Clinical Question: 58 y.o male patient with no significant PMHx presents to the orthopedic surgery clinic with decreased range of motion in his right shoulder and a positive drop arm test. An MRI was performed and the patient was diagnosed with a tear of his supraspinatus tendon. He was curious about the different treatment options available for his injury.
PICO Question: In adults diagnosed with full thickness rotator cuff tears, does non surgical management yield similar results compared to surgical management in shoulder function and pain.
does surgical intervention yield better results in shoulder function and pain vs non operative management.
Search Strategy:
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Population |
Intervention |
Comparison |
Outcome |
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Adults with full thickness rotator cuff tears |
surgery |
Conservative management |
Shoulder function |
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Adults with complete supraspinatus tear |
Arthroscopic surgery |
Non operative treatment |
Shoulder pain |
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Surgical repair |
Physical therapy |
Range of motion |
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Noninvasive treatment |
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PubMed
- Full thickness rotator cuff injury surgery vs conservative management pain and function à 1291
- Complete Rotator cuff injury surgery vs conservative management pain and function (within 5 years) à 879
Google Scholar
- Rotator cuff repair vs non operative rehabilitation pain and function à 28,700
- rotator cuff repair vs non operative rehabilitation pain and function ( since 2020) à 17,400
Science Direct
- rotator cuff surgery vs non operative treatment patient pain and function à 1,112
- rotator cuff surgery vs non operative treatment patient pain and function (since 2020, review articles) à 90
For the selection of articles for my Mini-Cat, I wanted to find high levels of evidence that were also studies performed within recent years. With the rapidly evolving and innovative culture in orthopedic surgical approaches and treatment options finding studies that were performed within the last 10 or 5 years was of high importance to me. There were many articles pertaining to what I was interested in researching so finding articles that were performed in the USA and were most related to the search terms I used was my method of article selection.
Articles Chosen:
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Citation Karasuyama, M., Gotoh, M., Tahara, K., Kawakami, J., Madokoro, K., Nagamatsu, T., Imai, T., Harada, N., Kudo, Y., & Shiba, N. (2020). Clinical results of conservative management in patients with full-thickness rotator cuff tear: a meta-analysis. Clinics in shoulder and elbow, 23(2), 86–93. https://doi.org/10.5397/cise.2020.00031
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Abstract: Background: Several systematic reviews have reported on the conservative treatment of full-thickness rotator cuff tears; however, clinical results of this treatment still remain determined. Methods: PubMed, Cochrane Library, PEDro, and CINAHL databases were systematically searched for randomized clinical trials and observational studies. Two independent researchers reviewed a total of 2,981 articles, 28 of which met the criteria for inclusion in the study. Clinical outcome measures included Constant score, visual analog scale score for pain, range of motion, and short-form 36 questionnaires. The meta-analysis used a linear mixed model weighted with the variance of the estimate. Results: The meta-analysis showed a significant improvement after surgery. Pain score is 26.2 mm (1 month) to 26.4 mm (3 months), and 24.8 mm (12 months) (P<0.05); active abduction: 153.2º (2 months), 159.0º (6 months), 168.1º (12 months) (P<0.05); Constant score: 67.8 points (2 months) to 77.2 points (12 months) (P<0.05); short-form 36 questionnaires “vitality” section: 57.0 points (6 months) to 70.0 points (12 months) (P<0.05). Conclusions: Our data confirmed the effectiveness of conservative treatment in patients with full-thickness rotator cuff tears 12 months post-intervention. The results suggest that conservative treatment for patients with full-thickness rotator cuff tears should be the first line of treatment before considering surgery. Keywords: Conservative management; Rotator cuff injuries; Shoulder.
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Citation: Piper, C. C., Hughes, A. J., Ma, Y., Wang, H., & Neviaser, A. S. (2018). Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery, 27(3), 572–576. https://doi.org/10.1016/j.jse.2017.09.032 |
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Abstract: Background: This study aims to compare conservative versus surgical management for patients with full-thickness RC tear in terms of clinical and structural outcomes at 1 and 2 years of follow-up. Methods: A comprehensive search of CENTRAL, MEDLINE, EMBASE, CINAHL, Google Scholar and reference lists of retrieved articles was performed since the inception of each database until August 2020. According to the Cochrane Handbook for Systematic Reviews of Interventions, two independent authors screened all suitable studies for the inclusion, extracted data and assessed risk of bias. Only randomized controlled trials comparing conservative and surgical management of full-thickness RC tear in adults were included. The primary outcome measure was the effectiveness of each treatment in terms of Constant-Murley score (CMS) and VAS pain score at different time points. The secondary outcome was the integrity of the repaired tendon evaluated on postoperative MRI at different time points. The GRADE guidelines were used to assess the critical appraisal status and quality of evidence. Results: : A total of six articles met the inclusion criteria. The average value of CMS score at 12 months of follow-up was 79.2 ± 13.7 in the surgery group and 72.7 ± 17.2 in the conservative group. The average value of CMS score at 24 months of follow-up was 80 ± 15 in the surgery group and 77 ± 15 in the conservative group. Results showed statistically significant differences between the CMS measured at one year of follow-up in favour of surgical RC repair compared with patients treated conservatively (P = 0.003). No significant differences were demonstrated in terms of CMS at 24 months of follow-up (P = 0.15). The mean of VAS pain score at 12 months of follow-up was 1.4 ± 1.6 in the surgery group and 2.4 ± 1.9 in the conservative group. Quantitative synthesis showed better results in favour of the surgical group in terms of VAS pain score one year after surgery (− 1.08, 95% CI − 1.58 to − 0.58; P < 0.001). Conclusion: At a 2-year follow-up, shoulder function evaluated in terms of CMS was not significantly improved. Further high-quality level-I randomized controlled trials at longer term follow-up are needed to evaluate whether surgical and conservative treatment provide comparable long-term results. |
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Citation: Jain, N. B., Ayers, G. D., Fan, R., Kuhn, J. E., Warner, J. J. P., Baumgarten, K. M., Matzkin, E., & Higgins, L. D. (2019). Comparative Effectiveness of Operative Versus Nonoperative Treatment for Rotator Cuff Tears: A Propensity Score Analysis From the ROW Cohort. The American journal of sports medicine, 47(13), 3065–3072. https://doi.org/10.1177/0363546519873840
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Abstract: Background: The evidence to support operative versus nonoperative treatment for rotator cuff tears is sparse and inconclusive. Purpose: To assess pain and functional outcomes in patients undergoing operative and nonoperative treatments for rotator cuff tears. Study Design: Cohort study; Level of evidence, 3 Methods: From March 2011 to February 2015, a multicenter cohort of patients with rotator cuff tears undergoing operative and nonoperative treatments was recruited. Patients completed a detailed history questionnaire, the Shoulder Pain and Disability Index (SPADI), and the American Shoulder and Elbow Surgeons (ASES) standardized form and underwent magnetic resonance imaging. In addition to baseline assessments, patients received follow-up questionnaires at 3, 6, 12, and 18 months. Propensity score weighting was used to balance differences in characteristics of the operative and nonoperative groups. Results: Adjusted for propensity scores, the operative (n = 50) and nonoperative (n = 77) groups had similar characteristics, as evidenced by the small standardized mean differences between the groups. Adjusted mean differences in the SPADI and ASES scores between the operative and nonoperative groups were -22.0 points (95% CI, -32.1 to -11.8) and -22.2 points (95% CI, -32.8 to -11.6) at 18 months, respectively. The operative group had a significantly higher proportion of patients who showed ≥30% (P = .002) and ≥50% (P < .0001) improvement in SPADI and ASES scores as compared with the nonoperative group. Conclusion: In this prospective cohort study, patients undergoing operative treatment had significantly better pain and functional outcomes as compared with patients undergoing nonoperative treatment for rotator cuff tears. Differences between the 2 groups in SPADI and ASES scores at the 6- to 18-month time points met the minimal clinically important difference (depending on the threshold used). A large randomized controlled trial is needed to answer this question more definitively. Keywords: arthroscopic surgery, nonoperative; rotator cuff tears |
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Citation: Piper, C. C., Hughes, A. J., Ma, Y., Wang, H., & Neviaser, A. S. (2018b). Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery, 27(3), 572–576 |
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Abstract: Background: Rotator cuff disease is the most common pathology of the shoulder, responsible for approximately 70% of clinic visits for shoulder pain. However, no consensus exists on the optimal treatment. The aim of this study was to analyze level I and II research comparing operative versus nonoperative management of full-thickness rotator cuff tears. Methods: A literature search was performed, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, to identify level I and II studies comparing operative versus nonoperative treatment of rotator cuff tears. Two independent researchers reviewed a total of 1013 articles. Three studies qualified for inclusion. These included 269 patients with 1-year follow-up. The mean age ranged from 59 to 65 years. Clinical outcome measures included the Constant score and visual analog scale (VAS) score for pain. Meta-analysis, using both fixed- and random-effects models, was performed on pooled results to determine overall significance. Results: Statistically significant differences favoring surgery were found in both Constant and VAS scores after 1 year, with mean differences of 5.64 (95% confidence interval, 2.06 to 9.21; P = .002) and −1.08 (95% confidence interval, −1.56 to −0.59; P < .0001), respectively. Conclusion: There was a statistically significant improvement in outcomes for patients managed operatively compared with those managed nonoperatively. The differences in both Constant and VAS scores were small and did not meet the minimal difference considered clinically significant. Larger studies with longer follow up are required to determine whether clinical differences between these treatments become evident over time. |
Summary of the Evidence:
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Author (Date) |
Level Of Evidence |
Sample/Setting (#of subjects/studies, cohort definition etc.) |
Outcome Studied |
Key Findings |
Limitations and Biases |
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Karasuyama, Gotoh, Tahara, Kawakami, Madokoro, Nagamatsu, Imai, Harada, Kudo, Shiba (2020) |
Systematic Review |
Systematic review of 28 r articles (andomized trails and observational studies) that met criteria in study. (PubMed, Cochrane, PEDro, CINAHL databases) |
Outcomes measured included constant score, visual analog scale score of pain, range of motion, short-form 36 questionnaire.
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Studies have shown significant improvement in all clinical outcomes of surgical treatment in full thickness rotator cuff injuries. Clinical results from conservative treatment are limited but indicated that conservatively treated patients diagnosed with full thickness rotator cuff tear have improvements in constant score, VAS score, range of motion at 3 months and patient based questionnaire at 6 months. |
Some limitations of the study included various types of full thickness tears were included (isolated supraspinatus tear and two or three tendon tears. There was a lack of uniformity in the conservative treatment patients. The study waws also an international study but I felt it was appropriate to include as it was a systematic review. |
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Longo, Ambrogioni, Candela, Berton, Carnevale, Schena & Denaro (2021) |
Systematic Review & Meta Analysis |
6 articles found after comprehensive search of CENTRAL,MEDLINE,EMBASE, CINAHL, Google Scholar.. only Randomized controlled Trials involving surgical vs non surgical treatment of full-thickness RC tear in adults were used. |
Outcome measured included effectiveness of each treatment using Constant-Murley Score (CMS) and Visual Analogue Scale (VAS) for pain at different time points. Other outcomes measured included postoperative MRI performed at different times evaluating integrity of repaired tendon. |
Results showed that there were no significant differences of CMS score in surgical groups and non-surgical groups at 12 months and 24 months. The mean VAS pain scored showed results that favored the surgical patients on year after surgery. |
Limitations included the types of injuries included. Some studies reported isolated supraspinatus tears while another study varying types of RC tears and another didn’t specify. Treatment for the non surgical group was not uniform as to the number of injections and duration of physical therapy. The type of surgical approach for surgical patients also differed (arthroscopic vs open vs mini open) |
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Jain, Ayers, Fan, Kuhn, Warner, Baumgarten, Matzkin, Higgins (2019) |
Cohort Study |
Multi-Center cohort from 03/2011-02/2015 of 127 patients (50 surgical) (77 non-operative). |
Outcomes measured included a detailed history questionnaire, the shoulder Pain and Disability Index (SPADI), the American Shoulder and Elbow Surgeons Standardized Form (ASES), and a shoulder MRI. Questionnaires were performed at baseline, 3,6,12, and 18 month follow ups. |
Significantly better pain and functional scores were seen in the surgical patients vs the non-surgical patients over an 18-month follow up as measured by the SPADI and ASES. |
Limitations included a small sample size (127), missing MRI data in 17 patients, and the unavailability of complete data at all of the outcome time points. The study suggest the need for a randomized controlled trial and states a cohort study as the one conducted is another limitation. |
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Piper, Hughes, Ma, Wang, Neviaser (2017) |
Systematic Review and Meta-Analysis |
269 patients with 1-year follow up were included. These patients were from three qualified studies in the Systematic Reviews and Meta-Analyses. |
Outcomes measured included constant Murley scores and visual anal score for pain. |
Results of the study show significant improvement in outcomes for patients who are managed operatively compared with those managed non-operatively in Constant and VAS scores after 1 year. |
Limitations included variation of the types of rotator cuff tears within the 3 studies included. Both traumatic and atraumatic tears were included in one of the studies. There was no uniform treatment among the patients in the three studies. |
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Brief Conclusions:
Article 1:
- The findings of the article show that patients who suffer from full thickness rotator cuff tears and received conservative treatment have improved in VAS scores, ROM scores, and constant scores at 3 months and had improvements in patient questionnaires at 6 months. The article also stated limited data of patients diagnosed with full thickness tears receiving conservative treatment.
Article 2:
- Findings of this study suggest that pain scores are worse in patients who did not receive surgical treatment 2 years post surgery. Ironically there were no significant differences seen in CMS scores between the two groups at 12 months and 24 months.
Article 3:
- Results showed that SPADI and ASES scores favored patients who opted for surgical repair of RTC injury vs non operative repair over an 18 month follow up.
Article 4:
- Outcomes of the study favored patients who were treated surgically for their RTC injuries vs those who were treated non operatively after 1 year post op follow up.
Overarching Conclusion:
- Assessing the articles, I don’t believe that conservative management of full thickness rotator cuff injures definitively provides comparable improvements as surgical management. Although the first article suggested conservative treatment is an appropriate treatment prior to surgery and is my highest weighted article, the other three articles I selected showed surgical management yielded higher degree of improvements in pain and function. There are many variables that these studies were unable to minimize which included the size of the tear, the tendons involved, what conservative treatment consisted of, etc… My highest weighted article (1), who concluded that conservative management was an appropriate initial treatment for full thickness rotator cuff tears stated there were minimal studies examining conservative management of full thickness rotator cuff tears.
Clinical Bottom Line:
Weight of Evidence:
Article 1: I felt that the first article was my highest weight of evidence. It specifically included full thickness tears and included range of motion studies which helped directly assess function, and VAS scores which assessed pain which were both directly included in my PICO elements. It included 28 studies in the systematic review which was a large sample size compared to my other articles. The studies were mostly randomized controlled trials which eliminated any bias as much as possible. The biggest limitation and a difficult variable to control was what conservative treatment was defined as and the limited amount of research including conservative treatment of full thickness rotator cuff tears. This limitation was also present in my other studies. The authors of the article concluded that conservative treatment for full-thickness rotator cuff tears is an appropriate treatment before surgical management.
Article 2: I felt that this was the article I chose that had the second highest weight of evidence. It is a systematic review and meta-analysis that included 6 articles. One of the strengths of this article was that all the studies that were involved in the meta-analysis were randomized controlled trials. The article also directly involved the two groups I was looking to examine in my PICO elements (surgical and non-surgical) patients. The outcomes it also looked at included Constant scores, and vision analogue scores which were outcome elements I was looking to examine. Drawbacks from this article include different types and severity of RTC injury amongst patients as well as no uniform treatment for surgical and non-surgical patients. Compared to some of my other articles I felt that this article had a larger subject group.
Article 4: My 4th article had the 4nd highest weight of evidence in my opinion. It is a meta-analysis that included 269 patients from 3 studies. Outcomes also included Constant-Murley scores and vision analogue scores. Compared to my other articles this study had more patients involved in the study. Limitations like the first study also included no uniformity in the type of rotator cuff injury as well as the treatment modalities among the three studies. The results from the 2 studies also were different, as the 2nd study showed more promising results in surgical patients.
Article 3: The article that had the least weight of evidence in my opinion was Article 3. This was a multi-center cohort study that included 50 surgical patients and 77 non surgical patients. The outcomes of measurement included detailed history questionnaire, the shoulder and Pain Disability Index (SPADI) and the American Shoulder and Elbow Surgeons Standardized Form and a shoulder MRI. This was an extremely small sample size which had me weight its evidence last. A left shoulder MRI was not included in my PICO search elements.
After reviewing my articles and the outcomes that were evaluated it is hard to say there is a definitive answer to my research. Many of the articles themselves stated that further randomized controlled trials would be needed to compare non-surgical treatment of full thickness rotator cuff tears and surgical treatment. After conducting my research there seems to be many variables that make one method of treatment more effective than the other. These include the type of surgical treatment used, the severity, size, and tendons involved in the rotator cuff tear, the nature of injury, and methods of conservative treatment. Although the highest weighted article suggested conservative treatment as an appropriate 1st line treatment method, there are too many mixed outcomes in my other articles to have a definitive conclusion.
Article PDF’s:
1) article1.pdf
