**1. Introduction**

Rotator cuff disease is prevalent in the general population, accounting for 10% of all shoulder pain and resulting in major shoulder disability. Despite the large prevalence of rotator cuff

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

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 complete RCTs.

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 out-

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

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

17

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

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

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

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

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

to increase in size in approximately half of patients aged 60 years or younger.

come, and treatment may be best managed conservatively.

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

of the RCTs 3.5 years after the initial MRA.

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

arthropathy.

(50% for FTTs) [9].

**2.4. Demographics**

*2.4.1. Age*
