**7. Risks of conservative treatment in managing a rotator cuff tear**

(VEGF) and stimulate tendon stem cells to differentiate into tenocytes when certain growth factors are released, which promotes healing of the rotator cuff [67, 68]. Furthermore, PRP can also assist in the proliferation of muscle cells [69], promoting inflammation [70], and the use of adhesion molecules to repair the torn tendon [71]. The proliferation of muscle cells allows for an increased number of fibroblasts and myotubes, thereby decreasing the overall time of recovery and increasing the strength of the rotator cuff [69]. Non-growth factors released from platelets such as serotonin, histamine, dopamine, calcium and adenosine aid in inflammation proliferation [70]. Finally, adhesion molecules such as fibronectin, fibrin and vitronectin can

MSCs can be found in a variety of locations throughout the human body, but are most commonly found around vascular tissue, bone marrow, and fat [72]. MSCs are derived from pericytes that detach from the blood vessels and become activated MSCs [72]. These stem cells, like many other stem cells, can proliferate and eventually differentiate into fully functional osteocytes, adipocytes, and fibroblasts or remain as activated MSCs [73]. MSCs can be both immunomodulatory and trophic, which aid in regeneration. The cells can act as an autoimmune response to combat pathogens that infect the ruptured tissue [74]. Further, MSCs inhibit both apoptosis (cell death) and scar formation while stimulating angiogenesis and mitosis (through the secretion of mitogens) [64]. Because of the many functions of MSCs, the activation of MSCs is critical in the healing process. These activated MSC cells provide the

An in vitro study found that PRP stimulated cell proliferation and the synthesis of tenocytes in RCTs [75]. In an experiment in which rats were treated for RCT, the group given the PRP treatment demonstrated better collagen linear alignment. Furthermore, the research team found positive effects when administering the PRP injections 3 weeks after the initial surgery

A clinical trial in 2012 found reduced pain and positive effects in the healing process of RCTs [77]. These clinical trials demonstrate the effect PRP has in stimulating the already present

A commonly used source for regenerative injection therapy (RIT) is bone marrow aspirate that is centrifuged to form a concentrate. Bone marrow aspirate concentrate (BMAC) can possess a number of different stem or progenitor cells that can aid in the body's natural selfregenerative processes [78]. BMAC can be used as a regenerative injection therapy for various injuries and primary conditions, as well as be used during surgery. One study compared BMAC augmented surgery vs. arthroscopic repair alone. Of the 45 patients augmented with BMAC, 100% of patients were healed 6 months after surgery compared to 67% of the 45 control patients. At 10-year follow-up found that 87% of patients in the BMAC group compared

damaged part with necessary chemicals to heal itself more quickly.

be delivered in a clot [71].

26 Advances in Shoulder Surgery

**6.2. Laboratory investigation**

**6.3. Clinical investigation**

natural healing process.

with 44% of control patients were healed [79].

[76].

Non-operative treatment has been recommended as an initial treatment for patients with rotator cuff pathology ranging from tendinopathy to partial and even complete RCTs [80]. Although several reviews and studies have demonstrated the effectiveness of non-operative treatment in RCTs, as previously described, there are concerns regarding the risks of conservative treatment as well. The overall goal of conservative management is to diminish pain, increase ROM and strength, and to ultimately decrease the functional limitations of the patient [81]. There appears to be some consensus that a conservative treatment program is a reasonable approach within the first 6–12 weeks in patients with non-traumatic tears under the age of 60 years. If the patient does not respond within the initial 4–6 weeks, then it can be an indicator for transition to surgical treatment. Edwards et al. [56] has demonstrated that if the patient does respond well, the conservative treatment will be effective for up to 2 years. Tanaka et al. [81] reviewed the literature and noted that conservative treatment is an effective method for the treatment of RCTs, with success rates ranging from 33 to 88%. The large variability appears to be dependent on the method of treatment chosen, as well as the observations and monitoring that occurs in between the pre-established patient follow-up dates. Although effective, the benefits of non-operative treatment have also been accompanied by progression of the tear, muscle atrophy, fatty infiltration, worse surgical outcomes and increased pain and symptoms.

Tempelhof et al. [15] studied asymptomatic RCTs longitudinally to improve the understanding of the risks of tear progression and pain development over time. The study followed patients for a median of 5.1 years, following the identification of the asymptomatic degenerative tear. They observed that tear enlargement occurred in a time-dependent manner with greater risks of enlargement relative to larger and more severe tears. This was observed in 110 of 224 patients (~49%) over an average span of 2.8 years. FTTs were 1.5–4 times more likely to enlarge than PTTs. In addition to the risk of tear progression, the transition from an asymptomatic tear to a symptomatic tear was observed due to the development of new pain, and the median time until pain developed was roughly 2.6 years. The development of new pain occurred in 46% of the patients, and the occurrence of symptoms correlated with an average enlargement rate of 63%, whereas those who remained asymptomatic had a 38% increase in the size of their tears.

These results demonstrate the long-term potential for an FTT to increase in size over several years, which is in agreement with Hsu and Keener [82], who thought that the risks of tear progression and muscle atrophy are present early on, but the rate of progression is slow enough to allow adequate time to attempt conservative treatment [82]. They developed a stratification of the several treatment options in which the patients were categorised and recommended a treatment option based on their natural history and pathology. The system established by Hsu and Keener [82] contained three groups in which the risks of non-operative treatment varied and the potential benefits of surgery were optimised. The groups were assigned according to the symptoms presented at the time of the patient interview. In group I, early operative repair was recommended for acute tears, while those in group II were initially treated conservatively and, if they did not respond, they were transitioned to surgical treatment. Furthermore, group III was concerned with maximising conservative treatment, where the healing of the patient's RCT was unlikely. This group typically included patients over the age of 65, with chronic tears and FTT. Patients in the group were shown to have retracted tendons and advanced muscle degeneration. The goal of conservative treatment was to improve the overall functioning level of the patient. This study demonstrated that although these variables improved, there was also a 50% chance of tear progression within 5 years, especially in the FTT [82].

strongest indicators when deciding how to treat a patient. Dunn et al. [87] and Fucentese et al. [8] demonstrated a direct correlation between the expectations of the patient and the results

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

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

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The demographics of a patient have also been shown to directly correspond with a transition in treatment. The strongest of these include the patient's age, body mass index (BMI) score, and socioeconomic status. Interestingly, patients with a higher BMI score were shown to be more likely to adopt a nonsurgical option, where those with a lower BMI opted for surgical

Regarding age, patients under the age of 60 years are thought to have better outcomes with operative treatment, because of significant risks of irreversible changes with non-operative treatment and a high likelihood of healing if a repair was performed. It has been generally recommended that surgical repair be performed instead of an initial conservative treatment in active patients with acute tears following trauma [4]. Early operative treatment appears to be warranted in this case and in the case of poor function for the achievement of maximal return of shoulder function. The importance of the timing following the initial patient interview is critical and dependent on the factors associated with the tear as well as how long the tear has been present. In a systematic review, Lazarides et al. [40] reported that the RCTs present in patients younger than age 40 years are more commonly FTTs and of traumatic origin. These patients typically respond well to surgery in terms of pain relief due to the good tendon and muscle quality at the time of the repair. The definition of "early" repair is

Bjornsson et al. [89] determined that there was no difference in tendon healing, pain, shoulder elevation, or functional outcomes when an acute tear was fixed within the first 3 months of injury compared to within the first 3 weeks. However, if symptoms have persisted for longer than a year, and functional impairment was observed, the expectation for a successful surgical approach is worse in patients with FTTs [56]. Patients over the age of 60 years were twice as likely to develop a tear that was larger than those under 60 years. With each decade after 60,

Importantly, the mechanism of injury plays a significant role in decision-making for operative treatment. Schmidt and Morrey [91] described a measurement of the "appropriateness" of the various treatment options available to assist in RCT treatment, which are dependent on the associated benefits and risks of each method. The scale is referred to as the appropriate use criteria (AUC), and it was developed by a voting panel composed of mostly orthopaedic surgeons. This panel determined the 'appropriateness' level of a treatment based on the current literature. The AUC determined that a treatment was deemed 'appropriate' if the benefits outweighed the risks, 'may be appropriate' if the difference was null, and 'rarely Appropriate' when the risks outweighed the benefits. A large indicator favouring nonoperative treatment included the initial response a patient exhibited during their initial trial of conservative treatment. If there was a positive response noted by the patient, then they would continue with non-operative treatment. Conversely, if the initial trial of conservative

the odds of tear enlargement increased 2.69-fold [90].

of conservative treatment.

treatment [88].

often unclear.

Several other studies of asymptomatic tears followed by either an ultrasound or a MRI have been reported in the literature [2, 15, 83, 84]. Maman et al. [7] described age as a large determinant of progression, with 54% of the tears in the patients over 60 years of age demonstrating progression, in comparison to 17% of tears in subjects under the age of 60 years. Safran et al. [11] found that FTTs had a higher rate of progression in younger patients, with 49% of the tears increasing in size under ultrasound.

Tear progression as well as muscle atrophy and fatty infiltration have been directly associated with pain. In a study conducted by Moosmayer et al. [85], these three variables were found to correlate with the presence of symptoms in comparison to an asymptomatic group. The authors compared non-operative to operative treatment for smaller tears of 3 cm in size, and found a progression in tear size and structural deterioration over time, which resulted in the recurrence of symptoms and functional depreciation over time. In the cases in which the patients were asymptomatic, they found that progression of the tear was directly related with the development of pain [30].

In contrast to these studies, Fucentese et al. [8] found that after a follow-up period of 3.5 years following non-operative treatment, there was no increase in the average tear size and only 25% of the initial tears demonstrated progression. An issue with this study is that the average initial tear size was small, averaging 1.6 cm. This further supports the notion that the likelihood of progression is dependent on the initial size of the tear, with larger tears more likely to develop progression.
