Practice Guidelines regarding the Treatment of Rotator Cuff Problems: My Commentary

[mtomaino]

On the Shoulder page of this website I recently attached an article addressing the current consensus of the AAOS (American Academy of Orthopaedic Surgeons) regarding practice guidelines for Optimizing the management of rotator cuff problems.
See the following link to take you directly there: http://www.rearmyourself.com/article/arthroscopic-repair-of-full-thickness-cuff-tears


In what follows below, I have first copied text from the article, in the order that the points are made, and after each point I provide my comment/opinion. One must remember that practice guidelines are largely predicated on "evidence" in the literature. Because there are many aspects of "practice" that we may know to be efficacious---from experience etc----even when not technically supported by "evidence in the literature" there will , at times, be conflict. My commentary is an attempt at reconciling these "conflicts".

AAOS Guidelines:

Full Thickness Tears and Asymptomatic Patients
1. In the absence of reliable evidence, it is the opinion of the work group that surgery
not be performed for asymptomatic, full thickness rotator cuff tears.
Strength of Recommendation: Consensus

MMT: I agree. However, an increase in symtoms should be regarded as an indication that the tear in increasing in size. See this link:
http://www.rearmyourself.com/question/If%20my-rotator%20cuff%20is-torn,%20but%20I%20do%20not%20want-surgery,%20what%20are%20the%20downsides
Full Thickness Tears and Symptomatic Patients

2. Rotator cuff repair is an option for patients with chronic, symptomatic full thickness
tears.
Strength of Recommendation: Weak

MMT: I agree that this is an option. However, if plain x-ray shows superior elevation of the humeral head, and if MRI reveals muscle atrophy, the success of a repair is unlikely. From a practical standpoint, if one is active, and symptomatic, a diagnostic arthroscopy may be worthwhile, before making the assumption that there are no other options other than living with the problem or having a Reverse shoulder replacement. Sometimes a Biceps tenotomy may be helpful in providing pain relief.

Rotator Cuff Tears and Exercise
3. a. We cannot recommend for or against exercise programs (supervised or
unsupervised) for patients with rotator cuff tears.
Strength of Recommendation: Inconclusive

MMT: Depsite inconclusive evidence, in my experience a short trial of PT, either as part of a home exercise program or under the supervision of a Therapist can help--by improving range of motion (especially the posterior capsule) and the balance between glenohumeral motion and scapulothoracic motion.


Rotator Cuff Tears and Corticosteroid Injections
3. b. We cannot recommend for or against subacromial injections for patients with
rotator cuff tears.
Strength of Recommendation: Inconclusive

MMT: Agree that the evidence is not clearly supportive, however, I have seen value in terms of acute pain relief. In that light, I often offer a cortisone shot--to supplement therapy--without any guarantees.

Rotator Cuff Tears and NSAIDS, Activity Modification, Ice, Heat, Iontophoresis,
Massage, T.E.N.S., PEMF, and Phonophoresis
3. c. We cannot recommend for or against the use of NSAIDS, activity modification,
ice, heat, iontophoresis, massage, Transcutaneous Electrical Nerve Stimulation
(TENS), Pulsed Electromagnetic Field (PEMF), or phonophoresis (ultrasound) for
nonoperative management of rotator cuff tears.
Strength of Recommendation: Inconclusive

MMT: Similar to the above point (3b)---I have seen both no effect AND benefit.


Rotator Cuff Related Symptoms and Exercise or Nonsteroidal Anti-Inflammatory
Medication
4. a. We suggest that patients who have rotator cuff-related symptoms in the absence of
a full thickness tear be initially treated non-operatively using exercise and/or nonsteroidal
anti-inflammatory drugs.
Strength of Recommendation: Moderate

MMT: Agree. Conservative care is effective inthe majority of patients. (see this link: http://www.rearmyourself.com/article/arthroscopic-acromioplasty-for-impingement-syndrome) But--if after a few months one is dissatisfied, and an MRI reveals tendonopathy or partieal tears, arthroscopic intervention is an option.


Rotator Cuff Related Symptoms and Corticosteroid Injections or PEMF
4. b. We cannot recommend for or against subacromial corticosteroid injection or Pulsed
Electromagnetic Field (PEMF) in the treatment of rotator cuff-related symptoms in
the absence of a full thickness tear.
Strength of Recommendation: Inconclusive

MMT: I have no experience with PEMF, but many of my patients have reported pain relief from a subacromial cortisone shot.

Rotator Cuff Related Symptoms and Iontophoresis, Phonophoresis, Transcutaneous
electrical nerve stimulation (TENS), ice, heat, massage or activity modification
4. c. We cannot recommend for or against the use of iontophoresis, phonophoresis,
transcutaneous Electrical Nerve Stimulation (TENS), ice, heat, massage, or activity
modification for patients who have rotator cuff related symptoms in the absence of a
full thickness tear.
Strength of Recommendation: Inconclusive

MMT: agree. These modalities may help--but there is little evidence to categorically support their use.

Acute Traumatic Rotator Cuff Tears and Surgery
5. Early surgical repair after acute injury is an option for patients with a rotator cuff tear.
Strength of Recommendation: Weak

MMT: Despite the weak evidence, I regard an acute full thickness tear with weakness as an indication for surgicall repair. In other words, if one is high demand and active, a torn rotator cuff is best addressed with surgical repair to optimize the liklihood of tendon healing and restoration of function. However, if my patient does not want surgery, a trial of PT is certainly an option, and repair can be delayed.

Perioperative Interventions –Corticosteroid Injections/NSAIDS
6. We cannot recommend for or against the use of perioperative subacromial
corticosteroid injections or non-steroidal anti-inflammatory medications in patients
undergoing rotator cuff surgery.
Strength of Recommendation: Inconclusive

MMT: There are cases prior to surgery where a patient may request a shot for pain relief. I have seen this help, but it is not a routine practice.


Confounding factors – Age, Atrophy/Fatty Degeneration and Worker’s Compensation
Status
7. a. It is an option for physicians to advise patients that the following factors correlate
with less favorable outcomes after rotator cuff surgery:
• Increasing Age
• MRI Tear Characteristics
• Worker’s Compensation Status
Strength of Recommendation: Increasing Age: Weak,

MMT: I have not seen age, alone, impact on success. Rather it is the status of the tendon and muscle, and the quality of the repair. Indeed, I have restored good function in patients in their 70s and 80s with cuff repair.

MRI Tear Characteristics: Weak

MMT: When an MRI shows fatty infiltration and atrophy, successful healing is less likely. But "retraction" on an MRI does not mean that a repair will not be possible.

Worker’s Compensation Status: Moderate

MMT: There is abundant "evidence" to suggest that when a case involves Worker's compensation, outcomes are less ideal. However, taking each patient as an individual, this makes little sense, and in my experience, an injured worker has as good a chance of recovering function after treatment of their rotator cuff problem as a patient whose problem was not caused by a wrok-related injury.

Confounding Factors - Diabetes, Co-morbidities, Smoking, Infection, and Cervical
Disease
7. b. We cannot recommend for or against advising patients in regard to the following
factors related to rotator cuff surgery:
• Diabetes
• Co-morbidities
• Smoking
• Prior Shoulder Infection
• Cervical Disease
Confounding Factor
Strength of
Recommendation
Diabetes Inconclusive
Co-morbidities Inconclusive
Smoking Inconclusive
Infection Inconclusive
Cervical Disease Inconclusive

MMT: agree

[mtomaino]

Surgery - Acromioplasty
8. We suggest that routine acromioplasty is not required at the time of rotator cuff repair.
Strength of Recommendation: Moderate

MMT: agree. However, if there is a large spur, or if it is clear that the tear was the result of "Impingement", then I recommend release of the CA ligament and an acromioplasty.


Surgery – Partial Rotator Cuff Repair, Debridement, or muscle transfers for patients with
irreparable rotator cuff tears when surgery is indicated.
9. It is an option to perform partial rotator cuff repair, debridement, or muscle transfers
for patients with irreparable rotator cuff tears when surgery is indicated.
Strength of recommendation: Weak

MMT: Partial cuff repairs are of benefit. Muscle transfers can be helpful, but patient selection is critical. In my experience, a latissimus transfer is best suited for a patient with an irreparable tear who does not have pseudoparalysis. Now that the Reverse shoulder is such a good option, I would lean towards that option in patients older that 60 who desire improved pain relief and overhead function.

Surgery – Tendon to Bone Healing
10. a. It is an option for surgeons to attempt to achieve tendon to bone healing of the cuff
in all patients undergoing rotator cuff repair.
Strength of Recommendation: Weak

MMT: I am not sure what the point is here; anytime one elects to repair a torn cuff tendon, the goal is tendon to bone healing if the tendon can be brought back to its normal footprint without tension. Although it is known that in some cases of "good outcome" the cuff has not actually healed to bone---which may raise the question of whether tendon to bone healing is critical--it is certainly the goal to achieve this.

Surgery - Suture Anchors and Bone Tunnels
10. b. We cannot recommend for or against the preferential use of suture anchors versus
bone tunnels for repair of full thickness rotator cuff tears.
Strength of Recommendation: Inconclusive

MMT Agree. The fundamental tenet is secure fixation--and both are options. It is certainly more common to use anchors when a repair is performed arthroscopically. The theoretical advantage of bone tunnels is the avoidance of foreign material were an infectious complication to develop, or to avoid interfering with a postoperative MRI (if a metal anchor were to be used, for example.)

Surgery – Arthroscopic, Open, Mini-Open
10. c. We cannot recommend for or against a specific technique (arthroscopic, mini-open
or open repair) when surgery is indicated for full thickness rotator cuff tears.
Strength of Recommendation: Inconclusive

MMT: Agree. We do know that all are effective. However, the overwhelming majority of shoulder experts perform repairs arthroscopically in most cases because the minimally invasive nature of this technique diminishes soft tissue trauma and may result in a bit less pain after surgery. The "biology" of repair, and the necessity of being in a sling for 6 weeks is the same regardless of technique.

Surgery - Non-Crosslinked, Porcine Small Intestine Submucosal Xenografts
11. a. We suggest surgeons not use a non-crosslinked, porcine small intestine submucosal xenograft patch to treat patients with rotator cuff tears.
Strength of Recommendation: Moderate

MMT: Agree I have had to remove these and do not recommend use to augment thin tendon or to bridge defects

Surgery - Allografts and Xenografts
11. b. We cannot recommend for or against the use of soft tissue allografts or other
xenografts to treat patients with rotator cuff tears.
Strength of Recommendation: Inconclusive

MMT: I have no experience using these over the course of 17 years---in light of inconclusive evidence, I see no reason to start.

Post-Operative Treatment - Cold Therapy
12. In the absence of reliable evidence, it is the opinion of the work group that local cold
therapy is beneficial to relieve pain after rotator cuff surgery.
Strength of Recommendation: Consensus

MMT Agree. However, I have stoppped using expensive, commercially available devices due to cost, and have found that ice packs (filling a bag with ice) is equally efficiacious.


Post-Operative – sling, shoulder immobilizer, abduction pillow, or abduction brace
13. a. We cannot recommend for or against the preferential use of an abduction pillow
versus a standard sling after rotator cuff repair.
Strength of Recommendation: Inconclusive

MMT: Though a wedge/abduction pillow are not critical, there is evidence that shows that the strain on the repaired tendon is eased by the wedge. For that reason, there may be a beneficial, though unproven, impact on healing. It's for that reason that I routinely advise the use of this type of sling for 6 weeks after repair.

Post-Operative Rehabilitation – Range of Motion Exercises
13. b. We cannot recommend for or against a specific time frame of shoulder
immobilization without range of motion exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive

MMT Agree. However, there is some new evidence to support "No Motion" for 6 weeks as opposed to Passive motion. See this link: http://www.rearmyourself.com/article/Physical%20Therapy-after-Rotator%20Cuff-Repair

Post-Operative Rehabilitation – Active Resistance Exercises
13. c. We cannot recommend for or against a specific time interval prior to initiation of
active resistance exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive

MMT: The initiation of such exercises will "load" the repair. This may stimulate healing, but it may also cause gapping at the repair site. For that reason I start isometrics at 8-10 weeks but defer resistance exercises until 3 months.

Post-Operative Rehabilitation – Home Based Exercise and Facility Based Rehabilitation
13. d. We cannot recommend for or against home-based exercise programs versus
facility-based rehabilitation after rotator cuff surgery.
Strength of Recommendation: Inconclusive

MMT:Agree --compliance with whatever program is selected is the key.

Post-Operative - Infusion Catheters
14. We cannot recommend for or against the use of an indwelling subacromial infusion
catheter for pain management after rotator cuff repair.
Strength of Recommendation: Inconclusive

MMT: in light of the risk of Chondrolysis when these catheters are used inside the glenohumeral joint, and because a cuff repair may not be "watertight", I do not use these catheters any more. I have found that a good regional block will provide 8-10 hours of pain relief, and my patients did not seem to complain more after I stopped using these devices.