Massive Rotator Cuff Tears: Nonoperative Treatment 

Peter B. MacDonald, M.D., FRCSC
University of Manitoba
Winnipeg, MB

As surgeons, we have a tendency to consider operative treatment as definitive - especially when discussing most tendon ruptures. However, when it comes to rotator cuff tears, particularly massive ones, nonoperative treatment definitely has a role in the elderly patient over age 65. When considering cuff tears, we must remember the relative prevalence of this pathology, often asymptomatic, in this advanced age group. Why some cuff tears are more symptomatic and more disabling than others is difficult to explain. Many factors may contribute including: 1) general health of the patient, 2) strength of secondary shoulder muscles especially the deltoid muscle1-4, 3) the presence or absence of biceps tendon pathology, 4) the acuteness of the injury compared to some tears which occur with gradual attrition and adaptation, 5) the size and configuration of the tear. These issues create some difficult choices for the treating surgeon and dilemmas related to surgical treatment.

The evaluation of a patient with cuff tear should include a thorough history and physical examination paying particular attention to the extent of disability. This may be quantified through standardized and validated rotator cuff scores such as the Western Ontario Rotator Cuff score, the Constant score, the American Shoulder and Elbow Surgeons score and the Simple Shoulder test. The Western Ontario Rotator Cuff score is a disease-specific quality of life score that can easily be administered in the waiting room prior to seeing the patient. However, the results of these scores might be difficult to evaluate in the acutely injured patient where pain and disability are severe. Other important features in the history and physical exam are: general medical condition, smoking habits, general nutrition and fitness, and anesthesia risk factors. Physical examination should focus on affect and signs of chronic pain behavior, localized tenderness in the rotator cuff insertion sites, the AC joint and the biceps groove, signs of referred pain especially from cervical spine sources, range of motion, both active and passive, strength of rotator cuff musculature including tendons which are not torn, and finally, but most importantly - strength of the deltoid which can be a great compensator in the massive cuff tear situation.

Radiological evaluation should include at least three views (AP, lateral scapular and axillary view) to assess for arthritic changes in the glenohumeral and theacromioclavicular joint. The physician should also evaluate the degree of superior migration of the humeral head (acromio-humeral interval less than 6 mm)5. Severe superior migration with articulation of the humeral head against the undersurface of the acromion or the presence of cuff tear arthropathy are almost certainly signs of an irreparable rotator cuff. Thus treatment is limited to nonoperative measures unless major surgical procedures such as reverse ball and socket arthroplasty are entertained (Figure 1).

pmacdonald_fig1
Figure 1: Massive irreparable rotator cuff tear with superior migration.

MRI or ultrasound evaluation of the rotator cuff will give a reliable indication of cuff tear size and, in the case of MRI, fatty atrophy of the torn cuff muscles. Both of these are predictors of the likelihood of being able to repair the cuff. Cuff tears which retract medial to the articular surface of the glenoid are less likely to be repairable. The potential for recovery of strength is minimal with severe fatty atrophy, which is generally not reversible)6 (Figure 2).

pmacdonald_fig2
Figure 2: MRI demonstrating fatty atrophy of supraspinatus on sag. cut.

Armed with all the available information, an informed discussion can then be scheduled with the patient to review the options. Generally, acute massive tears in the younger active patient should be repaired. In the older, sedentary or medically compromised patient a three-month trial of nonoperative treatment can be attempted. This includes: 1) adequate pain control with NSAIM and physiotherapy modalities, 2) consideration of corticosteroid injection which may provide short-term relief while physiotherapy is being instituted, 3) a supervised home exercise programme aiming at restoring function especially active forward elevation. Supine elevation exercises and structured deltoid rehabilitation as described by Levy et al7, pulley exercises, and pool therapy can eliminate gravity make it easier to restore active elevation.

With the failure of three months of nonoperative treatment7,8, surgery may be re-considered. In the obvious, massive irreparable cuff situation, surgery may include simple arthroscopic debridement9, and, importantly biceps tenotomy - especially where biceps pain signs (Speed's, Yergason's and or O'Brien's test) are positive. Arthroscopic debridement will have the advantage of deltoid preservation, which is important in this situation. If the surgeon is experienced in tendon transfers, a latissimus dorsi (intact subscapularis) or pectoralis major transfer (subscapularis deficient) may be considered. Finally, arthroscopic or open cuff repair augmented with a patch (although based on little scientific evidence so far) may be considered where tissue deficiency is an issue.

References 

  1. 1. Hansen M.L., Otis J.C., Johnson J.S., Cordasco F.A., Craig E.V., Warren R.F. Biomechanics of massive rotator cuff tears: implications for treatment. J Bone Joint Surg Am 2008;90-2:316-25.
  2.  Bechtol C.O. Biomechanics of the shoulder. Clin Orthop Relat Res 1980;146-146:37-41.
  3.  Inman V., Saunders J., Abbot L. Observations on the function of the shoulder joint. J. Bone Joint Surg. 1944;26:1-30.
  4.  Burkhart S.S. Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale. Clin Orthop Relat Res 1991;267-267:45-56.
  5. Weiner D.S., Macnab I. Superior migration of the humeral head. A radiological aid in the diagnosis of tears of the rotator cuff. J Bone Joint Surg Br 1970;52-3:524-7.
  6. Quinn S.F., Sheley R.C., Demlow T.A., Szumowski J. Rotator cuff tendon tears: evaluation with fat-suppressed MR imaging with arthroscopic correlation in 100 patients. Radiology 1995;195-2:497-500.
  7. Levy, O., et al. The role of anterior deltoid reeducation in patients with massive irrepairable degenerative rotator cuff tears. J Shoulder Elbow Surg. 2008 Nov-Dec; 17(6): 863-870. Epub 2008 Aug 20.
  8. Wirth, M.A., Basmania, C., Rockwood, C.A. Jr. Non operative management of full thickness tears of the rotator cuff. Orthop. Clinics N America. 1997 Jan;28 (1): 59-67. Review.
  9. Rockwood, C.A., Williams, G.R., Burkhead, W.Z: Debridement of degenerative, irreparable lesions of the rotator cuff. Journal Bone Joint Surg Am 1995 Jun;77(6): 857-66.

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