Massive rotator cuff tears: Who will respond to nonoperative treatment?

Our chief medical editor asks Bernhard Jost, MD, 4 Questions about conservative-care candidates.

Issue: October 2008

For this month’s 4 Question interview, I presented my questions to Bernhard Jost, MD, who is currently the director of shoulder and elbow surgery in the Department of Orthopaedics at the University Hospital Balgrist in Zurich. He coauthored an excellent article on the follow-up of their nonoperative outcomes with massive rotator cuff tears that was published in the Journal of Bone and Joint Surgery last year. Their experience raised many points that I found helpful in discussing these tears with my patients and wanted to share some of their insights with our readers.

Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: How do you define a massive rotator cuff tear and is there any danger in not repairing them?

Bernhard Jost, MD: One accepted definition of a massive rotator cuff tear of the shoulder is rupture of at least two complete tendons. The three major tendons of the rotator cuff tendons, supraspinatus, infraspinatus and subscapularis, are each accessible to clinical tests during examination.

Yes, there is a substantial risk that a reparable massive tear, according to established radiographic and magnetic resonance imaging (MRI) criteria, can become irreparable over time. Irreparable means that although a tendon could possibly be reattached back to its bony insertion, the likelihood is high that it will not heal to the bone anymore and retear.

Jackson: What did you learn in your study about the 4-year natural history of massive rotator cuff tears?

Jost: We learned that selected elderly oligosymptomatic patients can preserve their limited shoulder function over a 4-year period despite a massive tear. But, we have also learned that the degenerative changes significantly continue and that during this 4-year interval 50% of the initially reparable tears had become irreparable.

Bernhard Jost, MD

This means that especially younger patients with a diagnosed massive reparable rotator cuff tear should not delay rotator cuff repair too long even when they are oligosymptomatic and have an acceptable shoulder function at time of diagnosis because they risk that later the tear can not be successfully repaired anymore.

Jackson: Which candidates are more responsive to nonoperative care?

Jost: That mainly depends on the symptoms like pain, mobility and strength, but also on the patient’s demand on her or his shoulder. Generally, in younger patients, those less than 60 to 65 years of age, a reparable massive tear has probably the best prognosis of tendon healing to the bone with recovery of a good and durable shoulder function.

Nonoperative treatment is a good choice when serious co-morbidities prevent the patient from having shoulder surgery or in oligosymptomatic elderly patients, especially with irreparable massive tears where the shoulder function is still acceptable for their demands.

Figure 1: AP radiograph showing the upward migration of the humeral head in a patient with a massive irreparable tear
AP radiograph showing the upward migration of the humeral head in a patient with a massive irreparable tear. The distance between the undersurface of the acromion and the humeral head is less than 6 mm to 7 mm (white lines).

Figure 2: Parasagittal NRI view of the rotator cuff muscles
Parasagittal NRI view of the rotator cuff muscles in a patient with a massive tear. The supraspinatus is located superior (black arrow), the infraspinatus posterior (black double arrow) and the subscapularis anterior. The supraspinatus and infraspinatus are irreparably torn with fatty infiltration (bright) of the dark muscle mass of more than 50% compared to a normal dark mass of the subscapularis.

Images: Jost B

Jackson: How is imaging used in managing these patients?

Jost: Standard radiographs can initially give important information particularly whether there is osteoarthritis and especially whether the joint is still centred. An upward migration of the humeral head is a reliable sign of a relevant rotator cuff tear. A distance of less than 6 mm to 7 mm in a true AP radiograph with the arm in neutral rotation is one of the established criteria that a rotator cuff tear is irreparable (Figure 1).

Today, the most important imaging modality to assess a rotator cuff tear is MRI, best in combination with intra-articular arthrography. With MRI, the size of tear, the number of involved tendons, retraction of the tendon stump and degeneration of the related musculature (fatty infiltration) can be determined in details. It helps also to define whether a tendon is reparable. A torn cuff tendon is generally regarded as irreparable if the amount of fatty infiltration in the rotator cuff muscles exceeds 50% of its mass (Figure 2).

For more information:

Bernhard Jost, MD, is head of shoulder and elbow surgery in the Department of Orthopaedics, University Hospital Balgrist, University of Zurich, CH-8008 Zurich, Switzerland. He can be reached at bernhard.jost@balgrist.ch.

Reference:

Zingg PO, Jost B, Sukthankar A, et al. Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am. 2007;89(9):1928-1934.