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A Prospective Evaluation of Survivorship of Asymptomatic Degenerative Rotator Cuff Tears

Keener JD, Galatz LM, Teefey SA, Middleton WD, Steger-May K, Stobbs-Cucchi G, Patton R, Yamaguchi K. A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears. J Bone Joint Surg Am. 2015 Jan 21;97(2):89-98. doi: 10.2106/JBJS.N.00099. PubMed PMID: 25609434; PubMed Central PMCID: PMC4296477.

Location: Shoulder and Elbow Service, Dept. Orthopaedic Surgery, Washington University, St. Louis, Missouri

Goals: To better define the natural history of degenerative rotator cuff tears (more specifically, to assess risks for tear enlargement or symptom progression in degenerative, asymptomatic RTC tears)

Level of Evidence: II[box] [AMAZONPRODUCTS asin=”149631333X”][/box]

Methods:

  • inclusion criteria: unilateral pain with bilateral ultrasound confirmed tears (controls had no tears), no trauma to shoulder
  • yearly physical exams to include ROM, strength, VAS, and SST performed
  • ultrasound used to measure tear width and length – classified as partial, full, or none (control group)
    • full thickness considered enlarged if size increased ≥ 5mm
    • partial thickness considered enlarged when once converted to full thickness (complete tendon disruption)
    • control development of tear defined as defect of at least 5 mm

Results:

  • Baseline Demographics
    • ~ 90% f/u rate, similar demographics between tear types
    • no difference in pain or strength between groups
  • Tear Progression
    • The worse the initial tear, the greater the risk for progression
    • Greater risk of progression if dominant extremity
  • Symptom Progression
    • 46% of all shoulders developed new pain
    • more advanced FINAL tear – increased likelihood of pain
    • enlargement was risk factor for pain development
      • OF PATIENTS WHO both enlarged and had pain, 2/3 had pain BEFORE OR AT TIME of initial enlargement (this could be useful if we knew they had a tear to begin with)
    • Muscle Degenerative Changes
      • Association between tear enlargement and supraspinatus degeneration (as assessed by ultrasound)

Discussion

  • Clinical Relevance: full thickness tears more likely to enlarge, greater risk for pain if tear enlarges
  • Authors suggest close surveillance or surgery for painful degenerative full thickness tears due to risk for progression
  • Symptom progression does appear to correlate with tear progression 

Take Home: Helps better define expected course (natural history) of degenerative rotator cuff tears, potentially makes us take pain more seriously as being clinically significant (tear progression)

Question: should we get an ultrasound (cheap) of the other shoulder in patient’s with unilateral symptoms, especially if their asymptomatic side is dominant? It’s cheap and could be prophylactic

Problems: Difficult to apply clinically in all situations because we usually don’t see people until they hurt

 

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