Introduction

The debate about whether surgical or conservative management of rotator cuff tears is preferred is frequently held and still ongoing. As rotator cuff tears affect a large proportion of the working population, it is necessary to have a clear understanding of the preferred management option in order to refer patients more efficiently. According to the authors, systematic reviews and meta-analyses investigating this topic in the medium-term follow-up are scarce, and this study tried to fill this gap.

Methods

This systematic review included randomized controlled trials comparing conservative and surgical management of full-thickness rotator cuff tears in patients aged 18 years or more. The primary outcome was the effectiveness of conservative or surgical management of rotator cuff tears on the Constant-Murley score (CMS) and the visual analog scale (VAS). As a secondary outcome, the integrity of the rotator cuff tendon, evaluated with MRI or ultrasound, was reported.

The CMS is a questionnaire that evaluates the level of pain and the ability to carry out activities of normal daily life. It is rated on a 100-point scale and comprises 4 domains: pain, activities of daily living, strength, and range of motion in forward elevation, external rotation, abduction, and internal rotation of the shoulder. A higher score represents a better quality of functioning.

Results

The systematic review included 6 studies, which consisted of 3 different cohorts: 2 by Kukkonen et al., 3 by Moosmayer et al., and 1 by Lambers-Heerspink et al. At 1 year the CMS score in 257 patients revealed an increase after both the surgical and conservative management of rotator cuff tears. The average CMS score at 12 months was 79.2 (+/-13.7) in the surgery group and 72.7 (+/- 17.2) in the conservative group. This difference was statistically significant in favor of the surgical group.

At 2 years 211 patients were evaluated with the CMS outcome and scores were 80 (+/- 15) and 75 (+/- 15) in the surgically treated and conservatively managed groups respectively. This difference was not statistically significant.

The VAS pain score at 1 year was evaluated in 147 patients and was 1.4 (+/-1.6) in the surgical group and 2.4 (+/-1.9) in the conservative group. Likewise, the surgical management of rotator cuff tears was superior in terms of VAS. The evaluation of the structural integrity of the rotator cuff repair after surgical management of rotator cuff tears by MRI revealed that in 24 of 69 patients retears were found at 1 year follow-up.

Questions and thoughts

What is interesting about the primary outcome, the CMS, is that objective findings are responsible for two-thirds of the total score. Subjective findings like pain severity and ability to carry out activities of daily living are responsible for the remaining one-third of the total score. Both are important to interpret, but clinicians often rely more on objective parameters to rate the progress of rehabilitation. The mix between the patient-reported subjective and objectively measured outcomes makes this questionnaire an interesting tool to use.

A statistically significant difference was found at 1 year in the functional outcome measured by the CMS in favor of the surgical group. This difference, however statistically significant, cannot be considered clinically relevant given that at least a difference of 10.4 points was needed to obtain a clinically important improvement in functional outcome, as determined in an earlier study by Kukkonen et al. (2013). Pain intensity measured on the VAS at 1 year was not important as a difference of at least 1.4 points was postulated to be necessary to achieve a minimal clinically meaningful difference in a study by Tashjian et al. (2009), examining patients with rotator cuff disease managed conservatively. Likewise, in a study by Kim et al. (2020), in patients after arthroscopic management of rotator cuff tears, the minimal important difference was set at 1.5 points.

The review emphasizes the statistical differences in favor of the surgical management of rotator cuff tears, however, the differences were not clinically meaningful and even in more than one-third (35%), retears of the surgically managed cuff tears were seen. Taking into account the potential complications after surgery, we would rather not overemphasize the importance of surgery in light of these small differences between both groups.

Furthermore, it isn’t very surprising that at 1 year, the surgical management of rotator cuff tears was “superior”. Many studies comparing surgery versus conservative management find quicker improvements after surgery, leveling out at longer-term follow-up.

Talk nerdy to me

Nothing to say about the methodological aspects of this systematic review, as it was performed according to the rules of art. A limitation for me personally is that the importance of surgery is overemphasized. Further limitations acknowledged by the authors include the extensive heterogeneity in the analyzed patients (for example they include isolated supraspinatus tears, or varying tears of infra-, supraspinatus, and subscapularis). Similarly, no information about the tear size was provided and different surgical procedures were compared.

In one study, conservative management of the rotator cuff tears was supplemented with corticosteroid injections, which may increase the risk for retears. No information on the physiotherapy management of rotator cuff tears was provided but when looking at the included studies it became clear that they often used “standardized” physiotherapy protocols in outpatient settings or at home. At home, compliance may be less optimal, even more so in patients signing up for surgery being then randomized to a conservative “control group”. The use of standardized exercises may not be able to match the capabilities of individualized tailored exercise therapy. In conclusion, this review attempted to answer an interesting clinical question, but the results between surgical and physical therapy treatment of rotator cuff tears are similar given the lack of clinically important differences.

Take home messages

Statistically significant differences were found after surgical management of rotator cuff tears, but minimal clinical differences were not obtained. Like in many studies comparing surgery to conservative management, a rapid improvement was seen with surgery, but this difference leveled out in the mid-term follow-up. To conclude, surgical management of rotator cuff tears is not superior to conservative management.

Reference

Longo, U. G., Risi Ambrogioni, L., Candela, V., Berton, A., Carnevale, A., Schena, E., & Denaro, V. (2021). Conservative versus surgical management for patients with rotator cuff tears: a systematic review and META-analysis. BMC musculoskeletal disorders, 22, 1-10.

Additional references

Kukkonen, J., Kauko, T., Vahlberg, T., Joukainen, A., & Äärimaa, V. (2013). Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery. Journal of shoulder and elbow surgery, 22(12), 1650-1655.

Tashjian, R. Z., Deloach, J., Porucznik, C. A., & Powell, A. P. (2009). Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease. Journal of shoulder and elbow surgery, 18(6), 927-932.

Kim, D. M., Kim, T. H., Kholinne, E., Park, J. H., Shin, M. J., Kim, H., … & Koh, K. H. (2020). Minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after arthroscopic rotator cuff repair. The American Journal of Sports Medicine, 48(11), 2650-2659.

Cook, T., & Lewis, J. (2019). Rotator cuff-related shoulder pain: to inject or not to inject?. journal of orthopaedic & sports physical therapy, 49(5), 289-293.