Rotator Cuff Tears - Predictive Factors For Management
Rotator cuff tears are very common and it is well known that their prevalence increases with age.
One common kinematic dysfunction seen in rotator cuff deficient patients is proximal migration of the humeral head.
This is particularly so since one major function of the intact rotator cuff complex is to stabilize the humeral head within the center of the glenoid fossa upon movement of the upper extremity.
Pain, tear location, and tear size all have been implicated in altered glenohumeral mechanics, however, their specific effects remain relatively unknown.
These particular factors may play an important role for us as diagnosticians and manual therapists, since a proper understanding of each may influence the treatment plans within our scopes of practice.
Specifically, do the presence or characteristics of any of the above (or other) predictive factors have the potential to guide the management of rotator cuff disease and dictate whether or not conservative care will be sufficient, or can specific characteristics predict whether surgical management is warranted? These questions form the basis of the studies included in this review.
Pertinent Results: To shed some light on the questions above, two separate studies were reviewed together.
Keener et al.
specifically examined the relative effects that rotator cuff tear size and pain had on proximal humeral migration in both symptomatic and asymptomatic individuals with rotator cuff deficient shoulders.
The premise for the inclusion of subjects with and without pain was to provide insight as to whether or not pain modalities and/or medication have the potential to influence glenohumeral kinematics in a clinical setting.
Pertinent results from this study include: •Average proximal humeral migration in symptomatic individuals was significantly greater than in those who did not suffer from pain (migration: 0.
26 + 1.
6 mm vs -0.
28 + 1.
3 mm) •For both symptomatic and asymptomatic individuals, proximal humeral migration was significantly greater in those shoulders whose tears involved the infraspinatus (either alone or in conjunction with the supraspinatus).
Interestingly, infraspinatus involvement was significantly more frequent in the symptomatic group.
•Symptomatic rotator cuff tears with an area > 175mm-squared significantly correlated with altered glenohumeral mechanics (proximal migration) •While pain significantly correlated with migration and tear area in full-thickness tears > 175mm-squared, this relationship was negated upon multivariate analysis (where tear area was the most significant predictor of proximal migration).
Maman et al.
evaluated the outcomes of individuals with rotator cuff tears who were managed non-operatively.
Evaluations were performed via review of magnetic resonance imaging studies and results were correlated with age and anatomical variables, among others.
Pertinent results from this study include: •Grouping follow-up time of non-operative treatment on a continuous scale (from 25 months), the odds ratio for an increase in rotator cuff tear size was 2.
1 as follow-up time doubled.
Significantly more full-thickness tears increased in size as compared to those partially torn.
•When patients were classified either as younger-than or older-than 60 years of age, significantly more tears progressed in size in the older group.
•While only 8% of tears decreased in size over time, none of these were from shoulders whose tears involved more than one tendon.
•No significant relationships were found among acromioclavicular joint arthritis, acromial spurs, and supraspinatus atrophy with tear progression.
However, tear size progression was significantly more common in those shoulders that demonstrated fatty infiltration of the musculature.
(Note: the presence of fatty infiltration was no different in the partial- and full-thickness groups.
) Clinical Application & Conclusions: Various factors influencing the kinematics of the glenohumeral joint were examined in the first study.
Through the simultaneous inclusion of both symptomatic and asymptomatic individuals, as well as a multivariate analysis of potential predictors, it was revealed that proximal humeral migration was significantly related to rotator cuff tear size and the involvement of the infraspinatus tendon.
Further, long-term follow up of individuals who receive conservative care for such injuries involving the rotator cuff complex provides valuable insight not only to anatomical changes that may or may not result over time, but also to the cost-effectiveness of such non-operative treatment.
As such, it was demonstrated that progression of rotator cuff tears was more likely to occur in patients older than 60 years, those involving a full-thickness tear, and in shoulders demonstrating fatty infiltration upon magnetic resonance imaging.
As demonstrated from the findings within these two studies, one may deduce that conservative management alone may not be sufficient in those individuals presenting with the specific characteristics described above.
Therefore, in conjunction with an initial attempt at rehabilitative care, prudent patient-management would also include simultaneous referral for orthopaedic consultation.
One common kinematic dysfunction seen in rotator cuff deficient patients is proximal migration of the humeral head.
This is particularly so since one major function of the intact rotator cuff complex is to stabilize the humeral head within the center of the glenoid fossa upon movement of the upper extremity.
Pain, tear location, and tear size all have been implicated in altered glenohumeral mechanics, however, their specific effects remain relatively unknown.
These particular factors may play an important role for us as diagnosticians and manual therapists, since a proper understanding of each may influence the treatment plans within our scopes of practice.
Specifically, do the presence or characteristics of any of the above (or other) predictive factors have the potential to guide the management of rotator cuff disease and dictate whether or not conservative care will be sufficient, or can specific characteristics predict whether surgical management is warranted? These questions form the basis of the studies included in this review.
Pertinent Results: To shed some light on the questions above, two separate studies were reviewed together.
Keener et al.
specifically examined the relative effects that rotator cuff tear size and pain had on proximal humeral migration in both symptomatic and asymptomatic individuals with rotator cuff deficient shoulders.
The premise for the inclusion of subjects with and without pain was to provide insight as to whether or not pain modalities and/or medication have the potential to influence glenohumeral kinematics in a clinical setting.
Pertinent results from this study include: •Average proximal humeral migration in symptomatic individuals was significantly greater than in those who did not suffer from pain (migration: 0.
26 + 1.
6 mm vs -0.
28 + 1.
3 mm) •For both symptomatic and asymptomatic individuals, proximal humeral migration was significantly greater in those shoulders whose tears involved the infraspinatus (either alone or in conjunction with the supraspinatus).
Interestingly, infraspinatus involvement was significantly more frequent in the symptomatic group.
•Symptomatic rotator cuff tears with an area > 175mm-squared significantly correlated with altered glenohumeral mechanics (proximal migration) •While pain significantly correlated with migration and tear area in full-thickness tears > 175mm-squared, this relationship was negated upon multivariate analysis (where tear area was the most significant predictor of proximal migration).
Maman et al.
evaluated the outcomes of individuals with rotator cuff tears who were managed non-operatively.
Evaluations were performed via review of magnetic resonance imaging studies and results were correlated with age and anatomical variables, among others.
Pertinent results from this study include: •Grouping follow-up time of non-operative treatment on a continuous scale (from 25 months), the odds ratio for an increase in rotator cuff tear size was 2.
1 as follow-up time doubled.
Significantly more full-thickness tears increased in size as compared to those partially torn.
•When patients were classified either as younger-than or older-than 60 years of age, significantly more tears progressed in size in the older group.
•While only 8% of tears decreased in size over time, none of these were from shoulders whose tears involved more than one tendon.
•No significant relationships were found among acromioclavicular joint arthritis, acromial spurs, and supraspinatus atrophy with tear progression.
However, tear size progression was significantly more common in those shoulders that demonstrated fatty infiltration of the musculature.
(Note: the presence of fatty infiltration was no different in the partial- and full-thickness groups.
) Clinical Application & Conclusions: Various factors influencing the kinematics of the glenohumeral joint were examined in the first study.
Through the simultaneous inclusion of both symptomatic and asymptomatic individuals, as well as a multivariate analysis of potential predictors, it was revealed that proximal humeral migration was significantly related to rotator cuff tear size and the involvement of the infraspinatus tendon.
Further, long-term follow up of individuals who receive conservative care for such injuries involving the rotator cuff complex provides valuable insight not only to anatomical changes that may or may not result over time, but also to the cost-effectiveness of such non-operative treatment.
As such, it was demonstrated that progression of rotator cuff tears was more likely to occur in patients older than 60 years, those involving a full-thickness tear, and in shoulders demonstrating fatty infiltration upon magnetic resonance imaging.
As demonstrated from the findings within these two studies, one may deduce that conservative management alone may not be sufficient in those individuals presenting with the specific characteristics described above.
Therefore, in conjunction with an initial attempt at rehabilitative care, prudent patient-management would also include simultaneous referral for orthopaedic consultation.
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