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Rotator Cuff Injuries

More than 4 million people seek treatment for shoulder pain each year, with an estimated 250,000 Americans undergoing rotator cuff repair surgery annually.

When it comes to the treatment of painful rotator cuff disease, patients are often faced with a dilemma — undergo surgery to repair a partial or full thickness rotator cuff tear or elect medical management of their pain with options such as steroid injections and therapy. But how do they choose the optimal course of care and when should surgery be discussed?

After almost 15 years of research into the natural history of rotator cuff tears, orthopedic specialists at Washington University School of Medicine have identified key clinical risk factors that can objectively influence the “surgery or no surgery” decision.

“There was a controversy of sorts in orthopedics with respect to how to manage painful rotator cuff tears and when to intervene surgically,” says Jay Keener, MD, Chief of the Shoulder and Elbow Service in the Department of Orthopedic Surgery at Washington University School of Medicine and principal investigator of a long-standing, multimillion dollar NIH study focused on rotator cuff tears. “We wanted to understand the natural progression of rotator cuff tears in order to make better, more accurate clinical decisions.”

Keener and his colleagues followed hundreds of patients and found that the risk of a full thickness rotator cuff tear growing larger increased by 22 percent within the first two years. Over five years, the risk increased to 60 percent. “Tears that continued to enlarge or tears that were along the front edge of the rotator cuff subsequently had a greater risk of developing muscle degeneration,” he says.

Why is that significant? Tear size and muscle degeneration, along with a patient’s age, negatively impact surgical outcomes. So while studies have found that 70 percent of patients do feel better with steroid injections and physical therapy for small tears, that positive impact likely declines over time and there are risks of tears enlarging and healthy muscles degenerating. Although tear progression does not occur with all tears, for those with progression of the disease, the likelihood of successful cuff tendon repair surgery diminishes.

“Now we have objective data that highlights a potential downside to delaying surgery over the long-term,” says Keener. “We also now know that we need to regularly monitor patients with certain tear size and patterns who elect nonsurgical options to see if and when the tear is getting larger.”

Earlier research here also found that patients with one painful rotator cuff tear often had an unknown, painless tear in the opposite shoulder. Of those, 30 percent eventually noted progressing pain in the second shoulder, especially as they aged. The combined research points to the importance of evaluating rotator cuff disease in both shoulders.

Featured Patient: Melanie Getz
Melanie was one of Dr. Keener's patients who found that she had a painless rotator cuff tear in the opposite shoulder by enrolling in an NIH funded study while being treated for her initial rotator cuff tear. She has since made a full recovery and is back to enjoying an active lifestyle.

“We also found that we can monitor tear progression through the use of ultrasound versus a more expensive MRI, which means our research has impacted not only clinical decision-making but also the cost of healthcare in treating rotator cuff disease,” says Keener.

“The bottom line,” he adds, “is that our data is helping us counsel patients better on what their risks are with both surgical and nonsurgical treatment and when they should more strongly consider surgical options.”

Next article: Standing X-Ray Versus MRI