PT vs. Surgery for Rotator Cuff Tear

Major ? Alert!
A while back we posted about a randomized controlled trial comparing decompression surgery with physiotherapy in the case of lumbar spinal stenosis. The outcome: Physiotherapy yielded similar outcomes as surgery!
Inspired by these findings, I prepared an inservice during my last clinical rotation in the form of a critically appraised topic on the current evidence comparing surgical to conservative treatment of rotator cuff tears.

The results:

– A total of 3 RCTs were published between 2014 & 2015.
– Patientgroups amounted to 56 (1), 103 (3), and 180(2) Patients
– Follow-Up Evaluations at 1 (1) (2) and 5 (3) years

– No significant differences in age/gender across studies
– Symptoms since 1 (1) (3) and 2 (3) years
– Studies included degenerative, atraumatic ruptures (1) (2) (3) and traumatic ruptures (3)
– Affected tendons: Supraspinatus (2), supraspinatus + ≥1 additional (1) (3)

– Trauma as onset of symptoms (1) (2)
– local & systemic diseases (1) (2) (3)
– previously operated shoulder (1) (2) (3)
– cognitive impairments influencing participation (1) (2) (3)

– Surgical protocol:
Open/miniopen (1) (3) or arthroscopic (2) surgery followed by ≥12 weeks of Physiotherapy mostly identical to the conservative protocol

– Conservative protocol:
inconsistent description (2) (3)
4-6 weeks: Maintain Glenohumeral/Scapular Mobility
6-12 weeks: Stabilitytraining, Increase Strength

– Primary outcome across all studies:
Constant Murley Score: Combines Shoulderfunction (65 Points) with subjective evaluation of disabilites (35 Points)

– Secondary:
…MRT post (1) (3), VAS (1) (3), several questionnaires (1) (3), SF-36 (3), Costs (2),…

– Heerspink (2015) (1): No significant difference in the per-protocol analysis. Statistically significant difference in the intention-to-treat (Surgery better than Physiotherapy). Difference below Minimal Clinically Important DifferenceHeerspink et al

– Kukkonen (2015) (2): No significant difference

Kukkonen et al

– Moosmayer (2014): Statistically significant difference. Surgery better than Physiotherapy. Difference below Minimal Clinically Important Difference

Moosmayer et al


– Re-rupture rate 20-73% (1) (3)
– Rupture progression ≥5mm in 37% of conservative shoulders.
– Costs: 2417€ for Physiotherapy, 5709€ for surgery


– Patientgroups equal at baseline
– Appropriate randomization/blinding
– Intention-to-treat (1) (2) (3) and per-protocol analysis
– Subgroup analysis (intact vs. rerupture, rerupture vs. conservative)
– High follow up rate ≥95%

– Insufficient/inconsistent description of conservative Protocols (2) (3)
– Pragmatic Studies
– Cause and Extend of ruptures differ greatly
– Kukkonen (2015) (2): Included only well compensated, small, isolated ruptures. No info whether full-thickness or partial thickness tear. Patients had full ROM at inclusion => The CMS has great focus on ROM improvement. They have no follow-up MRI.

Clinical Bottom Line:
In practice, conservative protocols yield similar outcomes to surgical intervention. Patients with degenerative ruptures should be advised to start with a conservative treatment and only cross over to surgery if it doesn’t yield satisfactory results.
Concerning the re-rupture rate, further research should be done on prognostic factors indicating successful surgery.

This is again fairly recent evidence underlining the power of our profession. In the end, we CAN prevent surgery in many cases. Furthermore, patients received the same physiotherapy as their conservative counterpart. What made the improvement? Really the surgery? And once again, physiotherapy could save a tremendous amount of money. so #GetPT1st




Heerspink, F. O. L., van Raay, J. J., Koorevaar, R. C., van Eerden, P. J., Westerbeek, R. E., van’t Riet, E., … & Diercks, R. L. (2015). Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. Journal of Shoulder and Elbow Surgery, 24(8), 1274-1281.

Kukkonen, J., Joukainen, A., Lehtinen, J., Mattila, K. T., Tuominen, E. K., Kauko, T., & Äärimaa, V. (2015). Treatment of Nontraumatic Rotator Cuff Tears.J Bone Joint Surg Am, 97(21), 1729-1737.

Moosmayer, S., Lund, G., Seljom, U. S., Haldorsen, B., Svege, I. C., Hennig, T., … & Smith, H. J. (2014). Tendon repair compared with physiotherapy in the treatment of rotator cuff tears. J Bone Joint Surg Am, 96(18), 1504-1514.


Approaching Graduation

Kai and Andreas have successfully finished their last clinical placement in Switzerland and Germany respectively!
We passed our Final patient assessment along with our classmates who are spread all over the globe From Sydney, over Switzerland to Nashville!
We want to congratulate everyone of our class who has passed their internship! Super proud of the class of 2016! We will round up our undergraduate study in the next six weeks! After that we will focus on our Manual Therapy Masters Degree and of course – Physiotutors!

First randomized controlled trial

This semester, Kai and I conducted a randomized controlled trial with two other students from our class. We investigated the effects of two PNF (proprioceptive neuromuscular facilitation) stretching techniques on hamstring extensibility measured by the sit-and-reach test. In the past, research had been conducted on PNF vs. other stretching techniques (static, ballistic, etc.) but there was no research on the different PNF compared to each other. We compared the so called PNF target muscle (TM) with the opposing muscle (OM) techniques. Our trial included 97 particpants.

Background: Proprioceptive neuromuscular facilitation (PNF) is a stretching technique known to be the most effective method for increasing range of motion. There are different techniques within PNF whose mechanism of response has traditionally been attributed to autogenic and/or reciprocal inhibition. The purpose of this study was to compare the immediate effects of PNF target muscle (TM) versus opposing muscle (OM) in hamstring extensibility.
Methods: Ninety-seven healthy college students completed the study. Participants were randomly placed in either PNF-TM or PNF-OM group and were tested pre-intervention and post-intervention by the sit-and-reach test.
Results: Statistical analysis revealed that first: there was not a significant difference (p = 0.364) in the sit and reach test between groups; and second: there was a significant difference between post and pre intervention within the groups with p = 0.000 for PNF-TM group and p = 0.000 for PNF-OM.
Conclusion: These results suggest that PNF-OM is as effective and valuable as PNF-TM.

Check the research article below!


Biomechanics of the Snatch

During this semester Kai and I had to follow the course Biomechanics 3. In previous courses (1 & 2) we learned a lot about the several forces acting on the body, as well as, in and around a joint. We focused a lot on the biomechanics of gait, specific muscle activity, and more.
In Biomechanics 3, the ultimate goal was to write a biomechanical analysis of a chosen movement. The analysis should inc


lude: Phases of the movement, kinematics, external forces, and joint analysis including muscle activity.

Kai and I chose the olympic snatch as we thought it represented a relatively complex

movement, which we could analyze in the sagittal plane.
In the video below you will see the olympic snatch with the different phases it's divided in.

You can download the report by clicking here