- Email: [email protected]
Natural history or outcome with conservative treatment of degenerative rotator cuff tears
Available online at www.sciencedirect.com
Joint Bone Spine 74 (2007) 527e529 http://france.elsevier.com/direct/BONSOI/
Editorial
Natural history or outcome with conservative treatment of degenerative rotator cuff tears
Keywords: Natural history; Shoulder; Rotator cuff; Degenerative tear; Conservative treatment
Anatomic data suggest e but do not prove e that the natural history of degenerative rotator cuff tears may involve a sequence of events that unfolds over time. Knowledge of the natural history of rotator cuff tears would be extremely useful for interpreting the long-term clinical results of conservative treatment. A well-known and crucial fact is that degenerative rotator cuff tears may be asymptomatic. Clinicopathologic studies laid the foundations of the study of degenerative rotator cuff tears. In 1960, M. de Se`ze and co-workers distinguished various causes of shoulder pain, placing degenerative rotator cuff tears at the core of a well-known classification system [1]. Routine autopsy or imaging studies have yielded convincing data [2e7]. The supraspinatus tendon is involved first. Supraspinatus tears may involve the full thickness of the tendon. Partial-thickness tears involve the superficial (bursa-side) or the deep (joint-side) aspect of the tendon or extend longitudinally within the tendon. A supraspinatus tear may be accompanied with a tear in the infraspinatus or, less often, the subscapularis tendon; involvement of all three tendons is the least common pattern. Data from cross-sectional studies suggest a sequence of events unfolding over time. Studies of anatomic findings according to age have established that degenerative rotator cuff tears are exceedingly rare before 40 years of age and that both their prevalence and their extent increase with advancing age [3e6]. Thus, partial-thickness tears usually occur in the sixth decade of life, full-thickness tears in the seventh decade, and involvement of multiple tendons in the oldest patients. Three longitudinal studies suggest that this age-related sequence may reflect the natural history of degenerative rotator cuff tears [8e10]. In a 5.5-year follow-up study of 45 shoulders with full-thickness asymptomatic rotator cuff tears detected by ultrasonography, 50% of shoulders developed symptoms, after a mean interval of 3 years [10]. A repeat physical examination and ultrasonography scan were performed at last follow-up in 23 shoulders. Tear progression, 1297-319X/$ - see front matter Ó 2007 Published by Elsevier Masson SAS. doi:10.1016/j.jbspin.2007.07.009
defined as widening by 5 mm or more, occurred in 20% (2/ 9) of the asymptomatic shoulders compared to 50% (7/14) of the symptomatic shoulders. The other two studies focused on symptomatic patients who were treated conservatively [8,9]. In a study of 90 shoulders with arthrographically documented full-thickness tears, indirect criteria suggested the same progression over time [8]. Thus, the acromiohumeral distance measured on standard radiographs decreased in 70% of cases, after a mean interval of 4.5 years. Distances smaller than 7 mm were seen after 7 years and were associated with a predominance (59%) of supraspinatus and infraspinatus tears at baseline. Degenerative lesions of the glenohumeral joint developed in 13% of cases. Importantly, despite the evidence of lesion progression, nearly 80% of patients reported perceived improvements compared to baseline. The other study collected follow-up data on 40 joint-side partial-thickness degenerative tears [9]. The supraspinatus tendon was involved in 25 cases, the infraspinatus tendon in 9 cases, and both tendons in 6 cases. Lesion progression occurred in 80% of cases, with development of full-thickness tears in 25% of cases. Nevertheless, objective tests consistently showed improvements in pain and function. Thus, the Japanese Orthopaedic Association ratings at study completion ranged from 76 to 93 points on 100, indicating good or very good clinical outcomes. Although the outcome did not seem influenced by the number of tendons involved at baseline, few shoulders had involvement of two tendons at baseline. These data support clinical experience regarding the progression of degenerative rotator cuff tears. Furthermore, they confirm that the anatomic damage fails to correlate with the clinical manifestations, indicating that surgical repair is not always appropriate. Notwithstanding the irreversible nature of the lesions and relatively high rate of progression, which are widely used as arguments to support the widespread use of surgery, conservative treatment seems to produce outcomes that satisfy many patients. Thus, the clinical expression of
528
Editorial / Joint Bone Spine 74 (2007) 527e529
degenerative rotator cuff tears may be an event e a term that indicates transitoriness e whose determinants need to be identified. Although an influence of lesion site, size, and kinetics cannot be denied, not all of these determinants seem directly related to the intrinsic characteristics of degenerative rotator cuff tears. Tear progression may be more common in patients with symptoms: 50% versus 20% in the above-mentioned study [10]. Nevertheless, half the patients with symptoms experienced no progression. An ultrasound study of 120 shoulders with or without symptoms showed that pain was far more closely correlated to subacromial bursitis and long biceps tendinopathy than to tear size [11]. These data support the conservative treatment of degenerative rotator cuff tears. Although proof of efficacy from welldesigned therapeutic trials is lacking, a recent guideline recommends conservative treatment [12]. Conservative treatment includes level I and II analgesics, nonsteroidal antiinflammatory drugs, local glucocorticoid injections, and specific physical therapy. Data on mid- and long-term efficacy come only from case-series [8,13e21]. A full-thickness tear documented by arthrography was the inclusion criterion in most of these studies [8,13,14,16e19]; some studies, however, used clinical, ultrasound or MRI criteria [15,20,21]. A detailed description of the lesions is lacking in some reports [20,21]. One study focused on tears involving at least two tendons and measuring at least 5 cm [21], whereas another preferentially included patients with isolated supraspinatus involvement [20]. Few details on the treatment regimens are given in the reports. Clearly, the treatments were not standardized, indicating room for treatment optimization. The evaluation criteria were either individual symptoms (e.g., pain, motion range, and strength) or global assessments of the degree of improvement or of the final status assessed separately from the baseline status. The percentage of patients with improvements or good to very good results varied widely, from 40% to 80%, and seemed independent from follow-up duration, which ranged from 19 to 96 months. Thus, no firm conclusions can be drawn about the efficacy of conservative treatment or about whether the clinical results are maintained or deteriorate in the long-term. Subgroup analyses and details about the changes over time are more informative. In some studies, a time to treatment shorter than 6 months or a rapid therapeutic response predicted better outcomes [15,17]. Among the components of the algofunctional status of the shoulder, strength failed to improve [16,17,21]. In contrast, conservative treatment consistently alleviated the pain and improved the range of motion. Strength in abduction remained unchanged in a study with a follow-up of 41 months [16]. In a 96-month study, strength in abduction and external rotation remained unchanged, whereas strength in forward elevation decreased [17]. These data are important to clinicians: despite good to very good results, conservative treatment failed to restore shoulder strength [16,17,21]. Evaluations of baseline characteristics of respondents support this finding [16,19,21]. In three studies, baseline strength in abduction, external rotation, and forward elevation correlated with the outcome, whereas baseline motion range and pain showed inconsistent or no correlations with outcomes. As expected,
improvements in motion range and pain correlated with better outcomes [18]. These data suggest that the effectiveness of conservative treatment may be limited in patients who have shoulder weakness at baseline. Although the nature and size of the tear probably affect the outcome, direct proof of a role for these factors remains unavailable. In two studies, indirect radiographic criteria suggested that greater lesion severity was associated with poorer outcomes [15,21]. A study that used ultrasonography, arthrography, or MRI to assess the lesions found no evidence that tear size predicted the result of conservative treatment [20]. A possible explanation is the high prevalence of isolated supraspinatus tears in this study [20]. Muscle strength as evaluated in clinical practice does not provide accurate information on the extent of rotator cuff damage [22]. Attempts at quantitative evaluations produced approximative results. Other factors may contribute to cause muscle weakness in patients with degenerative rotator cuff tears, most notably fatty degeneration of the cuff muscles [23]. Once the tendon is torn, fat accumulates within the muscle, as shown by computed tomography studies. Fatty degeneration, which seems irreversible, governs the result of surgical repair [24]. The more advanced forms of fatty degeneration are seen in patients with large tears, most notably involving all three tendons, and in those with long symptom durations. Within the first 6 months of the clinical history, fatty degeneration remains limited and does not compromise the results of surgical repair [23]. Thus, the natural history of degenerative rotator cuff tears remains incompletely understood. Nevertheless, three main facts are important to consider when defining treatment strategies. First, the prevalence and the severity of the lesions increase with age, probably as a result of slow lesion progression over time. Prevalent tears and tear progression may remain asymptomatic. The occurrence of symptoms is not dependent solely on the characteristics of the tear; instead, pain and functional impairment may be transient and inconsistent manifestations during the natural history of the tear. Second, acceptable midand long-term improvements are achieved in 40e80% of patients who are treated conservatively, and earlier treatment is associated with better outcomes. Therefore, conservative treatment should be used for the first-line management of degenerative rotator cuff tears. Third, weakness at baseline, whose determinants are incompletely understood, may predict limited improvements in pain and function with conservative treatment. This possibility should encourage efforts to optimize the treatment regimen by providing physical therapy aimed at developing substitute muscles. Furthermore, surgery should be considered to restore shoulder strength in patients with incapacitating weakness and no response to first-line treatment. Because the early response to conservative treatment predicts the outcome, and given the time needed for fatty degeneration to develop, surgical repair can be offered within 6 months of symptom onset. In most cases, 3 months of conservative treatment are sufficient to assess the clinical gains achievable without surgery. The indications and modalities of conservative treatment need to be further refined. Anatomic and functional outcomes
Editorial / Joint Bone Spine 74 (2007) 527e529
of isolated supraspinatus tendon tears should be determined. Studies of long-term outcomes of conservative treatment according to the extent of the lesions are needed. Most of the available studies either failed to describe the tears in detail or included patients who were heterogeneous in terms of tear location and number of torn tendons. Data are also needed on the incidence of degenerative glenohumeral disease with loss of head centering, which may be viewed as the last stage in the natural history of degenerative rotator cuff tears. They may be useful to define more accurately the time of surgical repair or replacement: the long-term outcomes of arthroplasty for degenerative glenohumeral disease with abnormal cuff function remain indeed unclear [25]. Future studies should lead to the anatomic and clinical characterization of tear patterns associated with specific treatment requirements and outcomes, as well as to a more accurate determination of the optimal time to surgery and of the best imaging study strategy. References [1] Se`ze de S, Ryckewaert A, Welfling J, Caroit M, Hubault A. Epaule pseudo paralyse´e, e´paule douloureuse, e´paule bloque´e. Presse Me´d 1964;72:1795e8. [2] Petersson CJ. Ruptures of the supraspinatus tendon. Cadaver dissection. Acta Orthop Scand 1984;55:52e6. [3] Ozaki J, Fujimoto S, Nakagawa Y, Masuhara K, Tamai S. Tears of the rotator cuff of the shoulder associated with pathological changes in the acromion. A study in cadavera. J Bone Joint Surg Am 1988;70:1224e30. [4] Hijioka A, Suzuki K, Nakamura T, Hojo T. Degenerative change and rotator cuff tears. An anatomical study in 160 shoulders of 80 cadavers. Arch Orthop Trauma Surg 1993;112:61e4. [5] Milgrom C, Schaffler M, Gilbert S, van Holsbeeck M. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br 1995;77:296e8. [6] Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10e5. [7] Goutallier D, Postel JM, Lavau L, Bernageau J. Clivage des tendons de la coiffe. In: Laredo JD, Bard H, editors. La coiffe des rotateurs et son environnement. Montpellier: Sauramps me´dical; 1996. p. 45e9. [8] Noe¨l E. Les ruptures de la coiffe des rotateurs. Re´sultats du traitement conservateur. (A propos de 171 e´paules) (p. 113e8). In: Simon L, Pe´lissier J, He´risson Ch, editors. Actualite´s en re´e´ducation fonctionnelle et re´adaptation, 19e se´rie. Paris: Masson; 1994. [9] Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff. A follow up study by arthrography. Clin Orthop Relat Res 1994;304:68e73. [10] Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg 2001;10:199e203. [11] Zeitoun-Eiss D, Brasseur JL, Goldmard JL. Corre´lations entre la se´miologie e´chographique et la douleur dans les ruptures transfixiantes de la coiffe des rotateurs. In: Blum A, Tavernier T, Brasseur JL, et al., editors. Une approche pluridisciplinaire. Montpellier: Sauramps me´dical; 2005. p. 287e94. [12] Recommandations pour la pratique clinique. Modalite´s de prise en charge d’une e´paule douloureuse chronique non instable chez l’adulte. Available from: http://www.has-sante.fr; Avril 2005.
529
[13] Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. J Bone Joint Surg Am 1974; 56:14e26. [14] Samilson RL, Binder WF. Symptomatic full thickness tears of rotator cuff. An analysis of 292 shoulders in 276 patients. Orthop Clin North Am 1975;6:449e66. [15] Caroit M, Rouaud JP, Texier T, Gaudouen Y, Delcambre B, Deloose F. Outcome of rupture and complete perforation of the unoperated rotator cuff of the shoulder. Rev Rhum Mal Osteoartic 1989; 56:815e21. [16] Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin Orthop Relat Res 1992;275:165e73. [17] Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop Relat Res 1993;294:103e10. [18] Hawkins RH, Dunlop R. Nonoperative treatment of rotator cuff tears. Clin Orthop Relat Res 1995;321:178e88. [19] Wirth MA, Basamania C, Rockwood CA. Nonoperative management of full-thickness tears of the rotator cuff. Orthop Clin North Am 1997;28:59e67. [20] Goldberg BA, Nowinski RJ, Matsen FA. Outcome of nonoperative management of full-thickness rotator cuff tears. Clin Orthop Relat Res 2001;382:99e107. [21] Vad VB, Warren RF, Altchek DW, O’Brien SJ, Rose HA, Wickiewicz TL. Negative prognostic factors in managing massive rotator cuff tears. Clin J Sport Med 2002;12:151e7. [22] Leroux JL, Thomas E, Bonnel F, Blotman F. Diagnostic value of clinical tests for shoulder impingement syndrome. Rev Rhum Engl Ed 1995;62:423e8. [23] Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 1994;304:78e83. [24] Goutallier D, Postel JM, Lavau L, Bernageau J. Impact of fatty degeneration of the supraspinatus and infraspinatus muscles on the prognosis of surgical repair of the rotator cuff. Rev Chir Orthop Reparatrice Appar Mot 1999;85:668e76. [25] Goutallier D, Postel JM, Zilber S, Van-Driessche S. Shoulder surgery: from cuff repair to joint replacement. An update. Joint Bone Spine 2003;70:422e32.
Johann Beaudreuil* Thomas Bardin Philippe Orcel Centre Viggo Petersen, Fe´de´ration de Rhumatologie, Hoˆpital Lariboisie`re, 2 rue Ambroise Pare´, 75475 Paris cedex 10, France *Corresponding author. Tel.: þ33 149 956 308; fax: þ33 149 958 631. E-mail address: [email protected] (J. Beaudreuil) Daniel Goutallier Orthopaedic Surgery and Trauma Unit, Henri Mondor Teaching Hospital, Cre´teil, France 29 March 2007 Available online 18 October 2007
Joint Bone Spine 74 (2007) 527e529 http://france.elsevier.com/direct/BONSOI/
Editorial
Natural history or outcome with conservative treatment of degenerative rotator cuff tears
Keywords: Natural history; Shoulder; Rotator cuff; Degenerative tear; Conservative treatment
Anatomic data suggest e but do not prove e that the natural history of degenerative rotator cuff tears may involve a sequence of events that unfolds over time. Knowledge of the natural history of rotator cuff tears would be extremely useful for interpreting the long-term clinical results of conservative treatment. A well-known and crucial fact is that degenerative rotator cuff tears may be asymptomatic. Clinicopathologic studies laid the foundations of the study of degenerative rotator cuff tears. In 1960, M. de Se`ze and co-workers distinguished various causes of shoulder pain, placing degenerative rotator cuff tears at the core of a well-known classification system [1]. Routine autopsy or imaging studies have yielded convincing data [2e7]. The supraspinatus tendon is involved first. Supraspinatus tears may involve the full thickness of the tendon. Partial-thickness tears involve the superficial (bursa-side) or the deep (joint-side) aspect of the tendon or extend longitudinally within the tendon. A supraspinatus tear may be accompanied with a tear in the infraspinatus or, less often, the subscapularis tendon; involvement of all three tendons is the least common pattern. Data from cross-sectional studies suggest a sequence of events unfolding over time. Studies of anatomic findings according to age have established that degenerative rotator cuff tears are exceedingly rare before 40 years of age and that both their prevalence and their extent increase with advancing age [3e6]. Thus, partial-thickness tears usually occur in the sixth decade of life, full-thickness tears in the seventh decade, and involvement of multiple tendons in the oldest patients. Three longitudinal studies suggest that this age-related sequence may reflect the natural history of degenerative rotator cuff tears [8e10]. In a 5.5-year follow-up study of 45 shoulders with full-thickness asymptomatic rotator cuff tears detected by ultrasonography, 50% of shoulders developed symptoms, after a mean interval of 3 years [10]. A repeat physical examination and ultrasonography scan were performed at last follow-up in 23 shoulders. Tear progression, 1297-319X/$ - see front matter Ó 2007 Published by Elsevier Masson SAS. doi:10.1016/j.jbspin.2007.07.009
defined as widening by 5 mm or more, occurred in 20% (2/ 9) of the asymptomatic shoulders compared to 50% (7/14) of the symptomatic shoulders. The other two studies focused on symptomatic patients who were treated conservatively [8,9]. In a study of 90 shoulders with arthrographically documented full-thickness tears, indirect criteria suggested the same progression over time [8]. Thus, the acromiohumeral distance measured on standard radiographs decreased in 70% of cases, after a mean interval of 4.5 years. Distances smaller than 7 mm were seen after 7 years and were associated with a predominance (59%) of supraspinatus and infraspinatus tears at baseline. Degenerative lesions of the glenohumeral joint developed in 13% of cases. Importantly, despite the evidence of lesion progression, nearly 80% of patients reported perceived improvements compared to baseline. The other study collected follow-up data on 40 joint-side partial-thickness degenerative tears [9]. The supraspinatus tendon was involved in 25 cases, the infraspinatus tendon in 9 cases, and both tendons in 6 cases. Lesion progression occurred in 80% of cases, with development of full-thickness tears in 25% of cases. Nevertheless, objective tests consistently showed improvements in pain and function. Thus, the Japanese Orthopaedic Association ratings at study completion ranged from 76 to 93 points on 100, indicating good or very good clinical outcomes. Although the outcome did not seem influenced by the number of tendons involved at baseline, few shoulders had involvement of two tendons at baseline. These data support clinical experience regarding the progression of degenerative rotator cuff tears. Furthermore, they confirm that the anatomic damage fails to correlate with the clinical manifestations, indicating that surgical repair is not always appropriate. Notwithstanding the irreversible nature of the lesions and relatively high rate of progression, which are widely used as arguments to support the widespread use of surgery, conservative treatment seems to produce outcomes that satisfy many patients. Thus, the clinical expression of
528
Editorial / Joint Bone Spine 74 (2007) 527e529
degenerative rotator cuff tears may be an event e a term that indicates transitoriness e whose determinants need to be identified. Although an influence of lesion site, size, and kinetics cannot be denied, not all of these determinants seem directly related to the intrinsic characteristics of degenerative rotator cuff tears. Tear progression may be more common in patients with symptoms: 50% versus 20% in the above-mentioned study [10]. Nevertheless, half the patients with symptoms experienced no progression. An ultrasound study of 120 shoulders with or without symptoms showed that pain was far more closely correlated to subacromial bursitis and long biceps tendinopathy than to tear size [11]. These data support the conservative treatment of degenerative rotator cuff tears. Although proof of efficacy from welldesigned therapeutic trials is lacking, a recent guideline recommends conservative treatment [12]. Conservative treatment includes level I and II analgesics, nonsteroidal antiinflammatory drugs, local glucocorticoid injections, and specific physical therapy. Data on mid- and long-term efficacy come only from case-series [8,13e21]. A full-thickness tear documented by arthrography was the inclusion criterion in most of these studies [8,13,14,16e19]; some studies, however, used clinical, ultrasound or MRI criteria [15,20,21]. A detailed description of the lesions is lacking in some reports [20,21]. One study focused on tears involving at least two tendons and measuring at least 5 cm [21], whereas another preferentially included patients with isolated supraspinatus involvement [20]. Few details on the treatment regimens are given in the reports. Clearly, the treatments were not standardized, indicating room for treatment optimization. The evaluation criteria were either individual symptoms (e.g., pain, motion range, and strength) or global assessments of the degree of improvement or of the final status assessed separately from the baseline status. The percentage of patients with improvements or good to very good results varied widely, from 40% to 80%, and seemed independent from follow-up duration, which ranged from 19 to 96 months. Thus, no firm conclusions can be drawn about the efficacy of conservative treatment or about whether the clinical results are maintained or deteriorate in the long-term. Subgroup analyses and details about the changes over time are more informative. In some studies, a time to treatment shorter than 6 months or a rapid therapeutic response predicted better outcomes [15,17]. Among the components of the algofunctional status of the shoulder, strength failed to improve [16,17,21]. In contrast, conservative treatment consistently alleviated the pain and improved the range of motion. Strength in abduction remained unchanged in a study with a follow-up of 41 months [16]. In a 96-month study, strength in abduction and external rotation remained unchanged, whereas strength in forward elevation decreased [17]. These data are important to clinicians: despite good to very good results, conservative treatment failed to restore shoulder strength [16,17,21]. Evaluations of baseline characteristics of respondents support this finding [16,19,21]. In three studies, baseline strength in abduction, external rotation, and forward elevation correlated with the outcome, whereas baseline motion range and pain showed inconsistent or no correlations with outcomes. As expected,
improvements in motion range and pain correlated with better outcomes [18]. These data suggest that the effectiveness of conservative treatment may be limited in patients who have shoulder weakness at baseline. Although the nature and size of the tear probably affect the outcome, direct proof of a role for these factors remains unavailable. In two studies, indirect radiographic criteria suggested that greater lesion severity was associated with poorer outcomes [15,21]. A study that used ultrasonography, arthrography, or MRI to assess the lesions found no evidence that tear size predicted the result of conservative treatment [20]. A possible explanation is the high prevalence of isolated supraspinatus tears in this study [20]. Muscle strength as evaluated in clinical practice does not provide accurate information on the extent of rotator cuff damage [22]. Attempts at quantitative evaluations produced approximative results. Other factors may contribute to cause muscle weakness in patients with degenerative rotator cuff tears, most notably fatty degeneration of the cuff muscles [23]. Once the tendon is torn, fat accumulates within the muscle, as shown by computed tomography studies. Fatty degeneration, which seems irreversible, governs the result of surgical repair [24]. The more advanced forms of fatty degeneration are seen in patients with large tears, most notably involving all three tendons, and in those with long symptom durations. Within the first 6 months of the clinical history, fatty degeneration remains limited and does not compromise the results of surgical repair [23]. Thus, the natural history of degenerative rotator cuff tears remains incompletely understood. Nevertheless, three main facts are important to consider when defining treatment strategies. First, the prevalence and the severity of the lesions increase with age, probably as a result of slow lesion progression over time. Prevalent tears and tear progression may remain asymptomatic. The occurrence of symptoms is not dependent solely on the characteristics of the tear; instead, pain and functional impairment may be transient and inconsistent manifestations during the natural history of the tear. Second, acceptable midand long-term improvements are achieved in 40e80% of patients who are treated conservatively, and earlier treatment is associated with better outcomes. Therefore, conservative treatment should be used for the first-line management of degenerative rotator cuff tears. Third, weakness at baseline, whose determinants are incompletely understood, may predict limited improvements in pain and function with conservative treatment. This possibility should encourage efforts to optimize the treatment regimen by providing physical therapy aimed at developing substitute muscles. Furthermore, surgery should be considered to restore shoulder strength in patients with incapacitating weakness and no response to first-line treatment. Because the early response to conservative treatment predicts the outcome, and given the time needed for fatty degeneration to develop, surgical repair can be offered within 6 months of symptom onset. In most cases, 3 months of conservative treatment are sufficient to assess the clinical gains achievable without surgery. The indications and modalities of conservative treatment need to be further refined. Anatomic and functional outcomes
Editorial / Joint Bone Spine 74 (2007) 527e529
of isolated supraspinatus tendon tears should be determined. Studies of long-term outcomes of conservative treatment according to the extent of the lesions are needed. Most of the available studies either failed to describe the tears in detail or included patients who were heterogeneous in terms of tear location and number of torn tendons. Data are also needed on the incidence of degenerative glenohumeral disease with loss of head centering, which may be viewed as the last stage in the natural history of degenerative rotator cuff tears. They may be useful to define more accurately the time of surgical repair or replacement: the long-term outcomes of arthroplasty for degenerative glenohumeral disease with abnormal cuff function remain indeed unclear [25]. Future studies should lead to the anatomic and clinical characterization of tear patterns associated with specific treatment requirements and outcomes, as well as to a more accurate determination of the optimal time to surgery and of the best imaging study strategy. References [1] Se`ze de S, Ryckewaert A, Welfling J, Caroit M, Hubault A. Epaule pseudo paralyse´e, e´paule douloureuse, e´paule bloque´e. Presse Me´d 1964;72:1795e8. [2] Petersson CJ. Ruptures of the supraspinatus tendon. Cadaver dissection. Acta Orthop Scand 1984;55:52e6. [3] Ozaki J, Fujimoto S, Nakagawa Y, Masuhara K, Tamai S. Tears of the rotator cuff of the shoulder associated with pathological changes in the acromion. A study in cadavera. J Bone Joint Surg Am 1988;70:1224e30. [4] Hijioka A, Suzuki K, Nakamura T, Hojo T. Degenerative change and rotator cuff tears. An anatomical study in 160 shoulders of 80 cadavers. Arch Orthop Trauma Surg 1993;112:61e4. [5] Milgrom C, Schaffler M, Gilbert S, van Holsbeeck M. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br 1995;77:296e8. [6] Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10e5. [7] Goutallier D, Postel JM, Lavau L, Bernageau J. Clivage des tendons de la coiffe. In: Laredo JD, Bard H, editors. La coiffe des rotateurs et son environnement. Montpellier: Sauramps me´dical; 1996. p. 45e9. [8] Noe¨l E. Les ruptures de la coiffe des rotateurs. Re´sultats du traitement conservateur. (A propos de 171 e´paules) (p. 113e8). In: Simon L, Pe´lissier J, He´risson Ch, editors. Actualite´s en re´e´ducation fonctionnelle et re´adaptation, 19e se´rie. Paris: Masson; 1994. [9] Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff. A follow up study by arthrography. Clin Orthop Relat Res 1994;304:68e73. [10] Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg 2001;10:199e203. [11] Zeitoun-Eiss D, Brasseur JL, Goldmard JL. Corre´lations entre la se´miologie e´chographique et la douleur dans les ruptures transfixiantes de la coiffe des rotateurs. In: Blum A, Tavernier T, Brasseur JL, et al., editors. Une approche pluridisciplinaire. Montpellier: Sauramps me´dical; 2005. p. 287e94. [12] Recommandations pour la pratique clinique. Modalite´s de prise en charge d’une e´paule douloureuse chronique non instable chez l’adulte. Available from: http://www.has-sante.fr; Avril 2005.
529
[13] Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. J Bone Joint Surg Am 1974; 56:14e26. [14] Samilson RL, Binder WF. Symptomatic full thickness tears of rotator cuff. An analysis of 292 shoulders in 276 patients. Orthop Clin North Am 1975;6:449e66. [15] Caroit M, Rouaud JP, Texier T, Gaudouen Y, Delcambre B, Deloose F. Outcome of rupture and complete perforation of the unoperated rotator cuff of the shoulder. Rev Rhum Mal Osteoartic 1989; 56:815e21. [16] Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin Orthop Relat Res 1992;275:165e73. [17] Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop Relat Res 1993;294:103e10. [18] Hawkins RH, Dunlop R. Nonoperative treatment of rotator cuff tears. Clin Orthop Relat Res 1995;321:178e88. [19] Wirth MA, Basamania C, Rockwood CA. Nonoperative management of full-thickness tears of the rotator cuff. Orthop Clin North Am 1997;28:59e67. [20] Goldberg BA, Nowinski RJ, Matsen FA. Outcome of nonoperative management of full-thickness rotator cuff tears. Clin Orthop Relat Res 2001;382:99e107. [21] Vad VB, Warren RF, Altchek DW, O’Brien SJ, Rose HA, Wickiewicz TL. Negative prognostic factors in managing massive rotator cuff tears. Clin J Sport Med 2002;12:151e7. [22] Leroux JL, Thomas E, Bonnel F, Blotman F. Diagnostic value of clinical tests for shoulder impingement syndrome. Rev Rhum Engl Ed 1995;62:423e8. [23] Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 1994;304:78e83. [24] Goutallier D, Postel JM, Lavau L, Bernageau J. Impact of fatty degeneration of the supraspinatus and infraspinatus muscles on the prognosis of surgical repair of the rotator cuff. Rev Chir Orthop Reparatrice Appar Mot 1999;85:668e76. [25] Goutallier D, Postel JM, Zilber S, Van-Driessche S. Shoulder surgery: from cuff repair to joint replacement. An update. Joint Bone Spine 2003;70:422e32.
Johann Beaudreuil* Thomas Bardin Philippe Orcel Centre Viggo Petersen, Fe´de´ration de Rhumatologie, Hoˆpital Lariboisie`re, 2 rue Ambroise Pare´, 75475 Paris cedex 10, France *Corresponding author. Tel.: þ33 149 956 308; fax: þ33 149 958 631. E-mail address: [email protected] (J. Beaudreuil) Daniel Goutallier Orthopaedic Surgery and Trauma Unit, Henri Mondor Teaching Hospital, Cre´teil, France 29 March 2007 Available online 18 October 2007