Cederqvist et al. 2021

To Cut or Not to Cut? A Pragmatic Trial for Rotator Cuff Disease

Rotator cuff disease can be treated conservatively with equal results to surgery

Full-thickness tears might require reconstruction

Full physiotherapy program included

Introduction

Rotator cuff disease (RCD) is one of the most common causes of prolonged shoulder pain in adolescents. Often it is treated with surgery. This trial aims to compare surgical and non-surgical treatments for RCD with or without full-thickness tendon tears.

Methods

Patients with more than 3 months of shoulder pain were recruited from two Finnish hospitals. A total of 417 patients were included. After inclusion, patients underwent 15 sessions of non-surgical treatment.

The intervention was as follows:

  • ​​Ice 10-15′ before exercises if needed for pain relief
  • Exercise therapy
    • 20RM, to 15RM, to 10RM over 0, 1, and two months respectively
    • 3 sets
    • Frequency 3x/w
    • Progression in weight if number of reps was achievable
    • Exercises
      • Bent over row with dumbell
      • Biceps curl with dumbells
      • Dumbell benchpress
      • Cable adduction
      • IR with dumbells on side or standing with cables
      • Ditto ER
      • Glenohumeral stretches
      • Hang-stretches were recommended for ROM
  • If the ROM was limited, muscle energy techniques were performed by the physiotherapist in the direction of limitation
  • Friction massage of the cuff

After three months of therapy, candidates received an MRI. Patients who were suitable for surgery were randomized into surgical or non-surgical treatment.

Results

The primary outcome measure was the mean VAS. The Constant Score (CS) was used as a secondary outcome. 

Patients without cuff tears on MRI were equally well off with the non-surgical and surgical treatment. This is in terms of VAS and CS (pain and function). The VAS decreased roughly 3-4/10 after two years.

Patients with full-thickness cuff tears did less well in the conservative group. Surgery decreased pain four points and conservative treatment by 2.5. The same was true for the CS questionnaire. Again, the follow-up was two years.

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An important limitation of the study is that during the two-year follow-up, only 38% of the patients underwent physical therapy, only 46% did their home exercises, and 8% obtained corticosteroid injections. This was likely related to the fact that patients had been suffering for some time and were familiar with the exercises, for which there may have been less persuasion.

The findings in this study are largely consistent with previous trials. Being, exercise therapy is non-inferior to surgery in the absence of a full-thickness rupture but possibly inferior in its presence. However, conservative management should probably be advised before thinking about surgery, even in full-thickness cases.

Reference

https://pubmed.ncbi.nlm.nih.gov/33272959/

 

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