Rotator cuff tear surgery and older patients

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

A large percentage of older patients have minimal symptoms with a rotator cuff tear and continue to function without pain or disability.

In one study, up to 40% of patients over the age of 70 had no symptoms in the presence of a rotator cuff tear.

Many symptomatic older patients (defined as patients 60 years and greater) may be managed conservatively with anti inflammatory medicines, physical therapy, and glucocorticoid injections.

The goal of physical therapy is to maximize the function of the remaining tendons, and hopefully avoid surgery. In the younger age groups, particularly when tears are caused by a sudden injury, early surgery is generally recommended to insure a successful treatment outcome.

It is known that many patients with deficient cuffs (not enough tissue to sew together) are surprisingly comfortable and functional and, therefore, never undergo surgery. It is also apparent that tissue insufficiency can lead to less than a durable repair, yet the patient still improves after surgery. These observations bring up the question of the relationship of cuff integrity to the quality of the result after cuff surgery.

A study of 105 surgical repairs of chronic rotator cuff tears in 89 patients at an average of five years postoperatively was undertaken at the University of Washington (Matsen FA, et al). The patients' ages at the time of repair averaged 60 years (range 32 to 80). Eighty-six (82%) of the shoulders had no prior attempt at repair of the cuff.

From the study, the investigators concluded that the integrity of the rotator cuff at follow-up (and not the size of the tear at the time of repair) was the major determinant of the outcome of surgical repair. An intact repair of a recurrent tear was likely to yield a result comparable to that of an intact repair of a primary tear. Likewise, intact repairs of large tears yielded results comparable to intact repairs of small tears.

The chances of the repair of a large tear remaining intact, however, were not as good as those for a small tear. Older patients tended to have larger tears and to have a higher incidence of recurrent defects.

When rotator cuff tears are relatively recent and when a significant force was required to tear the tendon, the chances of regaining shoulder strength by rotator cuff repair surgery are good. Conversely, when the defect is long-standing and occurred in the absence of a major injury, the quality and quantity of tissue available for repair may not be sufficient for the restoration of good shoulder function. Thus with long-standing shoulder weakness from rotator cuff defects, attempts at strengthening the remaining muscles may be worthwhile before considering surgical repair. If surgery is undertaken, proper postoperative care is particularly important.

Surgical exploration and attempted cuff repair is an option for the patient who understands the limitations of the procedure. Prompt surgical exploration of the rotator cuff is considered for young patients with acute tears. Repair should be carried out before tissue loss, retraction, and atrophy occur. For tears older than 12 months, a period of stretching and gentle strengthening exercises may be enough to ensure a patient may do well with nonoperative management.

Patients with severe arthritis change accounting for the rotator cuff tear may have a poorer long term prognosis.

In our community experience, rotator cuff repair for the older individual has not been successful. Since the shoulder is a complex joint we have generally advised a patient to see a shoulder specialist at a teaching hospital. The outcomes using this approach has been better than when a patient sees a general community orthopedist.

A newer treatment for tendonitis and smaller tears may be more effective and prevent the need for surgery. Percutaneous needle tenotomy is a technique where a small gauge needle is introduced using local anesthetic and ultrasound guidance. The needle is used to poke several small holes in the fascia. This procedure is called "tenotomy." Tenotomy induces an acute inflammatory response. Then, platelet rich plasma, obtained from a sample of the patient's whole blood is injected into the area where tenotomy has been performed. Platelets are cells that contain multiple healing and growth factors. The result? Normal good quality fascial tissue is stimulated to grow with natural healing.

For more information about rotator cuff tendonitis, visit our sister site:
Tendonitis provides reliable, accurate, and useful information on tendonitis treatment written by a board-certified rheumatologist. Learn more about how to get tendonitis relief using the most up-to-date methods.

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