OPERATIVE MANAGEMENT VS NON-OPERATIVE MANAGEMENT

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).

In the 10-year follow up study, Moosmayer et al (2019) identified a retear in 34% patients who were treated by primary repair. A comparison of the Constant score after 10 years between the 16 patients with a retear at the last follow-up (76.9 points) and the 31 patients with an intact repair (82.9 points) showed a better result for intact repairs, with a between-group difference of 6.0 points (95% CI, 0.2 to 11.8 points; p = 0.04) (Moosmayer, 2019). In contrast, the 32 patients with 5-year and 10-year sonography treated by physical therapy only, patients with tear progression of >10 mm had a Constant score of 63.9 points, an outcome that was inferior by 14.0 points (95% CI, 4.1 to 24.0 points; p = 0.007) compared with the score of 78 points in patients with tear progression <10 mm (Moosmayer, 2019). Identification of factors contributing to tear progression was not conducted.

In summary, tear progression occurs in some patients treated non-operatively over time, and the degree of tear size progression correlates negatively with patient outcomes. Retears also occur in some patients who undergo surgical repair, which also negatively impacts patient outcomes. This appears to occur to a lesser extent in the long term.

Risks and Harms of Implementing this Recommendation
There may be a risk of inferior patient-reported outcomes for patients who elect non-operative treatment in the long-term (10 years). In a prospective randomized trial with a 10 year follow up, a statistically significant difference in patients allocated to physical therapy who later crossed over to secondary surgery (p = 0.03) compared to primary surgery was shown (Moosmayer, 2019). Fourteen patients who had crossed over from physiotherapy to secondary surgery had an outcome on the Constant score that was 10.0 points inferior compared with that of the primary tendon repair group (Moosmayer, 2019).

Future Research
Continued long term comparative studies comparing multimodal supervised physical therapy and surgical repair in patients with larger tear sizes, and longitudinal studies with pre-and postoperative advanced imaging are needed. Identification of risk factors leading to tear progression in patients treated non-operatively and retears in those treated operatively would be important.