LONG TERM NON-OPERATIVE MANAGEMENT

Two prospective randomized controlled trials with 5- to 10-year follow up comparing physical therapy only to operative repair for treatment of small to medium rotator cuff tears have shown that physical therapy can result in improved patient outcomes, but the rotator cuff tears continue to enlarge with time (Moosmayer, 2019; Kukkonen, 2021). At the 10-year follow-up of the patients treated with physical therapy, there was an increase in tear size > 5 mm in 19 patients (59%) and >10 mm in 13 patients (41%) (Moosmayer, 2019). In contrast, retears (full- or partial-thickness) occurred in patients treated surgically in only 21% (10 patients) after 1 year, 28% (13 patients) after 5 years, and 34% (16 patients) after 10 years. After an average of 8.8 years, 49% (18/37) of patients who were treated non-operatively also showed substantial muscle atrophy and 41% (15/37) fatty degeneration to a degree of 3 or 4 in (Moosmayer, 2017). Kukkonen et al. reported 2-year imaging outcomes showing that the patients with tears treated with physical therapy instructed home exercise program enlarged from an average of 9.6 mm to 11.7 mm, while the repaired tendons tear size decreased from 8.4 mm to 4.2 mm (p<0.01), suggestive of retears in some patients (Kukkonen, 2015).

Risks and Harms of Implementing this Recommendation
Patients treated non-operatively are at risk for reduced strength with rotator cuff tear progression. Moosmayer, et.al., compared patients treated with physical therapy that had an increase in tear size ≤ 5mm to those that progressed to > 5mm and reported the > 5mm group showed a loss of strength at 5-year follow-up (between-group difference of 4.2 kg, p=0.02) (Moosmayer, 2014). In a prospective cohort study, the Constant score was 81 points for patients with tear size increases < 20 mm compared to 58.5 points in those ≥ 20 mm (p=0.008) (Moosmayer, 2017). Patients who select physical therapy should be informed that over a 10-year period their tear size may progress, and this could lead to a substantial decline in their perceived and measurable outcomes. Surveillance with serial clinical evaluation and imaging for patients treated non-operatively following a rotator cuff tear may be considered if surgical repair remains a viable option.

Future Research
Continued long term comparative studies between physical therapy and surgical repair investigating larger tear sizes with pre-and postoperative advanced imaging studies are needed. It is still unclear what factors influence tear progression and if tear progression advances enough to preclude future repair and subsequent resolution of symptoms.

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

2. Moosmayer S, Gärtner AV, Tariq R. The natural course of nonoperatively treated rotator cuff tears: an 8.8-year follow-up of tear anatomy and clinical outcome in 49 patients. J Shoulder Elbow Surg. 2017;26(4):627-634. doi:10.1016/j.jse.2016.10.002