Operative Management
Moderate evidence supports that healed rotator cuff repairs show improved patient-reported and functional outcomes compared to physical therapy and unhealed rotator cuff repairs.

In a 1-year prospective randomized controlled trial (RCT) comparing physical therapy to surgical repair for treatment of small to massive rotator cuff tears, Lambers Heerspink, et.al., reported a superior Constant score for intact repairs (88.5) compared to physical therapy (75.6, p<0.05) and re-tears (73.2). (Lambers Heerspink 2015) A 5-year prospective RCT of small to medium sized rotator cuff tears comparing physical therapy with an option of surgical treatment (what the authors termed secondary surgery) to primary surgical repair reported that 24% (12/51) patients failed to substantially improve their Constant score (mean increase of 1.8 points) with physical therapy and opted for surgical repair within the first two years. (Moosmayer 2014). The post hoc as-treated analysis comparing primary tendon repair, physical therapy only, and secondary surgery after failed physical therapy showed a significantly larger Constant score in favor of primary repair over physical therapy (between-group difference of 9.7 points, p=0.006), but no significant difference between primary and secondary tendon repair (p=0.23). (Moosmayer 2014) At 5 years, re-tears were diagnosed by ultrasound in 25% (15/60) of the patients; 7 partial and 8 full thickness tears. The partial thickness tears showed significant inferior results compared to intact repairs (mean Constant score difference of 23.1 points, p=0.001); full thickness tears demonstrated no difference in Constant score compared to intact repairs (p=0.92). (Moosmayer 2014) However, in a level II cross-sectional study, healed rotator cuff repairs compared to full thickness re-tears showed significant improvement in the ASES and SST scores; intact ASES 91, SST 10.2 verses full-thickness defect ASES 69, SST 6.5 (p<0.01). (Kim 2014)

Risks and Harms of Implementing this Recommendation
There are no harms in associated in implementing this recommendation. There were no reported statistical differences between primary or secondary repair, when physical therapy fails (p=0.23). (Moosmayer 2014)

Future Research
Continued long term comparative studies between physical therapy and surgical repair investigating larger tear sizes with pre-and postoperative advanced imaging studies. The long-term consequences of a persistent rotator cuff tear or a re-tear is currently not known.