Best fix for rotator cuff tear remains uncertain

Evidence on the pros and cons of various surgical and non-surgical treatments for rotator cuff tears is limited and inconclusive, a new review of published studies concludes.

The bottom line from the researchers: the data are sparse, but patients improved substantially with all interventions; there were few clinically important differences between approaches, and complications were rare.

The rotator cuff is the band of muscles and tendons that stabilize the shoulder. Rotator cuff tears are among the most common conditions affecting the shoulder.

Most patients try to resolve their pain and disability with a course of physical therapy before attempting surgery, but the new study found "very little good quality research" to guide the choice of non-surgical treatment, the timing of treatment, and who would most benefit from various forms of treatment, senior researcher Dr. David M. Sheps from Canada's University of Alberta (in Edmonton) told Reuters Health by e-mail.

Sheps, a surgeon, added that "there is limited evidence to guide some of the surgical decision making."

He and his colleagues analyzed 137 studies looking at various therapies for torn rotator cuff.

Four out of five studies comparing surgical and nonsurgical management favored surgical repair, but "the evidence was too limited to make conclusions regarding comparative effectiveness," the researchers report in the latest issue of the Annals of Internal Medicine.

One randomized trial comparing early versus late surgical repair after failed non-surgical management found that average functional outcomes were better after early repair, but the trial investigators didn't report the statistical significance.

One hundred thirteen studies comparing various operations found no differences in functional outcomes between the different types of procedures. However, patients who had "mini-open" repair returned to work about a month earlier than patients who had open repair.

On the other hand, improvement in shoulder function was better after open repair compared with arthroscopic debridement, which involves removing loose fragments of tendon and other debris from the space in the shoulder where the rotator cuff moves.

As for post-surgery rehabilitation strategies, most studies found no difference in health-related quality of life, function, pain, range of motion, and strength with one approach versus another (e.g., with or without aquatics, individualized versus at home alone, videotape versus therapist-based, etc.).

Complications were uncommon in the 64 studies that reported on them, and few were clinically important. Twenty-one studies reported no complications during follow-up.

All the controlled clinical trials contained sources of potential bias, such as inadequate blinding of researchers involved, and the "methodological" quality of the other uncontrolled studies was judged to be only moderate.

"It is crucial moving forward," said Sheps, that "higher quality trials" are conducted. This would allow doctors to practice in "an evidence-based fashion and make more informed decisions regarding treatment options for our patients."

SOURCE: http://link.reuters.com/jav36m Annals of Internal Medicine, July 5, 2010.