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...ess-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/questio...he%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...ement-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