AUC ASSUMPTIONS AND DISCLAIMER
The purpose of this AUC is to report on the optimal management of symptomatic full-thickness rotator cuff tears based on expert experience and review of the literature as an appropriate use document for AAOS members, assuming the patient has sufficient pain and/or dysfunction that they are seeking out the opinion of an orthopaedist and that the treating clinician is trained and capable of effectively performing the recommended treatment(s). This AUC is not meant to be used as a standalone algorithm and should be used in conjunction with clinical evaluation, clinician judgment, and patient preference. Confounding factors and concurrent diagnoses may alter the treatment. The target patient group is assumed to have a clinical history (i.e. anterolateral shoulder pain not radiating past the elbow), physical examination (e.g.. external rotation lag, positive drop arm test, and/or pain relief but sustained weakness after impingement test), and imaging findings (i.e. MRI) all consistent with a full-thickness rotator cuff tear. This exercise implies that an MRI has been obtained for treatment decision purposes. This does not imply that this document recommends an MRI be obtained in all scenarios. Several caveats and confounding variables have to be addressed before the physician can start applying these criteria to treat their patients. Rotator cuff tears can present in an acute or chronic fashion.As one of the patient indication variables is “Response to previous treatment”, it is the assumption of the voting panel that each patient has already been evaluated by a medical practitioner and undergone some form of initial conservative management.
The clinician has to take a full history, as well as conduct a thorough physical exam. This cannot be substituted for a complete history and thorough physical examination for patients with an imaging study documenting a full thickness rotator cuff tear. Pain patterns that do not fit or are suggestive of other pathologies need to be assessed, i.e. radiculopathy. The physical exam should include assessment of potential alternative pathologies that may have a similar clinical presentation to rotator cuff tears, such as limitation in active motion, patients with frozen shoulder/shoulder stiffness, and concomitant cuff tears, compose a distinct clinical entity.
It is assumed that the patient scenarios are a snapshot in time. The patient scenarios do not account for changes in symptoms and other findings that may occur during follow-up. That is, a patient presenting initially in one scenario may subsequently present in a different scenario on follow-up. Furthermore, the AUC voting panel acknowledges that each AUC scenario is a generalization based only on a handful of prognostic factors and only these factors were considered when voting was conducted. Additional factors that were not considered, such as patient age or participation in professional sports, might drastically alter the vote for any specific patient scenario.
For surgical candidates with any other concomitant diagnoses, such as biceps tendonitis, labral fraying/tearing, and osteophytes at the inferior surface of the AC joint which may act as pain generators or contribute to mechanical tendon attrition, these appropriate use criteria may still be applicable if the candidate meets both of the following conditions:
- If after the history, exam, and imaging review the clinician determines that the rotator cuff tear accounts for the majority of the symptoms.
- Treatment of this secondary pathology is necessary as part of the surgical procedure to treat potential pain generators and relieve pathology that may deteriorate the surgical outcome.
Ultimately, the treating physician needs to a) tailor the treatment to the severity of the symptoms as described by the patient and appreciated through the history and b) use their expertise, knowledge, and experience to treat the patient with the optimal management (considering patient’s expectations) for that particular patient after discussing the options with the patient.
CONDITIONS NOT COVERED WITHIN THIS DOCUMENT
These conditions listed below are specifically not addressed in this AUC, there is no comment regarding recommendations for treatment or non-treatment for these patients:
- Rotator cuff re-tears/history of previous rotator cuff repair
- Partial-thickness tears or rotator cuff tendonitis/impingement syndrome/rotator cuff bursitis
- Secondary diagnosis that the surgeon determines is more likely to be the relevant pathology creating pain such as:
- Glenohumeral Arthrosis
- Calcific tendinitis
- Plexopathy, radiculopathy or muscle weakness from SSN nerve compression
- Isolated clinically symptomatic AC joint arthritis
Volunteer physicians from multiple medical specialties created and categorized these Appropriate Use Criteria. These Appropriate Use Criteria are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These Appropriate Use Criteria represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician’s independent medical judgment, given the individual patient’s clinical circumstances, should always determine patient care and treatment. Practitioners are advised to consider management options in the context of their own training and background and institutional capabilities when selecting recommended treatment options