Background: The natural history of massive rotator cuff tears is not
well known. The purpose of this study was to determine the clinical and
structural mid-term outcomes in a series of nonoperatively managed massive
rotator cuff tears.
Methods: Nineteen consecutive patients (twelve men and seven women;
average age, sixty-four years) with a massive rotator cuff tear, documented by
magnetic resonance imaging, were identified retrospectively. There were six
complete tears of two rotator cuff tendons and thirteen complete tears of
three rotator cuff tendons. All patients were managed exclusively with
nonoperative means. Nonoperative management was chosen when a patient had low
functional demands and relatively few symptoms and/or if he or she refused to
have surgery. For the purpose of this study, patients were examined clinically
and with standard radiographs and magnetic resonance imaging.
Results: After a mean duration of follow-up of forty-eight months,
the mean relative Constant score was 83% and the mean subjective shoulder
value was 68%. The score for pain averaged 11.5 points on a 0 to 15-point
visual analogue scale in which 15 points represented no pain. The active range
of motion did not change over time. Forward flexion and abduction averaged
136°; external rotation, 39°; and internal rotation, 66°.
Glenohumeral osteoarthritis progressed (p = 0.014), the acromiohumeral
distance decreased (p = 0.005), the size of the tendon tear increased (p =
0.003), and fatty infiltration increased by approximately one stage in all
three muscles (p = 0.001). Patients with a three-tendon tear showed more
progression of osteoarthritis (p = 0.01) than did patients with a two-tendon
tear. Four of the eight rotator cuff tears that were graded as reparable at
the time of the diagnosis became irreparable at the time of final
Conclusions: Patients with a nonoperatively managed, moderately
symptomatic massive rotator cuff tear can maintain satisfactory shoulder
function for at least four years despite significant progression of
degenerative structural joint changes. There is a risk of a reparable tear
progressing to an irreparable tear within four years.
Level of Evidence: Prognostic Level IV. See Instructions
to Authors for a complete description of levels of evidence.