I'm really catching on to this new idea of choosing medical treatment based on evidence rather than just doing what everyone has always done it because "that's the way it's always been done." When it comes to treatment for rotator cuff, what do the experts have to say? I've already had surgery for mine (several years ago), but I'd kinda like to know if surgery is really still recommended.
The American Academy of Orthopaedic Surgeons has published Clinical Practice Guidelines (CPGs) for the care and management of rotator cuff tears. The guidelines consist of 14 recommendations based on all available current (high-quality) evidence in the literature. The full guidelines are available on line at the American Academy of Orthopaedic Surgeons website (www.aaor.org/guidelines).
But if you take a look at them, don't be surprised by what you see. The evidence just isn't there yet to support one type of treatment over another in most cases. There is agreement among all the physicians who came up with these guidelines that "if it's not broke, don't fix it."
In this case that means, if a person has a rotator cuff tear but it doesn't hurt and doesn't bother them, then don't do surgery to repair it. Anyone who does have painful symptoms, loss of motion, decreased strength, and altered function should consider having surgery.
The evidence was inconclusive more often than not. Answers to many questions are lacking. Does exercise help? If so, what kind of exercise? Should you have the joint injected with a steroid and numbing agent? Does ice work better than heat? When would electrical stimulation be effective? When should you take a nonsteroidal antiinflammatory medication? These are questions that must be investigated further before any recommendations can be made.
And that's just on the side of conservative care. When it comes to recommendations about surgery, the waters get even murkier. Should the surgeon use suture anchors to reattach the torn tendon to the bone or is it better to drill a tunnel through the bone and thread the tendon through to anchor it down? Should the surgeon perform the surgery using an open incision, arthroscopic repair, or the more recently develop mini-open approach? Once again, the evidence is inconclusive on these points.
What did the evidence support? There was weak support for doing surgery to repair chronic, full-thickness rotator cuff tears that cause pain and other disabling symptoms. Early surgery following the acute tear may have better outcomes than waiting until the problem becomes chronic. If the tear is only a partial one and doesn't go all the way through the tendon, then conservative care with inflammatory meds and physical therapy may really be acceptable choices.
The panel concluded there is a definite lack of strong evidence to help guide surgeons. The path in choosing the best treatment for optimal outcomes in patients with rotator cuff tears isn't clear. Every patient deserves an individual evaluation with all factors and variables taken into consideration. No doubt that is how your surgeon developed the plan of care you followed.
Ken Yamaguchi, MD. New Guideline On Rotator Cuff Problems. In AAOS Now. January 2011. Vol. 5. No. 1. Pp.1, 46-47.
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