**2. Natural history**

For appropriate management of RCTs, it is imperative to appreciate the stages of progression of PTTs to FTTs and the contributing factors that lead to symptoms. A thorough patient history includes age, occupation, activities, hand dominance, history of trauma, time since onset of symptoms, history of smoking, diabetes mellitus and patient's expectations. A clinical examination is then supplemented with imaging studies, in particular ultrasound and magnetic resonance imaging (MRI), to further identify the location, size, thickness, retraction of RCTs and any other shoulder pathology such as long head of biceps tendonitis, labral tears, glenohumeral chondrosis, and muscle atrophy.

It is thought that older patients, patients with diabetes mellitus and osteoporosis and smokers will have a less successful repair of a complete tear [3]; however, there is no strong evidence for this. Chronic tears may have poor healing due to associated surrounding fatty infiltration and muscle atrophy [4]. An elderly patient with limited activities may be able to manage activities of daily living with a full-thickness RCT. In contrast, an active young patient may require surgery, even with a small complete RCT.

#### **2.1. Traumatic vs. atraumatic tears**

From the patient history, we can establish whether the RCT is a traumatic or degenerative one. Studies by Hantes et al. [5] and Petersen et al. [6] advocate early surgical treatment of complete traumatic RCTs, regardless of size and patient age, to avoid further RCT progression, with subsequent degenerative changes, fatty infiltration of surrounding muscle and cuff

retraction. Early surgery should be performed to obtain the best functional results. Atraumatic (degenerative) tears usually occur in elderly patients with larger tears, retracted rotator cuff tendons, poor surrounding tissue and fatty infiltration. In addition, they are likely to have fewer demands from their shoulder. Therefore, surgery may provide a less favourable outcome, and treatment may be best managed conservatively.

## **2.2. Partial to full-thickness tears**

tears (RCTs), there is still limited information concerning the natural history and treatment approaches for the disorder. An RCT may initially present as a partial-thickness tear (PTT) that progresses to a full-thickness tear (FTT) in the seventh decade of life [1]. Currently, there are no comprehensive British National Institute of Clinical Excellence (NICE) guidelines and European guidelines on the management of RCTs in general, and conclusions made by the American Academy of Orthopaedic Surgeons (AAOS) show weak evidence. Through understanding the natural history of RCTs, the progression from PTT to FTTs, and the different factors that influence progression such as age and comorbidities that influence progression, we can better advise our patients regarding optimum therapy. Such therapies include rehabilitation, physiotherapy, systemic medications and progression to surgical intervention. Although studies regarding physical therapy and surgical interventions show success in the recovery process, it has become increasingly clear that some biologics may augment the healing of tendon to bone when used as a primary treatment or as an adjunct to surgical procedures [2]. However, there are risks of conservative management, and it is important to identify the indications for transition from conservative to surgical management and appreciate patient satisfaction indices. To do so, the authors performed a critical review of the most recent evidence, providing an overview of the best evidence-based management for

For appropriate management of RCTs, it is imperative to appreciate the stages of progression of PTTs to FTTs and the contributing factors that lead to symptoms. A thorough patient history includes age, occupation, activities, hand dominance, history of trauma, time since onset of symptoms, history of smoking, diabetes mellitus and patient's expectations. A clinical examination is then supplemented with imaging studies, in particular ultrasound and magnetic resonance imaging (MRI), to further identify the location, size, thickness, retraction of RCTs and any other shoulder pathology such as long head of biceps tendonitis, labral tears,

It is thought that older patients, patients with diabetes mellitus and osteoporosis and smokers will have a less successful repair of a complete tear [3]; however, there is no strong evidence for this. Chronic tears may have poor healing due to associated surrounding fatty infiltration and muscle atrophy [4]. An elderly patient with limited activities may be able to manage activities of daily living with a full-thickness RCT. In contrast, an active young patient may

From the patient history, we can establish whether the RCT is a traumatic or degenerative one. Studies by Hantes et al. [5] and Petersen et al. [6] advocate early surgical treatment of complete traumatic RCTs, regardless of size and patient age, to avoid further RCT progression, with subsequent degenerative changes, fatty infiltration of surrounding muscle and cuff

complete RCTs.

16 Advances in Shoulder Surgery

**2. Natural history**

glenohumeral chondrosis, and muscle atrophy.

require surgery, even with a small complete RCT.

**2.1. Traumatic vs. atraumatic tears**

PTTs can be bursal-sided or articular-sided tears. Over the course of time, PTTs enlarge and propagate into FTTs, developing distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These changes lead to a reduction in tendon elasticity and viability. Although PTT to FTTs are described as a continuum in the literature, these tears can occur without following this natural history path. In its end-state, the glenohumeral joint experiences a series of degenerative alterations known as cuff tear arthropathy.

Maman et al. [7] reported that, based on MRI imaging over an 18-month period for 59 patients, 52% of FTTs will increase in size and were substantially less stable than PTTs. Each shoulder underwent a baseline MRI, and a repeat imaging performed at a minimum interval of 6 months. Progression of tear size was found in 48% of the tears that were followed for at least 18 months compared with just 19% of those followed for less than 18 months. This contrasts with a study by Fucentese et al. [8], who reported seemingly contradictory findings in their report of 24 patients refusing operative treatment for full-thickness supraspinatus tears. They used magnetic resonance arthrography (MRA) as their initial imaging modality and MR without arthrography for their follow-up imaging and reported no increase in the mean size of the RCTs 3.5 years after the initial MRA.

#### **2.3. Small vs. large full-thickness tears**

The risk of tear enlargement is greater for shoulders with more advanced tears and is associated with a greater risk of cuff muscle degenerative changes. This group reported that tear enlargement is also associated with greater risk of pain development across all tear types (50% for FTTs) [9].

The same study by Fucentese et al. [8] concludes that small isolated FTTs of the supraspinatus in patients under the age of 65 do not necessarily progress over time. Yamaguchi et al. [10] reported no increase in tear size over 5 years in 23 patients evaluated by ultrasound. This contrasts with a larger case series of 51 patients by Safran et al. [11] which reports that FTTs tend to increase in size in approximately half of patients aged 60 years or younger.

## **2.4. Demographics**

#### *2.4.1. Age*

Advancing age has been considered the most important prognostic factor for surgical outcome. Gumina et al. [12] reported that patients older than 60 years of age were twice as likely to develop a tear that was likely to progress to full-thickness and larger tears (54% of tears in patients older than 60 years showed such progression compared to only 17% of tears in those younger than 60 years). A cohort of patients younger than 60 years who were treated non-operatively for FTTs was found to have a higher rate of tear progression than older patients. Of the 61 tears, 49% increased in size according to the findings of ultrasound imaging [11].

*2.4.7. Family history*

*2.4.8. Posture*

impingement.

*2.4.9. Mental health*

*2.4.10. Symptoms and pain*

opment of symptomatic RCTs [23].

health in patients with complete RCTs [28].

There is limited evidence regarding the genetic predisposition and hereditary component for RCTs; however, a study examining the genealogical database in Utah, USA by Tashjian et al. [22] a population-based controlled study of 3091 patients, with a subgroup analysis of 652 patients diagnosed before 40 years of age, showed a significant association between individuals with rotator cuff disease in close and distant relations (reportedly up to third cousin relations). This study was included in the systematic review conducted by Dabija et al. [23], which includes the study by Harvie et al. [24], concluding that siblings of patients diagnosed with RCTs were twice as likely to develop complete RCTs. In addition, they identified single-nucleotide polymorphisms (SNPs) associated with RCTs, indicating the future risk for development of RCTs to enable prophylactic rehabilitation techniques and to avoid the devel-

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

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

19

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

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

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
