Epidemiology, Natural History, and Indications for Treatment of Rotator Cuff Tears

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Introduction

Rotator cuff disorders are the most common cause of disability related to the shoulder.1 Despite a large amount of literature on the management of rotator cuff tears, surgical indications remain controversial and are not standardized.2 Potential reasons for this lack of consistent management of rotator cuff tears are the significant variability of clinical manifestations and a lack of information regarding the natural history of symptomatic tears.3, 4 Limited natural history information is likely due to many tears being surgically treated after the development of symptoms. By attempting to understand the natural history of rotator cuff tears, significant insight can be gained into the etiology of the disease process as well as an understanding of when early surgical intervention should be considered versus conservative care to limit irreversible rotator cuff changes.

In order to thoroughly define the indications for treatment of rotator cuff tears, the risks and benefits of both operative and nonoperative treatment must be fully examined. Although much attention has been focused on the relative risks and benefits of surgical intervention, the risks of nonoperative treatment are just as important when considering options. The basis for an organized approach to treating rotator cuff tears is grounded in the risk for chronic rotator cuff changes associated with nonoperative treatment, the potential for healing of partial-thickness and full-thickness tears, the reparability of tears, and the prognostic factors associated with functional outcomes after treatment. This article reviews the current data regarding the prevalence of rotator cuff tearing, the natural history of asymptomatic and symptomatic rotator cuff tears, the potential for healing after rotator cuff repair, and the indications for and timing of operative and nonoperative treatment of rotator cuff tears.

Section snippets

Prevalence

Several investigators have attempted to estimate the prevalence of partial-thickness and full-thickness rotator cuff tears using both cadaver investigations and various imaging techniques in asymptomatic and symptomatic individuals. Cadaver and autopsy dissections have revealed a prevalence of rotator cuff tendon defects ranging from 5% to almost 40%.5, 6 Neer6 reported that full-thickness tears occurred less than 5% of the time in more than 500 cadaveric specimens, whereas Lehman and colleagues

Asymptomatic Full-Thickness Tears

The study of asymptomatic rotator cuff tears provides important information, including knowledge regarding the clinical manifestation of rotator cuff tears and the potential treatment options for symptomatic cuff tears that become asymptomatic. As discussed previously, a high percentage of individuals have asymptomatic rotator cuff tears. A significant number of these patients are at risk for the development of symptoms over time. Yamaguchi and colleagues4 evaluated patients with symptomatic

Spontaneous Tendon Healing

The rotator cuff has a limited ability for intrinsic healing without repair. Several investigators have investigated spontaneous rotator cuff healing in animal models.36, 37, 38 No evidence of rotator cuff healing was found at 3 weeks in a 12-mm tear in a rabbit suprapsinatus tear model.36 Similarly, an active but inadequate repair response was found in a rat supraspinatus tear model where 78% of tendons had persistent defects at 12 weeks after a 2-mm2 defect was created.37 The material and

Indications and timing for surgical repair

Treatment of rotator cuff tears should be based on the risks and benefits associated with both operative and nonoperative management. The long-term clinical results of both arthroscopic and open rotator cuff repairs are good, with more than 90% good or excellent results at 10 years.47, 58 Similarly, results of nonoperative treatment of rotator cuff tears have shown reasonable success with between 50% and 60% satisfactory results.30, 31, 32 Although most surgeons consider reparability and

Summary

The etiology of rotator cuff disease is likely multifactorial, including age-related degeneration and microtrauma and macrotrauma. The incidence of rotator cuff tears increases with aging with more than half of individuals in their 80s having a rotator cuff tear. Smoking, hypercholesterolemia, and genetics have all been shown to influence the development of rotator cuff tearing. Substantial full-thickness rotator cuff tears, in general, progress and enlarge with time. Pain, or worsening pain,

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    Disclosures: Conflict of interest—none.

    Funding source—Department of Orthopaedics, University of Utah, Veterans Administration Merit Review Grant.

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