rotator cuff repair in the older people???

And yet another article suggests that we are doing too much surgery.  this one is on nontraumatic rotator cuff tears in older patients (see rotator cuff tear nonsurg JBoneJointSurg2015 in dropbox, or J Bone Joint Surg Am. 2015;97:1729). details:

--160 patients (mean age 64, 50% female, 50% working, mean duration of symptoms 27 months) in Finland with 167 symptomatic, nontraumatic, isolated full-thickness supraspinatus tears were randomized into:

    --group 1: physiotherapy-- patients given written info and guidance on home-based excercise program. first six weeks aimed at improving glenohumeral motion and active scapular retraction; then static and dynamic exercises to improve scapular and glenohumeral muscle function until 12 weeks, then increased resistance and strength training until 6 months. also 10 sessions of PT in outpatient facility to monitor progress. 

    --group 2: physiotherapy plus acromioplasty. PT as in group 1, plus arthroscopic acromioplasty (to reduce the friction between the supraspinatus and the acromion)

    --group 3: group 2 plus anatomic repair of the ruptured tendon

--Primary outcome was Constant score (a combo of 4 scores: pain, ADLs, range of motion, and strength), recorded prior to intervention and after 3, 6, 12 and 24 months). Baseline Constant score was about 60 points. scores are from 0-100

--all patients had repeat MRI at 2 years

--results at 2 years:

    --similar changes in Constant score between the groups at 2 years vs prior to intervention: 18.4 point improvement in group 1, 20.5 points in group 2, and 22.6 points in group 3. these changes not significantly different from each other

    --no significant difference in visual analog scale for pain or patient satisfaction in the 3 groups (high patient satisfaction in all 3 groups: 89% in group 1, 95% in group 2, and 94% in group 3​)

    --mean sagittal size of the tendon tear by MRI initially was approx 10.5 mm; at 2 years,  tendon tear size was signifcantly smaller in group 3 (4.2 mm, p<0.01) vs approx 11.0 mm in groups 1 and 2.

    --rotator cuff repair and acromioplasty cost more....

    --on review of the Constant subscores: 

            --pain and ADL: significantly better in group 2 or 3, beginning at 3 months and continuing for the 2 years, but ROM and strength initially best in group 1 then equalized

            ​--these differences were on the order of 2 points, where a 10 point difference is considered clinically important

so, 

--rotator cuff tears are really common, up to 30% of those >60yo. they may be asymptomatic or lead to significant pain/shoulder dysfunction

--the tear thickness did increase slightly in groups 1 and 2 and decreased in group 3 (who had tendon repair). at 2 years, MRI-documented full thickness tear was found in 80% of groups 1 and 2, but 31% of group 3. not sure what the clinical significance of this is.

--though there were statistical differences in the Constant subscores, especially pain and ADL, these numbers were small and the visual-analog scale for pain was no different amongst the groups.

--the finding that there was no difference in these groups is reinforced by the considerable placebo effect of surgery in other studies

--bottom line: conservative therapy seems to be a viable option for initial treatment in older patients with non-traumatic rotator cuff tears, though the patients probably would need to be pretty motivated to follow the PT program and have consistent support/guidance.