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    Physical Therapy As Effective As Surgery for Rotator Cuff Tears

    A recent study from Finland asserts that when it comes to treatment of nontraumatic rotator cuff tears, physical therapy alone produces results equal to those produced by arthroscopic surgery and open surgical repair. According to the study's authors, follow-ups of 167 shoulders treated show that "conservative treatment should be considered as the primary treatment for this condition."

    The research, published in the January issue of Bone and Joint Journal (abstract only available for free), was built around treatment of 173 patients aged 55 and older (mean age 65) with supraspinatus tendon tears. Patients were assigned to 3 groups: the first group received physical therapy only; the second group received acromioplasty and physical therapy; and the third group was treated with rotator cuff repair, acromioplasty, and physical therapy. Each group contained similar age ranges and equal distribution by sex. After exclusions and drop-outs, 167 shoulders were available for assessment.

    Components of the physical therapy treatment remained the same across groups: patients were given guidance and information on home exercise that focused on glenohumeral motion and active scapular retraction for the first 6 weeks, with increases during the next 6 weeks, followed up by increased strength and resistance training for up to 6 months. Participants were also referred for 10 physical therapy sessions in an outpatient clinic.

    When patients were assessed using the Constant score at 3 months, 6 months, and 1 year, researchers found substantial similarity in rates of improvement. "Contrary to our hypothesis, surgical repair of a supraspinatus tear does not improve the Constant score when compared with acromioplasty only or conservative treatment," the authors write. Additionally, the patients' subjective satisfaction ratings were the same for all 3 approaches.

    The findings even seemed to contradict the placebo effect often associated with surgery. Authors noted that participants were aware of the treatment path assigned to them, yet the surgery group did not report markedly different perceptions of improvement. The results led authors to speculate that the similar Constant scores among groups "may simply be due to the similar physiotherapy [regimens]."


    Comments

    Based on the prior research regarding the strong correlation between bursal/articular tears and when surgery is appropriate, I find this study to be a possible starting point, but may be misleading in the headline. As the abstract is the only thing I can access, can someone with greater access please assess and report on the power or lack of power in regards to the statistical analysis?
    Posted by sean on 3/13/2014 1:07 AM
    I need to access the full research article to see what the criteria was for improvement, and how long the patiets had the tears before receiving treatment as well as the degree of fatty infiltration of muscle at initiation of treatment. The title is misleading and should read "non-traumatic rotator cuff tears"
    Posted by Julie Hagigeorges on 3/13/2014 10:49 AM
    I had my rotar cuff surgery three years ago for a torn rotator cuff and some calcium deposits on my shoulder. It still hurts I went to an orthopedic surgeon and he said the way my arm bends the bone to bone is hitting together I don't know what to do
    Posted by Liza Perry on 3/14/2014 12:15 PM
    Years ago I worked for a large well-known orthopedic group. Yes, I was employed by a POPTS - respected as a colleague for my skills, experience, and my professional judgment. I treated many patients with definitive partial rotator cuff tears - some traumatic, some attritional or of other non-traumatic origin. Unless findings and symptoms were so overwhelming indicative of necessitating specialized imaging and subsequent surgery, the conservative rehabilitation approach was almost universally tried. The treatment plan, progression, and rehabilitation management of the patient was entirely my responsibility. Most patients that myself and colleagues treated were able to proceed to a successful outcome, never requiring surgery. Of course, this is all anecdotal and reported by a pariah who worked for a POPTS, and unless one's supreme sensitivity to my reportage is an anathema- I am certain many of us do not find this report at all surprising. Conservative care of partial cuff tears has been one of the most rewarding experiences for orthopedic physical therapists for years. Personally, I experienced a definite partial cuff tear in my dominant arm at age 50. My shoulder ER strength was 2/5, flexion 3+/5, ABD 3/5. Pain level at rest 6/10, ROM WFL. Sleep was close to nil unless in reclining position. MRI and probable surgery recommended. Despite my pain and strength deficits, I self-treated for months, continued to practice, continued to exercise - albeit carefully - and avoided all pain reproducing movements/functions/activities. I was able to return to full and uninhibited activity - including racquetball - in six months. Again, an anecdotal report, but an example of a common story we can all probably relate from our own practices. As an aside, I am now 74 and continue to play racquetball with no recurrence of RC injury.
    Posted by Herschel Budlow P.T. on 3/14/2014 9:35 PM
    How many of us have treated non traumatic rotator cuff tears that were referred to us as "bursitis or tendinitis" and had no imaging for diagnosis but had all the clinical signs? Some recovered and some had significant enough pain to be referred back for imaging and sometimes ultimately surgery. I guess the pain issue is what drives most of my patients to get the surgery. Not everyone can tolerate a rotator cuff tear and the sleep deprivation. I did have the pain and sleep disturbance and I did debate having the surgery but did not. I think it depends on the individual sometimes.
    Posted by J W Corwin PT on 3/17/2014 10:35 AM
    The MRI is "the tool of the devil" according to Ned Kuhn, MD, orthopedic surgeon from Vanderbilt. I say it typically is the key to the cash register. RCTs are quite common, especially in men over 50, and most of them don't have pain or weakness prompting a visit to their doctor who then refers them to the surgeon; hence the trap has been set and they have walked into it. Dr. Kuhn reported that about 10% of folks over 60 have RCTs - this is about 5.7 million people. They do about 250,000 shoulder surgeries/year in the US and assuming these are all RC surgeries, that amounts to about 4% of the RCTs out there. What do the other 96% do? Research shows that failed repairs are very likely to have a good outcome - so why are so many operated on? In my opinion and that of many others, if he patient does not have frank weakness and/or intractable pain then DO NOT get the MRI! I predict in 10 years or less the shoulder MRI will go the way of the NSLBP MRI and will not be covered - too many false positives that just lead to harms (and of course a transfer of wealth). Asymptomatic full thickness tears are quite common. I suggest PTs do some research in this area and they will find this to be very true.
    Posted by Ed Scott PT, DPT, OCS on 3/20/2014 11:10 AM
    An impartial review of patient care across all health professionals is not possible when we all work under the umbrella of the medical Profession. They have louder, richer voices than the rest of us. Thanks for studies like this one, we need more of them. If all other Allied Health workers combined, forgot their differences and shared their common interests they would become a more effective lobby. Otherwise we will remain the poor relations.
    Posted by Clare O'Hagan on 3/26/2014 7:18 PM
    3-4 MONTHS POST INJURY, I HAVE HAD AN MRI SHOWING FULL THICKNESS TEAR. THE PAIN LEVEL FOR APPX 2 MONTHS WAS EXCRUCIARING AT NIGHT. AFTER THAT TIME, SYMPTOMS BEGAN TO IMPROVE. I AM REFUSING SURGERY, PAIN MEDS AND MUSCLE RELAXANTS AS IMPROVEMENT IS OBVIOUS. DUE TO PRIOR INJURIES, I AM AWARE THAT THE BODY CAN HEAL ITSELF, IF GIVEN THE OPPORTUNITY. THIS INJURY SIDELINED MY SWIMMING REGEMINE. I WOULD LIKE TO GET INFO ON DOING MY OWN "PT". I AM OPPOSED TO INVASIVE PROCEDURES UNLESS ABSOLUTELY NECESSARY. FYI: I BEGAN AS A SURGICAL TECHNOLOGIST IN 1972 AND AS AN OR RN IN 1983. WHY NOT MAKE INFORMATION AVAILABLE FOR SPECIFIC EXERCISES FOR THOSE WHO CHOOSE NON-INVASIVE TREATMENT?
    Posted by JOEDAN CAVENAUGH on 5/22/2014 9:59 AM
    In answer to Sean, there were 180 patients originally included in the study, and they were divided evenly between three groups. The study was structured on the hypothesis that the repair surgery would have the best outcomes. So a lack of a statistically significant difference between the outcomes triggered the null hypothesis. When comparing the Constant score between the three treatment groups, p = 0.34.
    Posted by Gary Brazzell on 5/28/2014 5:50 PM
    I have completely torn 3 tendons in my rt. shoulder (superspinatus and intraspinatus. ) I was told that surgery would not be successful and therapy was prescribed . I play golf left handed and now am unable to finish my follow thru due to the pain. I need advice on whether to continue therapy or go thru the surgery. I would be willing to continue physical therapy if I can play without pain. Please advise. Tony Lamonica
    Posted by Tony LaMonica on 6/24/2014 7:07 PM
    I have an old AC dislocation from a car accident 25 years ago and 6 months ago fell and had severe shoulder and upper arm pain - an MRI showed a full thickness rotator cuff injury and an x ray significant arthritis. After 6 weeks of very limited shoulder use and heat i felt good and had fair ROM. Now with more activity -i.e gardening and some lifting my shoulder is more painful but no tendenitis as I originally had. Hot showers seem to help. What next?
    Posted by Laurie on 7/5/2014 12:44 AM
    I am finding the information on this Web site to be very helpful. It is difficult to decide whether or not to have the surgery. There is often tremendous pain with the rotator cuff injury, and, of course, restrictions in one's lifestyle. (Especially at the outset.) However, it is my understanding that this may be considered "elective surgery"...which adds to the dilemma for a retiree (re. medical coverage).
    Posted by Donna McCusker on 8/5/2014 12:58 PM
    Can someone tell me what exercises I should do to strengthen my rotator cuff and I am willing to do it. I will really appreciate as I have been dealing with pain and pain and I don't want surgery. GOD BLESS YOU and Thank you email: rajpura@yahoo.com
    Posted by Raj on 9/2/2014 8:07 PM
    I am avid tennis player, and my guess is that I have a partially torn infrapinatus with a full thickness tear due to serving. I do not have any pain when doing normal,physical activities or problems with sleeping. I am now in physical therapy. Overhead activity, mostly trying to serve in tennis is something that definitely hurts. I am of course not playing tennis. I have some interior pain on the right side of the shoulder which is minimal. The MRI showed the partial tear. I do,not want surgery, but am wondering if I will be able to play tennis again. I can serve underhand without pain . Has anyone tried soft tissue therapy? By the way I am 70 years old.
    Posted by Liz on 9/6/2014 1:53 PM
    I tripped and fell catching myself with my right arm, and my shoulder hurts; sure that I have a possible tear in one of the tendons. Also, my primary physician refered me to a surgean. Through my on method of physical therapy with a "green" band, I'm improving. I believe that your body and good oxygened blood flow can produce the ability to heal itself without surgery.
    Posted by Jim on 9/18/2014 9:46 PM
    My follow suffers of rotator cuff injuries. Go to website for the American Academy of Orthopedic Surgeons and download the exercises for rotator cuff injuries. They do help!
    Posted by JOHN LOHERER on 9/27/2014 7:37 AM
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