A study published by Kukkonen et al. sought to compare conservative treatment with 2 surgical interventions for patients with atraumatic, small rotator cuff tears. The article found that the conservative treatment, physiotherapy, had similar outcomes to acromioplasty or acromioplasty and rotator cuff repair at 1 year based on Constant score, but physiotherapy had significantly less direct and indirect cost. Due to these results, the authors propose that physiotherapy should be the primary treatment for small, non-traumatic rotator cuff tears.

The study used a group of 180 shoulders in 173 patients referred to 3 Finnish hospitals over 5 years. The patients accepted to the study were over 55 years of age, with small atraumatic supraspinatus tears confirmed by MRI, no previous shoulder surgery, full range of motion in shoulder without evidence of arthritis in the shoulder and without major or malignant illness. The patients were then randomized into 3 groups of 60 patients each, physiotherapy treatment, Acromioplasty and physiotherapy, or rotator cuff repair, acromioplasty and physiotherapy. Physiotherapy for all patients included exercises to improve glenohmeral motion for the first six weeks, followed by strengthening and resistance training for up to six months, and 10 outpatient physiotherapy appointments. Patients in non-rotator cuff repair groups were allowed to cross over to the rotator cuff repair group after 6 months if they felt that their current treatment did not provide adequate relief. The primary outcome measure was the Constant score, but the article also used economic measures, accounting for costs to the health care system, direct costs to patients such as transportation, and indirect costs like lost income.

Constant scores at 1 year were comparable between treatments, the physiotherapy group mean score was 74.1 (14.2 SD), the acromioplasty and physiotherapy group mean score was 77.2 (13.0 SD), and the Rotator cuff repair, acromioplasty and physiotherapy group mean score was 77.9 (12.1 SD). This result wasn’t expected, as there is a placebo effect just from having a surgery performed which was expected to interfere with results. Patient satisfaction was rated at 87% in the physiotherapy group, 96% in the acromioplasty and physiotherapy group and 95% in the rotator cuff, acromioplasty and physiotherapy group and found to have an insignificant p value. Unsurprisingly, the physiotherapy only group was the least expensive to treat, and had less direct or indirect costs.

Unfortunately, this study has several shortcomings, such as not using other shoulder scores or patient reported outcomes to validate the Constant scores, and only following up for 1 year after the start of treatment. Surgical repairs of the rotator cuff often re-tear, and often require further treatment. A year is not long enough for this possible result to be studied. The results of this study still appear to be valid, as other studies have had similar results, such as a Norwegian study cited by the authors. The Norwegian study, authored by Moosmayer et al. had a similar design to this study, but used two groups, physiotherapy and Rotator cuff repair. As in this study, physiotherapy only patients in the Moosmayer study were allowed to cross over to surgical treatment.  After the Moosmayer study removed patients who crossed over to the surgical group from analysis of either group, Constant scores between physiotherapy and Rotator cuff repair showed only a 7-point difference at final follow up. Compared to this study, 7 points is an insignificant difference, as Moosmayer et al. included patients with traumatic and medium sized, full thickness tears, both conditions known to have better results with surgical interventions.

Free full text summary and commentary from the Journal of Bone and Joint Surgery available here. Full text from The Bone and Joint Journal available here.

References

Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Aärimaa V. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81. doi: 10.1302/0301-620X.96B1.32168. PubMed PMID: 24395315.
Wellmann M, Scheibel M, Nebelung W, Flury M, Agneskirchner J, Buess E, Lanz U, Auffarth A, Wambacher M, Lorbach O, Kraus N. Response to Kukkonen, J. et al., Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J 2014;96-B:75-81. Doi: 10.1302/0301-620X.96B1.32168
Feeley B. Repair and/or acromioplasty added to physiotherapy did not improve outcome in rotator cuff tear more than physiotherapy alone. J Bone Joint Surg Am. 2014 Nov 19;96(22):1922. doi: 10.2106/JBJS.9622.ebo321. PubMed PMID: 25410512; PubMed Central PMCID: PMC4238394.
Moosmayer S, Lund G, Seljom U, Svege I, Hennig T, Tariq R, Smith HJ. Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A randomised controlled study of 103 patients with one-year follow-up. J Bone Joint Surg Br. 2010 Jan;92(1):83-91. doi: 10.1302/0301-620X.92B1.22609. PubMed PMID: 20044684.

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