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The Natural History of Asymptomatic Rotator Cuff TearsA Three-Year Follow-up of Fifty Cases
Stefan Moosmayer, MD, PhD1; Rana Tariq, MD2; Morten Stiris, MD3; Hans-Jørgen Smith, MD, PhD4
1 Department of Orthopaedic Surgery, Martina Hansens Hospital, PO Box 23, N-1306 Baerum, Postterminal, Norway. E-mail address: st.moos@online.no
2 Unilabs Diagnostics, Middelthunsgate 23, N-0368 Oslo, Norway
3 Unilabs Radiology & Laboratory Services, Bryn, Oslo, Østensjøveien 79, N-0667 Oslo, Norway
4 Department of Radiology and Nuclear Medicine, Oslo University Hospital, University of Oslo, PO Box 4950 Nydalen, N-0424 Oslo, Norway
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Investigation performed at Martina Hansens Hospital, Baerum, Norway

A commentary by Jay D. Keener, MD, is linked to the online version of this article at jbjs.org.



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Jul 17;95(14):1249-1255. doi: 10.2106/JBJS.L.00185
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Abstract

Background: 

Little is known about the clinical and anatomic progression of asymptomatic rotator cuff tears. The purpose of our study was to assess if deterioration in rotator cuff tear anatomy would be correlated to the development of symptoms.

Methods: 

Fifty patients with initially asymptomatic full-thickness rotator cuff tears were followed clinically, sonographically, and by magnetic resonance imaging over three years. Changes of tear size, muscle atrophy, fatty degeneration, and condition of the long head of the biceps tendon were compared between tears that developed symptoms and those that did not.

Results: 

Eighteen of fifty tears developed symptoms during follow-up. There was a significantly larger increase (p = 0.02) in the mean tear size in the newly symptomatic group (10.6 mm) when compared with the still-asymptomatic group (3.3 mm). The rate of progressing to advanced muscle atrophy was higher (p = 0.08) in the newly symptomatic group (35% [six of seventeen subjects]) when compared with the still-asymptomatic group (12% [three of twenty-five subjects]). The rate of fatty degeneration was significantly higher (p = 0.02) in the newly symptomatic group (35% [six of seventeen subjects]) when compared with the still-asymptomatic group (4% [one of twenty-five subjects]). The rate of pathology of the long head of the biceps tendon was significantly higher (p = 0.02) in the newly symptomatic group (33% [six of eighteen subjects]) when compared with the still-asymptomatic group (6% [two of thirty-two subjects]).

Conclusions: 

During a relatively short-term follow-up, a substantial percentage of asymptomatic rotator cuff tears became symptomatic and underwent anatomic deterioration. Increase in tear size and decrease of muscle quality were correlated to the development of symptoms. Subjects diagnosed with an asymptomatic rotator cuff tear should be informed about the natural history of the condition and follow-up with repeated imaging may be indicated to monitor tear progression.

Level of Evidence: 

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Benjamin JF Dean
    Posted on July 24, 2013
    Participants with a different ‘pain phenotype’?
    University of Oxford, Oxford, UK

    I read the excellent study by Moosmayer et al. with great interest (1).  As the authors remark in the discussion, the development a painful rotator cuff tear in one shoulder significantly increases the risk of developing a painful cuff tear in the other shoulder (2) .  It is worth remembering that the rate of symptom development demonstrated by this study and other previous studies (3, 4) is likely much higher than would be observed in a randomly selected cohort of the population with asymptomatic rotator cuff tears; this is because of the way in which all studies have selected their participants.  The study recruited 30 patients from "420 individuals with asymptomatic shoulders were found randomly among persons who earlier had been managed at our hospital for minor orthopaedic conditions unrelated to the shoulder", in addition to the 20 patients with pre-existing contralateral shoulder problems.  I would be interested to know specifically which orthopaedic conditions these 30 patients had initially been managed, as if these conditions were painful then one could argue that the selection of participants with a different ‘pain phenotype’ to that of the general population may increase the rate of pain development in their asymptomatic cuff tears.

    1.          Moosmayer S, Tariq R, Stiris M, Smith HJ. The Natural History of Asymptomatic Rotator Cuff Tears: A Three-Year Follow-up of Fifty Cases. The Journal of bone and joint surgery American volume. 2013;95(14):1249-55. Epub 2013/07/19.

    2.          Gwilym SE, Watkins B, Cooper CD, Harvie P, Auplish S, Pollard TC, et al. Genetic influences in the progression of tears of the rotator cuff. The Journal of bone and joint surgery British volume. 2009;91(7):915-7. Epub 2009/07/02.

    3.          Mall NA, Kim HM, Keener JD, Steger-May K, Teefey SA, Middleton WD, et al. Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and sonographic variables. The Journal of bone and joint surgery American volume. 2010;92(16):2623-33. Epub 2010/11/19.

    4.          Yamaguchi K DK, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. JBJS (Am). 2006;88(8):1699-704.

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