and walking may experience an exertion-related rotator cuff tear.

Usually, this isn’t the case. The common culprit is none other than that old reliable we like to call Father Time. A full-thickness rotator cuff tear is actually an injury that is acutely common among elderly Americans—although most of these rotator cuff tears tend to be asymptomatic in nature. In fact, according to Dr. Miller, some degree of this injury is essentially inevitable as we all age. Patients 80 years of age and older must live with a sky-high rotator cuff tear prevalence rate of 80 percent.

“It’s almost a fact of life that if you live long enough, you’re probably going to have some form of rotator cuff disease,” says Dr. Miller. “It’s a disease that exists primarily in adults over the age of 60. By age 60, around 30 percent of all adults will have a full-thickness rotator cuff tear, whether they know it or not. By age 70, the prevalence rises to around 50 percent. Not all are symptomatic. Most individuals have asymptomatic rotator cuff tears.”

The most ideal treatment option for alleviation of pain and restored shoulder function in the elderly patient population is still being debated.

The untreated rotator cuff tear.

No matter whether it’s via surgery or non-surgical intervention methods, full-thickness rotator cuff tears must always be attended to. If left untreated, rotator cuff tears can become more of a challenge to the patient—regardless of his or her age, occupation, or activity level. Particularly as it relates to older patients, rotator cuff tears can render the patient effectively unable to perform many critical tasks on a day-to-day basis.

Of course, untreated rotator cuff tears can also worsen—sometimes quite rapidly. Patients who experience enlarging rotator cuff tears are five times more likely to develop symptoms than those with tears that remain the same.

“The untreated tear leads to progression, retraction, and atrophy,” explains Dr. Miller. “All of which can pose serious challenges in a chronic setting.”

Listen to Dr. Bruce Miller go into more detail about how to manage rotator cuff tears, via surgical and non-surgical methods, in this compelling NEJM Journal Watch Audio General Medicine issue. You can also preview AudioDigest’s Top 5 Orthopaedics audio lectures–and earn valuable CME–at your own convenience.

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