12/12/2024
Just published in NEJM 🔥
Degenerative Rotator-Cuff Disorders
📘 https://www.nejm.org/doi/full/10.1056/NEJMcp1909797
👉 Rotator-cuff disorder encompasses a spectrum of tendon degeneration, including (in order of increasing severity) rotator-cuff tendinopathy, partial-thickness tears, full-thickness tears, and rotator-cuff–tear arthropathy (a chronic rotator-cuff tear that leads to superior migration of the humeral head and arthritis over time). (https://pubmed.ncbi.nlm.nih.gov/39602631/, https://pubmed.ncbi.nlm.nih.gov/38332156/)
👉The rotator cuff comprises four tendons: supraspinatus (assists with abduction of the arm), infraspinatus (assists with external rotation of the arm), subscapularis (assists with internal rotation), and teres minor (assists with external rotation. (figure from https://pubmed.ncbi.nlm.nih.gov/39602631/)
👫 The incidence of surgery for rotator-cuff disorder, the most common cause of shoulder pain, across U.S. states ranges from 12 to 185 per 100,000 (https://pubmed.ncbi.nlm.nih.gov/31825507/).
🤕 Tears of the rotator cuff can result from substantial traumatic injury (e.g., a motor vehicle accident, assault, a blow from a fast-moving projectile, or a fall from greater than standing height, https://pubmed.ncbi.nlm.nih.gov/31397866/) or can occur insidiously (atraumatic or degenerative rotator-cuff tear).
👴 Age above 40 years is by far the strongest risk factor for degenerative tears (https://pubmed.ncbi.nlm.nih.gov/30335631/), with increasing prevalence with advancing age (https://pubmed.ncbi.nlm.nih.gov/25441568/): 1/5 in the 50s and 1/3 in the 80s. It is interesting to know that the prevalence of asymptomatic tear also increased with age: 1/2 in the 50s and 2/3 in those older than 60s, (https://pmc.ncbi.nlm.nih.gov/articles/PMC3768248/).
🫀Several disease conditions have been postulated to have a role in the development and progression of rotator cuff disease, and subsequently, may influence healing rates following surgical repair. These conditions include type 2 diabetes mellitus, hyperlipidaemia, s*x hormone deficiency, obesity, smoking, hypertension, gout, connective tissue diseases and depression (https://pubmed.ncbi.nlm.nih.gov/34660827/, https://pubmed.ncbi.nlm.nih.gov/34424222/, https://pubmed.ncbi.nlm.nih.gov/30808669/, https://pubmed.ncbi.nlm.nih.gov/27600100/, https://pubmed.ncbi.nlm.nih.gov/28486089/, https://pubmed.ncbi.nlm.nih.gov/36252786/)
🫀 In natural-history studies of degenerative rotator-cuff tears, at 5 years of follow-up, the tears were enlarged in half the persons with full-thickness tears (https://pubmed.ncbi.nlm.nih.gov/31627964/) and the tears had progressed to full thickness in approximately one third of those with partial-thickness tears (https://pubmed.ncbi.nlm.nih.gov/26589385/). But there is a lack of correlation between patient symptoms and the size and thickness of the tear on imaging (https://pubmed.ncbi.nlm.nih.gov/24875019/).
📶Full-thickness tears are classified according to Codman classification (https://pubmed.ncbi.nlm.nih.gov/34012769/, tear size in anterior to posterior direction) as:
• Small: 0–1 cm
• Medium: 1–3 cm
• Large: 3–5 cm
• Massive: >5 cm
Although there is expert consensus that traumatic rotator-cuff tears should be treated operatively timely soon after the diagnosis is made to avoid long-term consequences such as rotator-cuff muscle degradation and tendon retraction (https://pubmed.ncbi.nlm.nih.gov/24292934/), most patients with symptomatic degenerative rotator cuff disorders can be treated nonoperatively.
🏋️♂️ Nonoperative treatment using an exercise based protocol is effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years (https://pubmed.ncbi.nlm.nih.gov/23540577/), 5 years (https://www.jshoulderelbow.org/article/S1058-2746(18)30852-8/abstract) and even 10 years (https://www.sciencedirect.com/science/article/pii/S2666638324004778). Compared with natural history, patients who performed physical therapy within the first 3 months had statistically significant improvements in pain and function as measured by the SPADI score at 3 months (https://pubmed.ncbi.nlm.nih.gov/30553798/).
😷 Consensus is lacking regarding indications for surgical intervention. Observational data support that surgery is associated with better function and reduced pain in patients who are younger (e.g.,
