Factors associated with progression of symptomatic isolated supraspinatus tears 2 years after exercise therapy.

Background:Exercise therapy is recommended for the initial treatment of individuals with rotator cuff tears but fails in 25% to 50% of cases. Determining the baseline factors associated with patient-reported outcomes and tear propagation immediately following exercise therapy may improve treatment decision-making.Purpose:To prospectively identify factors associated with tear propagation and patient-reported outcomes immediately following a 12-week personalized exercise therapy program in individuals with symptomatic isolated supraspinatus tears.Study Design:Cohort study; Level of evidence, 2.Methods:In total, 109 individuals were recruited for this prognostic prospective longitudinal cross-sectional study and underwent a 12-week personalized exercise therapy program for the treatment of rotator cuff tears. Individuals underwent assessments of passive glenohumeral range of motion (ROM), isometric muscle strength (internal and external rotation and abduction), and glenohumeral arthrokinematics during scapular plane abduction immediately before the initiation of exercise therapy. Immediately before and after the exercise therapy program, tear size was quantified using ultrasound (propagation defined as tear size change ≥4.6 mm), and individuals completed the Western Ontario Rotator Cuff (WORC) Index score. Logistic and multiple linear regression were used to determine if baseline glenohumeral contact path length, tear size, passive glenohumeral ROM, and isometric strength were predictors of tear propagation and patient-reported outcomes immediately following exercise therapy.Results:Overall, 7 individuals (8.5%) experienced tear propagation immediately following exercise therapy. Logistic regression analysis indicated that baseline tear size was the only predictor associated with tear propagation immediately following exercise therapy. There was a 29.0% decrease in the odds of tear propagation for each 1.0-mm increase in baseline tear size (odds ratio, 0.71; 95% CI, 0.51-0.99; P = .04). Higher baseline isometric internal rotation strength predicted higher WORC scores (P = .044).Conclusion:Immediately following a 12-week personalized exercise therapy program, the percentage of individuals who experienced tear propagation was low, and baseline tear size and higher internal rotation strength were associated with tear propagation and WORC scores, respectively. Thus, the current study identified factors immediately before exercise therapy that affect tear propagation and WORC scores following an exercise therapy program.

Background:Partial-thickness rotator cuff tears (PTRCTs) often progress to full-thickness rotator cuff tears (FTRCTs). Thus, it is important to analyze the risk factors for tear progression to determine the proper timing of repair.Purpose:To identify the risk factors associated with progression of PTRCT.Study Design:Case-control study; Level of evidence, 3.Methods:Included were 89 patients diagnosed with PTRCT on magnetic resonance imaging (MRI) scans who underwent nonoperative treatment at the authors’ institution between August 2012 and August 2019. Patient characteristics, shoulder stiffness (compared with the contralateral shoulder); work level (classified as high [heavy manual labor], medium [manual labor with less activity], and low [sedentary activity]); and radiological factors including initial tear size, acromion type (flat, curved, hooked, or heel-shaped), and initial tear involvement (as a percentage of the rotator cuff tendon footprint length) were analyzed to assess their association with tear progression, defined as >20% increase in tear involvement.Results:The mean MRI follow-up period was 22.3 ± 17.2 months (median, 16.1 months; range, 6.4-89.5 months), and tear progression was observed in 12 patients (13.5%). In these 12 patients, tear involvement increased by 60% of the rotator cuff footprint, while mediolateral (ML) and anteroposterior (AP) tear sizes progressed by 1.1 and 1.8 mm, respectively. Univariate regression analysis showed that shoulder stiffness (P = .031), work level (P = .001), initial tear involvement (P < .001), ML and AP tear sizes (P < .001 and P = .005, respectively), and acromion type (P = .003) were significantly associated with tear progression. Multivariate regression analysis showed that initial tear involvement (odds ratio [OR], 1.053; 95% CI, 1.006-1.102; P = .026) and high work level (OR, 15.831; 95% CI, 1.150-217.856; P = .039) were independent risk factors for tear progression. The cutoff value for initial tear involvement was 47.5% (sensitivity, 81.8%; specificity, 85.7%).Conclusion:Tear progression was observed in 14% of patients with PTRCT in this study. To predict tear progression, evaluating the tear involvement during initial MRI is essential. The risk of tear progression increased with initial tear involvement >47.5% and a heavy work level.

Initiation and progression of rotator cuff tears due to fatigue loading: a cadaveric study

To determine whether scapular morphology could predict isolated supraspinatus tendon tear propagation after exercise therapy. We hypothesised that a larger critical shoulder angle (CSA) and type III acromial morphology predict a positive change in tear size. Fifty-nine individuals aged 40-70 years with isolated symptomatic high-grade partial or full-thickness supraspinatus tendon tears were included. Individuals participated in a structured, individualised 12-week exercise therapy programme and underwent ultrasound to measure tear size at baseline and 12 months following therapy. Computed tomography images were segmented to create three-dimensional subject-specific bone models and reviewed by three trained clinicians to measure CSA and to determine acromion morphology based on the Bigliani classification. A binary logistic regression was performed to determine the predictive value of CSA and acromion morphology on tear propagation. The CSA was 30.0 ± 5.4°. Thirty-one individuals (52.5%) had type II acromial morphology, followed by type III and type I morphologies (25.4% and 22.0%, respectively); 81.4% experienced no change in tear size, four (6.8%) individuals experienced tear propagation and seven (11.9%) individuals had a negative change in tear size. No significant difference in tear propagation rates based on CSA or acromion morphology (not significant [NS]) was observed. The model predicted tear size status in 81.4% of cases but only predicted tear propagation 8.3% of the time. Overall, CSA and acromion morphology only predicted 24.3% (R 2 = 0.243) of variance in tear propagation (NS). CSA and acromion morphology were NS predictors of tear propagation of the supraspinatus tendon 12 months following an individualised exercise therapy programme. II.

BackgroundThere is no clear information on structural changes of rotator cuff tears during nonsurgical management. In particular, the risk factors for the progression of tear size and fatty infiltration still remain poorly understood. Identifying such factors is essential for optimizing treatment strategies and follow-up planning.MethodsWe retrospectively examined 80 shoulders (43 men, 37 women; mean age, 68.4 years) with partial- and full-thickness rotator cuff tears treated nonsurgically. All patients underwent initial and follow-up magnetic resonance imaging examinations at ≥12 months, with a mean follow-up of 22.2 ± 12.6 months. Progression of supraspinatus (SSP) tear size was defined as a mediolateral increase of ≥10 mm or ≥5 mm/yr, and progression of SSP fatty infiltration was defined as an increase in the modified Goutallier classification. Univariate analyses were conducted to determine potential risk factors, including age, sex, initial tear size, subscapularis (SSC) tear, infraspinatus (ISP) tear, initial fatty infiltration of SSC, SSP, and ISP, critical shoulder angle (CSA), and the presence of persistent pain at follow-up. Factors with significant associations were entered into multivariate logistic regression for determining independent predictors.ResultsOn follow-up magnetic resonance imaging, both SSP tear size and fatty infiltration demonstrated significant progression. Univariate analyses revealed a significant association between tear size progression and initial tear size (P < .001), SSC fatty infiltration (P = .004), and larger CSA (P = .013). SSP fatty infiltration progression was significantly associated with older age (P = .04), initial tear size (P = .01), SSC tear (P = .03), SSC fatty infiltration (P < .001), and larger CSA (P = .04). Multivariate logistic regression identified medium-sized tears (odds ratio [OR], 17.1; 95% confidence interval [CI], 4.3-68.3; P < .001) and SSC fatty infiltration grade ≥ 2 (OR, 8.1; 95% CI, 1.7-38.5; P = .009) as independent risk factors for SSP tear size progression, whereas CSA was not significant (OR, 1.1; P = .2). For fatty infiltration progression, SSC fatty infiltration grade ≥ 2 was an independent risk factor (OR, 10.4; 95% CI, 1.7-64.1; P = .01), whereas age (OR, 1.2; P = .05), medium-sized tears (OR, 3.3; P = .13), SSC complete tear (OR, 1.9; P = .5), and CSA (OR, 1.1; P = .41) were not significant.ConclusionProgression of SSP tear size and fatty infiltration during nonsurgical treatment is closely associated with SSC fatty infiltration. Monitoring of SSC involvement may help identify patients at higher risk for progression of SSP tear size and fatty infiltration and support decisions.

Symptomatic Rotator Cuff Tear Progression: Conservatively Treated Full- and Partial-Thickness Tears Continue to Progress

There have been numerous reports of clinical outcomes associated with tendon healing after repair that suggest a nonhealed tendon has a negative effect on postoperative clinical outcomes. However, to our knowledge, there has been no report on the relationship between tear size progression of nonhealed tendons and clinical outcomes. (1) Do patients with healed arthroscopic rotator cuff repairs have better outcomes, less pain, and more strength than patients whose repair did not heal? (2) In patients with nonhealed rotator cuff tendons, does tear size progression (increase or decrease) affect outcomes, pain, and strength? (3) Is there continued improvement beyond 6 months in outcomes, pain, and strength; and how do the improvements differ based on whether the tear size has increased or decreased? Between May 2008 and December 2012, 647 patients underwent arthroscopic rotator cuff repair for full-thickness tears at our institution. Of those, 442 patients (68%) had all MRI and clinical information available to permit inclusion in this retrospective study at a minimum of 2 years followup (mean, 33 ± 4 months; range, 24-43 months). Healing of the repaired tendon and tear size progression were assessed using MRI at 6 months postoperatively. Eighty-two of 442 tears (19%) were not healed. Of the nonhealed tears, 45 (55%) had a decrease and 37 (45%) had an increase in tear size. Shoulder function outcomes using the American Shoulder and Elbow Surgeon (ASES) and Constant scores and pain severity using VAS scores were evaluated preoperatively, at 6 months postoperatively, and at the latest followup. Isometric muscle strength was measured at 6 months postoperatively and at the latest followup. Compared with patients with nonhealed tendons after arthroscopic rotator cuff repair, patients with healed repairs had improved ASES scores (healed, 93 ± 5; nonhealed, 89 ± 8; mean difference, 4; 95% CI, 3-5; p < 0.001), better Constant scores (healed, 91 ± 5; nonhealed, 85 ± 8; mean difference, 6; 95% CI, 4-7; p < 0.001), and greater strength ([flexion: healed, 96% ± 7%; nonhealed, 85% ± 12%; mean difference, 11%; 95% CI, 9%-13%; p < 0.001]; [external rotation: healed, 92% ± 8%; nonhealed, 80% ± 12%; mean difference, 11%; 95% CI, 9%-14%; p < 0.001]; [internal rotation: healed, 97% ± 8%; nonhealed, 92% ± 8%; mean difference, 5%; 95% CI, 3%-7%; p < 0.001]); however there was no difference in pain level based on VAS scores (healed, 0.9 ± 0.8; nonhealed, 1.0 ± 0.8; mean difference, 0.2; 95% CI, 0.0-0.4; p = 0.226). Compared with patients with increased tear size, patients with decreased tear size had better ASES scores (decreased, 91 ± 6; increased, 8 6 ± 8; p = 0.001), improved Constant scores (decreased, 88 ± 6; increased, 82 ± 9; p = 0.003), greater flexion strength (decreased, 91% ± 9%; increased, 78% ± 11%; p < 0.001), and greater external rotation strength (decreased, 86% ± 10%; increased, 73% ± 11%; p < 0.001). However, the difference does not seem to meet a minimal clinically important difference. Patients with increased tear size differed from those with decreased tear size with respect to flexion and external rotation strength where the former had no improvement. There was no improvement in flexion (6 months, 78% ± 11%; latest followup, 78% ± 11%; p = 0.806) and external rotation strength (6 months, 74% ± 12%; latest followup, 73% ± 11%; p = 0.149). Patients who had healed tendons after arthroscopic rotator cuff repair had better shoulder function than patients who had nonhealed tendons. Among patients with nonhealed rotator cuff tendons after surgery, those with decreased tear size, observed on their 6-month postoperative MRI, compared with their initial tear size, showed better shoulder function and muscle strength than those with increased tear size beyond 6 months. Although results are statistically different, they seem insufficient to achieve clinically important differences. Level III, therapeutic study.

Factors associated with choice for surgery in newly symptomatic degenerative rotator cuff tears: a prospective cohort evaluation

Background: The risk factors for tear progression in symptomatic rotator cuff tears have not been clarified yet. It is important for orthopaedic surgeons to know the natural course of tear progression when nonoperative management is to be chosen. Hypothesis: Tears in younger patients, high-activity patients, or heavy laborers would progress in size more than those in older patients, low-activity patients, or light laborers. Study Design: Case-control study; Level of evidence, 3. Methods: Two hundred twenty-five consecutive patients with symptomatic rotator cuff tears visited our institute between 2009 and 2015. Of these, 174 shoulders of 171 patients (mean age, 66.9 years) who underwent at least 2 magnetic resonance imaging (MRI) examinations were prospectively enrolled. The mean follow-up was 19 months. Tear progression was defined as positive when the tear size increased by ≥2 mm. The demographic factors that were analyzed by multivariate analysis included age, sex, hand dominance, smoking, alcohol drinking, hypercholesterolemia, sports participation, job type, tear size, and tear type (full or partial thickness). Results: Of the 174 shoulders, 82 shoulders (47%) showed tear progression. The mean (±SD) tear length and width in the progression group on final MRI were 23.1 ± 12.5 mm and 17.3 ± 9.6 mm, respectively; the tear size progressed by a mean 5.8 ± 5.6 mm in length and 3.1 ± 5.2 mm in width. The mean propagation speed was 3.8 mm/y in length and 2.0 mm/y in width. The size of full-thickness tears significantly increased compared with that of articular-sided partial-thickness tears (P = .0215). The size of medium tears significantly increased compared with that of other tears (P < .0001). According to the logistic regression analysis, smoking was significantly correlated with tear progression (P = .026). Subgroup analyses showed that male sex, hand dominance, and trauma were correlated with tear progression. Age, alcohol drinking, hypercholesterolemia, sports participation, and job type did not show any correlation with tear progression. Conclusion: The tear size of symptomatic rotator cuff tears progressed in 47% of the shoulders during a mean of 19 months, and the speed of progression was 3.8 mm/y in length and 2.0 mm/y in width. The risk factors for tear progression were (1) a medium-sized tear, (2) a full-thickness tear, and (3) smoking.

Paper #27 - Correlation of clinical outcomes of retear and tear progression after arthroscopic rotator cuff repair

V 45 Evolution of non-operatively treated supraspinatus tears

The association between body fat and rotator cuff tear: the influence on rotator cuff tear sizes

Effects of tear size and location on predictions of supraspinatus tear propagation

Synovitis of the glenohumeral joint (GHJ) and subacromial space (SAS) is one of the most common findings during arthroscopic rotator cuff repair (RCR). The purpose of this study is to determine clinical factors associated with the degree of synovitis in patients with a rotator cuff tear and whether macroscopic synovitis affects early clinical outcomes following arthroscopic RCR. Arthroscopic videos of 230 patients treated with arthroscopic RCR were randomly reviewed by two experienced shoulder surgeons. The synovitis scores of the GHJ using Davis's grading system and the SAS using Jo's grading system were rated with a consensus. Univariate and multivariate analyses were used to identify the associations between the synovitis scores and various parameters, including demographics, preoperative, and postoperative clinical outcomes. Univariate analyses revealed that age, side, body mass index, duration of symptoms, preoperative stiffness, diabetes, muscle atrophy, fatty infiltration, tear size, preoperative clinical scores, and preoperative range of motion were significantly associated with the GHJ synovitis score (all p < 0.05). Multivariate analyses revealed that the duration of symptoms, tear size, and diabetes was significantly associated with the GHJ synovitis score (p = 0.048, p = 0.025, p = 0.011, respectively). Longer duration of symptoms, larger tear size, and the presence of diabetes was independently associated with increased GHJ synovitis in patients with a rotator cuff tear. These results suggest that GHJ synovitis might be more involved in the pathogenesis for pain and tear progression of rotator cuff disease compared with SAS synovitis.

Rotator cuff tendon strain correlates with tear propagation