Clinical and Structural Outcomes of Nonoperative Management of Massive Rotator Cuff Tears
Abstract
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 follow-up.
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.
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.
Materials and Methods
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 calledthe 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.
Figs. 1-A and 1-B
True anteroposterior radiographs of the right shoulder of a seventy-four-year-old man with supraspinatus and infraspinatus tears. Fig. 1-A At the time of diagnosis, there was an acromiohumeral distance of 10 mm and stage-2 osteoarthritis according to the classification of Samilson and Prieto. Fig. 1-B At the time of follow-up, at forty-five months, the acromiohumeral distance had decreased to 1 mm and the osteoarthritis had progressed to stage 4. Clinically, the patient had no pain and had active forward flexion to 130°.
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.
Results
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.
Figs. 2-A and 2-B
T2-weighted parasagittal magnetic resonance images of the left shoulder of a seventy-year-old woman with a massive rotator cuff tear, including the supraspinatus, infraspinatus, and subscapularis tendons. Fig. 2-A At the time of diagnosis, there was stage-2 fatty infiltration of the supraspinatus (white arrowheads) and infraspinatus (black arrowheads) and stage-0 fatty infiltration of the subscapularis, according to the classification system of Goutallier et al.. Fig. 2-B At the time of follow-up, at fifty-two months, fatty infiltration of the supraspinatus (white arrowheads) and infraspinatus (black arrowheads) had increased to stage 4 and fatty infiltration of the subscapularis had increased to stage 1. Clinically, the patient had mild pain and active forward flexion to 140°.
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.
Discussion
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. ▪
Footnotes
- Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
- Investigation performed at the Departments of Orthopaedics and Radiology, University of Zurich, Balgrist, Zurich, Switzerland
- Copyright © 2007 by The Journal of Bone and Joint Surgery, Incorporated
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