Your MRI Reports Says Rotator Cuff Tear Do You Need Surgery?

If you're watching this video, you probably obtained an MRI of your shoulder and been told you have a rotator cuff tear. So I'm Dr. Patrick Denard from the Oregon Shoulder Institute, and I specifically specialize in the shoulder completely. And I'm going to go over with you what to think about with your MRI and specifically some natural history studies and outcome studies that can help give you some guidelines of treatment. And I'll wrap up with how I think about approaching rotator cuff tears from a surgical perspective. Now, first off, if you hear a tear, it's often a very scary term, but remember that many people have shoulder pain in their lifetime, about 70%, and this typically goes away in most cases. When you actually look at the need for surgery for a rotator cuff tear, it's actually quite low. Somewhere between 70 to 80% of people will get by without surgery. So despite that being a scary term, many of the tears actually are not something that actually need to go on and have an operation. Let's just back up really quickly with the rotator cuff. What are we talking about? We're talking about 4 muscles that surround the ball and socket joint. You have the supraspinatus on top, which is the most commonly torn tendon, the subscapularis in the front, and the infraspinatus and supraspinatus in the back. And these 4 muscles stabilize the shoulder and allow you to not only rotate but move your shoulder in space. And the shoulder is an incredible joint because it's the most mobile joint in the body. Now, as a spectrum of disease, when it comes to thinking about tears, we often think about it progressing from impingement injurement, or often termed bursitis, where somebody has an irritation. The tear can then become partial thickness, where it goes partway through the tendon, a full thickness tear, and then full thickness tears can progress to where they retracted all the way to the level of the socket. Specifically with partial tears, there's a wide variety. So we divide these into low grade and the high grade. If your MRI says you have a low grade tear, that is likely not a problem. It's typically the high grade tears or the full thickness tears that actually need to be considered for surgery or therapy in those cases. So what does a partial tear look like on an MRI? Well, on the left, you see what would be considered low-grade partial tearing. There's just a little bit of white signal in the tendon here. Whereas on the right, there is about 50% of the tendon footprint. The tendon on this image typically being black has a white signal. And that signal shows that there's partial tearing that is high-grade in this case. In this particular case, this is what's called an interstitial tear. It means that it's between the layers. Sometimes it's called an articular-sided tear if it's on the undersurface, or a bursal-sided tear if it's on the top of the rotator cuff. Now, if you have a full-thickness rotator cuff tear, there's complete disruption of at least one spot where the tendon is pulled off of the bone. On the left, you see an example of a small full-thickness rotator cuff tear. And on the right, you see an example of a massive rotator cuff tear where the tendon is retracted all the way to the level of the socket. Rotator cuff tears are really common. They increase with age. Everybody wants to know, how did I do this? And the biggest factor really is age and then genetics. If you look at the incidence, that is how many people have a rotator cuff tear, approximately 50% of people at age 65 have a rotator cuff tear. And that grows to an even higher amount when people get into their 70s or 80s. And I think that number is important because it shows you again that not all rotator cuff tears need surgery and shows that, you know, it's also something that occurs just over time. So you don't necessarily have had to have an injury to lead to a rotator cuff tear. Now, do tears get bigger over time? This is really important to consider because if you're thinking about, if I have a rotator cuff tear, what do I do with it? And how is it gonna change if I treat it conservatively? Partial tears progress at a much lower rate than full thickness tears. So on average, partial tears, 25% of those are gonna progress over a couple year period based on systematic review, large studies, whereas full thickness tears, if you have a tear that goes all the way through the tendon, is gonna progress about 50% of the time over a similar period. So progression is gonna happen, if you treat it conservatively. Therapy does not heal a rotator cuff tear. What therapy does is help you build back up your body and compensate. So particularly with this information, it's important to think about a young individual who has a tear versus an older individual. If somebody's in their 40s or 50s and they have a long lifespan, going through surgery and a recovery period of say 6 months is probably worth it Whereas if somebody's older, they may not think they want to undergo a 6-month period knowing that yes, it's going to progress, but they have a good chance of doing well with therapy and perhaps they're less worried about the consequences over time. When we look specifically at high-grade partial rotator cuff tears, those do tend to progress as well. So they don't progress quite as quickly, but this study here, um, out of Asia looked at this specifically high-grade partial rotator cuff tears. Again, those that are over 50% and and found that 30% of those progressed over a 3-year period to full thickness tears. By 4 years, 64% of them converted to 4 years— sorry, at 4 years, 64% of them converted to full tears. Meaning that generally speaking, partial tears progress at a slow rate. But if you have a high-grade partial rotator cuff tear, we tend to treat these more like full thickness rotator cuff tears because they have a higher risk of progression. And this just makes sense. Because it just means that you have more tendon involvement. But that's why it is again key to think about low-grade versus high-grade on your MRI in consideration of what to do with treatment. The other interesting thing is that if you have a rotator cuff tear on one shoulder, you have a high chance of having a rotator cuff tear on the other shoulder. Some studies say about 35 to perhaps even higher percentage of people who have a rotator cuff tear on one shoulder have one on the other shoulder, and they may not even know it. Not only that, but I often tell people, especially if they're younger, to watch the other shoulder closely. If you develop a full thickness rotator cuff tear in your 40s or 50s, you probably want to keep an eye on that other shoulder to make sure you get to that tear at an earlier time period. Now the risk of progression varies by location. So this is another important thing. When we think about the rotator cuff, We often describe this as a rotator crescent, whereas there is this thickened tissue that kind of runs from front to back that forms a cable attachment. If a tear occurs in the middle area, which is very common, they have a lower chance of progression and they have a lower chance of developing atrophy of the muscle. Atrophy is where the muscle shrinks down. As you can see in the graph on the right, if you're closer to the biceps tendon, which means the anterior cable or front of the shoulder, those have a higher chance of progressing. So when I see somebody who has a tear at the anterior cable, the front of the shoulder, right at that important attachment, I tell them that they have a higher risk of progressing the tear and developing atrophy. And that is really key because atrophy is not thought to be reversible. Unfortunately, once you develop it, it continues to progress, and it also impacts the chance that the rotator cuff tear will heal. So let's talk about rotator cuff repairs. It's a very common procedure. I mean, several hundred thousand are done across the US annually, and it's increasing in incidence as our population stays more active. So some information that's useful to think about treating tears conservatively or with surgical treatment comes from this study here. This is the MOON trial. This is a very well-known trial in the shoulder community They examined 452 patients and overall they said that 70% of people actually with a full thickness rotator cuff tear did not go on to surgery. Now at first glance, that is really, really appealing, especially in people in their 50s or 60s as they enrolled them in this study. I will point out, however, that about half of the people declined to participate in this study. So the information may not fully reflect the success rate, but nonetheless, it appears that it was overall good. Here you see what the survival rate is, and you notice that essentially that if people did well early, they did very well in general. In other words, those that converted to surgery converted pretty quickly. What they defined physical therapy was, as was 6 weeks. So they gave participants 6 weeks of treatment, and those that tended to be, have success at 6 weeks did well out to 10 years. Those that dropped off or ended up going on to surgery because therapy failed, that occurred early. In other words, it didn't happen that they got a year or two down the line and they ended up going on to surgery. They did really did pretty well long term. Interestingly, functional outcome— this is the SANE score, Single Assessment Numeric Evaluation. This is a scale that's 0 to 100, so anything above 80 in the 90 range is a good score. And you can see over time that people did maintain their function, this study. So this study really says that therapy can be successful in most cases, and that period of time is typically 6 weeks. After that, people are going to do well or they are not going to do well and often go on to surgery. This is perhaps a better study. This is a randomized controlled trial of non-operative operative treatment compared to surgery for full thickness rotator cuff tears. This study was performed in Norway, so 103 patients were randomized to surgery or non-operative treatment. And you can see that again, there was some crossover from non-operative treatment to surgical treatment. Overall, when they looked short-term, there was no difference in outcomes. But when they looked long-term in this study, at the 10 to 15 year point the amount of people that felt satisfied with their shoulder was higher in the surgical treatment group. So in, for instance, in this case, 70% of people reached what was called a PASS, which is a patient acceptable symptomatic state, with surgery compared to 43% without. And satisfaction with treatment was 86% versus 53% with conservative treatment. Now what's important about those numbers is they probably downplay the results of surgery because they did what is called an intention-to-treat analysis. In other words, if people were enrolled in conservative treatment to begin with and crossed over, they, they analyzed them as if they were in the conservative group. So there's probably a bigger gap than is represented by this study. Here again you see the long term. I mentioned short term, no difference in functional outcomes. This is what's called an ASES score, American Shoulder and Elbow Surgeons score. Again, 80 to 90 points is pretty good. And you can see in the dashed line that the physical therapy group did pretty well, but the repair group did better. And that's because those tears are having a chance of healing with surgery, whereas the tears in the conservatively managed group are getting larger over time, as they showed in their table where the tears that were treated conservatively gradually progressed in size over time, and we discussed that earlier. Now, what about some other information here? This is a study, uh, that was performed at Washington University of St. Louis. Does surgical intervention alter the natural history of degenerative rotator cuff tears? A comparative analysis from a prospective longitudinal study. They had 83 controls, that is patients who were in a non-surgical group compared to 65 who were in a surgical group. They had about 5-year follow-up, and you can see here again, long-term, those who had surgery had lower pain scores, they had higher ASCS scores— we talked about that, the American Shoulder and Elbow Surgeon scores— and those that were treated surgically had a lower rate of developing fatty degeneration. That's basically the same thing as atrophy. Those those who had repair, they had chance of healing, so they did not go on to develop as much atrophy, whereas those who were treated non-surgically had not only increased pain, but they developed atrophy over time. The last thing I want to talk about is traumatic tears, because this is a different animal. Now, most of the studies I showed already really talk about degenerative, uh, rotator cuff tears that occur over time, but you can get traumatic rotator cuff tears from falls, etc. There's a couple of studies I want to share. This is a study from the Rothman Group in Pennsylvania, and they analyzed who did well with surgical treatment and specifically the timeline. And if somebody had a traumatic tear, the bottom line is they found that those who had treatment within 4 months had better functional outcomes compared to those who waited. And there was even a trend trend toward an improved functional outcome if surgery is done within 3 weeks. So it's a much different situation if I see somebody who falls and develops a traumatic rotator cuff tear that we can confirm on MRI with edema on the MRI, compared to the person who has developed pain slowly over time for 6 weeks or so and comes in, we find out they have a rotator cuff tear. That latter patient, I'm going to be more apt to recommend conservative treatment in the form of physical therapy. Whereas if somebody has a traumatic tear, given the importance of the timeline, we may go straight to surgery and forego physical therapy. Yet another study here in terms of looking at the overall outcomes, a similar cohort from the same study group. And the bottom line is when they had patients that were treated non-operative compared to operatively, satisfaction with traumatic chronic rotator cuff tears was 83% in the surgical group compared to 55% of those who underwent physical therapy. So yet another way of looking at this. So now, how do I put this all together? We know that people with a chronic rotator cuff tear can do well, and they can do well with physical therapy. So generally speaking, when I consider the natural history, if somebody has a full thickness rotator cuff tear and they are under the age of 60, I advise having a surgical repair because we know that tear has a best chance of healing when the tear is small. And if we leave it, it's going to get larger over time. You can get atrophy, and we know those people do better with surgery long-term. If somebody's over the age of 70, however, generally speaking, I start with conservative treatment. And then between the ages of 60 and 70, I recommend a case-by-case decision based on the health and activity level. If it's a traumatic rotator cuff tear, I generally recommend repair within 3 months. We extend up the age knowing that people are going to do better by having it treated surgically because the early repair leads to better outcomes. And then partial tears, in most cases, I want to start conservatively. That's physical therapy that may include injections such as steroid injections or platelet-rich plasma injections. We see how that goes because we know that those have a slower timeline for progression, and we may treat it differently if it's a high-grade partial rotator cuff tear. But most of these are the low-grade partial rotator cuff tears. We're going to start conservatively, or if it's a high-grade tear in a young individual, we can say, well, let's make a time to repair this. It doesn't have to be immediate, but we know over several years it's going to progress. So let's just set aside some time that's convenient for you to get through this, assuming pain is controlled. Now these are general guidelines, um, but I think they give you an overall framework to think about this, and you can put this into your own situation, and hopefully it can help you make a decision. If you're not sure what your MRI shows and you want to have my eyes on your scan and get a clear answer, I'm happy to provide that to you. I provide MRI reviews for patients virtually. I can go over your MRI, send you a video with a clear explanation, and hopefully help give you some steps to think about treatment.