**3. Effectiveness of physiotherapy rehabilitation**

The role of physiotherapy as a form conservative treatment for complete RCTs to improve pain, function, and reduce disability has long been debated. Recently, there have been some studies that have compared the effectiveness of physiotherapy vs. surgical intervention for RCTs.

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 warranted.

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 symp-

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.

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

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

Therefore, RCTs do not always progress, with FTTs demonstrating a higher rate of enlarge-

The role of physiotherapy as a form conservative treatment for complete RCTs to improve pain, function, and reduce disability has long been debated. Recently, there have been some studies that have compared the effectiveness of physiotherapy vs. surgical intervention for

RCTs were age greater than 60 years, FFTs and fatty infiltration of muscle.

**3. Effectiveness of physiotherapy rehabilitation**

toms can be progressive and not necessarily due to tear size or progression.

*2.4.11. Radiographic changes*

20 Advances in Shoulder Surgery

over a 2-year follow-up period.

ment in time than PTTs.

RCTs.

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 physiotherapy.

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 entity from partial tears are needed. In addition, high-quality studies in which comparisons between different conservative interventions and surgical treatment are made to determine the optimal conservative management for RCTs are necessary.

the patient's pain in relation to the tear as well as the level of exercise in terms of intensity and

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The review also concluded that the size of the tear is not as important as the presence of pain in the patient. This is supported by the findings discussed previously with the current research and MRI scans in relation to the patient's clinical symptoms. It also highlighted that RCT repairs appear to be less successful in the elderly, and the review lean more towards conservative management as a first line of treatment. This idea is also supported by the Tashjian algorithm [42] and Levy [49], who further explain that due to older patients being more likely

The present study acknowledged that until there is more understanding of how some patients with FTTs can have a spectrum of symptoms from minimum to severe, it will be difficult to

There are differences in opinion on the focus of rehabilitation between anterior deltoid retraining or working on the humeral head depressors to rehabilitate shoulder elevation in abduction only [50]. The anterior deltoid training is supported by Levy et al. [49] and by Ainsworth [51] on the basis of the biomechanics of how the anterior deltoid works. The anterior deltoid was believed to act as a humeral head elevator, but a study by Gagey and Hue [52] concluded that the deltoid functions to prevent upward migration of the humeral head. This theory is supported in present clinical practice of using the Torbay exercise program, which is proposed in the aforementioned studies. In the Levy et al. study [49] instructions were to exercise 3–5 times per day for the first 6 weeks, with the patient supine for the exercises, and progressing to an incline, and then standing. This study found that this technique would be beneficial for older patients with atraumatic, massive tears. However, this study was not compared with another intervention; therefore, there was no randomised allocation, and the lack of quality and a small study group of 17 patients made it difficult to form a significant conclusion.

Ainsworth et al.'s [48] prospective randomised controlled study had 60 patients over the course of 1 year. The intervention group consisted of anterior deltoid training as well as other treatment modalities such as functional exercises, proprioception and stretching. It is therefore difficult to establish which specific treatment modality had an impact on improving patient pain and function compared to the control group, whose treatment consisted of ultrasound, advice, and steroid injections, if required. The SF-36 score showed statistical significance in the intervention group over the control group at 3 and 6 months, but there were no differences by 12 months. Despite these improvements in functional and pain scores, further studies with standardised treatment interventions and larger numbers of patients over a longer period are

This study also highlighted the role of education in altering the patient's perception of pain and therefore reduce pain and disability, which is also supported in previous studies [53, 54]. It is believed that advice and education alone allow the patient to use the shoulder, by reducing their fears of causing more harm. This may have contributed to why the control group had no statistical difference from the intervention group. Despite these findings, physiotherapy with this specific anterior deltoid exercise program is deemed to

dosage are still unclear due to the poor quality of the trials.

to have multiple comorbidities, RCTs should be managed conservatively.

establish an optimal treatment and rehabilitation program for RCTs.

needed to support the use of anterior deltoid training.

The present study also had a high incidence (73%) of re-tears in the surgical repair group at 1-year follow-up. However, tear progression or failed rotator cuff repair may not be indicative of why the patients have more pain and less function, as studies have shown that large tears can be asymptomatic [45, 46]. This uncertainty in the extent of RCTs in relation to the patient's clinical presentation may not be an accurate representation of the outcome of the patient's pain and function post intervention in this study. The best pain and functional outcomes in this study were observed in surgical patients with an intact rotator cuff repair at the final follow-up, but the numbers to treat for successful rotator cuff repair would be high in this case considering the 73% of failed repairs that reported slightly less favourable outcome than the conservative approach. The insignificant difference in the outcome of this study demonstrates that physiotherapy may possibly be considered as an intervention due to it being less expensive than surgery as reported in this article. However, longer duration of follow-ups in this study would be beneficial to determine the outcome of both interventions in relation to MRI findings, pain, function and economic impact.

Kukkonen et al. [47] concluded in their 1-year follow-up study that there was no statistical significance between rotator cuff repair with acromioplasty and physiotherapy, or physiotherapy alone. There was only a difference in patient satisfaction scores in the first 3 and 6 months, where the two groups without repair reported higher patient satisfaction than the repair group. This may be due to the postoperative restrictions for the surgery group, leading to more dissatisfaction in this group. However, the overall outcome was the same by the 1-year follow-up

Overall, the three studies showed low risk of bias that cannot completely be avoided because of the nature of interventions. Despite the conservative and surgical interventions in all three trials being standardised with the same treatment aims, the patients' irritability and severity of their symptoms and the effect on their daily function varied the intensity, dosage, and duration of treatment. This variation made it difficult to compare conservative and surgical approaches for the management of RCTs. The treatment strategies and aims among all three trials for physiotherapy were similar in that all three randomised controlled trials focused on initiating static and dynamic glenohumeral movement, scapulohumeral movement, and stabilisation, and increasing the level of progression from 6 to 12 weeks.

## **3.1. Physiotherapy treatment techniques**

There is some debate on the optimal conservative treatment and rehabilitation approach for RCTs and its role in improving the symptoms associated with an RCT.

Ainsworth et al. [48] conducted a systematic review of exercise therapy for the conservative management of RCTs. This review could not find any high-quality trials and found only 10 observational studies and 2 case studies. The primary conclusion of this review was that physiotherapy may have some benefit; however, the method of distinguishing the extent of the patient's pain in relation to the tear as well as the level of exercise in terms of intensity and dosage are still unclear due to the poor quality of the trials.

entity from partial tears are needed. In addition, high-quality studies in which comparisons between different conservative interventions and surgical treatment are made to determine

The present study also had a high incidence (73%) of re-tears in the surgical repair group at 1-year follow-up. However, tear progression or failed rotator cuff repair may not be indicative of why the patients have more pain and less function, as studies have shown that large tears can be asymptomatic [45, 46]. This uncertainty in the extent of RCTs in relation to the patient's clinical presentation may not be an accurate representation of the outcome of the patient's pain and function post intervention in this study. The best pain and functional outcomes in this study were observed in surgical patients with an intact rotator cuff repair at the final follow-up, but the numbers to treat for successful rotator cuff repair would be high in this case considering the 73% of failed repairs that reported slightly less favourable outcome than the conservative approach. The insignificant difference in the outcome of this study demonstrates that physiotherapy may possibly be considered as an intervention due to it being less expensive than surgery as reported in this article. However, longer duration of follow-ups in this study would be beneficial to determine the outcome of both interventions in relation to

Kukkonen et al. [47] concluded in their 1-year follow-up study that there was no statistical significance between rotator cuff repair with acromioplasty and physiotherapy, or physiotherapy alone. There was only a difference in patient satisfaction scores in the first 3 and 6 months, where the two groups without repair reported higher patient satisfaction than the repair group. This may be due to the postoperative restrictions for the surgery group, leading to more dissatisfaction in this group. However, the overall outcome was the same

Overall, the three studies showed low risk of bias that cannot completely be avoided because of the nature of interventions. Despite the conservative and surgical interventions in all three trials being standardised with the same treatment aims, the patients' irritability and severity of their symptoms and the effect on their daily function varied the intensity, dosage, and duration of treatment. This variation made it difficult to compare conservative and surgical approaches for the management of RCTs. The treatment strategies and aims among all three trials for physiotherapy were similar in that all three randomised controlled trials focused on initiating static and dynamic glenohumeral movement, scapulohumeral movement, and

There is some debate on the optimal conservative treatment and rehabilitation approach for

Ainsworth et al. [48] conducted a systematic review of exercise therapy for the conservative management of RCTs. This review could not find any high-quality trials and found only 10 observational studies and 2 case studies. The primary conclusion of this review was that physiotherapy may have some benefit; however, the method of distinguishing the extent of

stabilisation, and increasing the level of progression from 6 to 12 weeks.

RCTs and its role in improving the symptoms associated with an RCT.

the optimal conservative management for RCTs are necessary.

MRI findings, pain, function and economic impact.

by the 1-year follow-up

22 Advances in Shoulder Surgery

**3.1. Physiotherapy treatment techniques**

The review also concluded that the size of the tear is not as important as the presence of pain in the patient. This is supported by the findings discussed previously with the current research and MRI scans in relation to the patient's clinical symptoms. It also highlighted that RCT repairs appear to be less successful in the elderly, and the review lean more towards conservative management as a first line of treatment. This idea is also supported by the Tashjian algorithm [42] and Levy [49], who further explain that due to older patients being more likely to have multiple comorbidities, RCTs should be managed conservatively.

The present study acknowledged that until there is more understanding of how some patients with FTTs can have a spectrum of symptoms from minimum to severe, it will be difficult to establish an optimal treatment and rehabilitation program for RCTs.

There are differences in opinion on the focus of rehabilitation between anterior deltoid retraining or working on the humeral head depressors to rehabilitate shoulder elevation in abduction only [50]. The anterior deltoid training is supported by Levy et al. [49] and by Ainsworth [51] on the basis of the biomechanics of how the anterior deltoid works. The anterior deltoid was believed to act as a humeral head elevator, but a study by Gagey and Hue [52] concluded that the deltoid functions to prevent upward migration of the humeral head. This theory is supported in present clinical practice of using the Torbay exercise program, which is proposed in the aforementioned studies. In the Levy et al. study [49] instructions were to exercise 3–5 times per day for the first 6 weeks, with the patient supine for the exercises, and progressing to an incline, and then standing. This study found that this technique would be beneficial for older patients with atraumatic, massive tears. However, this study was not compared with another intervention; therefore, there was no randomised allocation, and the lack of quality and a small study group of 17 patients made it difficult to form a significant conclusion.

Ainsworth et al.'s [48] prospective randomised controlled study had 60 patients over the course of 1 year. The intervention group consisted of anterior deltoid training as well as other treatment modalities such as functional exercises, proprioception and stretching. It is therefore difficult to establish which specific treatment modality had an impact on improving patient pain and function compared to the control group, whose treatment consisted of ultrasound, advice, and steroid injections, if required. The SF-36 score showed statistical significance in the intervention group over the control group at 3 and 6 months, but there were no differences by 12 months. Despite these improvements in functional and pain scores, further studies with standardised treatment interventions and larger numbers of patients over a longer period are needed to support the use of anterior deltoid training.

This study also highlighted the role of education in altering the patient's perception of pain and therefore reduce pain and disability, which is also supported in previous studies [53, 54]. It is believed that advice and education alone allow the patient to use the shoulder, by reducing their fears of causing more harm. This may have contributed to why the control group had no statistical difference from the intervention group. Despite these findings, physiotherapy with this specific anterior deltoid exercise program is deemed to be beneficial because it allows patients to return to their activities of daily living (ADLs) earlier, which could impact aspects such as reducing time away from work and the risk of depression, and improving quality of life (which are associated with poor outcome). Future studies should further investigate this exercise program. Kuhn et al. [55] conducted a multi-centre prospective cohort study of 381 patients who underwent physiotherapy over a 12-week period with a 2-year follow-up. The patients' compliance diaries showed a variation in programs from no therapy to supervision and home, home only, and supervision only. If after 6 weeks the patients were no longer in pain and/or the pain was not affecting their ADLs, then conservative management was successful. Only 9% of patients had surgery after 6 weeks, and a total of 15% of patients had surgery in the first 12 months. After this time, it is deemed that the patient is unlikely to have surgery for RCT. This study was performed only on atraumatic patients only; thus, it is not a reflection of acute traumatic tears. The treatment strategies for these patients were primarily focused on exercise therapy, manual therapy, and heat and cold therapy. However, there were no comparison intervention groups to establish which treatment modality was superior to another, and the therapist could tailor the therapy to the patient's individual presentation, making it difficult to form a conclusion on the most effective aspect of the therapy program. Edwards et al. [56] conducted a review of the current treatment strategies during rehabilitation and concluded the use of anterior deltoid training allows adequate shoulder elevation without upward migration of the humeral head. In this review, the authors also noted the role of the teres minor during external rotation with infraspinatus tears as part of allowing the greater tuberosity of the humerus to clear the acromion during shoulder elevation. Studies that have been researched currently show a general trend of 10–15 repetitions twice a day; however, further research to justify using the prescription recommended for this specific type of training is warranted.

**5. Injections**

strength in CS subjects [59].

**6. Biologics**

**6.1. Basic science**

The concept of using injections for the treatment of RCTs is not new to the field of orthopaedic surgery, as the practice of using injections such as corticosteroids (CS) and sodium hyaluronate (HA) is common in many practices. CS and HA are both injectable pharmaceutical agents that can be used to decrease pain and stiffness, and they have demonstrated significant

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A 2015 in vitro study found that CS injections decreased cell proliferation in rotator cuff tendons, and the resulting strength of these tendons decreased as compared to the strength after HA injections [59]. The same study also conducted an experiment on the effects of CS and HA injections in rats. Like the in vitro study, the animal study found apoptosis in rotator cuff tendons, inhibition of cell proliferation, a delay in tendon healing, and decreased biomechanical

Clinical application of these agents is highlighted by a study conducted in 2001, in which 40% of a group with RCTs that received HA injections were satisfied with the durable effects produced at 24-weeks follow-up [60]. In addition, 35% of the group that received CS injections expressed satisfaction over a 5-week period with the injections [60]. Moreover, another study found statistically significant pain relief in groups with HA injections as compared to the control group [61]. In another study, a combination of HA injections and rehabilitation programs led to an improvement of mobility in elderly patients [62]. When using CS injections, no dif-

Biologics are similar to the aforementioned injections, as they are injected into the RCT zone to assist in regeneration of the tendons. Biologics are specific proteins and cells that are obtained

Biological injections can include platelet-rich plasma (PRP), which is prepared from a patient's blood by concentrating thrombocytes, usually a multiple of the normal circulating concentration. This injection is produced through standardised preparations: blood is drawn from the patient and spun in a centrifuge to separate the parts of the blood, and the highly concentrated plasma is re-administered to the patient in the affected area [65]. The idea of PRP follows simple scientific logic as the platelets are the body's primary way of reaching structural defects and injuries through proteins, cytokines, and growth factors that stimulate healing. Once platelets reach the specific site, they release different growth hormones that trigger natural and regenerative healing processes [66]. PRP has been known to stimulate both the response of mesenchymal stem cells (MSCs) to the local area through growth factors such as plateletderived growth factor (PDGF), fibroblast growth factor and vascular endothelial growth factor

ference was found in groups with different frequencies of injections [63].

from the patient; therefore, they are personalised for the individual [64].

impact on improving quality of life for patients with RCTs.

It appears that the nature of the studies that have been reviewed do not always focus on complete RCTs, which is due to the lack of available evidence on the management of complete RCTs. Therefore, the conclusions in this review are limited. More studies focusing on the surgical and conservative management of complete RCTs need to be completed to delve further into the optimal management of this pathology.
