NONOPERATIVE MANAGEMENT OF FULL-THICKNESS TEARS OF THE ROTATOR CUFF

THE ROTATOR CUFF, PART I 0030-5898/97 $0.00 + .20

NONOPERATIVE MANAGEMENT

THE ROTATOR CUFF OF FULL-THICKNESS TEARS OF

Michael A. Wirth, MD, Carl Basamania, MD, and Charles A. Rockwood, Jr, MD

. . . the more experienced the surgeon, the more emphasis he will place on the conservative

management of rotator cuff lesions, and the slower he is to approach this problem surgically.

CARTER R. ROWE, MD

Since Codman5 first described the repair of the supraspinatus tendon in 1911, surgical management of complete lesions of the rotator cuff has been well accepted. Although most clinicians favor surgical intervention for these lesions, the precise management of all full- thickness tears remains controversial, and the optimal nonoperative treatment program has not been defined. A simple review of the literature reveals numerous reports describing operative management of rotator cuff defects, but there is a paucity of information regarding the nonoperative management of these conditions. To the best of our knowledge, no randomized prospective studies comparing conservative management of rotator cuff tears with operative treatment exist in the literature.

This article reviews the literature pertaining to the nonoperative management of rotator cuff tears and describes our 2-year minimum follow-up experience with a physical-directed rehabilitation program for patients with a radiographically documented full-thickness tear of the rotator cuff.

INCIDENCE OF ROTATOR CUFF TEARS

Rotator cuff tears and subacromial impingement are among the most common causes of shoulder pain and disability. Degenerative changes of the rotator cuff represent a spec- trum of disease severity ranging from inflammation and edema to irreparable ruptures of the cuff mechanism. The reported incidence of full-thickness tears of the rotator cuff ranges from 5% to 40%, and studies clearly show an increasing frequency of cuff failure with ad- vancing age.9, lo, 15, 16, 18, z', z6, z9 The incidence of cuff rupture in asymptomatic patients is un- known, but the frequency with which full- thickness tears occur in anatomic studies sug- gests that this finding may be the result of a normal senescence process.6, 8,13, 22, z4, 25, 30,31,32

CLINICAL PRESENTATION

History

Impingement tears of the rotator cuff are common after 50 years of age. Many of these patients have no prior history of trauma, and an attritional defect develops insidiously. In our

From the Medical School, Department of Orthopaedics, The University of Texas Health Science Center, San Antonio, San Antonio, Texas

ORTHOPEDIC CLINICS OF NORTH AMERICA

VOLUME 28 NUMBER 1 JANUARY 1997 59

60 WIRTHet a1

experience, less than half of the patients with cuff tears can recall a specific event that initiated the symptoms. In this setting, the rotator cuff tear is brought to the attention of the physician when the patient presents with a long-standing history of intermittent shoulder pain that has become progressively more symptomatic. At this juncture, pain is usually constant, worse at night and with overhead activities, and only mildly improved with anti-inflammatory agents. The pain is commonly referred to the base of the neck and the upper arm. Although rare, some patients complain of discomfort as far distal as the wrist and hand. Additional complaints include weakness, subacromial popping or grinding, and loss of motion.

Physical Examination

Visual inspection of the posterior aspect of the shoulder in a patient with a chronic rotator cuff tear demonstrates atrophy of the supraspinatus fossa. Depending on the size of the tear, atrophy may also be appreciated in the infra- spinatus fossa. When the atrophy is moderate to severe, a corresponding weakness in abduction, elevation, and external rotation is noted with resistive manual muscle testing. The degree of weakness usually depends on the size of the tear but may be greatly influenced by the amount of pain present during the exami- n a t i ~ n . ~ A better estimation of the size of cuff rupture can be obtained by a repeat examination following a subacromial injection with a local anesthetic agent.

Tenderness to palpation may be present over the anterior acromion, the coracoacromial ligament, the lateral aspect of the tip of the coracoid, the bicipital groove, and the greater and lesser tuberosities of the humeral head. Subacromial crepitance with shoulder rotation is common in chronic impingement associated with ruptures of the rotator cuff. The impingement sign described by Neer” and the impingement reinforcement sign described by Hawkins and Kennedy” are positive. How- ever, one must keep in mind that these tests are nonspecific for full-thickness tears.

Passive shoulder motion is usually main- tained, whereas smooth active motion is diminished. The preservation of passive motion

and the absence of adhesive capsulitis are generally characteristic of complete full-thickness tears of the rotator cuff, whereas shoulders with partial-thickness tears have a propensity for adhesive capsulitis.20 Symptoms are often exacerbated in the midrange of motion when lowering the arm from an overhead position. Diminished internal rotation secondary to a tight posterior glenohumeral capsule is a common finding and affects the patient by making it difficult and painful to reach the back pocket, loop a belt, or fasten a bra.

LITERATURE REVIEW

McLaughlin17 emphasized that the rotator cuff was uniquely situated between two bones, and that compression between the acromion above and the humeral head below would cause it to “succumb to the ravages of attri- tion” long before other tendons of the human body. M~Laughlin‘~ did not advocate routine repair of all rotator cuff tears and stated, ”The wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prog- nosis.” These beliefs and recommendations were based on his experience and the following observations. First, he noted that approximately 25% of cadavers had torn rotator cuffs and believed that many of these had been asymptomatic. Second, his clinical experience indicated that approximately 50% of patients with rotator cuff tears would recover comfort- able and functional use of the shoulder with time. Third, the results of late and early repair were similar, affording the physician and patient ample time for expectant management. Fourth, repair did not always permit anatomic restoration. Fifth, early operation often proved to be unnecessary if satisfactory results were obtained without surgery.

RoweZ3 was also an advocate of treating rotator cuff tears in a conservative manner. He argued that the majority of rotator cuff lesions would respond satisfactorily to expectant management consisting of moist heat, pendulum exercises, occasional subacromial cortico- steroid injections, and patient education in avoiding repetitious irritation of the rotator cuff. RoweZ3 emphasized two exceptions to this

NONOPERATIVE MANAGEMENT OF FULL-THICKNESS TEARS OF THE ROTATOR CUFF 61

type of management: (1) a documented complete rotator cuff avulsion in a young patient and (2) a complete rotator cuff avulsion in an elderly patient associated with disabling pain unresponsive to conservative treatment.

A review of the literature indicates that the success rate of nonoperative treatment of rotator cuff tears ranges from 33%% to 92?’0.‘~ Itoi and Tabata14 reported their results with conservative treatment of complete rotator cuff tears in 54 patients (62 shoulders) with an average follow-up period of 3.4 years (range, 1 to 9 years). The overall scores of pain, motion, and function improved significantly, with 45 patients (51 shoulders) rated as excellent or good. An apparent diminution of satisfactory results was noted over time, but it was not mentioned whether the patients had discontinued their exercise program. Brown4 reported a complete return of function in 46 of 53 patients with rotator cuff tears treated with a conservative program if they initially had full abduction. The shortcoming of this study was that the diagnosis of a cuff tear was made clinically without radiographic confirmation. Nonethe- less, satisfactory outcomes were achieved in 53% of other patients with profound weakness consistent with large cuff defects. Wolfgang34 reported a 33% incidence of improvement in a 1974 series, and Takagishi** documented similar results in 44% of patients in his 1978 series. Boker and co-workers2 evaluated 53 patients with radiographically documented full-thickness tears of the rotator cuff who were treated nonoperatively with nonsteroidal anti-inflammatory medication, stretching, and strengthening exercises. The average follow- up exceeded 7 years (range, 3.7 to 12 years), and 44 of the patients were followed up for a minimum of 5 years. Between 75% and 80% of patients reported satisfactory pain relief, and many of these demonstrated no loss of functional shoulder motion. Of the 28 shoulders presenting within 3 months of injury, 24 (86%) were rated as satisfactory. In contrast, only 9 (56%) of 16 shoulders presenting with pain for over a 6-month duration were graded as satisfactory.

Hawkins and Dunlop” reported on 33 patients with full-thickness tears of the rotator cuff who were managed nonoperatively with rotator cuff strengthening exercises. At an av-

erage follow-up of 3.8 years (range, 2.6 to 4.6 years), 19 patients (58O/0) were graded as satisfactory according to the method of Constant and M ~ r l e y . ~ In their attempt to identify patients who would benefit from nonoperative care, Constant and Murley7 were unable to demonstrate that individual parameters such as rotator cuff strength, symptom duration, or functional impairment were useful in predict- ing outcome.

AUTHOR’S PREFERRED METHOD OF NONOPERATIVE MANAGEMENT

Our treatment philosophy is based on the tenet that most rotator cuff defects are the result of a natural degenerative or aging process, which may be hastened by chronic impingement. For this reason, we initially treat most patients with rotator cuff problems with or without the shoulder impingement syndrome with a conservative rehabilitation program.

During the initial visit, the diagnosis of a rotator cuff lesion or shoulder impingement syndrome is established based on the patient history, physical examination, and standard anteroposterior, axillary, and 30-degree caudal tilt radiographs. Patients with large rotator cuff tears generally have more profound weakness of external rotation, are usually older, and, frequently, have more limited range of motion. Specific stress radiographs can be helpful in differentiating between small and massive tears of the cuff if standard radiographs reveal a normal acromiohumeral dis- tance. At the University of Texas Health Sci- ence Center at San Antonio, the senior author (CAR) developed a simple abduction strap for this purpose. In patients with a significant rotator cuff defect, active abduction against a strap around the trunk and arms causes superior migration of the humeral head which is readily apparent on a standard anteroposterior radiograph of the shoulder. We do not routinely perform special radiographic studies (arthrography, ultrasonography, CT- arthrography, or MR imaging) to diagnose a rotator cuff tear because the presence or absence of a cuff defect does not change our treatment plan. However, the initial course of rehabilitation for a patient with a rotator cuff tear

62 WIRTH et a1

is usually longer than that for the patient with shoulder impingement syndrome in the absence of a torn cuff.

The exception to the initially conservative treatment philosophy is the active patient who presents with an acute tear following a trau- matic episode. In this scenario, the patient is evaluated clinically and radiographically and is best treated with early repair of the torn rotator cuff. The other exception is the middle- aged or elderly patient who does not respond satisfactorily to the rehabilitation program.

The mainstay of our conservative treatment protocol is a physician-directed rehabilitation program. We personally instruct each of our patients in the exercise program described in the following sections, and each patient is given a home therapy kit that includes elastic bands of six different colors and strengths, a pulley set, and a meter stick. Additionally, patients receive a fully illustrated booklet with all of the exercises, anatomic drawings, and definitions of related terms, and a demonstra- tion videotape to remind them how to perform the exercises. The program is tailored to each individual patient, altering the basic core program as necessary to fit the needs of that patient. We ask patients to perform all of the work on their own at home, while at work, or when traveling. The simplicity of the therapy kit and its compact nature facilitate this process. We caution patients never to push therapy to the point of causing discomfort. The senior author has coined the term ”orthotherapy” to describe this program, which is an interactive exchange between the patient and the orthopedic surgeon directed at creating an exercise regimen that gently and gradually im- proves motion and strength in the shoulder girdle.

ORTHOTHERAPY

Phase 1

The goal of the initial phase of the orthotherapy program is to restore full, painless range of motion to the affected shoulder. Codman pendulum exercises are utilized to initiate gen- tle stretching and are followed by passive forward flexion, abduction, extension, internal ro-

tation, and external rotation exercises utilizing the meter stick. Passive elevation is enhanced by the use of a pulley system employing the unaffected extremity as the power source. For- ward flexion and external rotation exercises can be performed in the supine position to diminish the effects of gravity in a shoulder that is particularly symptomatic. Other exercises initiated during this phase include wall walking, posterior capsular stretches, and overhead stretching using a chin-up bar. This last exercise is performed by grasping the overhead bar and then slowly flexing the knees which provides a gradual load to both shoulders using a portion of the patient’s body weight. Patients are asked to avoid using the affected extremity in the impingement arc above 70 degrees of elevation until symptoms begin to improve. However, they are encouraged to continue using the arm below shoulder level to perform simple activities of daily living. We have found moist heat in the form of a hot shower or a special heating pad to be effective in decreasing symptoms before performing the exercise program. Ice diminishes inflammation when applied to the sore shoulder after activities or therapy sessions.

Phase 2

When the passive range of motion is improved and a functional range of motion has returned (it is not unusual for patients to re- quire 4 to 6 weeks to restore a functional passive range of motion), patients are advanced to the second phase of the orthotherapy program. This phase includes a series of exercises de- signed to strengthen the remaining muscles of the rotator cuff, the scapular stabilizing musculature, and the deltoid (Fig. 1A).

These exercises do not substitute for the stretching exercises, and patients should continue to work on maintaining their passive range of motion once it is achieved. The shoulder girdle musculature is strengthened using rubber Therabands (Hygenics, Akron, OH). These elastic bands are 3 inches (7.6 cm) wide and 5 feet (152 cm) long and can be tied into a loop which is fastened to a fixed object such as a doorknob. Six color-coded bands are avail- able; each provides increasing resistance from


1 to 6 pounds (0.5 to 2.7 kg), at increments of 1 pound (0.5 kg). Theraband exercises permit concentric and eccentric strengthening of the shoulder muscles and are a form of isotonic exercises (characterized by variable speed and fixed resistance). This type of strengthening regimen is based on the principles of progres- sive resistance and is the foundation of many rehabilitation programs for both upper and lower extremities. The exercises are begun with the elbow flexed 90 degrees and the shoulder in the neutral position of 0 degrees forward flexion, abduction, and external rotation. The exercises are performed through an arc of 45 degrees in each of the five planes of motion. Some patients are unable to perform one specific exercise comfortably, so the exercise range is decreased to accommodate for this difficulty. If one specific exercise is too painful even after modification, it can be elimi- nated entirely.

Patients are instructed in the number of times the exercises are to be performed each day, the number of repetitions to be done, and the length of time that each exercise should be performed before they progress to the next exercise. Each of the five exercises is done two to three times a day, five repetitions each time, and each exercise is held for a count of five. The usual interval before progression to the next band is 2 to 3 weeks, although patients are instructed not to progress to the next band if there is any discomfort at the present level.

The anterior deltoid is the most important muscle of the shoulder girdle, and special emphasis must be placed on strengthening of this structure as decreased anterior deltoid strength greatly limits function. Patients with specific weakness of the anterior deltoid benefit from a simple supine exercise until the muscle is strong enough to participate in the isotonic program.

Similarly, we cannot overstate the importance of strengthening the scapular stabilizers (serratus anterior, rhomboids, latissimus dorsi, and trapezius), as these muscles have a very important role in the rotator cuff-deficient shoulder. Exercises to improve the strength of the scapular stabilizers include shoulder press- ups, shoulder shrugs, and push-ups (Fig. 1B). Shoulder press-ups are utilized to strengthen the latissimus dorsi and are performed in an

arm chair, raising the torso off the seat of the chair. Shoulder shrugs are initially performed with 10 pounds of weight which is gradually increased by 2-pound increments as symptoms permit. These exercises strengthen the trapezius and enhance compensatory scapular rotation, thereby protecting the humeral head from impingement in abduction. Push-up exercises progress from vertical wall push-ups to knee push-ups and eventually to military style. The improved serratus anterior and rhomboid strength gained from these exercises prevents scapular winging which can accompany any chronic shoulder disorder.

Most patients with rotator cuff defects re- quire a minimum of 3 months to complete the second phase of therapy. During this time, patients are encouraged to avoid the "no pain, no gain" axiom of physical therapy. Whether the patient is performing simple stretching or strengthening exercises, pain is to be mini- mized and, ideally, avoided altogether.

Phase 3

The last phase of the orthotherapy program involves the gradual reinstitution of normal activities, including work, hobbies, and sports. Patients should be monitored closely during this time and encouraged to remain on a maintenance program as there is a natural tendency to discontinue the rehabilitation exercises gradually, which frequently is associated with a return of symptoms or a decline in function. Generally, we advocate a maintenance program that is performed three times per week and that includes both stretching and strengthening exercises.

RESULTS

From 1981 to 1992, a total of 721 patients were referred to the senior author at the Uni- versity of Texas Health Science Center at San Antonio for the evaluation and treatment of rotator cuff pathology. Of these patients, 60 had a radiographically documented full- thickness tear of the rotator cuff. There were 38 male and 22 female patients with an average age of 64 years. The right shoulder was in-

64 WIRTH et a1

Shoulder Strengthening Exercises Shoulder Service-Department of Orthopaedics The University of Texas Health Science Center

at San Antonio

Do each exercise - times: hold position B for -counts. Do exercise program ~ times per day.

Begin with Yellow Theraband flube for - weeks. Then use Red Therabandflube for - weeks. Then use Green Therabandnube for - weeks. Then use Blue Therabandflube for ~ weeks. Then use Black Therabandnube for - weeks. Then use Gray Therabanmube for - weeks.

Note: 1. Do not proceed to the next colored band

Exercise 3

until the current band is easy to use. 2. After completion of the Jherabands you must remember to keep your shoulder strong by continuing to use the gray band for exercises 2-3 times a week.

Exercise 1 Exercise 4

4

A

Figure 1. A specific rehabilitation program to strengthen the deltoid, rotator cuff, and scapular stabilizer muscles. (A) Initially, the patient is given rubber Therabands (Hygenics, Akron, Ohio) to strengthen the muscles of the rotator cuff and the three parts of the deltoid.

Illustration continued on opposite page

volved in 38 patients, the left shoulder in 11 patients, and 11 patients had bilateral cuff tears. Symptoms had been present for an average of 19 months at the time of the initial evaluation. Each patient regardless of pain or function at the time of the initial evaluation was started on a physician-directed home-based orthotherapy program and followed up for at least 2 years. The subjective and objective

findings both on initial and 2-year minimum follow-up visits were scored according to the American Shoulder and Elbow Surgeons evaluation form33 and the UCLA end-result cri- teria.'

At the time of last follow-up, all of the patients showed a significant improvement in their UCLA score (mean pretreatment score, 13.4 points; post-treatment score, 29.4 points),


Push-up Exercises

Wall

Do each exercice - times; hold position B for - counts. Do exercise program ~ times a day. Only proceed on to the knee push up after - weeks.

Knee

Proceed on to the Regular push up after - weeks.

B

Shoulder Shrug Exercise

Do each exercise __ times; hold position B for - counts. Do exercise program ~ times a day. Begin with -pounds of weights. After ~ weeks increase weight by -pounds.

Shoulder Press-up Exercise

Do each exercise -times; hold position B for ~ counts. Do exercise program times a day.

Pulley Strengthening Exercise Note: Only to be done after you have used all of the other

Therabands and/or tubes

Do each exercice - times; hold position B for - counts. Do the exercise program __times a day. Begin with 10 Ibs. of weight and add 3 Ibs. every three weeks until - Ibs. of weight are obtained. After - Ibs. you must remember to keep your shoulder strong by exercising 2-3 times a week.

Figure 1 (Continued). (6) When the patient is proficient with exercises 1 through 5, exercises are begun with a kit that consists of a pulley, hook, rope, and handle. The pulley is attached to the hook, which is fixed to the wall, and the five exercises are performed. Initially, the patient is instructed to use 5 or 10 pounds (2 or 5 kilograms) of weight; this is gradually increased over a period of several months to as much as 25 pounds (11 kilograms). The purpose of the five exercises is to strengthen the three parts of the deltoid muscles, the internal rotators, and the external rotators. Recently, we have added exercises to strengthen the scapular stabilizer muscles. To strengthen the serratus anterior and rhomboids, the patient is instructed first to do wall push- ups and to gradually begin knee push-ups. The shoulder-shrug exercise is used to strengthen the trapezius and levator scapulae muscles. (Adapted from Burkhead WZ, Jr, Rockwood CA, Jr: Complications of a failed Bristow procedure and their management. J Bone Joint Surg 73A:972- 973, 1991 ; with permission).

66 WIRTH et a1

with an average improvement of 16 points. On initial examination, all of the shoulders were graded as poor. Post-treatment, three shoulders (4%) were graded as excellent, 41 shoulders (58%) as good, and 27 shoulders (38%) as poor. However, only two patients had a score of less than 25 points on the stringent UCLA grading system. Moreover, all of the patients showed an improvement of at least two standard deviations above their pretreatment scores, and only one patient improved less than three standard deviations. A stepwise multiple regression analysis of the indepen- dent variables showed that the only significant predictors of post-treatment UCLA score were pretreatment strength and sex of the patient, with men having higher scores. The American Shoulder and Elbow Surgeons evaluation parameters of pain, strength, and motion improved significantly. This coincided with patients reporting improvement in 14 of 15 activities of daily living.

DISCUSSION

The fact that simple modalities and rehabilitation exercises can improve pain and function in shoulders with full-thickness rotator cuff defects is not a new concept. Since Codman first described pendulum exercises, many in- vestigators have described the importance of conservative management, but this has not been greatly emphasized, and few guidelines exist. In the study reported on in this article, patients were successfully managed with nonoperative treatment despite long-standing symptoms and radiographically documented full-thickness tears of the rotator cuff. The ef- fectiveness of nonoperative treatment for these lesions is worthy of emphasis and should be regarded as an important factor in the management of these patients.

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of complete tears of the rotator cuff. In Takagishi S (ed): The Shoulder. Tokyo, Professional Postgraduate Services, 1987, p 241

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NONOPERATIVE MANAGEMENT OF FULL-THICKNESS TEARS OF THE ROTATOR CUFF