Rotator cuff tears are a common cause of shoulder pain and may occur without traumatic injury. The classic explanation for how a rotator cuff can tear without traumatic injury has been that the supraspinatus tendon impinges on the acromion,1 but more recently, authors have emphasized the role of intrinsic tendon degeneration.2-4 These types of tears are especially prevalent among patients age 60+, with prevalence estimates ranging from 20% to 30%.5 Both physical therapy and surgery have been considered among first-line treatments, but there has been little research on how to identify the patients most likely to benefit from physical therapy as a first-line treatment. Recently, Ian Lo, of the University of Calgary’s Department of Surgery, and fellow researchers published research to answer this need for information.6
They followed 76 patients with uncomplicated, partial-thickness rotator cuff tears. Patients received conservative treatment from doctors and physical therapy. Physical therapy programs included posterior capsular stretching, rotator cuff and parascapular muscle strengthening, and other treatments as individually indicated. Conservative physician treatment was individually determined but included pain medications, anti-inflammatories, and/or subacromial steroid injections. Ian Lo and colleagues considered conservative treatment a failure if patients elected surgery within 4.4 years and a success if patients did not elect surgery, although this definition of “failure” merits some examination.
Overall, conservative treatment resulted in improved clinical outcomes, but regression analysis did reveal characteristics that predicted success. These were dominant shoulder, tear thickness, and traumatic status. The most dramatic difference was in traumatic vs. atraumatic onset (16% and 84% success rates of conservative treatment respectively). Tears of less than 50% thickness had a 65% success rate. Success proved slightly more likely with non-dominant shoulders (51% vs 49%).
The success/failure dichotomy set up in this study is useful for easy examination of the outcomes, but we should be careful of overinterpreting the term “failure.” Kim et al. has previously found that delaying surgery for a course of conservative treatment in partial thickness tears improved functional results of surgery at six months.7 Even patients who elect surgery after conservative treatment likely benefit from the pre-surgical physical therapy.
The findings of the current study are consistent with a growing body of evidence showing that physical therapy can be considered a worthwhile first-line treatment.8-11 Orthopaedic surgeon J. Kukkonen found that for non-traumatic rotator cuff tears the results of physical therapy as first-line treatment were not inferior to the results of surgery.8 Similarly, the multi-center trial of Kuhn et al found a 90% success rate from physical therapy for chronic, atraumatic, full-thickness rotator cuff tears.9 The current body of research suggests that the majority of patients will be satisfied with the improvements achieved through conservative treatment alone when the tear is atraumatic and it is either full-thickness or less than 50% thickness. However, monitoring for tear progression may be indicated. For patients with traumatic rotator cuff tears and/or partial tears of greater than 50% thickness, surgery seems likely, but a pre-surgical course of physical therapy may improve the outcomes of surgical repair.
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