Which Patients Need Rotator Cuff Surgery?
Determining who is a candidate and when he or she needs surgery are as important as how to operate. Not all tears are symptomatic, and not all result in functional disability.
By Leesa Galatz - September 3, 2013
Author
Leesa M. Galatz, MD
Introduction
Rotator cuff repair is one of the most common procedures performed in the shoulder. Recent advances in techniques and instrumentation have made the procedure technically easier in many ways, yet no clear clinical differences result from any single repair configuration or device. [1-3] Choices in this regard depend entirely on surgeon preference.
The controversy, more often, is in regards to surgical indications. Determining who is a candidate and when he or she needs surgery are as important as how to operate. The prevalence of rotator cuff tears is high, especially in the older population. However, not all tears are symptomatic, and not all result in functional disability.
Factors Contributing to Treatment Guidelines
Natural History
Examining the natural history of rotator cuff disease illustrates the increasing prevalence and incidence of rotator cuff tears with age. In a study of individuals with unilateral shoulder pain, the presence of rotator cuff disease was highly correlated with increasing age, such that the presence of a rotator cuff tear and the presence of bilateral cuff tears were seen in the sixth and seventh decades, respectively. [4]
Another study found that of 924 patients screened with ultrasound, 99 had a tear. [5] The average age in the tear group was a decade older than in the non-tear group: 60 versus 70 years old. Although many patients were asymptomatic, the patients with tears had less shoulder function and more pain.
Understanding the natural history of rotator cuff tears helps form treatment guidelines:
Leesa M. Galatz, MD
Introduction
Rotator cuff repair is one of the most common procedures performed in the shoulder. Recent advances in techniques and instrumentation have made the procedure technically easier in many ways, yet no clear clinical differences result from any single repair configuration or device. [1-3] Choices in this regard depend entirely on surgeon preference.
The controversy, more often, is in regards to surgical indications. Determining who is a candidate and when he or she needs surgery are as important as how to operate. The prevalence of rotator cuff tears is high, especially in the older population. However, not all tears are symptomatic, and not all result in functional disability.
Factors Contributing to Treatment Guidelines
Natural History
Examining the natural history of rotator cuff disease illustrates the increasing prevalence and incidence of rotator cuff tears with age. In a study of individuals with unilateral shoulder pain, the presence of rotator cuff disease was highly correlated with increasing age, such that the presence of a rotator cuff tear and the presence of bilateral cuff tears were seen in the sixth and seventh decades, respectively. [4]
Another study found that of 924 patients screened with ultrasound, 99 had a tear. [5] The average age in the tear group was a decade older than in the non-tear group: 60 versus 70 years old. Although many patients were asymptomatic, the patients with tears had less shoulder function and more pain.
Understanding the natural history of rotator cuff tears helps form treatment guidelines:
- Asymptomatic degenerative tears in older people should be treated non-operatively.
- Patients who present with tears sooner than might be expected, such as in their 40s and early 50s, are at risk for tear size progression and concomitant development of degenerative muscle changes.
- Given that smaller tears and tears in younger individuals heal more predictably, [6,7] early intervention may be indicated.
- At the minimum, surveillance of known tears helps prevent progression to an irreparable state.
Functional and Structural OutcomeStudies reporting the functional and structural outcome after rotator cuff repair also contribute to treatment guidelines. [8-10] The literature clearly shows that rotator cuff tendon healing is less predictable after age 60 to 65 years. Tear size also has an impact on results. [11]
Therefore, factors to consider include:
Therefore, factors to consider include:
- Patient age
- Tear size and reparability
- Pain level
- Functional disability
- Extent of non-operative treatment
Potential patient outcome should also be considered. Pain relief can occur in many patients in spite of poor healing after a rotator cuff repair. [8,12] The pain relief alone is a benefit, aside from structural restoration of tendon continuity.
Leesa Galatz, MD
Leesa M. Galatz, MD, is Associate Professor, Shoulder and Elbow Service, Washington University Orthopedics, Barnes-Jewish Hospital, St. Louis, Missouri.
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