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Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Dec 18, 2015; 6(11): 902-918
Published online Dec 18, 2015. doi: 10.5312/wjo.v6.i11.902
Rotator cuff tears: An evidence based approach
Senthil Nathan Sambandam, Vishesh Khanna, Arif Gul, Varatharaj Mounasamy
Senthil Nathan Sambandam, Joint Reconstruction Center, Department of Orthopaedics, K.G. Hospital and Postgraduate Medical Institute, Coimbatore 641018, Tamil Nadu, India
Vishesh Khanna, DNB Orthopaedics, Department of Orthopaedics, K.G. Hospital and Postgraduate Medical Institute, Coimbatore 641018, Tamil Nadu, India
Arif Gul, Princess Alexandra Hospital, Harlow, Essex CM20 1QX, United Kingdom
Varatharaj Mounasamy, VCU Medical Center Ambulatory Care Center, Richmond, VA 23298, United States
Author contributions: Sambandam SN, Khanna V, Gul A and Mounasamy V contributed equally to this work; Sambandam SN and Khanna V designed the research; Sambandam SN, Khanna V, Gul A and Mounasamy V performed the research and analysed the data; Sambandam SN and Khanna V wrote the paper.
Conflict-of-interest statement: The authors Drs. Senthil Nathan Sambandam, Vishesh Khanna, Arif Gul, Varatharaj Mounasamy have not received fees for serving as a speaker, nor have they received research funding from any organization. None of the authors possess stocks and/or shares. There are no conflicts of interests.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Senthil Nathan Sambandam, Orthopaedic Surgeon, Joint Reconstruction Center, Department of Orthopaedics, K.G. Hospital and Postgraduate Medical Institute, Arts College Road, Coimbatore 641018, Tamil Nadu, India. sam_senthil2002@yahoo.co.in
Telephone: +91-98-40015401
Received: May 10, 2015
Peer-review started: May 12, 2015
First decision: July 27, 2015
Revised: August 4, 2015
Accepted: October 16, 2015
Article in press: October 19, 2015
Published online: December 18, 2015
Abstract

Lesions of the rotator cuff (RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an age-dependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears (PTT) can be bursal-sided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears (FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations - cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, anti-inflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being cost-effective, this helps in providing a functional shoulder with a stable cuff. An easily reproducible technique of maximal strength and sturdiness should by chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with debridement while more severe lesions mandate repair either by trans-tendon technique or repair following conversion into FTT. Early repair of repairable FTT can avoid appearance and progression of disability and weakness. The choice of surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the current scenario. The double-row repairs have an edge over the single-row technique in some patients especially those with massive tears. Stronger, cost-effective and improved functional scores can be obtained by the former. Both early and delayed postoperative rehabilitation programmes have led to comparable outcomes. Guarded results may be anticipated in patients in extremes of age, presence of comorbidities and severe tear patters. Overall, satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.

Keywords: Rotator cuff tears, Partial thickness tears, Full thickness tear, Natural history, Ultrasonography, Magnetic resonance imaging, Single row repair, Double row repair, Healing

Core tip: Close attention to history and examination enables early diagnosis in the frequently asymptomatic rotator cuff tear. Ultrasonography and magnetic resonance imaging serve as excellent visualization tools. While conservative measures are successful in elderly patients with minimal lesions and demands, regular monitoring helps in isolating the surgical candidate. Early surgery should be considered in younger, healthier, active and symptomatic patients. Lower grades of tears do well with debridement alone while more severe lesions warrant a repair. Arthroscopic double-row repairs are superior in patients with massive tears. Satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.