Current Controversies in the Management of Symptomatic Rotator Cuff Tears
The authors review the pros and cons of conservative and surgical treatment options.
Burak Altintas, MD; Jonathan A. Godin, MD, MBA; Erik M. Fritz, MD; Zaamin B. Hussain, BS; Matthew T. Provencher, MD, CAPT, MC, USNR; and Peter J. Millett, MD, MSc
Rotator cuff tears are a common source of shoulder pain, typically affecting older patients but occurring in patients of all ages. [1,2] If these tears are not managed appropriately, short- and long-term disability can result. Multiple extrinsic and intrinsic factors can contribute to tear formation: 
- Extrinsic factors
- Acromial morphology
- Intrinsic factors
- Tensile overload
- Microvascular supply
Despite the high prevalence of rotator cuff pathology and a dramatic increase in the number of scientific publications about it each year, the optimal management remains controversial in some instances. [4,5] The purpose of this article is to elucidate the conservative and operative treatment options for symptomatic rotator cuff tears.
Conservative Treatment for Symptomatic Full-Thickness Rotator Cuff Tears
Radiologic failure rates following rotator cuff repair have been reported as high as 90% with some older repair methods. [6,7] For that reason, non-operative treatment might appear be a reasonable alternative to operative management. In fact, a systematic review by Slabaugh et al.  could not definitively conclude, based on clinical outcomes, that operative repair was better than non-operative treatment.
Although studies with short-term follow-up have shown favorable results with non-operative management, longer follow-up of patients treated conservatively demonstrated inferior results compared with surgery. [9-12] This might be attributed to tear progression, with increased pain and decreased function due to disruption of the biomechanical force couples that stabilize the shoulder. [13,14]
For example, in a recent randomized, controlled study by Moosmayer et al.,  24% of patients with a full-thickness tear failed non-operative treatment with physiotherapy within the first 2 years and underwent surgical repair. Moreover, the decision to proceed with conservative treatment should be made judiciously in patients with acute rotator cuff tears or rapid tear progression.
The evidence for specific treatment protocols for the non-operative management of rotator cuff tears is limited. [6,15-17] Although nearly all patients with symptomatic tears report pain, weakness may vary and likely depends on tear size and the effectiveness of adaptive compensation.  Non-operative treatment usually includes oral anti-inflammatory and analgesic agents, as well as injected corticosteroids, to treat the pain.  This is combined with physical therapy that includes strengthening and stretching exercises aimed at balancing various force couples, increasing range of motion, and addressing possible concomitant scapulothoracic dyskinesis.
Although most studies on conservative treatment have shown an overall success rate of around 75%, the majority of them have also reported progression of tear size and fatty muscle infiltration over time.  It is important, therefore, to identify which patients will benefit most from a conservative treatment strategy. For example, low-demand, older patients with chronic attritional tears may be more suited to this approach, while younger, more active patients with acute traumatic tears may be better treated with surgical rotator cuff repair.
Tanaka et al.  identified several positive predictive factors for successful conservative treatment:
- Integrity of the intramuscular tendon of the supraspinatus
- No supraspinatus muscle atrophy
- Negative impingement sign
- Sufficient external rotation
Patients with a non-operatively managed, moderately symptomatic massive rotator cuff tear can maintain satisfactory shoulder function for at least 4 years despite significant progression of degenerative structural joint changes; however, there is a risk of a reparable tear progressing to an irreparable tear within 4 years.  In a prospective study by Keener et al. , 46% of the patients with an asymptomatic rotator cuff tear developed new pain, while 49% showed tear enlargement at a median of 2.8 years.
Millett et al.  analyzed 3-dimensional glenohumeral translation using biplane fluoroscopy and demonstrated that patients with well-compensated single- or 2-tendon rotator cuff tears showed an inferior shift during active elevation as a possible sign of initial instability. The senior author of this article prefers arthroscopic repair of reparable (Goutallier < stage 4) symptomatic full-thickness rotator cuff tears in active patients. This is due to the risk of tear progression with functional impairment, as well as progressive atrophy, fatty infiltration of the muscle, tendon loss, and tendon retraction that leads to irreparability and arthropathy. [21,22]
Surgical Treatment for Symptomatic Full-Thickness Rotator Cuff Tears
Surgical repair of rotator cuff tears has shown good to excellent outcomes, with significant pain reduction, enhanced muscle strength, and increased function regardless of the operative method. [24-29] Muscle atrophy and fatty infiltration are thought to be permanent and irreversible, although a recent study suggested that these factors may improve after surgical rotator cuff repair.  Even on long-term follow-up, surgical repair of chronic rotator cuff tendon tears can produce consistent and lasting pain relief, as well as improvement in range of motion. 
There are 3 options for surgical treatment:
The open approach has shown good to excellent middle- to long-term clinical outcomes, [27,29] although it is no longer widely utilized. Less-invasive techniques are now being used, obviating the need for detachment of the deltoid muscle that places the muscle at risk for subsequent insufficiency and also poses a higher risk of infection when compared with arthroscopic rotator cuff repair. [31,32]
The mini-open approach minimizes the iatrogenic injury to the deltoid muscle. A concomitant arthroscopy is often needed for adequate assessment and treatment of other structures, such as the labrum, the cartilage, the long head of the biceps, and the subscapularis tendon, that are not easily accessible through the limited approach. Some studies have shown a higher risk of complications with the mini-open repair, including revision, arthrofibrosis, and postoperative impingement. [33-35] A recent study by Baker et al.  showed that despite low morbidity with arthroscopic and open repairs, arthroscopic rotator cuff repair was associated with lower risks of adverse events and lower rates of re-operation during the initial 30-day postoperative period.
Arthroscopic repair is now considered the preferred treatment strategy for rotator cuff repair. Although arthroscopic repair has numerous advantages, increased cost has been a concern, as several studies have reported that open cuff repair is more cost-effective than arthroscopic repair. [37,38] However, a recent study reported no significant overall difference in the use or cost of resources or quality of life between arthroscopic and open management.  Dornan et al.  recently showed that primary arthroscopic rotator cuff repair was the most cost-effective initial surgical treatment strategy for patients of all ages with massive rotator cuff tears and non-arthritic shoulders.
Arthroscopic repairs are less invasive and pose less risk of infection and deltoid injury. The use of modern arthroscopic techniques results in excellent outcomes with a low risk of re-tear. Moreover, compared with the open approach, arthroscopic repairs have shown better outcomes. A recent study, for example, showed significantly higher ASES scores and lower re-tear rates at 6 and 24 months postoperatively with arthroscopic repair.  Colegate-Stone et al.  demonstrated better DASH, Constant, and Oxford Shoulder Scores at every time point for patients who underwent arthroscopy versus those who underwent a mini-open procedure. In addition, arthroscopic repair involves less pain than open repair and allows for earlier functional recovery, a shorter operative time, and better repair integrity. 
There are, however, some studies that support mini-open repair. Fink et al.  showed that the integrity of the rotator cuff repair and function of the shoulder were better after a mini-open repair than after arthroscopic repair.  Other studies have not been able to detect differences in effectiveness between open and arthroscopic repair of rotator cuff tears. [29,33,43]
In either case, as stated by Dugas et al.,  an understanding of the rotator cuff insertional anatomy is crucial for better restoration of function to the rotator cuff and, ultimately, a successful repair. In the authors’ opinion, it is easier to perform an anatomic repair with good reduction of the torn rotator cuff to the footprint without tension by using modern arthroscopic techniques. The senior author of this article prefers arthroscopic treatment because it allows for better assessment, enhanced visualization, and more effective repair with less pain, better cosmetic outcomes, improved functional outcomes, and fewer complications.
Single-Row Versus Double-Row Fixation
With the increasing number of techniques available for the repair of full-thickness rotator cuff tears, a double-row repair was proposed to more effectively restore the anatomy. The clinical superiority of double-row repairs is becoming clearer, with better anatomic restoration of the tendon, stronger repairs, early recoveries, and lower re-tear rates (Figure 1). 
Figure 1. Arthroscopic view of a left shoulder through the lateral portal. Note the final construct after knotless double-row repair.
The anatomic, double-row repair has become popular because of better biomechanical characteristics such as improved footprint coverage, [46-48] initial strength, and stiffness, as well as decreased gap formation and strain over the footprint when compared with a single-row repair.  In vivo studies in an acute repair sheep model have confirmed that double-row repair may enhance the speed of mechanical recovery of the tendon-bone complex when compared with single-row repair in the early postoperative period. [50,51] We have also seen this in our clinical practice.
Over time, the double-row repair has evolved into a transosseous-equivalent, interconnected technique with knotless systems to enhance biologic healing and to maximize reinforcement. Mook et al.  described the technical aspects of an anatomic, linked, self-reinforcing rotator cuff repair. At short-term follow-up, Vaishnav et al.  showed significant improvements in pain levels and postoperative outcomes scores, as well as high patient satisfaction with quick return to full activities, in 22 patients undergoing a primary rotator cuff repair with this technique. In a larger cohort of 102 patients, Millett et al.  reported excellent outcomes of this technique after a minimum 2-year follow-up.
Bhatia et al.  showed that the double-row technique is highly effective at reducing pain, improving function, and returning patients to sport even in recreational athletes age 70 and older. Another study by Ames et al.  noted excellent clinical outcomes following anatomic double-row rotator cuff repair. They also found that a larger acromial index was slightly associated with the ultimate clinical outcome, suggesting that the biomechanics of the patient’s anatomy may influence the result.  Greenspoon et al.  showed that this technique can even be used for massive rotator cuff repairs by using an extended linked double-row repair construct. The biomechanical properties of this construct were studied by van der Meijden et al.,  who showed superior results for double-row compared with single-row constructs for 2-tendon tear repairs.
Park et al  could demonstrate that knotless transosseous-equivalent repair shows an improved self-reinforcement effect, without diminishing footprint contact, compared with the same repair with medial knots. Moreover, a recent study be Huang et al  showed the double-row fixation to be more cost-effective than single-row fixation. Furthermore, a double-row reconstruction was found to be more economically attractive for larger rotator cuff tears. 
Various clinical studies have shown superior structural outcomes with double-row repair for different tear sizes. [61-64] Other studies have demonstrated that double-row repairs result in superior structural healing with significantly lower re-tear rates, especially with regard to partial-thickness re-tears. However, with short term follow-up, no detectable differences were seen in improvement in clinical outcomes scores between single-row and double-row repairs. [65-68] Other studies could not detect any clinical or MRI differences between the 2 techniques, although the sample sizes of these studies may have been inadequate. [69-71]
Current evidence suggests that patients with full-thickness rotator cuff re-tears have significantly lower clinical outcome scores and strength compared with patients with an intact or partially torn rotator cuff tendons.  Given these findings, along with the lower re-tear rates of the double-row repair, our preferred method is the anatomic double-row repair.  In addition, this method allows for accelerated postoperative rehabilitation, especially in patients with a high risk of shoulder stiffness. 
Arthroscopic surgical treatment is the preferred treatment strategy for most patients who present with symptomatic rotator cuff tears. Conservative treatment may be reasonable for patients with small tears without fatty degeneration and retraction, as well as older adult patients with more limited functional expectations after a detailed discussion of the risks regarding tear progression, tissue degeneration, and symptoms worsening over time. In most instances, in our opinion, primary rotator cuff repair should be considered. Although arthroscopic treatment is the preferred treatment strategy at the present time, a mini-open repair with prior diagnostic arthroscopy or an open rotator cuff repair can be regarded as reasonable alternatives.
Key Points and Pearls
- Consider conservative treatment for patients with small tears without fatty degeneration and retraction, as well as older patients with limited functional expectations.
- Consider anatomic, double-row repair for patients with symptomatic, full-thickness rotator cuff tears larger than 1 cm or if conservative treatment fails.
- For operative management, place the patient in the beach-chair position with a pneumatic arm holder or in the lateral decubitus position with traction.
- Use at least 4 portals (posterior, anterosuperior, anterolateral, posterolateral) for adequate visualization and instrumentation. An additional lateral portal may be created if necessary (Figure 2).
- Perform a subacromial bursectomy and decompression.
- Prepare the footprint, including microfracture, until there is sufficient bleeding from the bone.
- Recognize the tear pattern (crescent, L-shape, U-shape, massive a.o.) and plan the repair accordingly (Figure 3).
- Perform releases of the rotator cuff for better mobilization and reduction to the footprint (Figure 4).
- Begin with margin convergence if needed.
- Place medial anchors just lateral to the articular margin and keep a distance of 1.5-2 cm between medial anchors (Figure 5).
- Place lateral anchors approximately 5-10 mm lateral to the edge of the greater tuberosity and pay attention to the tendon tension (Figure 6).
- Don’t forget that a good mini-open repair is better than a bad arthroscopic one, so don’t hesitate to convert.
Figure 2. View of a left shoulder in the beach chair position with the portals drawn out (circles). Beginning from the left and going counter-clockwise are the anterosuperior, anterolateral, posterolateral, and posterior portals. The arrow designates the appropriate location of the lateral portal (not drawn here).
Figure 3. Arthroscopic view of a left shoulder through the lateral portal visualizing a complex delaminated full-thickness rotator cuff tear (GT = Greater tuberosity, RC = Rotator cuff).
Figure 4. Arthroscopic view of a left shoulder through the lateral portal. An arthroscopic grasper (arrow) is used to mobilize the rotator cuff for correct suture passage via the anterolateral portal (GT = Greater tuberosity, RC = Rotator cuff).
Figure 5. Arthroscopic view of a left shoulder through the lateral portal. The medial row anchor (arrow) is placed, via the anterolateral portal (GT = Greater tuberosity, RC = Rotator cuff).
Figure 6. Arthroscopic view of a left shoulder through the posterolateral portal. Via the anterolateral portal, the first lateral row anchor (arrow) is placed. The sutures from the medial row anchors have been loaded onto the lateral anchor and the rotator cuff is pulled to appropriate tension while the anchor is inserted (GT = Greater tuberosity).
Burak Altintas, MD; Erik M. Fritz, MD; and Zaamin B. Hussain, BS, are from the Steadman Philippon Research Institute, Vail, Colorado. Jonathan A. Godin, MD, MBA; Matthew T. Provencher, MD, CAPT, MC, USNR; and Peter J. Millett, MD, MSc, are with the Steadman Phillippon Research Institute and The Steadman Clinic, Vail, Colorado.
Dr. Altintas has disclosed that his position in the Steadman Philippon Research Institute is supported by Arthrex. Dr. Fritz and Mr. Hussain have disclosed that they are employees of the Steadman Philippon Research Institute, which receives funding from Smith & Nephew, Arthrex, Siemens, and Össur. Dr. Provencher has disclosed that he is a consultant for Arthrex and JRF Ortho; has patents issued: 9226743, 20150164498, 20150150594, 20110040339; and receives royalties from Arthrex and SLACK. Dr. Millett has disclosed that he receives consultant’s fees and royalties from Arthrex, Medbridge, and Springer Publishing; is a partner of The Steadman Clinic; owns stocks and stock options in GameReady and VuMedi; and receives financial support for a part of his research from Arthrex. Dr. Godin has no disclosures relevant to this article.
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