Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial

Application of multidisciplinary team-based integrated traditional Chinese medicine and Western medicine in rotator cuff injury patients undergoing arthroscopic surgery

BACKGROUND

Arthroscopic rotator cuff repair is a common surgical treatment for rotator cuff injuries (RCIs). Although this procedure has certain clinical advantages, it requires rehabilitation management interventions to ensure therapeutic efficacy.

AIM

To investigate the effect of integrated traditional Chinese medicine and Western medicine (TCM-WM) under the multidisciplinary team (MDT) model on the postoperative recovery of patients undergoing arthroscopic surgery for RCIs.

METHODS

This study enrolled 100 patients who underwent arthroscopic rotator cuff repair for RCIs at the Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine between June 2021 and May 2024. They were divided into a control group (n = 48) that received routine rehabilitation treatment and an experimental group (n = 52) that received TCM-WM under the MDT model (e.g., acupuncture, TCM traumatology and orthopedics, and rehabilitation). The results of the Constant–Murley Shoulder Score (CMS), Visual Analogue Scale (VAS), Shoulder Pain and Disability Index (SPADI), muscular strength evaluation, and shoulder range of motion (ROM) assessments were analyzed.

RESULTS

After treatment, the experimental group showed significantly higher CMS scores in terms of pain, functional activity, shoulder joint mobility, and muscular strength than the baseline and those of the control group. The experimental group also exhibited significantly lower VAS and SPADI scores than the baseline and those of the control group. In addition, the experimental group showed significantly enhanced muscular strength (forward flexor and external and internal rotator muscles) and shoulder ROM (forward flexion, abduction, and lateral abduction) after treatment compared with the control group.

CONCLUSION

TCM-WM under the MDT model improved shoulder joint function, relieved postoperative pain, promoted postoperative functional recovery, and facilitated the recovery of muscular strength and shoulder ROM in patients with RCIs who underwent arthroscopic rotator cuff repair.

Outcomes of initial nonoperative treatment of traumatic full-thickness rotator cuff tears

BACKGROUND

Nonsurgical management of chronic, degenerative rotator cuff tears (RCTs) can be an effective treatment strategy, but there is limited evidence to support conservative treatment of acute, traumatic RCTs. The objective of this study was to assess clinical outcomes and predictors of treatment success in patients with traumatic RCTs who elected for initial nonoperative treatment.

METHODS

Patients from a single institution were retrospectively identified using diagnostic codes for traumatic RCTs followed by confirmed initial treatment with ≥2 months of physical therapy. The exclusion criteria included surgery within 2 months of injury and greater than grade I fatty infiltration on magnetic resonance imaging. At minimum 2-year follow-up, patients were contacted by telephone to collect interval surgical history and standardized patient-reported outcomes. Physical therapy was considered to have failed in all those who underwent surgical treatment and those with satisfaction ratings of "moderately dissatisfied" or "very dissatisfied."

RESULTS

Follow-up outcomes were obtained in 40 of 49 patients (82%), with an average follow-up time of 4.2 years. Of the RCTs, 9 (22%) were small (<1 cm), 22 (54%) were medium (>1 cm to <3 cm), and 9 (22%) were large (>3 cm to <5 cm). Grade I fatty infiltration was seen on 25% of magnetic resonance imaging scans (n = 10). Rotator cuff repair was performed in 18 patients (45%) following an average of 6 months of nonoperative treatment (range, 3-12 months). Nonoperative treatment was determined to have failed in 23 of 40 patients (58%) in total. Conservative management was more likely to fail in patients with multiple tendons torn (P = .014). Tear size and retraction were not significantly different between patients who underwent surgery and those who did not. Patients who underwent surgical management had an 83% satisfaction rate at final follow-up compared with a 55% satisfaction rate for patients who did not undergo surgery (P = .054). There was no statistically significant difference in the American Shoulder and Elbow Surgeons score or visual analog scale score between these groups. Although patients who underwent surgery had a higher mean Single Alpha Numeric Evaluation score (86.3 vs. 75.1, P = .041), this difference was below the previously established minimal clinically important difference.

CONCLUSION

Nonoperative treatment remains a viable option for certain patients with traumatic RCTs; however, the results of our study demonstrate a considerable early failure rate. This study further supports historical literature demonstrating reliably successful outcomes with surgical treatment of acute, traumatic RCTs.

Factors determining the short-term clinical outcomes of conservative treatment in patients with supraspinatus tear

INTRODUCTION

To identify factors influencing the better and worse changes in the Western Ontario Rotator Cuff Index of patients undergoing conservative treatment for supraspinatus tendon tear.

METHODS

The study included 30 patients with supraspinatus tendon tear who underwent conservative treatment. The average duration of intervention was 35.4 days. The Western Ontario Rotator Cuff Index, shoulder range of motion, isometric muscle strength, supraspinatus tendon thickness, thickness of the supraspinatus, infraspinatus, and teres minor muscles, and acromiohumeral interval were assessed before and after the intervention. In the statistical analyses, change in the Western Ontario Rotator Cuff Index was the dependent variable, and the amount of change in each measurement variable before and after the intervention was the independent variable.

RESULTS

The average Western Ontario Rotator Cuff Index improved from 1067 at pre-treatment to 997 at post-treatment, but without a significant difference (p = 0.29). A multiple regression analysis revealed that supraspinatus tendon thickness and muscle strength in shoulder external rotation at 90° scaption had a significant effect on the change in the Western Ontario Rotator Cuff Index (R2 = 0.44, p < 0.01).

CONCLUSION

Supraspinatus tendon thickness and muscle strength in shoulder external rotation at 90° scaption were important factors for the Western Ontario Rotator Cuff Index score in the early stages of conservative treatment for patients with supraspinatus tendon tear.

Percutaneous bone marrow concentrate and platelet products versus exercise therapy for the treatment of rotator cuff tears: a randomized controlled, crossover trial with 2-year follow-up

BACKGROUND

Surgical repair is recommended for the treatment of high-grade partial and full thickness rotator cuff tears, although evidence shows surgery is not necessarily superior to non-surgical therapy. The purpose of this study was to compare percutaneous orthobiologic treatment to a home exercise therapy program for supraspinatus tears.

METHODS

In this randomized-controlled, crossover design, participants with a torn supraspinatus tendon received either 'BMC treatment', consisting of a combination of autologous bone marrow concentrate (BMC) and platelet products, or underwent a home exercise therapy program. After three months, patients randomized to exercise therapy could crossover to receive BMC treatment if not satisfied with shoulder progression. Patient-reported outcomes of Numeric Pain Scale (NPS), Disabilities of the Arm, Shoulder, and Hand, (DASH), and a modified Single Assessment Numeric Evaluation (SANE) were collected at 1, 3, 6, 12, and 24 months. Pre- and post-treatment MRI were assessed using the Snyder Classification system.

RESULTS

Fifty-one patients were enrolled and randomized to the BMC treatment group (n = 34) or the exercise therapy group (n = 17). Significantly greater improvement in median ΔDASH, ΔNPS, and SANE scores were reported by the BMC treatment group compared to the exercise therapy group (-11.7 vs -3.8, P = 0.01; -2.0 vs 0.5, P = 0.004; and 50.0 vs 0.0, P < 0.001; respectively) after three months. Patient-reported outcomes continued to progress through the study's two-year follow-up period without a serious adverse event. Of patients with both pre- and post-treatment MRIs, a majority (73%) showed evidence of healing post-BMC treatment.

CONCLUSIONS

Patients reported significantly greater changes in function, pain, and overall improvement following BMC treatment compared to exercise therapy for high grade partial and full thickness supraspinatus tears.

TRIAL REGISTRATION

This protocol was registered with www.

CLINICALTRIALS

gov (NCT01788683; 11/02/2013).

Re-tear after arthroscopic rotator cuff tear surgery: risk analysis using machine learning

BACKGROUND

Postoperative rotator cuff retear after arthroscopic rotator cuff repair (ARCR) is still a major problem. Various risk factors such as age, gender, and tear size have been reported. Recently, magnetic resonance imaging-based stump classification was reported as an index of rotator cuff fragility. Although stump type 3 is reported to have a high retear rate, there are few reports on the risk of postoperative retear based on this classification. Machine learning (ML), an artificial intelligence technique, allows for more flexible predictive models than conventional statistical methods and has been applied to predict clinical outcomes. In this study, we used ML to predict postoperative retear risk after ARCR.

METHODS

The retrospective case-control study included 353 patients who underwent surgical treatment for complete rotator cuff tear using the suture-bridge technique. Patients who initially presented with retears and traumatic tears were excluded. In study participants, after the initial tear repair, rotator cuff retears were diagnosed by magnetic resonance imaging; Sugaya classification types IV and V were defined as re-tears. Age, gender, stump classification, tear size, Goutallier classification, presence of diabetes, and hyperlipidemia were used for ML parameters to predict the risk of retear. Using Python's Scikit-learn as an ML library, five different AI models (logistic regression, random forest, AdaBoost, CatBoost, LightGBM) were trained on the existing data, and the prediction models were applied to the test dataset. The performance of these ML models was measured by the area under the receiver operating characteristic curve. Additionally, key features affecting retear were evaluated.

RESULTS

The area under the receiver operating characteristic curve for logistic regression was 0.78, random forest 0.82, AdaBoost 0.78, CatBoost 0.83, and LightGBM 0.87, respectively for each model. LightGBM showed the highest score. The important factors for model prediction were age, stump classification, and tear size.

CONCLUSIONS

The ML classifier model predicted retears after ARCR with high accuracy, and the AI model showed that the most important characteristics affecting retears were age and imaging findings, including stump classification. This model may be able to predict postoperative rotator cuff retears based on clinical features.

Assessment of description and implementation fidelity of clinical trials involving exercise-based treatment in individuals with rotator cuff tears: a scoping review

BACKGROUND

For evidence-based practice, clinicians and researchers can rely on well-conducted randomized clinical trials that exhibit good methodological quality, provide adequate intervention descriptions, and implementation fidelity.

OBJECTIVE

To assess the description and implementation fidelity of exercise-based interventions in clinical trials for individuals with rotator cuff tears.

METHODS

A systematic search was conducted in PubMed, Embase, CINAHL, LILACS, Cochrane Library, Web of Science, SCOPUS and SciELO. Randomized clinical trials that assessed individuals with rotator cuff tears confirmed by imaging exam were included. All individuals must have received an exercise-based treatment. The methodological quality was scored with the Physiotherapy Evidence Database (PEDro) scale. The Template for Intervention Description and Replication (TIDieR) checklist and the National Institutes of Health Behaviour Change Consortium (NIHBCC) were used to assess intervention description and implementation fidelity, respectively.

RESULTS

A total of 13 studies were included. Despite their adequate methodological quality, the description of the intervention was poor with TIDieR scores ranging from 6 to 15 out of 24 total points. The TIDieR highest-scoring item was item 1 (brief name) that was reported in all studies. Considering fidelity, only one of the five domains of NIHBCC (i.e., treatment design) reached just over 50%.

CONCLUSION

Exercise-based interventions used in studies for individuals with rotator cuff tears are poorly reported. The description and fidelity of the intervention need to be better reported to assist clinical decision-making and support evidence-based practice.

Factors associated with healing failure after early repair of acute, trauma-related rotator cuff tears

BACKGROUND

Healing failure after rotator cuff repair is a challenging problem. Acute, trauma-related tears are considered a separate entity and are often treated surgically. The aim of this study was to identify factors associated with healing failure in previously asymptomatic patients with trauma-related rotator cuff tears treated with early arthroscopic repair.

METHODS

This study included 62 consecutively recruited patients (23% women; median age, 61 years; age range, 42-75 years) with acute symptoms in a previously asymptomatic shoulder and a magnetic resonance imaging-verified full-thickness rotator cuff tear after shoulder trauma. All patients were offered, and underwent, early arthroscopic repair, during which a biopsy specimen was harvested from the supraspinatus tendon and analyzed for signs of degeneration. Of the patients, 57 (92%) completed 1-year follow-up and underwent assessment of repair integrity on magnetic resonance images according to the Sugaya classification. Risk factors for healing failure were investigated using a causal-relation diagram where age, body mass index, tendon degeneration (Bonar score), diabetes mellitus, fatty infiltration (FI), sex, smoking, tear location regarding integrity of the rotator cable, and tear size (number of ruptured tendons and tendon retraction) were included and analyzed.

RESULTS

Healing failure at 1 year was identified in 37% of patients (n = 21). A high degree of FI of the supraspinatus muscle (P = .01), a tear location including disruption of rotator cable integrity (P = .01), and old age (P = .03) were associated with healing failure. Tendon degeneration as determined by histopathology was not associated with healing failure at 1-year follow-up (P = .63).

CONCLUSION

Older age, increased FI of the supraspinatus muscle, and a tear including disruption of the rotator cable increased the risk of healing failure after early arthroscopic repair in patients with trauma-related full-thickness rotator cuff tears.

Adduction Manipulation of the Glenohumeral Joint versus Physiotherapy for Atraumatic Rotator Cuff Tears: A Randomized Controlled Trial

BACKGROUND

Atraumatic rotator cuff tears (ARCTs) are frequently concomitant with adduction restriction of the glenohumeral joint (GHJ). Adduction manipulation (AM) removes the restriction and relieves pain. The present study aimed to investigate the clinical efficacy of AM versus physiotherapy (PT) in ARCTs.

METHODS

Eighty-eight patients with adduction restriction were allocated to the AM and PT groups (n = 44 per group). The glenohumeral adduction angle (GAA) was calculated using X-rays at the first and last follow-up appointments. We recorded pain severity (visual analog scale, VAS), flexion, abduction, external rotation (ER), internal rotation (IR), and American Shoulder and Elbow Society (ASES) and Constant scores at baseline and at 1-, 3-, 6-, and 12- month follow-ups.

RESULTS

Forty-three patients (23 males, average age 71.3 years) in the AM group and 41 (16 males, average age 70.7 years) in the PT group were consequently analyzed. At the 1-month follow-up, VAS, shoulder motion except ER, ASES and Constant scores were much better in the AM group than in the PT group, whereas those in the PT group improved gradually up to 12 months. At the final follow-up, flexion, abduction, and Constant score were significantly better in the AM group than in the PT group. The GAA at the initial and final examinations was -21.6° and -3.2°, respectively, in the AM group, and -21.1° and -14.4°, respectively, in the PT group.

CONCLUSIONS

The AM procedure, which had better clinical efficacy than PT, is recommended as the first conservative treatment option for ARCTs.

No difference in clinical outcome after rotator cuff repair performed within or later than 3 months after trauma: a retrospective cohort study

PURPOSE

Rotator cuff (RC) tear is one of the most common injuries of the shoulder. Patients with RC tears often report a trauma initiating shoulder pain and impaired function. The aim of this retrospective analysis of a prospectively registered cohort was to elucidate whether the time interval between the trauma and RC repair, using a cut off of 3 months, affects the functional outcome after 2 years.

METHODS

In a single orthopedic unit, 819 consecutive patients were treated with rotator cuff repair during the period from 2010 to 2014 and 733 of the patients completed the Western Ontario Rotator Cuff (WORC) index preoperatively and at 2-year follow-up. The Constant-Murley (CM) score was completed by trained physiotherapists after a clinical examination both preoperatively and at 2-year follow-up. Preoperative magnetic resonance imaging (MRI) was performed in all patients and postoperatively in 65% of the included patients. Re-tears and partial repairs were excluded, as were patients with pseudoparalysis who were given high priority and underwent surgery during the first 3 weeks after trauma.

RESULTS

Of the 733 treated patients, 437 (60%) reported having had a shoulder trauma in their medical history initiating their shoulder symptoms, and of these, 358 met the inclusion criteria. 296 patients with non-traumatic tears, 9 repairs done within 3 weeks after trauma, 25 partial repairs, 33 re-tears and 12 others were excluded. At 2-year follow-up there was no significant difference in WORC index (n.s.) or CM score (n.s.) between patients who had their RC repaired within or more than 3 months after trauma. In patients where RC repair was performed within 3 months, the WORC index improved by 42.9%, and in the group of patients operated later than 3 months, the increase was 38.7%. This difference between the groups was neither statistically significant (n.s.) nor clinically relevant. On postoperative MRI, 80% of the repairs were healed in both groups.

CONCLUSION

In this retrospective cohort study, no differences in clinical outcome were found when RC repair was performed between 3 weeks and 3 months or later than 3 months after injury in patients describing their onset of symptoms as traumatic.

LEVEL OF EVIDENCE

III.

Animal Models of Rotator Cuff Injury and Repair: A Systematic Review

There are a large number of animal studies on rotator cuff injury and repair, but a lack of detailed research and evaluation on the animal models. This systematic review aims to provide a framework for animal studies and repair patches for rotator cuff injury. Four hundred nine animal studies were included, of which the most common animal model of rotator cuff injury is rat (53.56%), the most common site of rotator cuff injury is the supraspinatus tendon (62.10%), and the most common injury type (degree) is acute tear (full thickness) (48.41%). The most common research purpose is to evaluate the repair effect of the patch (24.94%), followed by the observation of pathophysiological changes after rotator cuff injury (20.87%). Among the five types of repair patch materials including nondegradable and degradable synthetic materials, autologous and allogeneic tissues, and naturally derived biomaterial, the last one is the mostly used (52.74%). For different animal models, the rodent models (rat and mouse) are the most commonly used and probably the most suitable species for preliminary studies of rotator cuff injury; the rabbit, canine, sheep, and goat models are more suitable for biomechanical performance testing, rehabilitation training, and validation of surgical methods; and the nonhuman primate models (monkey and baboon) are the closest to human, but it is more difficult to carry out the animal studies on them because of ethical issues, high feeding cost, and management difficulties.

[Injuries of the shoulder in winter sports]

Skiing as a sport has come a long way from the first competitive event in Norway in 1767 to about 200 million skiers today worldwide. With Germany alone recording around 8000 injuries annually, there is an increased need for awareness for winter-sport-related injuries and their management. According to the latest report by "Auswertungsstelle für Skiunfälle" (ASU, evaluation center for ski accidents), shoulder injuries alone account for more than 20% of injuries to all body regions (men 26.1% and women 13%). The most common injuries affecting the shoulder girdle are rotator cuff strains, glenohumeral dislocations, acromioclavicular dislocations and clavicle fractures. These injuries are primarily the result of four mechanisms: direct impact, axial load on an extended arm, resisted forced abduction of the arm, and external rotation forces resulting from a firmly planted ski pole in the grasp of a skier during a fall. In this article, we describe the three most common shoulder girdle injuries in winter sports along with their management and answer the most important questions for the athlete.

Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis

OBJECTIVE

To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions.

DESIGN

Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).

LITERATURE SEARCH

MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021.

STUDY SELECTION CRITERIA

RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year.

DATA SYNTHESIS

Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials.

RESULTS

One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias.

CONCLUSION

The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.

Biochemical Markers of Aging (Advanced Glycation End Products) and Degeneration Are Increased in Type 3 Rotator Cuff Tendon Stumps With Increased Signal Intensity Changes on MRI

BACKGROUND

Advanced glycation end products (AGEs) are end products of protein glycation that bind to the receptor for AGEs (RAGE) and activate nicotinamide adenine dinucleotide phosphate oxidase (NOX), resulting in increased oxidative stress and rotator cuff fragility. Stump classification using the signal intensity ratio of the tendon rupture site to the deltoid muscle in the coronal view of T2-weighted fat-suppressed magnetic resonance imaging (MRI) scans is an indicator of clinical outcomes after rotator cuff repair surgery. Comparing the signal intensities of the deltoid (D) and rotator cuff tears (C), Ishitani et al. classified C/D <0.8 as type 1, 0.8 to 1.3 as type 2, and >1.3 as type 3.

HYPOTHESIS/PURPOSE

It was hypothesized that the oxidative stress and collagen degeneration that occur in the rotator cuff due to accumulation of AGEs can be assessed on MRI scans (stump classification). Therefore, this study aimed to compare AGE-related factors in the rotator cuff tear site tissues based on stump classification.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The authors included 30 patients (11 with type 1, 9 with type 2, and 10 with type 3; mean age, 62.3 years) who underwent surgery for complete rotator cuff tears at our hospital. Tendon tissue was harvested from the torn rotator cuff site during surgery for tissue and cell evaluation.

RESULTS

There was no significant difference in the mean age according to stump classification. The number of patients with diabetes was significantly larger in type 3 than in the other types (P < .05). Tissue evaluation showed significantly higher expression of AGE and RAGE staining in type 3 than in the other types (~6.7-fold; P < .01). Cell evaluation showed that the expression rates of reactive oxygen species and apoptosis were significantly higher in type 3 than in the other types (~4.3-fold; P < .01). Gene expression by real-time polymerase chain reaction showed significantly higher RAGE (~5.1-fold), NOX (~5.3-fold), and IL (~3.0-fold) in type 3 than in the other types (P < .05).

CONCLUSION

Stump classification type 3 exhibited the highest accumulation of AGEs and the highest oxidative stress and apoptosis, suggesting a high degree of degeneration and inflammation. Imaging based on stump classification reflects the degeneration and fragility of the torn rotator cuff site.

CLINICAL RELEVANCE

This study provides evidence of a relationship between stump classification, which reflects rotator cuff fragility on MRI, and pathologies related to advanced glycation end products.

Comparison of single platelet-rich plasma injection with hyaluronic acid injection for partial-thickness rotator cuff tears

BACKGROUND

Partial-thickness rotator cuff tears (PTRCTs) is not uncommon, and various nonsurgical injection therapy for PTRCTs emerged. Platelet-rich plasma (PRP) and hyaluronic acid (HA) injection were proposed for treating PTRCTs; however, the relation of dose among injectates was still lacking.

METHODS

This was a prospective, nonrandomized, comparative study. The aim of the study was to compare the effects of ultrasound-guided single PRP injection with three doses of HA injection, combination of postinjection rehabilitation, for treating PTRCTs. Subjects received either ultrasound-guided PRP injection and rehabilitation exercise, or ultrasound-guided subacromial HA injection and rehabilitation exercise. Shoulder Pain and Disability Index (SPADI), range of motion (ROM), pain visual analog scale (VAS), and Constant-Murley Shoulder Score (CMSS) were recorded before injection, and at 1 and 3 months after injection.

RESULTS

Forty-eight patients were enrolled. They received either ultrasound-guided single PRP (n = 24) intralesional and peritendinous injection or three doses of HA (n = 24) subacromial injection plus rehabilitation exercise. In the PRP group, SPADI scores, VAS scores, CMSS significantly improved at 1-month and 3-month follow up; flexion and abduction ROM significantly increased at 3-month follow up. In the HA group, SPADI scores, VAS during overhead activities, VAS night pain, and CMSS significantly improved in the first and third months; flexion and active abduction ROM significantly increased in the third month. The PRP group revealed significantly better passive abduction ROM and CMSS at third month than HA group.

CONCLUSION

Ultrasound-guided single PRP injection exhibited comparable benefit to three doses of HA injection in patients with PTRCTs short-termly, with an extended effect regarding passive shoulder abduction ROM and CMSS.

Asynchronous and Tailored Digital Rehabilitation of Chronic Shoulder Pain: A Prospective Longitudinal Cohort Study

Background

Chronic shoulder pain (SP) is responsible for significant morbidity, decreased quality of life and impaired work ability, resulting in high socioeconomic burden. Successful SP management is dependent on adherence and compliance with effective evidence-based interventions. Digital solutions may improve accessibility to such treatments, increasing convenience, while reducing healthcare-related costs.

Purpose

Present the results of a fully remote digital care program (DCP) for chronic SP.

Patients and Methods

Interventional, single-arm, cohort study of individuals with chronic SP applying for a digital care program. Primary outcome was the mean change between baseline and 12 weeks on the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Secondary outcomes were change in pain (NPRS), analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.

Results

From 296 patients at program start, 234 (79.1%) completed the intervention. Changes in QuickDASH between baseline and end-of-program were both statistically (p < 0.001) and clinically significant, with a mean reduction of 51.6% (mean −13.45 points, 95% CI: 11.99; 14.92). Marked reductions were also observed in all secondary outcomes: 54.8% in NPRS, 44.1% ceased analgesics consumption, 55.5% in surgery intent, 37.7% in FABQ-PA, 50.3% in anxiety, 63.6% in depression and 66.5% in WPAI overall. Higher engagement was associated with higher improvements in disability. Mean patient satisfaction score was 8.7/10.0 (SD 1.6).

Conclusion

This is the first real-world cohort study reporting the results of a multimodal remote digital approach for chronic SP rehabilitation. High completion and engagement rates were observed, which were associated with clinically significant improvement in all health-related outcomes, as well as marked productivity recovery. These promising results support the potential of digital modalities to address the global burden of chronic musculoskeletal pain.

What are People That Seek Care for Rotator Cuff Tendinopathy Experiencing in Their Daily Life?

This qualitative study sought to answer three questions: What is it like to live with rotator cuff tendinopathy? What are the barriers and facilitators of a healthy lifestyle with an aging shoulder? And, what are the outcomes that matter most to people seeking care for rotator cuff tendinopathy? Patients diagnosed with rotator cuff tendinopathy participated in group discussions using semi-structured guides that focus on diagnosis, daily experiences living with rotator cuff tendinopathy, goals, concerns, and clinical care experiences. A hybrid of initial inductive coding of themes and subsequent deductive consideration of these themes within the capability, comfort, and calm framework was utilized. Themes associated with rotator cuff tendinopathy were less restful sleep, difficulty with work and life transitions, loss of baseline abilities, and limitation in social roles in the capability realm; physical pain, despair, and loneliness in the comfort realm; and lack of direction or progress and feeling uncared for in the calm realm. Barriers identified included: the sense that rotator cuff tendinopathy is something correctable rather than age-associated and the sense that painful activities will make the tendinopathy worse (common misconceptions); tenuous relationships and limited trust with clinicians; loss of hope; and a sense that care is directionless. What matters most to a person seeking specialty care for shoulder pain are feeling that they are getting effective care and not being dismissed; maintaining meaningful activity and life roles; and replacing despair and frustration with hope and progress. Anticipating these needs may facilitate the design of more effective care models.

Level of Evidence: N/A.

Management of Acute Rotator Cuff Tears

Acute, traumatic rotator cuff tears typically occur in younger patients with a fall on an outstretched hand, grabbing an object to catch oneself when falling, or a glenohumeral dislocation. These tears are best evaluated with MRI. Partial-thickness tears may be managed nonoperatively with physical therapy, NSAIDs, and injections. Full-thickness tears in most patients should be managed with surgical repair as soon as possible, with better outcomes shown when repaired within 4 months of injury.

Rotator cuff repair vs. nonoperative treatment: a systematic review with meta-analysis

BACKGROUND

Rotator cuff (RC) tears have been widely studied as many treatment strategies have been recommended. However, optimal management for patients with RC tears is still unclear.

PURPOSE

The main aim of this systematic review was to analyze randomized controlled trials using meta-analysis to compare repair to conservative treatments for patients with any type of RC tear.

METHODS

MEDLINE, Cochrane Library (CENTRAL database), PEDro, and Scopus databases were used. Two independent reviewers selected randomized controlled trials that compared surgical to conservative treatments for RC tear patients. The studies included were assessed using Cochrane Risk of Bias 2 tools, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and to summarize the study conclusions.

RESULTS

Six trials were included. Pooled results showed improvement in function and pain perception in favor of the repair group at 6 months (mean difference 1.26, 95% CI -2.34, 4.85, P = .49; and -0.59, 95% CI -0.84, -0.33, P < .001, respectively), at 12 months (mean difference 5.25, 95% CI 1.55, 8.95, P = .005, for function; and -0.41, 95% CI -0.70, -0.12, P = .006, for pain) and at 24 months (mean difference 5.57, 95% CI 1.86, 9.29, P = .003, for function; and -0.92, 95% CI -1.31, -0.52, P < .001, for pain) in RC tear patients. However, these differences did not reach the minimum clinically important difference. The certainty of evidence ranged from low to moderate because of imprecision in the studies included.

CONCLUSIONS

Overall analysis showed that in patients with RC tear, repair compared with conservative treatment could result in increased pain reduction and functional improvement at 6, 12, and 24 months. Even if these effects were often statistically significant, their clinical relevance was limited. Moreover, the certainty of body of evidence ranged from low to moderate.

Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years: over 5-year follow-up of a randomized controlled trial

BACKGROUND

Nontraumatic rotator cuff tear is a common shoulder problem that can be treated either conservatively or operatively. In the previous publications of the 1- and 2-year results of this trial, we found no significant between-group clinical differences. The aim of this study was to investigate the differences in mid-term clinical and radiologic outcomes in patients older than 55 years.

MATERIALS AND METHODS

One hundred eighty shoulders with symptomatic, nontraumatic supraspinatus tears were randomly assigned to 1 of the 3 cumulatively designed treatment groups: physiotherapy (group 1); acromioplasty and physiotherapy (group 2); and rotator cuff repair, acromioplasty, and physiotherapy (group 3). The change in the Constant score was the primary outcome measure. The secondary outcome measures were the change in the visual analog scale score for pain and patient satisfaction. Radiologic analysis included evaluation of glenohumeral osteoarthritis (OA) and rotator cuff tear arthropathy (CTA).

RESULTS

A total of 150 shoulders (mean age, 71 years) were available for analysis after a mean follow-up period of 6.2 years. The mean sagittal tear size of the supraspinatus tendon tear at baseline was 10 mm in all groups (P = .33). During follow-up, 8 shoulders in group 1 and 2 shoulders in group 2 crossed over to rotator cuff repair. The mean baseline Constant score was 57.1, 58.2, and 58.7 in groups 1, 2, and 3, respectively (P = .85). There were no significant differences (P = .84) in the mean change in the Constant score: 18.5 in group 1, 17.9 in group 2, and 20.0 in group 3. There were no statistically significant differences in the change in the visual analog scale pain score (P = .74) and patient satisfaction (P = .83). At follow-up, there were no statistically significant differences in the mean progression of glenohumeral OA (P = .538) or CTA (P = .485) among the groups. However, the mean progression of glenohumeral OA from baseline to follow-up was statistically significant in the trial population (P = .0045).

CONCLUSIONS

On the basis of this study, operative treatment is no better than conservative treatment regarding small, nontraumatic, single-tendon supraspinatus tears in patients older than 55 years. Operative treatment does not protect against degeneration of the glenohumeral joint or CTA. Conservative treatment is a reasonable option for the primary initial treatment of these tears.

The role of scapular dyskinesis on rotator cuff tears: a narrative review of the current knowledge

Scapular dyskinesis can be present in healthy individuals as in patients with shoulder pathology.Altered patterns of scapular kinematics can cause or exacerbate rotator cuff tear pathology. However, more research is needed.Regardless of the cause or the consequence of rotator cuff tear, scapular dyskinesis impairs shoulder function, worsens the symptoms, and compromises the success of clinical intervention.The available literature suggests physical therapy as the first treatment for degenerative cuff tears, and scapular dyskinesis should be addressed if present. Non-responsive cases or traumatic tears may require surgery.Postsurgical physical therapy protocols after rotator cuff repair must consider scapular dyskinesia to improve the outcomes. Cite this article: EFORT Open Rev 2021;6:932-940. DOI: 10.1302/2058-5241.6.210043.

A 5-Year Follow-up of Patients Treated for Full-Thickness Rotator Cuff Tears: A Prospective Cohort Study

Background:

The evidence in support of operative versus nonoperative management of rotator cuff tears (RCTs) is limited, based primarily on observational studies of lower scientific merit.

Purpose:

To (1) compare the efficacy of operative versus nonoperative management of full-thickness RCTs across time and (2) detect variables that predict success within each group.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

We included patients with symptomatic full-thickness RCTs who were enrolled in an institutional shoulder registry. Patient enrollment began in 2009 and continued until early 2018. The following outcome measures were collected at baseline, then 6 months, 1 year, and annually up to 5 years postoperatively: Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12-Item Health Survey (VR-12) mental and physical component subscales (MCS and PCS, respectively), 100-point Single Assessment Numeric Evaluation (SANE) rating, and 100-point visual analog scale (VAS) for pain and for patient satisfaction. We performed regression models for all outcome variables across all 5 years of follow-up and included the following predictor variables: treatment type (operative vs nonoperative), sex, age, symptom duration, smoking status, diabetes status, injury side, and obesity status.

Results:

A total of 595 patients were included. Longitudinal mixed-effects regression revealed that patients who received operative treatment did better across time on all outcomes. Women (n = 242; 40.7%) did not fare as well as did men on the ASES, WORC, or VR-12 PCS. Older patients tended to improve less on the VR-12 PCS and more on the VR12-MCS. Patients with longer symptom duration at baseline had better scores across time on the ASES, WORC, VAS for pain, and SANE. Current or recent smokers and patients with diabetes tended to have lower scores on all measures across time. For changes in scores from baseline, patients in the operative group improved to a larger degree out to 3 years compared with those in the nonoperative group.

Conclusion:

Patients with RCTs tended to improve regardless of whether they received operative or nonoperative treatment, but patients who underwent operative treatment improved faster. There appear to be several predictors of improved and worsened outcomes for patients with RCTs undergoing operative or nonoperative treatment.

Acceleration of Bone-Tendon Interface Healing by Low-Intensity Pulsed Ultrasound Is Mediated by Macrophages

OBJECTIVE

Low-intensity pulsed ultrasound (LIPUS) has been proven to facilitate bone-tendon interface (BTI) healing and regulate some inflammatory cytokines. However, the role of macrophages, a key type of inflammatory cell, during treatment remains unknown. This study aimed to investigate the role of macrophages in the treatment of BTI injury with LIPUS in a rotator cuff tear animal model.

METHODS

In this experimental and comparative study, a total of 160 C57BL/6 mature male mice that underwent supraspinatus tendon detachment and repair were randomly assigned to 4 groups: daily ultrasonic treatment and liposomal clodronate (LIPUS+LC), daily ultrasonic treatment and liposomes (LIPUS), daily mock sonication and liposomal clodronate (LC), and daily mock sonication and liposomes (control [CTL]). LIPUS treatment was initiated immediately postoperatively and continued daily until the end of the experimental period.

RESULTS

The failure load and stiffness of the supraspinatus tendon-humerus junction were significantly higher in the LIPUS group than in the other groups at postoperative weeks 2 and 4, whereas those in the LIPUS+LC and LC groups were lower than those in the CTL group at postoperative week 4. The LIPUS, LIPUS+LC, and LC groups exhibited significantly more fibrocartilage than the CTL group at 2 weeks. Only the LIPUS group had more fibrocartilage than the CTL group at 4 weeks. Micro-computed tomography results indicated that LIPUS treatment could improve the bone quality of the attachment site after both 2 and 4 weeks. When macrophages were depleted by LC, the bone quality-promoting effect of LIPUS treatment was significantly reduced.

CONCLUSION

The enhancement of BTI healing by LIPUS might be mediated by macrophages.

IMPACT

In our study, LIPUS treatment appeared to accelerate BTI healing, which was associated with macrophages based on our murine rotator cuff repair model. The expressions of macrophage under LIPUS treatment may offer a potential mechanism to explain BTI healing and the effects of LIPUS on BTI healing.

Good outcome after repair of trauma-related anterosuperior rotator cuff tears-a prospective cohort study

BACKGROUND

Anterosuperior rotator cuff tears with a displaced long head of the biceps tendon are most often trauma-related, and patients with these conditions often present with severe pain and shoulder dysfunction. Repair of the subscapularis and supraspinatus and a biceps tenodesis or a tenotomy are the recommended treatments based on retrospective studies. The aim of this study was to prospectively evaluate clinical and structural treatment outcome in a cohort of trauma-related anterosuperior injuries in patients with previously healthy shoulders.

MATERIALS AND METHODS

Patients seeking care for a suspected rotator cuff injury after shoulder trauma were screened according to a protocol including clinical examination, baseline scoring with Western Ontario Rotator Cuff Index (WORC) and numeric rating scale of pain, ultrasound, and magnetic resonance imaging (MRI). Those with anterosuperior injuries were offered surgical treatment, structured postoperative physiotherapy, and inclusion in the present study with 1-year follow-up, including MRI, baseline scores, Constant-Murley score, and Patient Global Impression of Change. Thirty-three patients (78% men) with a mean age of 59 (40-76) years were included.

RESULTS

All patients had a biceps pulley lesion, a displaced biceps tendon, and incomplete full-thickness subscapularis and supraspinatus tears. Six patients declined surgery. At follow-up, the operated patients reached a median WORC score of 86% and a median change from baseline to follow-up of 50% (P = .0001). Pain decreased (P = .0001) at rest, at night, and during activity. The median Constant-Murley score was 86% of the contralateral nonoperated shoulder, 58% of the contralateral abduction strength recovered after surgery, and 86% reported that they were recovered or much improved. All repairs and tenodeses healed except for 2 supraspinatus tendons. The 6 nonoperated patients reached a median WORC score of 90, a change in the median value from baseline to follow-up of 31, but reported more pain, and a smaller proportion considered themselves as recovered or much improved. In all patients, the 1-year MRIs had signal changes in the upper muscular portion of subscapularis, consistent with fatty infiltration, regardless of operative or nonoperative treatment.

CONCLUSION

Anterosuperior rotator cuff injury with an associated pulley lesion and displaced long head of the biceps tendon may be treated successfully with surgery as the majority of patients in our cohort clinically recovered or were much improved without pain after a year. With a 1-year perspective, nonoperatively treated patients may also reach a reasonable clinical outcome. Independently of treatment or tendon healing, residual subscapularis muscle injury was seen, which may have long-term implications.

Non-surgical and surgical treatments for rotator cuff disease: a pragmatic randomised clinical trial with 2-year follow-up after initial rehabilitation

BACKGROUND

Rotator cuff disease (RCD) causes prolonged shoulder pain and disability in adults. RCD is a continuum ranging from tendinopathy to full-thickness tendon tear. Recent studies have shown that subacromial decompression and non-surgical treatments provide equivalent results in RCD without a full-thickness tendon lesion. However, the importance of surgery for full-thickness tendon tears remains unclear.

METHODS

In a pragmatic, randomised, controlled trial, 417 patients with subacromial pain underwent 3-month initial rehabilitation and MRI arthrography (MRA) for the diagnosis of RCD. Of these, 190 shoulders remained symptomatic and were randomised to non-surgical or surgical treatments. The primary outcomes were the mean changes in the Visual Analogue Scale for pain and the Constant Murley Score for shoulder function at the 2-year follow-up.

RESULTS

At the 2-year follow-up, both non-surgical and surgical treatments for RCD reduced pain and improved shoulder function. The scores differed between groups by 4 (95% CI -3 to 10, p=0.25) for pain and 3.4 (95% CI -0.4 to 7.1, p=0.077) for function. Among patients with full-thickness ruptures, the reduction in pain (13, 95% CI 5 to 22, p=0.002) and improvement in function (7.0, 95% CI 1.8 to 12.2, p=0.008) favoured surgery.

CONCLUSIONS

Non-surgical and surgical treatments for RCD provided equivalent improvements in pain and function. Therefore, we recommend non-surgical treatment as the primary choice for patients with RCD. However, surgery yielded superior improvement in pain and function for full-thickness rotator cuff rupture. Therefore, rotator cuff repair may be suggested after failed non-surgical treatment.

TRIAL REGISTRATION DETAILS

ClinicalTrials.gov, NCT00695981 and NCT00637013.

No Difference in Outcome Between Articular-Sided and Bursal-Sided Tears: Comparative Study With Minimum 2-Year Follow-Up of Arthroscopic Repairs in 104 Patients in a Single-Surgeon Series

PURPOSE

To evaluate and compare the functional outcomes after arthroscopic repair of bursal-sided versus articular-sided partial-thickness rotator cuff tears.

METHODS

We conducted a retrospective analysis of patients who had undergone arthroscopic tear completion and subsequent repair of symptomatic partial-thickness rotator cuff tears in a single institution from 2010 to 2015. Range of motion (ROM) (forward flexion and abduction), the pain score as measured on the Numeric Pain Rating Scale, and outcome scores (Constant-Murley score, University of California, Los Angeles shoulder score, and Oxford Shoulder Score) were calculated preoperatively and at 1 year and 2 years postoperatively. The delta difference was calculated for each outcome parameter at the respective follow-up points as the difference from the preoperative baseline score.

RESULTS

A total of 104 patients were included. All tears involved the supraspinatus tendon and did not exceed 2 cm. Of the patients, 65 had an articular-sided tear (AST) whereas 39 had a bursal-sided tear (BST). The mean age of the patients was 53.4 years in the AST group and 55.8 years in the BST group. The AST and BST groups did not differ preoperatively in terms of age, sex, and the measured outcome parameters. Postoperatively, the patients in both groups achieved statistically significant improvement in pain relief and functional outcomes at 2 years. No statistically significant difference was observed between the 2 groups in terms of the delta-difference outcomes in ROM in forward flexion (P = .781) or abduction (P = .348), pain score (P = .187), Constant-Murley score (P = .186), University of California, Los Angeles shoulder score (P = .911), and Oxford Shoulder Score (P = .186) at 2 years.

CONCLUSIONS

Partial-thickness rotator cuff tears treated with arthroscopic tear completion and subsequent repair achieved good outcomes in terms of ROM, functional outcomes, and pain relief at 2 years. There was no difference in outcomes regardless of whether the location of the tear was articular sided or bursal sided.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Traumatic rotator cuff tears - Current concepts in diagnosis and management

Rotator cuff tears represent one of common shoulder pathologies presenting over a wide spectrum of age groups and varying presentation. Typically, rotator cuff tears occur more frequently in elderly than in younger patients, following a chronic or acute-on-chronic course and usually secondary to due to tendon degeneration. Though there has been a considerable debate in the literature of the terms "acute" and "traumatic" used in the classification of rotator cuff tears, there appears to be consensus about the need for early diagnosis to facilitate prompt surgical treatment and the improve patient outcome. Significant differences in rotator cuff tears between those occurring in younger and older patients could be due to mechanism of injury, presentation, severity of the tear, biological healing potential and rehabilitation. Acute traumatic rotator cuff tears especially in younger age group represent a distinct entity from other patterns of rotator cuff tears. Consequently, a high index of suspicion, focused clinical examination, complementary imaging is a pre-requisite for an early diagnosis and effective management. We analyze the biomechanical consequences of acute rotator cuff tears along with characteristic mechanism of injury and spectrum of tendon involvement. The evolving concepts in the diagnosis and management of these distinct injuries are discussed with review of current literature.

Early versus delayed repair of traumatic rotator cuff tears. Does timing matter on outcomes?

INTRODUCTION

The purpose of this study was to determine if delay (before or after 4 months) in repairing a symptomatic traumatic rotator cuff tear affected clinical outcome, re-rupture rates and use of interpositional dermal grafts.

METHODS

This was a case matched (age + tear size) series of patients who underwent an early (≤ 4 months) or delayed (> 4 months) rotator cuff repair following a traumatic tear. If a direct repair could not be achieved a dermal interposition graft was used. Outcomes were collected at a median time of 30 months post-operatively using the Oxford, Constant and EQ5D scores.

RESULTS

Twenty patients underwent rotator cuff repair within 4 months (1-4) of injury. Twenty age and cuff tear size-matched patients were identified who had undergone a delayed repair (4.1-24 months) after injury. We found no significant difference (p > 0.05) in patient reported outcomes scores between the early and delayed repair. [Oxford scores; Early 43(13-48), Delayed 45 (31-48); Constant scores; Early 73 (21-94), Delayed 73.5 (44-87); EQ5D; Early 0.75 (0.25-1), Delayed 0.77 (0.4-1)]. Time to full recovery was significantly longer (14 vs 33.8 months) for the delayed repair group (P > 0.05). When cuff tears were subdivided into < 3 cm tears or ≥ 3 cm tears, no significant difference outcome scores were founds. However, use of dermal interposition graft was 44% in delayed group for tears ≥ 3 cm. No grafts were used in early repair group. There was one symptomatic re-tear in our series which was in the early repair group.

CONCLUSION

When compared to the delayed repair group, patients that underwent early repair of traumatic rotator cuff tears had shorter time of recovery, and less need for allograft augmentation for tears 3 cm or greater. However, at mid-term follow-up, this study found no difference in patient reported outcomes following early versus delayed repair of traumatic rotator cuff tears.

LEVEL OF EVIDENCE

3.

Can a simple fall cause a rotator cuff tear? Literature review and biomechanical considerations

Purpose

A simple fall on the shoulder is often referred to as minor trauma that cannot cause a tendon tear but at best reveal a pre-existing rotator cuff pathology. We wanted to know whether this statement was true. The purpose of our study was therefore to summarize the causes of acute rotator cuff tears reported in the literature and provide a biomechanical explanation for tendon tears diagnosed after a fall.

Method

We searched PubMed and included studies reporting rotator cuff tears occurring due to a trauma. The number of cases, the tendons involved, the age of the patients, and the nature of trauma were summarized. In addition, we noted any information provided by the authors on the pathogenesis of acute tendon ruptures.

Results

Sixty-seven articles with a total of 4061 traumatic rotator cuff tears met the inclusion criteria. A simple fall was the most common cause (725 cases) and the supraspinatus tendon was most frequently affected. The postulated pathomechanism is a sudden stretch of the tendon-muscle unit while contracting (eccentric loading).

Conclusion

A simple fall can cause an acute rotator cuff tear and fall-related tears are not restricted to young individuals. They can affect patients of any age. The stresses occurring within the rotator cuff during an attempt to cushion a fall may locally exceed the tensile strength of the tendon fibers and cause a partial or full-thickness tear.

Arthroscopic Single Lateral Row Repair Technique for Small Rotator Cuff Tears

Small symptomatic rotator cuff tears are a common problem seen by orthopaedic surgeons. Arthroscopic repair has been shown to have favorable outcomes for these lesions. There is as yet no consensus on the ideal technique for the arthroscopic repair of small rotator cuff tears. We present a single lateral row technique for the repair of such lesions, which we believe to be reproducible and effective, that achieves good approximation of the tear while reducing the chance of suture cutouts.

Protocol for a multi-site pilot and feasibility randomised controlled trial: Surgery versus PhysiothErapist-leD exercise for traumatic tears of the rotator cuff (the SPeEDy study)

BACKGROUND

Clinically, a distinction is made between types of rotator cuff tear, traumatic and non-traumatic, and this sub-classification currently informs the treatment pathway. It is currently recommended that patients with traumatic rotator cuff tears are fast tracked for surgical opinion. However, there is uncertainty about the most clinically and cost-effective intervention for patients with traumatic rotator cuff tears and further research is required. SPeEDy will assess the feasibility of a fully powered, multi-centre randomised controlled trial (RCT) to test the hypothesis that, compared to surgical repair (and usual post-operative rehabilitation), a programme of physiotherapist-led exercise is not clinically inferior, but is more cost-effective for patients with traumatic rotator cuff tears.

METHODS

SPeEDy is a two-arm, multi-centre pilot and feasibility RCT with integrated Quintet Recruitment Intervention (QRI) and further qualitative investigation of patient experience. A total of 76 patients with traumatic rotator cuff tears will be recruited from approximately eight UK NHS hospitals and randomly allocated to either surgical repair and usual post-operative rehabilitation or a programme of physiotherapist-led exercise. The QRI is a mixed-methods approach that includes data collection and analysis of screening logs, audio recordings of recruitment consultations, interviews with patients and clinicians involved in recruitment, and review of study documentation as a basis for developing action plans to address identified difficulties whilst recruitment to the RCT is underway. A further sample of patient participants will be purposively sampled from both intervention groups and interviewed to explore reasons for initial participation, treatment acceptability, reasons for non-completion of treatment, where relevant, and any reasons for treatment crossover.

DISCUSSION

Research to date suggests that there is uncertainty regarding the most clinically and cost-effective interventions for patients with traumatic rotator cuff tears. There is a clear need for a high-quality, fully powered, RCT to better inform clinical practice. Prior to this, we first need to undertake a pilot and feasibility RCT to address current uncertainties about recruitment, retention and number of and reasons for treatment crossover.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT04027205 ) - Registered on 19 July 2019. Available via.

Definition of the terms "acute" and "traumatic" in rotator cuff injuries: a systematic review and call for standardization in nomenclature

BACKGROUND

Although of high relevance for clinical decision making, there exists no consensus throughout the literature of the terms "acute" and "traumatic" used in the classification of rotator cuff tears. With differing definitions, the comparability of outcome studies may be limited. The aim was to provide a detailed systematic review of the definitions used in the literature and present a suggestion for a standardization in nomenclature based on the findings.

METHODS

Four different internet databases were searched in February 2020 using the terms ("acute" OR "traumatic" OR "trauma" OR "athlete" OR "young") AND ("rotator cuff tears" OR "rotator cuff tear" OR "rotator cuff" OR "rotator cuff rupture" OR "supraspinatus" OR "infraspinatus" OR "subscapularis" OR "teres minor"). Prospective, retrospective, cohort and case-control studies as well as case series were included. Systematic reviews, cadaveric or laboratory studies and studies on non-traumatic or non-acute rotator cuff tears were excluded.

RESULTS

The literature search conducted 10,349 articles of which 10,151 were excluded based on the title, 119 based on the abstract and 33 based on the manuscript. A total of 46 studies were finally included for review and subsequently analyzed. Overall, there exists no consensus neither on the term "acute" nor on "traumatic" in the context of rotator cuff tears in the literature. The time span for acute injuries ranged between 2 weeks and 6 months. For traumatic injuries, only 20% of the selected studies described a specific and adequate injury mechanism in combination with adequate imaging.

CONCLUSION

The term "acute" should be reserved for RCT showing muscle edema, wavelike appearance of the central part of the torn tendon and joint effusion, which typically requires adequate imaging within 2 weeks from trauma. Repair of acute tears should occur within 8 weeks from trauma to benefit from possibly superior biological healing capacities. The term "traumatic" should be used for a sudden onset of symptoms in a previously asymptomatic patient, triggered by an adequate trauma, e.g., a fall on the retroverted arm with an axial cranioventral force or a traumatic shoulder dislocation.

Clinical Outcomes of Nonoperative Treatment for Rotator Cuff Retears and Analysis of Factors That Affect Outcomes

Background

Patients who sustain a rotator cuff retear after arthroscopic rotator cuff repair are generally considered to have worse clinical outcomes compared with patients with an intact rotator cuff. However, some patients have good clinical outcomes, even with a retorn rotator cuff.

Purpose

To report the clinical outcomes of nonoperative treatment for rotator cuff retears and analyze the factors affecting clinical outcomes after a retear.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent arthroscopic rotator cuff repair between 2011 and 2017 were reviewed, and those with a full-thickness retear on postoperative magnetic resonance imaging (MRI) were included in this study. According to their pre- and postoperative scores on the pain visual analog scale (pVAS) and functional visual analog scale (fVAS), the patients were divided into 3 groups: (1) mild group (pVAS ≤ 1 and fVAS ≥ 8), (2) moderate group (pVAS ≤ 1 and fVAS ≤ 7 or pVAS 2-3 and fVAS ≥ 8), and (3) severe group (pVAS ≥ 3 and fVAS ≤ 7). Preoperative data (dominant hand involvement, heavy labor) and tear size on 6-month postoperative MRI were analyzed as factors affecting clinical outcomes.

Results

A total of 712 patients were reviewed, and a retear was observed in 62 patients (8.7%). Of the patients with retears, 52 were included in this study: 25 men and 27 women with a mean age of 62.6 years (range, 49-80 years) and mean follow-up period of 40 months (range, 24-88 months). According to the pVAS and fVAS scores, 25 patients (48.1%) were classified into the mild group, 9 (17.3%) into the moderate group, and 18 (34.6%) into the severe group. There were no significant differences in preoperative data among the 3 groups. The tear size in the coronal and sagittal planes decreased by 5.1 and 6.6 mm, respectively, in the mild group but increased by 2.8 and 1.4 mm, respectively, in the severe group.

Conclusion

In patients with retears, 48.1% had only mild symptoms at a mean of 40 months postoperatively. Patients with severe symptoms tended to have an increased tear size on postoperative MRI.