Conservative treatment is considered as the first-line treatment for partial-thickness rotator cuff tears (PTRCT) while surgical treatment is generally indicated in patients with failure of conservative treatment for 3-6 months and in younger patients with a traumatic tear.
Although more research is needed concerning (the effectiveness) of conservative treatment management, it could be interesting for clinical practitioners to gain insight in the risk factors for failure of conservative treatment in this population. Can we do something about it as physiotherapist (i.e. are they modifiable) or not (i.e. non-modifiable risk factors)? Previous research has proposed intrinsic (including age-related microscopic changes and decreased vascularity of tissues) and extrinsic factors (including subacromial impingement, glenohumeral instability and traumatic events).
In addition, a recent retrospective study of Amroodi & Salariyeh (2019) tried to give an answer on following questions:
- What percentage of patients with a symptomatic PTRCT progress to surgery after 6-months conservative treatment
- Could the patients’ response to conservative management be predicted using the patient or tear characteristics?
So what are the answers?
- After 6 months of conservative treatment:
– 36.8% (100/272) of patients progressed to surgery
– 63.2% (172/272) of patients their symptoms disappeared or considerably subsided
– In 12.2% (21/172) of these patients, symptoms came back at a mean follow-up of 22.2 months
- Yes, the authors concluded that hand dominancy, tear depth and tear location are predictors of failure. More specifically: PTRCTs of the dominant extremity, tears with a depth of>50% of the tendon thickness, and bursal-side tears were more likely to terminate in surgery.
Additionally the bursal-side tears were associated with male gender, earlier referral of the patients, more nonsteroidal anti-inflammatory drug consumption, more positive painful arc syndrome, and lower Constant shoulder score.
Why is this relevant for us clinicians as all these risk factors are non-modifiable?
If a patient with a PTRCT is referred to you for conservative treatment showing these risk factors, know that your conservative treatment could lead to poor outcome because of factors you cannot control.
Reference: Nakhaei Amroodi M, Salariyeh M. Predictors of failure after conservative treatment of symptomatic partial-thickness rotator cuff tear. J Shoulder Elbow Surg. 2019 Aug 6. pii: S1058-2746(19)30334-9. doi: 10.1016/j.jse.2019.05.009. [Epub ahead of print]