*2.4.8. Posture*

The relationship between posture and shoulder pathology is still under investigation. For example, Gumina et al. [25] found a reduced subacromial space in 47 patients over the age of 60 years with hyperkyphosis, as compared to a control group. Yamamoto et al. [26] observed RCTs in 65.8% of patients with kyphotic-lordotic postures, 54.3% of patients with flat-back postures, and 48.9% with sway-back postures, whereas only 2.9% of patients with ideal alignment had symptomatic or asymptomatic RCTs. It is hypothesised that the reduced subacromial space is due to less posterior tilting and dyskinesis of the scapula, resulting in extrinsic impingement.

#### *2.4.9. Mental health*

Cho et al. [27] demonstrated that as many as 82% of patients with chronic shoulder pain had sleep disturbance and that rates of depression were significantly increased in patients with more than 3 months of shoulder pain. Educational level, employment status, pain levels and patient perception of percentage of shoulder normalcy were most predictive of emotional health in patients with complete RCTs [28].

#### *2.4.10. Symptoms and pain*

There is disagreement in the literature regarding the correlation between tear size and pain. These studies tend to be cross-sectional as opposed to prospective observational studies [11]. For example, in a prospective study of 50 patients, Moosmayer et al. [29] reported that 40% of asymptomatic RCTs became symptomatic and anatomically deteriorated, and that an increase in tear size and a decrease in muscle quality correlated with the development of symptoms. Mall et al. [30] who compared asymptomatic and symptomatic RCTs, determined that many with asymptomatic FTTs will develop symptoms with time and that pain development is associated with an increase in tear size and deterioration of shoulder function and active range of motion (ROM). In the study, this was primarily seen with larger tears and required significant time for progression to occur and for glenohumeral and scapular mechanical dysfunction to become apparent. There is therefore the concern that through conservative management of tears, these tears may progress to become more painful. This is supported by the study by Yamaguchi et al. [10] a report of 45 patients, in which 23 (51%) patients became symptomatic at a mean of 2.8 years; however, just 9 of the 23 (39%) demonstrated tear progression; hence, this could mean that over time symptoms can be progressive and not necessarily due to tear size or progression.

One systematic review assessed the effectiveness of surgery vs. conservative management of RCTs [35]. It concluded that the three randomised controlled trials that were included in this review showed no statistical or clinically significant difference in the patients' clinical outcomes. One of the limiting factors identified were that two of the studies had a 1-year follow-up in comparison to Moosmayer et al.'s [36] 5-year follow-up. It is therefore difficult to conclude whether the conservative management of the RCTs in the studies was more progressive, or if the surgical repairs failed and the shoulders become symptomatic again. In addition, the systematic review concluded that there were only three trials with adequately varied methods and appropriate inclusion criteria for the review, making it difficult to make a comparison on the overall outcome. This is also supported by a systematic review by Seida [37], who concluded that there was insufficient evidence to support conservative over surgical treatment and vice versa for the management of RCTs and suggested that further studies were required and standardised methods and inclusion criteria were

Complete Rotator Cuff Tear: An Evidence-Based Conservative Management Approach

http://dx.doi.org/10.5772/intechopen.70270

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The first randomised controlled trial by Moosmayer et al. [36] after 5 years showed no significance between surgery and physiotherapy, as the mean difference in the Constant-Murley Score (CMS) was only 5, which is deemed less than that considered a clinically relevant score of 10.4 [38]. This study also had traumatic tears in the conservative group, which may have influenced the results as previous research has suggested that early surgical intervention is recommended for younger patients with traumatic tears and severe functional deficit to avoid delays in tendon healing or prevent healing beyond repair [39]. The sample size was small in this study; therefore, it is difficult to make a conclusion on the effect of having the two subgroups over the results in this study. In this study, nine patients failed physiotherapy and switched to tendon repair in small and medium tears. Rotator cuff repairs may be recommended to prevent delay in progression of muscle atrophy and tendon retraction beyond the point of tendon healing if physiotherapy failed, which is more likely in the younger patient population with acute tears than in the older population who are more likely to present with degenerative FTTs [40, 41]. This is further supported by an algorithm on the management of RCTs by Tashijan [42] according to size, nature of the tear, and age of the patient; however, there is not enough high-quality evidence to support this. Further studies comparing interventions for traumatic and atraumatic complete tears as well as age groups would be required to decide initial treatment. In addition, further research on how long conservative management should be continued before resorting to surgical intervention would be required. This finding has also been discussed by Abdulwahab et al. [43], who concluded that timing to the end of conservative treatment is unknown, but likely is indicated when a patient demonstrates increased weakness and loss of function not recoverable by

Another randomised controlled trial by Heerspink et al. [44] was a small study of only 56 patients that showed no statistical or clinically significant difference. The CMS was 10.1 between surgery and physiotherapy. The patients in this study were atraumatic, which may have made the study more generalised compared to Moosmayer's randomised controlled trial [36]. There were more patients with a larger tear in the conservative treatment group, which could have created bias in the results of this study despite the random allocation. Further research on surgical intervention compared to physiotherapy for complete tears as a separate

warranted.

physiotherapy.

Through multiple observational and cross-sectional studies on more than 400 patients with atraumatic, FTTs, the multicenter orthopaedic outcomes network (MOON) Shoulder Group have found that pain and duration of symptoms are not strongly associated with the severity of RCTs [31, 32]. This is supported by a recent cross-sectional study by Curry et al. [33], which found that in patients with RCTs undergoing operative and non-operative treatment, pain and functional status were not associated with tear size and thickness, fatty infiltration, and muscle atrophy.

## *2.4.11. Radiographic changes*

There are studies following the progression of both asymptomatic and symptomatic tears, and most these studies conclude that there is a risk of tear progression according to ultrasound or MRI findings, regardless of whether they are partial or complete RCTs. However, the progression of these tears may not necessarily contribute to increase in symptoms [10]. One ultrasound investigation of 411 patients found the overall prevalence of asymptomatic FTTs to be 13% in patients over age 50 years, and 51% in subjects over 80 years of age [15]. Safran et al. [11] reported that 5 of 61 (8%) FTTs evaluated with ultrasound decreased in size over a 2-year follow-up period.

A recent study by Yang-Soo et al. [34] found that 28 of 34 patients (82.4%) with symptomatic FTTs and 23 of 88 patients (26.1%) with symptomatic PTTs had tears that increased in size over a follow-up period of 6 months to 8 years. The clinical relevance of these observations is that FTTs treated conservatively should be monitored more carefully than PTTs for progression. However, some study limitations should be noted: patients included were those who had refused surgery (allocation bias). In addition, assessor bias due to the reporting of outcomes was a factor; however, the musculoskeletal radiologist reporting the MR images was blind to the clinical data.

This study was supported by another previously described comparison study of 59 shoulders in 54 patients with 33 FTTs, 26 PTTs and 4 combined tears on MRI [7]. Seventeen of 33 (52%) FTTs and 2 of 26 PTTs progressed in size. Factors that were associated with the progression of RCTs were age greater than 60 years, FFTs and fatty infiltration of muscle.

Therefore, RCTs do not always progress, with FTTs demonstrating a higher rate of enlargement in time than PTTs.
