 SHOULDER AND ELBOW

Treatment of non-traumatic rotator cuff tears

A RANDOMISED CONTROLLED TRIAL WITH ONE-YEAR CLINICAL
RESULTS

J. Kukkonen, We have compared three different methods of treating symptomatic non-traumatic tears of
A. Joukainen, the supraspinatus tendon in patients above 55 years of age. A total of 180 shoulders (173
J. Lehtinen, patients) with supraspinatus tendon tears were randomly allocated into one of three groups
K. T. Mattila, (each of 60 shoulders); physiotherapy (group 1), acromioplasty and physiotherapy (group 2)
E. K. J. Tuominen, and rotator cuff repair, acromioplasty and physiotherapy (group 3). The Constant score was
T. Kauko, assessed and followed up by an independent observer pre-operatively and at three, six and
V. Äärimaa twelve months after the intervention.
Of these, 167 shoulders were available for assessment at one year (follow-up rate of
From Turku 92.8%). There were 55 shoulders in group 1 (24 in males and 31 in females, mean age 65
University Hospital, years (55 to 79)), 57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79)) and 55
Turku, Finland shoulders in group 3 (26 male and 29 female, mean age 65 years (55 to 81)). There were no
 J. Kukkonen, MD, PhD, between-group differences in the Constant score at final follow-up: 74.1 (SD 14.2), 77.2 (SD
Orthopaedic Surgeon 13.0) and 77.9 (SD 12.1) in groups 1, 2 and 3, respectively (p = 0.34). The mean change in the
 V. Äärimaa, MD, PhD,
Orthopaedic Surgeon Constant score was 17.0, 17.5, and 19.8, respectively (p = 0.34). These results suggest that at
Department of Orthopaedics
and Traumatology, Turku one-year follow-up, operative treatment is no better than conservative treatment with
University Hospital, P.O. Box 28, regard to non-traumatic supraspinatus tears, and that conservative treatment should be
FIN-20701, Turku, Finland.
considered as the primary method of treatment for this condition.
 A. Joukainen, MD, PhD,
Orthopaedic Surgeon
Department of Orthopaedics
Cite this article: Bone Joint J 2014;96-B:75–81.
and Traumatology, Kuopio
University Hospital, P.O. Box Rotator cuff tears are a common cause of 3) rotator cuff repair, acromioplasty and phys-
1777, FIN-70211, Kuopio,
Finland. shoulder pain and dysfunction, and may be iotherapy in the treatment of non-traumatic
 J. Lehtinen, MD, PhD, traumatic or non-traumatic in origin.1-3 rotator cuff tears in patients above 55 years of
Orthopaedic Surgeon
Department of Orthopaedics
According to Neer,4 the rotator cuff tears age in the short-term. Our hypothesis was that
and Traumatology, Hatanpää because the supraspinatus tendon impinges rotator cuff repair yields superior results
Hospital, P.O. Box 437, FIN-
33101, Tampere, Finland. on the acromion2,5,6 although more recent compared with the other treatment modalities.
 K. T. Mattila, MD, PhD, reports have emphasised the role of intrinsic
Musculoskeletal Radiologist tendon degeneration as the main cause of Patients and Methods
 E. K. J. Tuominen, MD, PhD,
Musculoskeletal Radiologist tears.7-9 The prevalence of these tears is This was a randomised, controlled superiority
Medical Imaging Centre of
Southwest Finland, Turku
reported to be between 20% and 30% in trial, with three comparative parallel treatment
University Hospital and those aged 60 to 80 years.10-12 Surgery is often arms. The trial took place at three hospitals in
Department of Diagnostic
Radiology, University of Turku, advocated as the treatment of choice even in Finland (Turku University Hospital, Kuopio Uni-
P.O. Box 52, FIN-20521, Turku,
Finland.
the elderly population, but there is a lack of versity Hospital and Hatanpää Hospital)
 T. Kauko, MSc, Biostatistician
robust comparative evidence.13-15 At least between October 2007 and December 2012. The
Department of Biostatistics, 250 000 rotator cuff repairs are performed study protocol was approved by the Ethics Com-
University of Turku,
Lemminkäisenkatu 1, FIN- each year in the United States, with estimated mittee of the Hospital District of Southwest Fin-
20520, Turku, Finland. direct costs of $3 billion.16 land and was registered at www.clinicaltrials.gov
Correspondence should be sent
to Dr J. Kukkonen; e-mail:
The healing capacity of tendons is affected (NCT01116518). Written informed consent was
jupeku@utu.fi by degeneration such that torn tendons may obtained from each patient. The inclusion and
not heal at all despite surgical repair.17 Not exclusion criteria are shown in Table I. The
©2014 The British Editorial surprisingly, the rate of post-operative re-tears patients were sequentially recruited from those
Society of Bone & Joint
Surgery is high.18-19 Alternatives to surgical tendon who were referred to one of the three participat-
doi:10.1302/0301-620X.96B1.
32168 $2.00
repair include acromioplasty20 and conserva- ing hospitals.
tive treatment,15,21-23 both of which yield A total of 271 shoulders meeting the clinical
Bone Joint J
2014;96-B:75–81. acceptable results. The purpose of our trial was trial criteria underwent MRI investigation.
Received 11 April 2013;
Accepted after revision 11
to compare the effectiveness of 1) physiother- Before inclusion special emphasis was put on
September 2013 apy, 2) acromioplasty and physiotherapy and the presence of symptoms relating to a rotator

VOL. 96-B, No. 1, JANUARY 2014 75

76 J. KUKKONEN, A. JOUKAINEN, J. LEHTINEN, K. T. MATTILA, E. K. J. TUOMINEN, T. KAUKO, V. ÄÄRIMAA

Table I. Inclusion and exclusion criteria

Criteria Description
Inclusion criteria Age > 55 years
Atraumatic symptomatic supraspinatus tendon tear comprising < 75% of the tendon insertion and documented with MRI
Full range of motion of the shoulder
Written informed consent

Exclusion criteria Age < 55 years

History of trauma relating to the onset of symptoms
A massive tendon tear involving the whole supraspinatus tendon and/or combined tear of two to three tendons, i.e.,
supraspinatus with infraspinatus or subscapularis tendon tear
Stiffness of the glenohumeral joint (passive external rotation < 30° ± elevation < 120°)
Glenohumeral osteoarthritis with present osteophytes in radiographs
Systemic corticosteroid or antimetabolite medication
Significant malignant, hematological, endocrine, metabolic, rheumatoid or gastrointestinal disease
History of alcoholism, drug abuse, psychological or other emotional problems that are likely to invalidate informed con-
sent
Previous surgery of same shoulder
Patient refusal

cuff tear including pain in abduction and at rest, and (AC) joint was resected if it had been painful before surgery
abduction weakness. All eligible patients with an isolated and if there were severe degenerative changes in the AC
supraspinatus tear were asked to participate in the trial. A joint on the MRI. If the long head of the biceps tendon was
flow chart of the trial is shown in Figure 1. All MRI images unstable or frayed, a biceps tenotomy was also performed.
were re-evaluated at the end of follow-up by two musculoskel- After the operation a physiotherapist gave the patient guid-
etal radiologists (KTM and EKJT) blinded to patient data. ance on how to exercise to improve free glenohumeral
The trial interventions were explained to patients and it motion and how to retract the scapula actively. After three
was pointed out that they were equally effective. Patients weeks the physiotherapist controlled the progress of reha-
were informed that they could consider crossing over to rota- bilitation and gave the patient written information for
tor cuff repair if adequate relief of symptoms was not movement and gradual resistance exercises to be conducted
achieved by six months after the allocated intervention. After at home and sessions of physiotherapy, as for group 1.
giving their consent the patients were randomised using Repair, acromioplasty and physiotherapy (group 3). Subac-
opaque, sealed envelopes and were informed of the allocated romial debridement and acromioplasty were performed
intervention and treatment started within one month. arthroscopically. The sagittal size of the supraspinatus tear
Physiotherapy (group 1). A physiotherapist trained in was measured with a probe. The rotator cuff was repaired
shoulder rehabilitation gave the patient written informa- anatomically using standard titanium bone anchors with
tion and guidance for exercises to be conducted at home. non-absorbable sutures (Corkscrew FT II; Arthrex Inc.,
The exercise protocol was standardised and started with Naples, Florida or Twinfix; Smith-Nephew, Andover, Mas-
exercises aimed at improving glenohumeral motion and sachusetts). AC resection and/or biceps tenotomy were per-
active scapular retraction for the first six weeks. Then static formed, if indicated, as in group 2. After the operation the
and dynamic exercises for the scapular and glenohumeral arm was immobilised in a sling for three weeks after which
musculature were gradually increased from six weeks to 12 the rehabilitation followed the same regime as group 1.
weeks, after which the participant increased resistance and Outcome measures. The Constant score was used as the
strength training up to six months. In addition to written primary outcome measure.24 The score was recorded by an
instructions the patient was referred for ten sessions of independent study nurse less than one month before any
physiotherapy in an outpatient health care facility where intervention, at three months, six months and at one year
their progress was monitored. after baseline. At the control visits patients were also asked
Acromioplasty and physiotherapy (group 2). All operations to grade whether the shoulder was better or worse com-
(group 2 and 3) were performed arthroscopically in a pared with pre-operative state and if they were satisfied or
standardised manner by four experienced shoulder sur- dissatisfied with the treatment outcome. All patient data
geons. Subacromial debridement and an arthroscopic acro- was saved in an electronic patient registry (ArtuX; BCB
mioplasty were carried out by smoothing the inferior Medical, Turku, Finland). A systematic analysis of the cost
surface of the acromion from a postero-anterior direction. of treatment of all patients was made. The total health care
The sagittal size of the supraspinatus tear was measured cost was retrieved from structured questionnaire forms.
with a probe. In addition, 6 mm of the acromioclavicular The form gathers economic information on direct costs for

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 TREATMENT OF NON-TRAUMATIC ROTATOR CUFF TEARS 77

REFERRAL
to outpatient clinic

OUTPATIENT CLINIC
- anamnesis, status,
radiographs not suitable*

criteria for inclusion

EXCLUSION
not suitable**
99 shoulders
MRI/MRA investigation
271 shoulders *claustrophobia 6
heart pacemaker 2

**massive tear 28
no (perforating) tear 47

OUTPATIENT CLINIC ***symptoms disappeared 2

patient information denial*** denial of the study 14

INCLUSION
180 shoulders

INFORMED CONSENT

RANDOMISATION of 180 patients

(60 patients per group)
Group 1 Group 2 Group 3

Baseline data
58 shoulders 59 shoulders 59 shoulders 5 shoulders
group 1: 4
missed pre-op data: 2 missed pre-op data: 1 missed pre-op data: 1 group 2: 1

Intervention 60 shoulders 59 shoulders 55 shoulders

cumulative drop-out: 1 cumulative drop-out: 5

57 shoulders 58 shoulders 55 shoulders

3-month follow-up
missed data at time point: 2 missed data at time point: 1 cumulative drop-out: 5
cumulative drop-out: 1 cumulative drop-out: 1

57 shoulders 54 shoulders 47 shoulders

6-month follow-up
missed data at time point: 1 missed data at time point: 5 missed data at time point: 8
cumulative drop-out: 2 cumulative drop-out: 1 cumulative drop-out: 5

4 crossovers 1

55 shoulders 57 shoulders 55 shoulders 4 shoulders

12-month follow-up
missed data at time point: 2 missed data at time point: 2 cumulative drop-out: 5 cumulative drop-out: 1
cumulative drop-out: 3 cumulative drop-out: 1

Fig. 1

Flow chart showing the shoulders through the study (Group 1, physiotherapy; Group 2, acromioplasty and physiotherapy; Group 3, rotator cuff
repair, acromioplasty and physiotherapy).

the patient (expenses for transportation, hospital, doctor, follow-up was estimated to be 0.40 to 0.50 (SD 20). By
physiotherapist, medication, and lost income), and indirect analysis of variance (ANOVA), with alpha = 0.05 and
societal costs (operation, supplies, patient care). Data was power = 85%, statistical significance could be reached with
collected cumulatively for each patient during the follow-up. 51 subjects per treatment group. The expected drop-out rate
Statistical analysis. The power calculations were based on was set at 15%, so the number of subjects per group was 60.
the assumed statistical behaviour of the Constant score. Outcome analysis was by intention to treat. The data
The mean score value at baseline was assumed to be 50 was analysed using methods suitable for clinical trials to
(SD 10). The score in the best treatment group at follow-up compare parallel treatment groups with repeated measure-
was assumed to be 70, and in the worst treatment group ments. The primary statistical method was analysis of var-
60.25 The correlation between the measurements during the iance with repeated measurements and generalised linear

VOL. 96-B, No. 1, JANUARY 2014

78 J. KUKKONEN, A. JOUKAINEN, J. LEHTINEN, K. T. MATTILA, E. K. J. TUOMINEN, T. KAUKO, V. ÄÄRIMAA

Table II. Patients lost to follow-up

Time of drop-out
Treatment group Age (yrs) Gender (mths) Reason for drop-out
1 56 Male 6.0 Patient withdrawal
1 64 Female 6.0 Malignant disease
1 65 Male 1.5 Death
2 74 Female 0.2 Patient withdrawal
3 66 Female 0.1 Patient withdrawal
3 82 Female 0.1 Patient withdrawal
3 70 Male 0.1 Patient withdrawal
3 69 Female 0.2 No tear in second-look MRI and operation
3 60 Male 0.3 No tear in second-look MRI and operation

Table III. Patient characteristics

Group 1 Group 2 Group 3 p-value

Shoulders (n) 55 57 55
Female (n, %) 31 (56) 28 (49) 26 (47) 0.60*
Mean (SD) age (yrs) 65 (5.8) 65 (5.1) 65 (6.0) 0.94†
Right side affected (n, %) 41 (75) 33 (58) 36 (65) 0.18*
Employment (n, %) 0.08*
Working 17 (31) 10 (18) 23 (42)
Sick leave 5 (9) 1 (2) 1 (2)
Retired 32 (58) 42 (74) 30 (55)
Data missing 1 (2) 4 (7) 1 (2)
Mean (SD) duration of symptoms (mths) 26 (9.9) 28 (9.7) 28 (9.5) 0.83†
Smoker (n, %) 10 (18) 5 (9) 8 (15) 0.36*
Prior corticosteroid injection (n, %) 39 (71) 33 (58) 31 (56) 0.23*
* Pearson’s chi-squared test
† analysis of variance F-test

Table IV. MRI findings

Group 1 Group 2 Group 3 p-value

Mean (SD) supraspinatus tear size (mm) 9.6 (5.2) 9.3 (5.3) 8.5 (4.0) 0.48†
Biceps pathology (n, %) 16 (29) 21 (37) 16 (29) 0.41‡
OA changes in glenohumeral joint (n, %) 19 (35) 28 (49) 23 (42) 0.29‡
OA changes in AC joint (n, %) 48 (87) 51 (89) 51 (93) 0.64‡
Volume atrophy in supraspinatus (n, %)* 17 (31) 23 (40) 19 (35) 0.50‡
Goutallier grade 2 supraspinatus (n, %) 29 (53) 26 (46) 26 (47) 0.73‡
Goutallier grade 3 supraspinatus (n, %) 1 (2) 5 (9) 2 (4) 0.20‡
Goutallier grade 2 infraspinatus (n, %) 34 (62) 26 (46) 31 (56) 0.21‡
Goutallier grade 2 subscapularis (n, %) 13 (24) 11 (19) 11 (20) 0.83‡
* mild, moderate or severe atrophy (Warner scale)
† Analysis of variance (ANOVA) F-test
‡ Pearson’s chi-squared test

mixed models for longitudinal data. p-values < 0.05 were 3 58.1 (SD 13.2) (p = 0.65). Detailed patient characteristics
considered statistically significant. All analyses were are presented in Table III.
performed using the SAS System for Windows, v9.3 (SAS Two shoulders were excluded from the study because
Institute Inc., Cary, North Carolina). of an intact supraspinatus tendon found at surgery after
an initial MRI diagnosis of a tear. The absence of a tear
Results was subsequently confirmed by reviewing the original
A total of 167 shoulders (55 in group 1, 57 in group 2, and MRI at the final follow-up (Table II). All the remaining
55 in group 3) were available for analysis at one year (drop- shoulders had an isolated supraspinatus tendon tear.
out rate 7.2%). The data on the drop-outs is presented in The mean sagittal size of isolated supraspinatus tendon
Table II. The mean pre-treatment Constant score in group 1 tears in group 1 was 9.6 mm ( SD 5.2) in group 1,
was 57.1 (SD 16.7), in group 2 59.6 (SD 13.3), and in group 9.3 mm ( SD 5.3) in group 2 and 8.5 mm (SD 4.0) in

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 TREATMENT OF NON-TRAUMATIC ROTATOR CUFF TEARS 79

80 The mean cost of treatment was €2417 (SD 1443) in

group 1, €4765 (SD 896) in group 2 and €5709 in group 3
75
(p < 0.0001). The mean direct cost for the patient was
€427, €486 and €456, respectively (p = 0.96). The mean
Constant score

indirect societal cost was €2130, €4486 and €5461, respec-

70
tively (p < 0.0001).

65 Discussion
Group 1
Group 2 The main finding in this trial is that patients treated for
60 Group 3 non-traumatic supraspinatus tears with three different
interventions had a similar outcome at follow-up after one
55 year. Contrary to our hypothesis, surgical repair of a
supraspinatus tear does not improve the Constant score
Pre− 3 months 6 months 12 months
treatment when compared with acromioplasty only or conservative
Fig. 2
treatment. The same was true for the patients’ subjective
satisfaction.
Graph showing total Constant score points in the three treatment groups.
Whiskers indicate standard deviation (Group 1, physiotherapy; Group 2,
A level I randomised controlled trial comparing conserv-
acromioplasty and physiotherapy; Group 3, rotator cuff repair, acromio- ative and operative treatment of rotator cuff tears showed
plasty and physiotherapy).
that open or mini-open operative treatment of a torn rota-
tor cuff resulted in a statistically significantly better out-
come than conservative treatment.26 The age of the patients
in that trial was similar to ours. However, the reported pre-
treatment Constant score values were lower than in our
group 3 (p = 0.48). The MRI findings are presented non-traumatic aetiology study and symptoms were trauma
in Table IV. related in 57% of their patients. At one year of follow-up,
The mean sagittal size of the bare area was 12.6 mm (SD the scores were essentially similar in their open operative
5.7) in group 2 and 14.2 mm (SD 6.5) in group 3 (p = 0.18). group as in our arthroscopically-operated groups. In the
An additional AC resection was performed in seven shoul- Norwegian trial the outcome was reported as the change in
ders (12%) in group 2 and eight shoulders (15%) in group 3 the numeric value of the Constant score and since they had
(p = 0.40). An additional biceps tenotomy was performed in more patients with a traumatic tear their pre-treatment
29 shoulders (51%) in group 2 and in 23 shoulders (42%) in scores were inevitably lower.
group 3 (p = 0.50). The mean operation time (from first inci- The Constant score we recorded exhibited an essentially
sion to wound closure) was 34 minutes (SD 11) in group 2 similar improvement in all treatment groups and this may
and 67 minutes (SD 22) in group 3 (p < 0.001). simply be due to the similar physiotherapy regimes. How-
The mean Constant score at one year of follow-up was ever, there is no peer-reviewed evidence of the true benefit of
74.1 (SD 14.2) in group 1, 77.2 (SD 13.0) in group 2 and physiotherapy when treating non-traumatic rotator cuff
77.9 (SD 12.1) in group 3 (p = 0.34) (Fig. 2). There was a tears. Therefore, the passage of time may also be a factor
significant difference in the mean Constant sub-scores related to the outcome. On the other hand, the duration of
between groups 1, 2 and 3 at the one-year follow-up symptoms at the outset, before trial intervention, was similar
concerning pain (p = 0.0321) and activities of daily living and moderately long in all groups. Nevertheless, in groups 1
(p < 0.0001) (Figs 3a and 3b). In the subscores concerning and 2 where patients had prompt rehabilitative physiother-
range of movement and strength there were no significant apy, the three-month Constant score was significantly higher
differences between the groups (p = 0.74 and p = 0.76, than in group 3. The decline in the Constant score (especially
respectively) (Figs 3c and 3d). Patient satisfaction at one strength) in group 3 from baseline to three months was very
year of follow-up was 87% in group 1, 96% in group 2 and likely due to post-operative immobilisation and delayed
95% in group 3 (p = 0.14). rehabilitation after rotator cuff repair. There was no differ-
There were four patients (four shoulders) (7.3%) in ence at the six month and one year follow-up.
group 1 and one patient (one shoulder) (1.8%) in group 2 Our trial was not blinded and the patients, as well as the
who chose to cross over to cuff repair after a mean of 0.7 hospital staff, were aware of their allocated treatment. It
years (0.65 to 0.76). The data on the available crossovers has been previously demonstrated that the act of surgery
are presented in Table V. The crossovers did not affect the has a distinct placebo effect;27 however, the outcome was
final statistical outcome, since post hoc patients grouped by ultimately the same in all our groups. The number of cross-
final treatment group rather than intention-to-treat did not overs from the conservatively treated group was negligible
differ significantly according to their one-year Constant and the three crossovers may represent the patients’ and
score (75.4 (SD 12.3) in group 1, 78.3 (SD 10.7) in group 2 physicians’ belief that operative care could be better than
and 75.6 (SD 15.8) in group 3, p = 0.69). conservative care. The outcome analysis in our study was

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80 J. KUKKONEN, A. JOUKAINEN, J. LEHTINEN, K. T. MATTILA, E. K. J. TUOMINEN, T. KAUKO, V. ÄÄRIMAA

14 18

Activities of daily living

13 16
Pain

12 14

12
11 Group 1 Group 1
Group 2 Group 2
Group 3 Group 3
10
10

Pre- 3 months 6 months 12 months Pre- 3 months 6 months 12 months

treatment treatment

Fig. 3a Fig. 3b

12
36
11

10
34 Strength

9
ROM

32
8
Group 1 Group 1
Group 2 7 Group 2
30 Group 3 Group 3
6
28
Pre- 3 months 6 months 12 months Pre- 3 months 6 months 12 months
treatment treatment
Fig. 3c Fig. 3d

Graph showing Constant subscores in the three treatment groups for a) pain, b) activites of daily living, c) range of movement (ROM) and d) strength.
Whiskers indicate standard deviation (Group 1, physiotherapy; Group 2, acromioplasty and physiotherapy; Group 3, rotator cuff repair, acromioplasty
and physiotherapy).

Table V. Crossovers to group 3 (available data)

Constant score
Original group Age (yrs) Gender Baseline 6 months Crossover time-point (mths) Constant score at 12 months
1 68 Male 65 71 8.5 56
1 60 Female 41 50 8.1 21
1 60 Female 49 65 7.8 81
2 69 Male 37 34 9.2 21

performed in an intention to treat fashion, and therefore demonstrates the clinical similarity of outcomes between
the crossovers marginally impaired the one-year outcome in the groups.
group 1. In a post-hoc analysis based on the actual treatment Our trial has certain limitations. The follow-up time was
received there were still no differences between the groups. only one year, which might be considered too short. Impor-
The Constant scoring system is appropriate for evaluat- tantly, however, it has been found that after arthroscopic
ing patients with rotator cuff tears.28,29 We have previ- rotator cuff repair the Constant score significantly
ously estimated that the smallest clinically significant improves until one year, after which it stabilises.31 There
difference in terms of the Constant score is ten points in a were also some differences in the initial MRI interpretation
cohort of operatively treated rotator cuff tear patients.30 and the re-evaluation of images by two musculoskeletal
This, together with a sufficient number of subjects, further experts. Thus, two shoulders in group 3 had to be excluded

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 TREATMENT OF NON-TRAUMATIC ROTATOR CUFF TEARS 81

from the final study group because of an intact supraspina- 12. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymp-
tomatic shoulders. J Shoulder Elbow Surg 1999;8:296–299.
tus tendon at re-evaluation. We do not have post-operative
13. Downie BK, Miller BS. Treatment of rotator cuff tears in older individuals: a sys-
MR images of our patients and we do not know if tears tematic review. J Shoulder Elbow Surg 2012;21:1255–1261.
might progress nor do we know the number of re-tears in 14. Ejnisman B, Andreoli CV, Soares B, et al. WITHDRAWN: Interventions for tears of
the repair group. We would argue that since imaging find- the rotator cuff in adults. Cochrane Database Syst Rev 2009;2:CD002758.
ings associate poorly with clinical symptoms,21,32 clinical 15. Longo UG, Franceschi F, Berton A, Maffulli N, Droena V. Conservative treat-
ment and rotator cuff tear progression. Med Sport Sci 2012;57:90–99.
outcomes are more important than MRI results.
16. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in
Our results are in accordance with previous studies dem- rotator cuff repair. J Bone Joint Surg [Am] 2012;94-A:227–233.
onstrating successful conservative treatment of rotator cuff 17. Neviaser A, Andarawis-Puri N, Flatow E. Basic mechanisms of tendon fatigue
tears.15,21-23 We support a conservative regime as the pri- damage. J Shoulder Elbow Surg 2012;21:158–163.
mary treatment for non-traumatic rotator cuff tears in 18. Mihata T, Watanabe C, Fukunishi K, et al. Functional and structural outcomes of
single-row versus double-row versus combined double-row and suture-bridge repair
older patients. Further longer term studies are needed to for rotator cuff tears. Am J Sports Med 2011;39:2091–2098.
define the optimal nature and true effect of physiotherapy, 19. Randelli P, Spennacchio P, Ragone V, et al. Complications associated with
as well as the long-term outcome of all the interventions we arthroscopic rotator cuff repair: a literature review. Musculoskelet Surg 2012;96:9–
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The authors would like to express their gratitude to research nurse M-L. Sutinen
arthroscopic subacromial decompression. J Shoulder Elbow Surg 2008;17(Suppl):12–
and physiotherapists H-M. Laiho and P. Karppi for their help in managing the 16.
patient material. 21. Kijima H, Minagawa H, Nishi T, Kikuchi K, Shimada Y. Long-term follow-up of
No benefits in any form have been received or will be received from a com- cases of rotator cuff tear treated conservatively. J Shoulder Elbow Surg 2012;21:491–
mercial party related directly or indirectly to the subject of this article. 494.
This article was primary edited by P. Baird and first-proof edited by D. Rowley. 22. Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating
atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J
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