The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 9

Commentary and Perspective | May 02, 2012

Risk of Tear Progression in Nonoperatively Treated Small Full-Thickness Rotator Cuff Tears: Commentary on an article by Sandro F. Fucentese, MD, et al.: “Evolution of Nonoperatively Treated Symptomatic Isolated Full-Thickness Supraspinatus Tears”

Robert Z. Tashjian, MD

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*The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or 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.

J Bone Joint Surg Am, 2012 May 02;94(9):e61 1-2. doi: 10.2106/JBJS.L.00200

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Commentary

Rotator cuff disorders are the most common cause of disability related to the shoulder. Despite a large amount of literature on the outcomes of surgical repair of rotator cuff tears, the indications for surgery still remain controversial and are not standardized. Dunn et al. reported on the variation in surgeons’ perceptions about the indications for the treatment of rotator cuff tears¹. One of the most important reasons for the lack of consistent indications is the paucity of quality information on the natural history of rotator cuff tears that are treated nonoperatively. This paucity of information on the natural history of these tears is likely due to the fact that many tears are surgically treated after the development of symptoms. By attempting to understand the natural history of rotator cuff tears, we can gain insight into the etiology of the disease process, which factors contribute to tendon healing, when conservative care should be utilized, and when early surgical intervention is appropriate.

This study by Fucentese et al. fills a niche in the current literature regarding the natural history of nonoperatively treated symptomatic rotator cuff tears. The article provides critical information related to the treatment of rotator cuff tears, specifically, how tear size affects the progression of nonoperatively treated symptomatic rotator cuff tears. With use of information regarding tear healing after rotator cuff repair and factors affecting healing along with the current article by Fucentese et al. and previously published reports on the natural history of symptomatic rotator cuff tears by Maman et al.² and Safran et al.³, a clear algorithm regarding the indications for the surgical treatment of rotator cuff tears can be outlined.

Maman et al. previously reported on the nonoperative treatment of fifty-nine symptomatic rotator cuff tears². Those authors reported that 52% of full-thickness tears progressed in size at an average of twenty-four months follow-up. Older age and initial rotator cuff fatty infiltration on magnetic resonance images were correlated with tear progression. The authors also determined that tear progression was more likely after eighteen months of follow-up. Safran et al. reported on fifty-one full-thickness tears in patients under the age of sixty years and found an almost identical (49%) rate of tear progression (>5 mm) at an average of twenty-four months of follow-up³. Pain at the time of follow-up was correlated with tear progression. The conclusions from those articles are that progression of nonoperatively treated full-thickness tears is common and occurs in about half the cases by an average of two years. Consequently, earlier consideration of surgical repair of symptomatic full-thickness tears is warranted for younger patients (those under sixty-five years of age) who have a good potential for healing and who are at higher risk for tear progression.

The current article by Fucentese et al. adds to the data from Maman et al.² and Safran et al.³ by examining the effect of tear size on progression. The current article evaluated only single-tendon supraspinatus tears with an average sagittal length of 1.6 cm. The authors found that only 25% of tears had some progression, with no significant increase in the average tear size. This rate of tear progression is half of that reported by Maman et al.² and Safran et al.³. Also, the progression that occurred did not affect tear reparability. Consequently, because the risk of progression is minimal and reparability is not affected even if progression occurs, it is reasonable to treat these smaller (<1 to 1.5-cm) full-thickness tears nonoperatively even in younger patients.

By combining all these data, refined indications for the surgical treatment of full-thickness rotator cuff tears can be derived. First, early surgical repair can be considered for younger patients (under the age of sixty-five years) with substantial (>1 to 1.5-cm) full-thickness acute or chronic tears because of the high risk of tear progression and the improved healing ability in this younger population. Second, nonoperative treatment of small (<1 to 1.5-cm) full-thickness tears is reasonable and can be considered, even in a younger population, because of a reduced risk of tear progression and a negligible effect on tear reparability if progression occurs. The current article provides this information on smaller tears, completing the framework for the indications for operative and nonoperative treatment. Further research similar to the current article by Fucentese et al. hopefully will improve the care of patients who have rotator cuff disease and will limit the variability in a surgeon’s indications for treatment that Dunn et al. previously reported¹.

Dunn WR; Schackman BR; Walsh C; Lyman S; Jones EC; Warren RF; Marx RG. Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am. 2005;87:1978-84.

Maman E; Harris C; White L; Tomlinson G; Shashank M; Boynton E. Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging. J Bone Joint Surg Am. 2009;91:1898-906.

Safran O; Schroeder J; Bloom R; Weil Y; Milgrom C. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med. 2011;39:710-4.

References

Safran O; Schroeder J; Bloom R; Weil Y; Milgrom C. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med. 2011;39:710-4.

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Robert Z. Tashjian; Risk of Tear Progression in Nonoperatively Treated Small Full-Thickness Rotator Cuff TearsCommentary on an article by Sandro F. Fucentese, MD, et al.: “Evolution of Nonoperatively Treated Symptomatic Isolated Full-Thickness Supraspinatus Tears”. The Journal of Bone & Joint Surgery. 2012 May;94(9):e61 1-2.

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