Shoulder Specialists Raise and Answer Some Questions About Rotator Cuff Tears
Question: If you have a torn rotator cuff (the tendons and muscles surrounding the shoulder), can you get better without surgery?
Question: If you have surgery to repair a damaged rotator cuff and you end up retearing the same area -- was it worth it to have the surgery in the first place?
Question: If you rerupture the repaired rotator cuff, what happens? Does your pain increase? Do you lose shoulder motion, strength, and/or function?
The authors of this article have been studying rotator cuff defects, their clinical effects on patients, and results of treatment for many years. Now, they turn their attention to what happens when one of these repairs retears.
This is a follow-up study of a group of 15 patients who were previously assessed three years after their first surgery for a torn rotator cuff. They were all known to have developed a retear of the repaired tendon. The researchers continued to follow them for another four years and now report on measures of pain, shoulder motion, strength, and function.
Besides using some standard tests to measure these variables, they also took ultrasound pictures of the tear to show what was going on inside the rotator cuff during those follow-up years. Ultrasound is a quick and inexpensive way to see if the tear is changing, either healing itself or getting larger (and by how much). None of the patients had a revision (second) surgery to repair the retear after the first operation to repair the initial injury.
There aren't very many studies on the subject of what happens to patients who experience a second tear of a rotator cuff. And part of the reason for that (as these surgeons have found out from their own studies) is that a lot of patients don't even know they have retorn the repair. They don't have any pain. And any change in motion, strength, or function doesn't bother them enough to have it checked out.
In the process of following their own patients, the authors discovered that more than one-quarter of the patients treated in their special sports medicine shoulder practice ended up with retears. The patients still had better strength and function with less pain than before their first surgery, so they were happy despite the retear.
At first glance, all may seem hunky dory. Patients weren't distressed, so why do another surgery to repair the second tear? Well, that's the rub. How do we know that leaving these retears alone isn't doing a disservice to the patient? What if years down the road, the structure deteriorates beyond repair? It may be that early revision surgery is a better idea than previously thought.
That's where this study comes in. By following patients with a surgically repaired but now retorn rotator cuff over time, it was possible to see what happens. That's referred to as the natural course or natural history of a condition. Here's what they found.
The surgeons suspect that patients aren't unhappy with the results of their first surgery even when they retear the rotator cuff because there's no pain and no change in function. The pain doesn't come back with a retear because the original cause of the pain (pinching of the soft tissues) is cleared up with the first surgery and isn't affected by a retear. Most of the patients were older adults who aren't very active. With no pain and limited use of the arm, they don't notice the loss of strength either.
So now the authors are faced with a new question. Does the age of the patient make a difference? Should younger patients be advised to have a revision surgery when a retear of their rotator cuff is discovered?
Of all the questions posed, the results of this study adds one new piece of information about rotator cuff tears. Retears without repair still provide patients with significant benefit. There is satisfactory pain relief. And despite ultrasound images showing an increase in the size of the tear over time, which was accompanied by a loss of muscle strength, the patients don't seem to be adversely affected.
It's back to the drawing board for this group. Now they have to follow the first group of older adults even longer to see what happens without a repair of the retear. At the same time, they need to begin a similar long-term study of younger patients with retears of surgically repaired rotator cuff tears.
Christopher C. Dodson, MD, et al. The Long-Term Outcome of Recurrent Defects After Rotator Cuff Repair. In The American Journal of Sports Medicine. January 2010. Vol. 38. No. 1. Pp. 35-39.