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Three Part Question

In [an adult with a rotator cuff tear] does [conservative management] acheive [a good functional outcome].

Clinical Scenario

A 45 year old man presents to the emergency department with a painful shoulder following a direct fall with hyper extension of the shoulder. After examination and appropriate investigations a tear of the rotator cuff is diagnosed. You wonder whether conservative management is suitable for this patient.

Search Strategy

Medline 1950 to January Week 4 2007 using OVID interface.
[{Rotator Cuff/in[Injury]} AND {"Sprain and Strain"/ OR Ruture/} AND {treatment.mp. OR Therapeutics/} AND {Conservative.mp OR Nonoperative.mp] LIMIT to human and English Language.

Search Outcome

23 papers found of which 19 were irrelevant to the study question or of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Itoi, Eiji and Tabata, Shiro 1992 Japan	302 shoulders from 1980-1989 with full thickness tears 124 treated conservatively: rest, anti-inflammitories and injections 59 men and 55 women average age of 63(range 28-83) Average follow-up at 3.4 years	Retrospective Study	Subjective-Pain and function. Objective-Motion and strength (Modified Wolfgang's Criteria)	82% satisfactory results. Improved pain, motion and function. Best results in those who already started with preserved range of movement and strength.	Looking at middle-aged group only <50% follow up. No control group Only 39% patients treated conservatively as many larger tears given surgical treatment
Hawkins, RH and Dunlop, R 1995 Canada	50 consecutive patients treated initially conservativly. 33 followed-up (27 men and 6 women). Average age 59.6 Follow-up 3.8 years later, including surgical and non-surgical symptomatic non-acute rotator cuff tears. Physiotherapy- supervised strengthening exercises	Retrospective study	Strength and functional parameters (Constant-Murley Score). Decision to undergo surgery	21 remain conservatively treated, although 2 unsatisfied. 12 opted for surgery. Unsatisfactory outcome predicted by insurance claim and sleep disturbance at presentation. Conservative group had higher percentage of good or excellent scores compared to surgical group before and after treatment.	No acute tears. Not intended to compare surgical and conservative management, mearly to identify determinants to predict eventual outcome.
Yamada N et al 2000 Japan	14 shoulder (mean age 70) treated conservatively– sling, steroid and LA injection, heat and physio. 26 shoulders (mean age 62) surgical treatment + physiotherapy. Mean follow up 4 years.	Retrospective Comparative study	Reslts assessed using Japanese Orthopaedic Association score- assessing pain, function, range of motion, radiographic evaluation and joint stability	Both groups in hows improved pain relief and function. Operative group improved range of movement and strength. Better reults in operation performed within 1 year of injury(significant).	Small study group Significant variation between two groups-age. Looking at large tears >5cm. Not randomized –patients choice.
Goldberg BA et al 2001 US	46 patients with a full thickness rotator cuff tear mean age of 65±11 years. Follow up at least a year. Election of nonoperative management. Home exercise program.	Retrospective study	Assessed with Simple Shoulder Test(shoulder function)	Responsiveness of shoulder function to nonoperative treatment low. Only ability so sleep on affected side and place hand behind head significantly improved.	Not acute tears. Small cohort. No control group.
			Short Form-36 (general health status) at 6 month intervals	Only significant improvement in comfort score. Significant decrease in vitality, physical function and general health.

Comment(s)

Although there are many papers on surgical management of rotator cuff tears there are few considering conservative treatment. Of these there are no RCTs. The comparitive study looks favourably to surgical treatment however this study has many weknesses. The other papers show a role for conservative management but are again of poor quality.

Clinical Bottom Line

There seems to be a role for conservative management of rotator cuff tears. The difficulty comes in identifying those suitable to be managed in this way. It seems that younger patients with acute tears and those involved in physical work should have an alternative management considered.

References

1. Itoi E, Tabata S. Conservative treatment of rotator cuff tears Clin Orthop 1992;275:165-73
2. Hawkins RH, Dunlop R Treatment of Rotator Cuff Tears Clin Orthop 1995;321; 178-188
3. Yamada N, Hamada K, Nakajima T, Kobayashi K, Funkuda H Comparison of Conservative and Operative Treatments of Massive Rotator Cuff Tears Tokai J Exp Clin Med 2000;25(4-6):151-163
4. Goldberg BA, Nowinski RJ, Matsen FA Outcome of Nonoperative Management of Full-Thickness Rotator Cuff Tears Clin Orthop 2001;382:99-107