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Patients with rotator cuff tears treated nonoperatively do well at longer follow-up
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Nonoperative management was effective in patients with chronic, full-thickness rotator cuff tears based on results of a study presented at the American Shoulder and Elbow Surgeons Annual Meeting.
“Nonoperative treatment can be an effective option for many patients with chronic, full-thickness rotator cuff tears,” Richard S. Boorman, MD, chief of shoulder and elbow surgery at the University of Calgary, Canada, said. “While some may assert [nonoperative treatment] delays inevitable surgical repair, our study shows that patients can do well over time.”
Home-based program
Patients with chronic, full-thickness rotator cuff tears participated in a comprehensive nonoperative, home-based treatment program. Boorman and colleagues defined patients’ results as successful if they were asymptomatic and did not require surgery or as failed if they were symptomatic and consented to surgical repair. Patient follow-up was at 1 year, 2 years and more than 5 years after treatment.
“We previously presented our results for a comprehensive nonoperative treatment program for patients with chronic full-thickness rotator cuff tears, in which we had a 75% success rate at 2 years,” Boorman said. “This comprehensive 3-month treatment program included physical therapy, home exercises, sport medicine physician-directed pain management, judicial cortisone injection and patient education.”
Boorman and colleagues had a 66% response rate for the 88 patients who were contacted at 5-plus years following treatment, with 58 patients who responded. Their results showed a mean rotator cuff quality of life (RCQoL) score of 80 points at 2 years and 82 points at 5 years in the successful group.
“Furthermore, between 2 [years] and 5 years, two of these patients had become symptomatic, usually related to an incident and underwent the surgical repair,” Boorman said.
The average RCQoL score was 89 among patients who originally failed nonoperative treatment and underwent surgical repair, which was not statistically different than the average RCQoL score in the nonoperative group, he noted.
Surgery out of fear
Boorman’s clinical impression of these results is that — despite literature that is unclear as to whether nonoperative treatment of rotator cuff tears leads to the best clinical outcomes — with the appropriate treatment, more than half of patients would do well with nonoperative treatment, which was demonstrated in his group’s original study that had a 75% success rate.
“There has been some criticism and worries about treating full-thickness cuff tears nonoperatively, and I would say that there may be some patients who end up having surgery because they are afraid of what might become of their shoulder down the road,” Boorman said. “They are [undergoing] surgeries to prevent future problems, and I think the existing literature, as well as this study, would show that people can have successful and longer-term successful results without [undergoing] surgery on their shoulder,” he said. – by Casey Tingle
- Reference:
- Boorman RS, et al. Paper #59. Presented at: American Shoulder and Elbow Surgeons Annual Meeting; Oct. 7-9, 2016; Boston.
- For more information:
- Richard S. Boorman, MD, can be reached at University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Ontario, Canada; email: slaptear@gmail.com.
Disclosure: Boorman reports no relevant financial disclosures.
Perspective
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Lennard Funk, BSc MSc FRCS(Tr&Orth) FFSEM(UK)
Boorman and colleagues evaluated quality of life scores on patients undergoing nonoperative management for chronic rotator cuff tears. The period of nonoperative management was 3 months, at which stage they were either successful or failed based on their subjective symptoms. All patients were then followed up with the rotator cuff quality of life (RC-QOL) questionnaire. The successful group had all maintained their RC-QOL score at 5 years and the failed group, who underwent surgery, had similar scores.
Essentially, this study does highlight that surgery should not be the initial treatment for chronic, non-traumatic rotator cuff tears and a 3-month comprehensive home-based program can be effective, with low chance of the patient becoming symptomatic 5 years on. However, one must not extrapolate these results to all rotator cuff tears, as this was clearly a selected group of patients with chronic tears. Also, the authors did not report on other factors that influence our decision making in the treatment of cuff tears, such as age, tear size, muscle quality, functional demand and etiology. There may also be an element of bias, as the patients underwent a controlled, comprehensive rehabilitation program as part of the study. This may not be extractable to other routine clinical settings.
Nonetheless, it is a useful addition to our literature and management decisions in chronic, atraumatic rotator cuff tears, but the clinician must be careful not to apply it to all types rotator cuff tears and bear in mind the other published predictors of outcomes that have not been reported in this study.
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