STRONG RECOMMENDATION Two prospective randomized controlled trials comparing physical therapy to operative repair for the treatment of small to medium rotator cuff tears showed substantial improvement in patient-reported outcomes (PROs) and strength over time (Moosmayer, 2019; Kukkonen 2021). At 5-year follow up, Moosmayer, et.al., reported that the results of primary repair were superior to physical therapy, with the mean group differences of 5.3 for the Constant score (p=0.05) and 9.0 for the ASES score (p<0.001); however, the differences in PROs were below the accepted minimal clinically important difference (Moosmayer, 2014). At 5 years, Kukkonen, et.al., reported no significant differences in the mean change of the Constant score (p=0.84) and pain (VAS) (p=0.74) between physical therapy and surgical repair in patients with small to medium rotator cuff tears (Kukkonen, 2021). At 10-year follow up, differences of 9.6 points (95%CI 3.6 to 15.7 points; p = 0.002) in the Constant score and 15.7 points in the ASES score [95% CI, 9.3 to 22.1 points]; p < 0.001) emerged in favor of surgery (Moosmayer, 2019). In summary, both physical therapy and operative repair groups demonstrated clinically meaningful improvement in those patients with symptomatic small to medium rotator cuff tears in regard to PROs, health related quality of life, and strength (Moosmayer, 2019; Kukkonen, 2021).
In patients with a traumatic rotator cuff tear, a single high quality prospective randomized controlled trial (Ranebo, 2020) demonstrated improvements in patient outcomes at 1 year in both physical therapy and surgical treatment groups. No significant differences were found between surgical repair and non-operative physical therapy management (10 visits across 16 weeks) with 1-year follow up in PROs with Constant-Murley Score (p=0.68), WORC (p=0.62), Pain (NPR) and (Euro) quality of life visual analog scale.
In a prospective randomized trial (Cederqvist, 2021), patients with rotator cuff disease (including no tears) who failed a 3-month (15 sessions) multi-modal physical therapy intervention were randomized to continued physical therapy management or surgical repair. In a subgroup of patients identified with a small to medium full-thickness rotator cuff tear, there were significant improvements with both physical therapy and surgical repair in pain (VAS) and Constant score in groups at 2 years in both groups. There was no difference between groups in pain improvements (mean difference: 7, 95% CI −3 to 17; p=0.19). While there was a statistically significant difference (mean difference: 7.0, 95% CI 1.8 to 12.2; p=0.008) between groups in Constant score, differences were small and fell below thresholds to be clinically important.
Risks and Harms of Implementing this Recommendation
There may be risks associated with implementing this recommendation for patients electing a prolonged course of non-operative management who eventually wish to proceed with surgical repair. In one randomized trial (Moosmayer, 2019), a subset of patients (n=14) allocated to physical therapy who later crossed over to secondary surgery had improvements in patient outcomes, but the Constant score was significantly less (i.e. 10.0 points, p = 0.03) compared with that of the primary tendon repair group.
Future Research
Continued comparative studies between non-operative treatment with physical therapy and surgical repair with or without post-operative supervised physical therapy in younger patients, traumatic tears, and acute on chronic traumatic tears, larger tear sizes and modern approaches to rehabilitation and surgical methods are needed. Additionally, studies with patient outcomes beyond 5 years are needed to better understand the true effectiveness and efficacy of each treatment over the long term.
Additional References
1. Moosmayer S, Lund G, Seljom US, et al. Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up. J Bone Joint Surg Am. 2014;96(18):1504-1514. doi:10.2106/JBJS.M.01393
- Cederqvist, S., Flinkkila, T., Sormaala, M., Ylinen, J., Kautiainen, H., Irmola, T., Lehtokangas, H., Liukkonen, J., Pamilo, K., Ridanpaa, T., Sirnio, K., Leppilahti, J., Kiviranta, I., Paloneva, J. Non-surgical and surgical treatments for rotator cuff disease: a pragmatic randomised clinical trial with 2-year follow-up after initial rehabilitation. Annals of the Rheumatic Diseases 2021; 6: 796-802
- Kukkonen, J., Ryosa, A., Joukainen, A., Lehtinen, J., Kauko, T., Mattila, K., Aarimaa, V. Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years: over 5-year follow-up of a randomized controlled trial. Journal of Shoulder & Elbow Surgery 2021; 11: 2455-2464
- Moosmayer, S., Lund, G., Seljom, U. S., Haldorsen, B., Svege, I. C., Hennig, T., Pripp, A. H., Smith, H. J. At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears. Journal of Bone & Joint Surgery - American Volume 2019; 12: 1050-1060
- Ranebo, M. C., Bjornsson Hallgren, H. C., Holmgren, T., Adolfsson, L. E. Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial. Journal of Shoulder & Elbow Surgery 2020; 3: 459-470