Rotator cuff tears are common, and they increase in frequency with
advancing age. They often lead to painful impairment of shoulder function.
After the first report of surgical reconstruction of a rotator cuff tendon
tear by Codman1 in
1911, various open and arthroscopic techniques have been developed and have
yielded good-to-excellent
results2-15.
The clinical outcomes of repairs of large rotator cuff tears have been shown
to be distinctly less satisfactory than those of repairs of small
tears16-19.
Furthermore, the rate of rerupture is high following repairs of large rotator
cuff tears and is even higher following repairs of massive
tears6,20,21.
Although structural failure after a repair does not necessarily define
clinical
failure22,23,
the functional results in patients without healing of a repair are inferior to
those in patients with a healed
repair20. Not every
patient with a massive rotator cuff tear undergoes surgery. Moderately
symptomatic patients may accept their functional limitations or have
comorbidities that make an attempt at repair hazardous, and some tears are
considered irreparable at the time of presentation.
Only a few studies have dealt with the outcome of nonoperative management
of massive rotator cuff
tears24,25.
Whereas there is some information on the clinical outcomes of repairs of large
cuff
tears16-19,
we are not aware of any reports on the structural results of nonoperative
treatment.
The purpose of this study was to determine the clinical and structural
mid-term outcomes of nonoperative management of massive rotator cuff tears.
Specifically, it was our goal to determine the changes in the tear size, fatty
infiltration of the rotator cuff muscles, glenohumeral osteoarthritis, and the
acromiohumeral distance.
Selection of Patients
All patients seen between January 1996 and December 1998 were
retrospectively selected from our database if (1) they had documentation, on
clinical examination and magnetic resonance imaging, of a massive rotator cuff
tear, which was defined as a full-thickness complete tear of at least two
tendons6, at the
time of presentation; (2) no previous surgery had been performed on the
affected shoulder; and (3) the duration of follow-up was more than twenty-four
months after the initial presentation.
The study was approved by the responsible investigational review board, and
all patients gave their written informed consent.
Seventy-four patients with a massive rotator cuff tear were identified. At
the time of presentation, operative and nonoperative treatment options,
depending on the clinical symptoms and structural alterations of the rotator
cuff and the glenohumeral joint, were discussed with the patients. Major
clinical symptoms were pain and/or loss of shoulder function. Structural
alterations were evaluated on the basis of magnetic resonance imaging and
radiographic criteria. The acromiohumeral
distance22,26-28
was measured on true anteroposterior radiographs made with the shoulder in
neutral rotation29.
A distance of <7 mm was considered to define an irreparable rotator cuff
tear30.
Glenohumeral degenerative changes were assessed on standard radiographs
according to the classification of Samilson and
Prieto31. The
precise extent of the tear as well as the degree of fatty infiltration of the
rotator cuff muscles were evaluated on magnetic resonance imaging. Tears were
classified as irreparable when there was fatty muscle infiltration of at least
stage 3 according to the criteria of Goutallier et
al.32. Operative
treatment was offered when a patient had a massive tear with pain and
disabling loss of function, and thirty-four (46%) of the seventy-four patients
were treated operatively.
Forty patients (54%) were initially managed nonoperatively. Nonoperative
treatment included a standardized rehabilitation program to restore a free
passive range of shoulder motion and strength and/or pain medication (systemic
and local anti-inflammatory agents as well as subacromial steroid injections)
or no treatment at all. Within the follow-up period, seven (18%) of these
forty nonoperatively treated patients underwent surgery because of increasing
pain or dysfunction.
The remaining thirty-three moderately symptomatic patients accepted their
functional limitations and were managed nonoperatively throughout the
follow-up period. These patients constituted the study group.
At the time of final follow-up, four of the thirty-three patients had died.
Three patients could not undergo the follow-up magnetic resonance imaging
examination for medical reasons (one patient was obese, one had a pacemaker,
and one had claustrophobia). Seven additional patients refused to undergo
magnetic resonance imaging and were therefore excluded from the study.
The remaining nineteen patients were available for a complete follow-up
examination. There were seven women and twelve men with an average age of
sixty-four years (range, fifty-four to seventy-nine years). The dominant side
was involved in sixteen patients. Three patients (group A) reported a gradual
onset of symptoms, and sixteen (group B) reported an acute, traumatic onset.
The time between the diagnosis and the acute injuries averaged twenty-three
months (range, two to 114 months). Overall, there were six two-tendon tears
(three supraspinatus and infraspinatus tears and three supraspinatus and
subscapularis tears) and thirteen three-tendon tears. The massive tears were
classified as reparable (fatty muscle infiltration of stage 2 or a lower stage
and an acromiohumeral distance of =7 mm) or irreparable (fatty muscle
infiltration of stage 3 or a higher stage and/or an acromiohumeral distance of
<7 mm). On the basis of these criteria, eight patients (seven men and one
woman; average age, sixty-two years) were deemed to have a reparable tear.
Rotator cuff repair had been recommended to these patients at the time of
presentation, but all of them refused operative treatment because they had
insufficient symptoms.
Eleven patients (five men and six women; average age, sixty-five years) had
an irreparable tear. There was no apparent difference between the patients
with the reparable tears and those with the irreparable tears in terms of
average age or the etiology of the tear (traumatic or degenerative).
Clinical Assessment
At the time of the initial diagnosis as well as at the time of follow-up,
the clinical assessment included a structured interview and a detailed,
standardized physical examination. At the time of follow-up, the shoulder
scoring system of Constant and
Murley33 was used,
in addition, for clinical evaluation according to the protocol described by
Gerber et
al.34,35.
The total score was also matched for age and gender as described by Constant
and
Murley33,36,
and the value was called the relative Constant
score5.
In addition, the patients were asked to assign a subjective shoulder
value6 as a
percentage of an entirely normal shoulder. Active forward flexion of
<90° in the presence of free passive motion was noted separately and
was classified as pseudoparesis of the
shoulder37.
Imaging
At the time of the initial diagnosis and at the time of follow-up,
radiographic assessment consisted of two standard radiographs (a true
anteroposterior view in neutral rotation and an axillary lateral view).
Glenohumeral osteoarthritis was assessed and the acromiohumeral distance was
measured in the standardized fashions described above.
A magnetic resonance imaging scan made at the time of diagnosis was
available for all nineteen patients. At the time of follow-up, magnetic
resonance imaging was performed with a 1.0-T unit (Siemens, Erlangen,
Germany). Rotator cuff rupture or continuity of the tendon was assessed on
coronal oblique T2-weighted and proton-density-weighted images as well as on
short tau inversion recovery sequences according to established magnetic
resonance imaging
criteria38-40.
When a fluid-equivalent signal or no visualization of the supraspinatus,
infraspinatus, or subscapularis tendon was found on at least one T2-weighted
or fat-suppressed section, the diagnosis of a full-thickness rupture was made.
Additionally acquired parasagittal T1-weighted turbo spin-echo magnetic
resonance images parallel to the glenohumeral joint were acquired for
qualitative and quantitative assessment of the rotator cuff
muscles41. The
slices covered the rotator cuff from the humeral tuberosities to the medial
third of the scapula. Cross-sectional areas of the supraspinatus were measured
on the most lateral image on which the scapular spine was in contact with the
scapular body (the Y-shaped view). Intramuscular fatty infiltration and
atrophy of the muscle bellies were assessed with the method described by
Goutallier et al.32
for computed tomography scanning and adapted by Fuchs et
al.42 for magnetic
resonance imaging. The sizes (maximal mediolateral and anteroposterior
diameters) of the tears were measured to compare the extent of the rotator
cuff defect before nonoperative treatment with the extent after treatment. For
better illustration of the ruptured area of the rotator cuff, an ellipsoidal
area was calculated with use of the maximal size of the rupture in the coronal
and sagittal planes.
Statistical Methods
Statistical analyses were performed by a statistical consultant. The paired
Wilcoxon signed-rank test was used to compare the values at the time of
diagnosis with those at the time of follow-up. The Spearman rank correlation
was applied to correlate the number of tendon ruptures with other variables.
The Mann-Whitney U test was used to correlate the etiology of the tendon
ruptures with other variables as well as to compare subgroups (irreparable
compared with reparable tears, chronic compared with acute traumatic tears,
two-tendon compared with three-tendon tears, presence compared with absence of
an infraspinatus tear, and presence compared with absence of a subscapularis
tear). The level of significance was set at p < 0.05.
Clinical Findings
After a mean duration of follow-up of forty-eight months (range, thirty to
sixty-five months), the mean absolute Constant score was 69 points (range, 41
to 94 points) and the mean relative Constant score was 83% (range, 57% to
100%) of the score for an age and gender-matched normal shoulder. The mean
subjective shoulder value was 68% (range, 30% to 95%). The relative Constant
score correlated with the subjective shoulder value (r = 0.534, p = 0.019).
The mean value on the visual analogue scale for pain was 11.5 points (range, 5
to 15 points), with 15 points indicating no pain. The mean score for
activities of daily living was 7.9 points (range, 5 to 10 points) of 10
points, and the mean score for arm function was 9.2 points (range, 8 to 10
points) of 10 points. Measurements of active motion demonstrated a mean of
136° (range, 70° to 160°) of forward flexion, 136° (range,
70° to 170°) of abduction, 39° (range, —30° to 85°)
of external rotation, and 66° (range, 50° to 100°) of internal
rotation. The mean abduction strength was 3.1 kg (range, 0 to 10 kg).
At the time of follow-up, the mean active forward flexion significantly
improved by 24°, compared with 115° (range, 0° to 170°) at the
time of diagnosis (p = 0.047). The changes in abduction (a mean gain of
21° compared with a mean of 118° [range, 20° to 170°] at the
time of diagnosis; p = 0.070), internal rotation (a mean loss of 9°
compared with a mean of 76° [range, 30° to 90°] at the time of
diagnosis; p = 0.054), and external rotation (a mean loss of 1° compared
with a mean of 44° [range, —30° to 85°] at the time of
diagnosis; p = 0.864) were not significant. Despite an overall good range of
motion at the time of diagnosis, six patients had pseudoparesis of the
shoulder (active flexion of <90°). Five of these six patients had a
traumatic rotator cuff tear. These five patients regained a good range of
motion after nonoperative therapy, whereas the one with a chronic rotator cuff
tear continued to demonstrate pseudoparesis at the time of final follow-up.
The small numbers of patients did not allow any statistical comparison.
Radiographic Findings
Standardized conventional radiographs made at the time of diagnosis were
available for twelve patients, and those made at the time of follow-up were
available for all nineteen patients. The acromiohumeral distance significantly
decreased by a mean of 2.6 mm, from a mean of 8.2 mm (range, 1 to 13 mm) at
the time of diagnosis to a mean of 5.6 mm (range, 1 to 10 mm) at the time of
follow-up (p = 0.005). The mean stage of the glenohumeral osteoarthritis
significantly progressed from 1.1 at the time of diagnosis to 1.8 at the time
of follow-up (p = 0.014) (Figs. 1-A and
1-B).
Magnetic resonance images were available for all nineteen patients at the
time of diagnosis and at the time of follow-up. The mean size of the rotator
cuff tear increased significantly from 5.6 to 6.0 cm (p = 0.01) in the
sagittal plane and from 4.2 to 4.7 cm (p = 0.011) in the coronal plane. There
was a significant increase in the mean tear size of 3.29 cm2
(range, 0.00 to 9.82 cm2, p = 0.003). Fatty infiltration
significantly increased by 1.0 stage in the supraspinatus muscle (p <
0.001), by 0.95 stage in the infraspinatus muscle (p = 0.001), and by 1.2
stage in the subscapularis muscle (p < 0.001)
(Figs. 2-A and 2-B). Of the
eight tears classified as reparable at the time of diagnosis, four became
irreparable; this was a result of both a decrease in the acromiohumeral
distance to <7 mm and progression of fatty infiltration beyond stage 2 in
three cases and to progression of fatty infiltration alone in one case. The
four rotator cuffs that remained reparable at the time of follow-up showed an
increase in fatty infiltration in at least two muscles; the acromiohumeral
distance decreased in two cases and remained unchanged in one. One case could
not be further analyzed because of missing information at the time of
diagnosis.
None of the six patients who initially had had a two-tendon tear had
progression to a three-tendon tear. The only difference that was found between
the two and three-tendon-tear groups was significantly greater progression of
osteoarthritis in the three-tendon-tear group (p = 0.01).
With the numbers studied, no significant differences were found between
group B (traumatic tears) and group A (chronic degenerative tears), except
that overhead shoulder function at the time of follow-up was significantly
better (p = 0.016) in group B.
Correlations
The number of ruptured tendons at the time of diagnosis correlated
significantly with the stage of glenohumeral osteoarthritis at the time of
follow-up (p = 0.003; r = 0.695). Furthermore, at the time of follow-up, there
was a significant correlation between the size of the tear and both the
acromiohumeral distance (p = 0.037, r = —0.523) and the stage of
glenohumeral osteoarthritis (p = 0.006, r = 0.651). The size of the tear at
the time of diagnosis was significantly correlated with the stage of fatty
infiltration of the supraspinatus and infraspinatus muscles at the time of
diagnosis (p < 0.001, r = 0.808 for the supraspinatus and p < 0.001, r =
0.799 for the infraspinatus) and at the time of follow-up (p < 0.001, r =
0.844, and p < 0.001, r = 0.874, respectively).
At the time of diagnosis, abduction weakness was significantly correlated
with the stage of fatty infiltration of the supraspinatus (p = 0.015, r =
—0.547) and infraspinatus (p = 0.023, r = —0.519) as well as with
the acromiohumeral distance (p = 0.037, r = 0.552). At the time of follow-up,
there was also a significant correlation between abduction strength and
activities of daily living (p = 0.035, r = 0.487) as well as activity at work
(p < 0.001, r = 0.73). At the time of follow-up, fatty infiltration of the
subscapularis correlated significantly with the range of active internal
rotation (p = 0.011, r = —0.571).
The subjective shoulder value had a significant inverse correlation with
fatty infiltration of the supraspinatus (p = 0.006, r = —0.606) and of
the infraspinatus muscle (p = 0.013, r = —0.557) but not with fatty
infiltration of the subscapularis.
The clinical and structural natural history of massive rotator cuff tears
is not well known. Over a period of three years in our practice, 46% of
seventy-four patients with a documented massive rotator cuff tear underwent
primary surgery to treat the disability. The other forty patients, who were
mainly elderly with low functional demands, were managed with nonoperative
means primarily because they found their symptoms tolerable and/or they
refused operative treatment. Primary nonoperative management failed in seven
of these forty patients, and they underwent operative treatment. This left
thirty-three patients who were managed nonoperatively throughout the complete
study period. Nineteen of these non-operatively managed patients could be
evaluated with staged clinical, radiographic, and magnetic resonance imaging
examinations at an average of four years after the diagnosis. This study thus
was not a comparison of different methods of treatment for massive rotator
cuff tears but only documented the clinical and radiographic results of
nonoperative management over time. A few
studies24,25
of nonoperative treatment of rotator cuff tears have demonstrated satisfactory
results regarding functional use of the arm and pain relief at short-term to
midterm follow-up intervals but less satisfying results after long-term
observation (longer than six years). Other investigators have reported poor
clinical outcomes of nonoperative treatment of massive rotator cuff
tears17,24,25,43-47.
In this series, patients maintained good shoulder function with only mild pain
at an average of four years after the diagnosis. The overall good active range
of shoulder motion at the time of diagnosis did not substantially decrease
over time. In particular, on the average, active forward flexion improved and
active abduction did not change significantly (each was >130° at the
time of follow-up), despite the presence of a torn supraspinatus in all
patients and a torn infraspinatus in all except three patients. In addition,
five of six patients with an acute traumatic tear and pseudoparesis of the
shoulder at the time of diagnosis showed substantial improvement in forward
flexion at the time of final follow-up.
Although the patients in this series had less abduction strength compared
with the strength reported after successful repairs of massive rotator cuff
tears6, the average
of 3 kg does not seem to restrict the daily activities of moderately
symptomatic patients with relatively low functional demands.
The good clinical results found in this study are in contrast to the
substantial structural deterioration of the shoulder joint and the rotator
cuff tendons that was documented radiographically. Glenohumeral osteoarthritis
progressed substantially by one to two grades, meaning that joint-preserving
procedures such as a latissimus dorsi transfer for a posterosuperior cuff tear
or a pectoralis major transfer for an anterosuperior cuff tear would have been
less likely to succeed. Over the four years, there was a substantial decrease
in the acromio-humeral distance of 2.6 mm to a distance of 5.6 mm at the time
of follow-up, which represents an irreparable condition according to the
criteria of
Bonnin30. As seen
on magnetic resonance imaging, fatty muscle infiltration progressed by
approximately one stage in each of the three rotator cuff muscles. The
progression of fatty infiltration can be explained by the observations
reported by Meyer et
al.48, who
suggested that further retraction is associated with an increase in fatty
infiltration. Although it was observed in only a small number of patients, the
structural progression of degenerative changes represented by fatty
infiltration of the muscle and the decrease in the acromiohumeral distance
resulted in a substantial risk of a reparable massive rotator cuff tear
becoming irreparable within four years (as occurred in four of eight
patients).
This study had several limitations. First, the number of patients was small
as a result, in part, of our strict inclusion criteria. Requiring a magnetic
resonance imaging scan at the follow-up examination led to a high dropout rate
(21%) because some patients with few symptoms were not willing to undergo
another scan. Second, there was a patient selection bias since patients with
high functional demands or unacceptable pain usually underwent surgery,
primarily or secondarily after unsuccessful nonoperative management, and thus
are not represented in this study. Therefore, the outcome in this selected
group of elderly patients with low functional demands or only mild pain might
not represent the outcome of nonoperative treatment in all patients with a
massive rotator cuff tear.
In conclusion, nonoperatively treated, moderately symptomatic patients with
a massive rotator cuff tear can maintain satisfactory shoulder function over
an average of four years despite significant progression of degenerative
structural changes. However, the relevant structural changes within this
period placed the rotator cuff in danger of becoming irreparable. This finding
should be disclosed to and discussed with patients with a reparable massive
rotator cuff tear because once a rotator cuff tear becomes irreparable and
symptomatic, operative treatment options may be limited to technically
demanding muscle transfers, open or arthroscopic débridement with only
limited
success49-51,
or implantation of a reverse total shoulder
prosthesis52.
?