Early surgical repair after acute injury is an option for patients with a rotator cuff tear.

Rationale
Rotator cuff tears are a common cause of shoulder pain and dysfunction.64 The prevalence of rotator cuff tears, even asymptomatic tears, increases with advancing age.6, 7 Treatment options for traumatic rotator cuff tears include a number of non-operative options as well as surgical repair. Delaying repair of acute traumatic rotator cuff tear may lead to the development of pathology associated with chronic rotator cuff tears including tendon retraction, and fatty infiltration and atrophy of the rotator cuff muscles with associated detrimental effects on upper extremity function. In earlier surgery after acute injury, the surgeon is more likely to encounter healthier tissue with better healing potential which may lead to better outcome.

Our systematic review did not identify any quality literature that addresses the issue of timing of surgery after acute rotator cuff injury. The evidence that we considered included five level IV case series70, 71 (limited evidence) of rotator cuff repair that focused on early surgical repair of rotator cuff tears. One study70 reported on a series of subjects with a history of a significant acute injury that were treated with surgery within three months of injury. This cohort represented less than 10 percent of the repairs that they performed in their overall experience, thus demonstrating that acute rotator cuff injuries are relatively uncommon. The patients repaired within 3 weeks of injury had better results than those repaired after 3 weeks. The second study71 reported the results of rotator cuff repair in a series of 26 patients who had a history of trauma with an acute onset of symptoms and a full thickness rotator cuff tear. All of the repairs were performed within 3 weeks of the injury. Similar to the findings of the first study, these cases only represented about 5 percent of the cases of full thickness rotator cuff tear that the authors treated. Although they reported a high rate of successful results (20 excellent, 4 good, 1 fair, and 1 poor) they did not determine whether the timing of surgery affected the outcome.

A third study72 reported the outcome of repair of traumatic anterior superior rotator cuff tears with combined subscapularis and supraspinatus tears. The patients had open repair at an average of 4.5 months after injury. Outcome assessment demonstrated restoration of subscapularis related function. The authors did not find a correlation between outcome and duration of symptoms. Two additional studies73, 74 addressed repair of traumatic anterior superior rotator cuff tears with combined subscapularis and supraspinatus tears. One study reported on thirty patients with a traumatic tear who had open repair at an average of 4.5 months after injury and the other reported on twenty-four patients of which twenty-two recalled a specific incident at which the injury occurred. (See Table 26 for the summary of these results.) One study reported there were no significant correlations between outcome and a number of preoperative factors including duration of symptoms. The other study did not provide statistical analyses.

Defining whether a rotator cuff tear is acute has relevance to this discussion. In evaluating patients, the surgeon should attempt to properly identify patients with acute tears as opposed to patients with pre-existing chronic tears that become symptomatic after an injury event. A discrete traumatic event is more suggestive of acute tear. Physical examination findings including supraspinatus and infraspinatus muscle atrophy as well as internal and external rotation lag signs may be indicative of larger and more chronic rotator cuff tears.

Evaluation of rotator cuff muscle quality with CT or MRI is an important consideration. Six Level IV case series47-52  addressed the MRI findings of fatty infiltration and muscle atrophy in relation to the outcome of rotator cuff repair. Chronic and larger tears are associated with muscle atrophy and fatty replacement, both of which correlate with inferior functional outcome after rotator cuff repair. It is thought that early repair of acute rotator cuff tears might mitigate the development of chronic tendon and muscle pathology and improve functional outcomes (see Recommendation 2: Full Thickness Tears and sympTomatic Patients: Supporting Evidence- MRI Tear Characteristics:

Tables relevant to this recommendation are: Table 7 through Table 10
Figures relevant to this recommendation are: Figure 4 through Figure 6

MRI Tear CharacteristicsTables relevant to this recommendation are: Table 24 through Table 25

Figures relevant to this recommendation are: Figure 61 through Figure 66
  1. (47) Shen PH, Lien SB, Shen HC, Lee CH, Wu SS, Lin LC. Long-term functional outcomes after repair of rotator cuff tears correlated with atrophy of the supraspinatus muscles on magnetic resonance images. J Shoulder Elbow Surg 2008;17(1 Suppl):1S-7S.
  2. (48) Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med 2007;35(5):719-728.
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