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Exploring treatment options for rotator cuff disorders: with recent advances, patients usually can expect a favorable outcome.

Article Excerpt
With recent advances in diagnostic capabilities, rehabilitation, and surgical techniques, patients with rotator cuff disease and injuries usually can expect a favorable outcome. Successful treatment requires a careful awareness of a diagnostic and treatment algorithm that takes into consideration comorbidities that may complicate a patient's rotator cuff disorder.

Several nonoperative treatment options are available that help avoid the inherent risks of surgery. However, arthroscopic evaluation and repair has become the gold standard for treatment because it allows for superior diagnostic capability and surgical versatility. Outcomes generally are favorable with a low incidence of complications, but total recovery may take longer than traditionally thought. Although most function usually is regained within 6 months, some gains in strength and motion have been documented at up to 2 years after surgery.

This 2-part article discusses and presents a rationale for patient evaluation and management of rotator cuff disease. In the first part ("Taking a closer look at rotator cuff disorders," The Journal of Musculoskeletal Medicine, October 2008, page 481), I reviewed the anatomy and pathogenesis of various types of rotator cuff disease and approaches to evaluation. This second part describes nonoperative and operative treatment options.

NONOPERATIVE TREATMENT Weighing the risks

Although nonoperative treatment helps avoid the risks of surgery, failed nonoperative treatment results in continued or recurrent symptoms or in progression of pathology, leading to eventual surgical treatment, possibly after irreversible changes have occurred in the rotator cuff. When counseling patients about treatment options, it is important to characterize a cuff disorder with respect to the patient's age, the tear size, the injury mechanism, chronicity, and muscle atrophy/fatty infiltration. Within this framework, the overall risk of irreversible changes to the cuff with continued nonoperative treatment is weighed against the potential for improvement with continued nonoperative treatment.

Tendinitis or partial-thickness tears probably will improve rapidly with nonoperative treatment. Therefore, a period of nonoperative treatment may be offered to a patient with little risk of progression of the pathology. In addition, a 67% success rate with nonoperative management of these conditions has been reported, with only 18% recurrence for an average of 2 years. (1)

Small to medium-size tears (2 to 3 cm), existing tears with a recent loss of function, and full-thickness tears of any size in a young, active person (younger than 60 years) are at risk for progression if early nonoperative therapy is not successful. In this age-group, prolonged nonoperative treatment has a low success rate and carries a risk of leading to irreversible changes in the tendon and muscle or progression of the tear, which may complicate the eventual surgical repair. For these patients, early surgical treatment after a short course of nonoperative treatment is preferable.

Patients older than 70 years with large chronic tears probably already have experienced irreversible changes in their cuff, leading to loss of function or pain or both. For these patients, there is...

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