Anterior deltoid reeducation for irreparable rotator cuff tears revisited

doi:10.1016/j.jse.2017.03.007

Journal of Shoulder and Elbow Surgery

Volume 26, Issue 9, September 2017, Pages 1562-1565

https://doi.org/10.1016/j.jse.2017.03.007 Get rights and content

Background

A previous study introduced a method of conservative treatment of irreparable rotator cuff tears (RCTs) using a rehabilitation program (anterior deltoid reeducation [ADR]). The purposes of this study were to present our experience with ADR and to compare our results with those of the previous study.

Methods

Thirty consecutive elderly patients with irreparable RCTs were prospectively enrolled and taught how to perform the home-based ADR program for a period of 3 months. Clinical and radiographic evaluations were determined at the first visit. Clinical follow-up was available after 9 and 24 months. Failure of the ADR program was defined as abandonment of the ADR program because of pain and/or a patient's decision to undergo surgery at any time or a less than 20-point improvement in the American Shoulder and Elbow Surgeons score at last follow-up.

Results

Of the 30 patients, 9 did not complete the 3-month ADR program because of pain. Of the 21 patients who completed the ADR program, 3 were not satisfied with the outcome and went on to undergo surgery. Eighteen of the 30 patients completed the program and had a follow-up at 24 months. Among these 18 cases, there were significant mean improvements between pre-ADR and follow-up outcome scores among all variables (P < .005). However, 6 of these 18 patients did not have an improvement in the American Shoulder and Elbow Surgeons score by at least 20 points. Overall, the ADR program had a success rate of only 40%.

Conclusion

A 3-month ADR program had limited success to treat irreparable RCTs. We could not reproduce the high rate of satisfactory results of 82% found in a previous study.

Section snippets

Patients and methods

From June 2009 to June 2010, 31 consecutive patients with a minimum age of 55 years and the diagnoses of chronic irreparable RCTs, were prospectively enrolled after patient consent. One patient died during the course of the study and was excluded. There were 19 female and 11 male patients enrolled in the study. The average patient age was 74 years (range, 55-89 years). The other exclusion criteria were prior fracture malunion, cancer or metastatic lesion to the shoulder, traumatic reparable

Results

Only 21 of 30 patients were compliant. The 9 noncompliant patients were not able to complete the ADR program because of pain and persistent symptoms. Of these 9 patients, 5 went on to undergo reverse TSA and 1 underwent partial rotator cuff repair. Twenty-one patients completed the 3-month ADR program. Of these 21 patients, 3 were not satisfied with the outcome at 3 months and went on to undergo reverse TSA (2 cases) or partial rotator cuff repair (1 case). Eighteen of the 30 patients completed

Discussion

ADR has been suggested as an alternative nonsurgical treatment option for older patients presenting with irreparable RCTs.10, 14 Biomechanical studies have shown that compensatory increases in force of the deltoid and the remaining rotator cuff are required to achieve improvements of shoulder function.9, 10, 15, 19, 22 This includes rehabilitation of the anterior deltoid muscle to resist superior escape forces.²² There are limited clinical studies, however, that have specifically examined

Conclusion

In non-debilitated elderly patients, a 3-month ADR protocol to treat symptomatic chronic irreparable RCTs had limited success at 2 years' follow-up. Success was less likely for those with pretreatment active forward flexion of less than 50°.

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Acknowledgments

We thank Raoul Burchette, MA, MS, biostatistician, for his help with the statistical analysis.

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Cited by (23)

Many patients fail to achieve MCID for PROMIS upper extremity and pain interference following nonoperative management of rotator cuff tears
2023, JSES International
Efficacy of nonoperative treatment for rotator cuff tears has been debated, especially for full-thickness tears. The purpose of this study was to a) define the minimal clinically important difference (MCID) of nonoperative treatment with regard to Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) and upper extremity (UE), and b) determine the proportion of patients with both partial and full-thickness tears (PTRCT, FTRCT) who achieve this improvement following initial nonoperative treatment. We hypothesized that >75% of PTRCT and FTRTC patients would achieve MCID for PROMIS PI and UE.
We performed a retrospective cohort study evaluating nonoperatively managed patients with image-confirmed PTRCT and FTRCT. Treatment modalities and follow-up PROMIS scores at least 6 months after their initial visit were recorded. Using a distribution technique, MCID was calculated.
A total of 111 FTRCT and 68 PTRCT patients were included with at least 6 months of follow-up. At 6 months from initial presentation, the MCID for PROMIS UE was 3.75 and 3.95 for FTRCT and PTRCT patients, respectively. For PROMIS PI, the MCID was 3.35 and 3.90 for FTRCT and PTRCT, respectively. In total, 41% of FTRCT and 41% of PTRCT achieved MCID for PROMIS UE. Thirty-four percent of FTRCT and 35% of PTRCT achieved MCID for PROMIS PI.
The majority of patients undergoing nonoperative treatment for supraspinatus/infraspinatus rotator cuff tears did not achieve MCID at 6 months for PROMIS PI (34% for FTRCT and 35% for PTRCT) or UE (41% for FTRCT and 41% for PTRCT).
Nonoperative Treatment of Rotator Cuff Tears
2023, Physical Medicine and Rehabilitation Clinics of North America
Treatment of Massive Rotator Cuff Tears with Reverse Shoulder Arthroplasty
2023, Clinics in Sports Medicine
Treatment of massive irreparable rotator cuff tears using dermal allograft bridging reconstruction
2021, Journal of Clinical Orthopaedics and Trauma
Various options are available for treating massive irreparable rotator cuff tears, but all have their own limitations and no gold standard currently exists. Our aim was to report on outcomes of bridging repair with a dermal allograft for symptomatic massive irreparable rotator cuff tears where primary or partial repair was not possible.
We prospectively reviewed 22 patients who underwent an open interposition bridging repair with an allograft (GraftJacket) sutured medially to the residual rotator cuff stump and laterally to the footprint with suture anchors. Mean age at time of surgery was 59 years (range 53–66 years). The Oxford Shoulder Score, pain visual analogue scale and range of motion were compared pre-operatively and at mean follow up of 2.8 years. All patients had a postoperative MRI scan.
There was a significant improvement in mean Oxford Shoulder Score from a pre-operative score of 14.2–34.3 points (p < 0.01) at final follow up. Pain VAS score improved from 6.6 points to 2.8 points (p < 0.05). Significant improvements in range of motion were also seen. Postoperative MRI scans showed a retear in 8 patients (36%), but the retear size was smaller and an improvement in outcomes maintained at final follow up.
Open dermal allograft bridging repair for massive irreparable rotator cuff tears can lead to satisfactory outcomes and delay the need for a reverse shoulder arthroplasty.
Functional outcomes after physiotherapy program in patients with massive and irreparable rotator cuff tear
2021, Revista Espanola de Cirugia Ortopedica y Traumatologia
Evaluar los efectos funcionales a corto plazo y al año de seguimiento de un programa de fisioterapia en pacientes mayores de 60 años con rotura masiva e irreparable del manguito rotador (MR).
Se reclutaron de forma prospectiva 96 pacientes con rotura masiva e irreparable del MR. Todos los pacientes fueron tratados con un programa de fisioterapia de 12 semanas de duración. Se realizaron tres evaluaciones, al inicio, al finalizar el tratamiento y al año de seguimiento. Se utilizó el cuestionario de Constant-Murley para evaluar la función del hombro, el cuestionario DASH para la función del miembro superior y la escala visual analógica (EVA) para la intensidad del dolor.
Al finalizar el tratamiento, hubo mejoría clínicamente relevante y estadísticamente significativa (p < 0,05) en todas las variables. Al año de seguimiento, el Constant-Murley mostró un incremento de 26,5 puntos (d de Cohen = 1,7; intervalo de confianza (IC) 95% 23,5 a 29,5; p < 0,001), el DASH mostró una disminución de 31,4 puntos (d de Cohen = 2,2; IC 95% 28,5 a 34,3; p < 0,001), y la EVA mostró una disminución de 3,9 cm (d de Cohen = 3,6; IC 95% 3,6 a 4,1; p < 0,001).
A corto plazo y al año de seguimiento, un programa de fisioterapia consiguió mejoría clínica y estadísticamente significativa en todas las variables funcionales en pacientes mayores de 60 años con rotura masiva e irreparable del MR.
To evaluate the short term and 1-year follow-up functional effects of a physiotherapy program in patients over 60 years of age with massive and irreparable Rotator Cuff (RC) tear.
A total of 96 patients with massive and irreparable RC tear were prospectively recruited. All patients were treated with a 12-week physiotherapy program. Three evaluations were performed, at the beginning, at the end of the treatment and at one year of follow-up. The Constant-Murley questionnaire was used to assess shoulder function, the DASH questionnaire for upper limb function, and the Visual Analogue Scale (VAS) for pain intensity.
At the end of the treatment, all the variables showed a clinically and statistically significant difference (p < 0.05). At one year of follow-up, the Constant-Murley showed an increase of 26.5 points (Cohen's d = 1.7; 95% CI 23.5 to 29.5; p < 0.001), DASH showed a decrease of 31.4 points (Cohen's d = 2.2; 95% CI 28.5 to 34.3; p < 0.001), and the VAS showed a decrease of 3.9 cm (Cohen's d = 3.6; 95% CI 3.6 to 4.1; p < 0.001).
In the short term and 1-year follow-up, a physiotherapy program showed clinically and statistically significant results in all functional variables in patients older than 60 years with massive and irreparable RC tear.
Nonoperative treatment of chronic, massive irreparable rotator cuff tears: a systematic review with synthesis of a standardized rehabilitation protocol
2021, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
There were no Level I or II studies identified. Eight of the 10 studies analyzed patients as one single cohort.2,3,10,21,27,46,52,54 One study divided patients into 5 groups based on rotator cuff tear location.11
A massive, irreparable rotator cuff tear may cause significant pain and dysfunction. However, the efficacy of nonoperative treatment modalities in this subset of patients is not currently well known. Also, there is currently no gold standard nonoperative protocol to guide treatment. The goal of the present systematic review is to determine if there is any evidence to support the use of various nonoperative treatment modalities and synthesize a standardized nonoperative treatment protocol for the patient with a massive irreparable rotator cuff tear.
A comprehensive review of the literature utilizing PRISMA guidelines was performed. Studies involving clinical outcomes of nonoperative treatment of massive, irreparable rotator cuff tears were included. Articles were reviewed by 2 reviewers to determine inclusion or exclusion based on established criteria. Selected articles were reviewed for results of clinical and functional outcomes. The studies were also reviewed to determine their level of evidence and potential sources of bias. A standardized nonoperative treatment protocol was developed by taking described elements of the protocols used in studies that demonstrated clinical improvement beyond the MCID for the outcome scores used by the authors.
A total of 10 studies met inclusion criteria for our studies. Of the included studies, 1 was Level III evidence and the remaining 9 were Level IV evidence. Multiple studies showed significant improvement exceeding the MCID for functional outcome scores following treatment. Also, several studies demonstrated significant improvements in strength and range of motion. The overall success of nonoperative treatment ranged from 32%-96%. The synthesized nonoperative treatment protocol is characterized by requiring some supervised physical therapy, often requiring 12 weeks or more, focusing on supine exercises with gradual progression to upright. Corticosteroid injections and nonsteroidal anti-inflammatory drugs may also be of benefit.
Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. Using these results, a synthesized rehabilitation program was developed to guide clinicians when treating patients with massive irreparable rotator cuff tears.

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: Approval authority: Kaiser Permanente Southern California Institutional Review Board (No. 5393).

View full text

Anterior deltoid reeducation for irreparable rotator cuff tears revisited

Background

Methods

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

Conclusion

Disclaimer

Acknowledgments

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Orthop Sci

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears

Musculoskeletal Care

Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency: a concise follow-up, at a minimum of five years, of a previous report

J Bone Joint Surg Am