Systematic review

Current evidence for effectiveness of interventions to treat rotator cuff tears

Bionka M.A. Huisstede
a, b,
*
, Bart W. Koes
b
, Lukas Gebremariam
b
, Ellen Keijsers
b
, Jan A.N. Verhaar
c
a
Erasmus MC, University Medical Center Rotterdam, Department of Rehabilitation Medicine, Room H-016, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
b
Erasmus MC, Department of General Practice, Rotterdam, The Netherlands
c
Erasmus MC, Department of Orthopaedic Surgery, Rotterdam, The Netherlands
a r t i c l e i n f o
Article history:
Received 1 April 2010
Received in revised form
9 October 2010
Accepted 25 October 2010
Keywords:
Rotator cuff
Shoulder
Therapy
Surgery
a b s t r a c t
In this systematic review we assessed effectiveness of non-surgical and (post)surgical interventions for
symptomatic rotator cuff tears (RotCuffTear). The Cochrane Library, PubMed, Embase, Cinahl, and Pedro
were searched for relevant systematic reviews and randomized controlled trials (RCTs). Two reviewers
independently selected relevant studies, extracted data and assessed the methodological quality.
Three Cochrane reviews (7 RCTs) and 14 RCTs were included (3 non-surgery, 10 surgery, 8 post-
surgery).
For small or medium RotCufftears, moderate evidence was found in favour of surgery versus
physiotherapy in mid- and long-term. In surgery, tendon-to-bone xation with one metal suture
anchor loaded with double sutures (TB) was more effective (moderate evidence) than a side-to-side
repair with permanent sutures (SS) in the mid- and long-term; limited evidence for effectiveness was
found in favour of debridement versus anchor replacement and suture repair of the type II SLAP tear in
the long-term. Further, no evidence was found in favour of any non-surgical, surgical or post-surgical
intervention.
In conclusion, although surgery seems to give better results compared to non-surgery and TB is more
effective than SS in rotator cuff repair (RCR), it remains hard to draw rm evidence-based conclusions for
effectiveness of non-surgical or (post)surgical interventions to treat RotCuffTears. More research is
clearly needed.
2010 Elsevier Ltd.
1. Introduction
The four rotator cuff muscles not only move but also stabilize
the glenohumeral joint by centralizing the humeral head in the
glenoid fossa (Neri et al., 2009). Tears of the rotator cuff tendons
may cause shoulder pain and can limit shoulder function. Also in
asymptomatic shoulders a rotator cuff tear (RotCuffTear) can
be present. It was found in 23% of those with asymptomatic
shoulders (n > 400, >50 years) (Tempelhof et al., 1999). It is
known that the prevalence of RotCuffTears increases with age and
is more frequently reported in males (Milgrom et al., 1995;
Tempelhof et al., 1999; Yamamoto et al., 2010). Genetic inu-
ences may also play a role (Gwilym et al., 2009). In a recent
systematic review, no associations were found between jobs or
risk factors and the occurrence of RotCuffTears (Van Rijn et al.,
2010). Therefore, it remains unclear which conditions convert an
asymptomatic RotCuffTear into a painful symptomatic tear. On the
basis of imaging ndings alone, it is impossible to differentiate
between RotCuffTears leading to clinical symptoms and those
without symptoms (Schibany et al., 2004). It is suggested that the
location rather than the size of the tear plays an important role
(Burkhart, 1991; Burkhart et al., 1994). Although other shoulder
muscles can compensate for the cuff tear, the critical amount of
intact tendon or muscle necessary to maintain normal strength
and normal range of motion has not yet been dened (Schibany
et al., 2004).
RotCuffTears are one of the 23 specic disorders included in the
CANS model, a consensus model that describes terminology and
denition of CANS (Complaints of the Arm, Neck and/or Shoulder)
(Huisstede et al., 2007). Treatments for symptomatic RotCuffTears
vary from conservative to surgical. During the last two decennia
a transition from open to less invasive operative techniques to
repair a RotCuffTear can be noticed (Schibany et al., 2004). More-
over, it seems that operative treatment for RotCuffTears is
becoming standard procedure when conservative treatment fails to
* Corresponding author. Erasmus MC e University Medical Center Rotterdam,
Department of Rehabilitation Medicine, Room H-016, P.O. Box 2040, 3000 CA
Rotterdam, The Netherlands. Tel.: 31 10 7034228; fax: 31 10 7033843.
E-mail address: b.huisstede@erasmusmc.nl (B.M.A. Huisstede).
Contents lists available at ScienceDirect
Manual Therapy
j ournal homepage: www. el sevi er. com/ mat h
1356-689X 2010 Elsevier Ltd.
doi:10.1016/j.math.2010.10.012
Manual Therapy 16 (2011) 217e230
Open access under the Elsevier OA license.
Open access under the Elsevier OA license.
relieve symptoms, mainly because unrepaired RotCuffTears may
progress and become irreparable (Yamaguchi et al., 2001).
However, evidence for the effects of the different treatment options
remains unclear. Therefore, we systematically reviewed the litera-
ture to assess the evidence for effectiveness of treatments for the
RotCuffTear.
2. Methods
2.1. Search strategy
A search of relevant systematic reviews was performed in the
Cochrane Library and relevant review articles and randomized
controlled trials (RCTs) were searched in PubMed, Embase, Cinahl
and Pedro (up to July 2010). Keywords related to the disorder such
as rotator cuff tear and supraspinatus tear and interventions were
included in the literature search. The complete search strategy is
available upon request.
2.2. Inclusion criteria
Cochrane reviews, Cochrane based (i.e. reviews using the same
methodology as done in Cochrane reviews), and RCTs were
included if they fullled all of the following criteria: a) patients
with a RotCuffTear were included, b) the tear was not caused by
an acute traumata or systemic diseases as described in the de-
nition of CANS (Huisstede et al., 2007), c) an intervention for
treating the disorder was evaluated, d) results on pain, function or
recovery with a follow-up time of at least 2 weeks were reported,
and e) the article was written in English, French, German or
Dutch. Studies on comparison of analgesics in RotCuffTears
surgery were excluded.
2.3. Study selection
Two reviewers (B.H. and L.G.) independently applied the inclu-
sion criteria to select potential relevant studies from the title and
abstracts of the references retrieved by the literature search. A
consensus method was used to solve any disagreements concern-
ing inclusion of studies, and a third reviewer (B.K.) was consulted if
disagreement persisted.
2.4. Categorization of the relevant literature
Relevant articles are categorized under three headers: System-
atic reviews describes all (Cochrane) reviews; Recent RCTs contain
all RCTs published after the search date of the systematic review on
the same intervention; Additional RCTs describe all RCTs concerning
an intervention that has not yet been described in a systematic
review.
2.5. Data extraction
Two authors (E.K and B.H.) independently extracted the data.
Information was collected on the study population, interventions
used, outcome measures and outcome. A consensus procedure
was used to solve any disagreement between the authors. The
follow-up period was categorized as short-term (3 months), mid-
term (4e6 months) and long-term (>6 months).
2.6. Methodological quality assessment
Two reviewers (L.G., M.R./B.H.) independently assessed the
methodological quality of each recent and additional RCT. The 12
quality criteria (Table 1) were adapted from Furlan et al. (2009).
Each item was scored as yes, no, or dont know. High quality
was dened as a yes-score of 50%. A consensus procedure was
used to solve any disagreement between the reviewers.
In a (Cochrane) review the use of a methodological quality
assessment is standard procedure. We describe the methodological
quality scale or criteria used in the review, and used their ratings as
high/low quality for the included studies.
2.7. Data synthesis
A quantitative analysis of the studies was not possible due to
heterogeneity of the outcome measures. Therefore, we summarized
the results using a best-evidence synthesis (van Tulder et al., 2003).
The article was included in the best-evidence synthesis only if
a comparison was made between the groups (treatment versus
placebo, control, or treatment) and the level of signicance was
reported. The results of the study were labeled signicant if one
of the three outcome measures (pain, function, improvement)
reported signicant results. The levels of evidence for effectiveness
are ranked as follow:
1. Strong evidence: consistent* positive (signicant) ndings
within multiple high-quality RCTs.
2. Moderate evidence: consistent positive (signicant) ndings
within multiple low-quality RCTs and/or one high-quality RCT.
3. Limited evidence: positive (signicant) ndings within one
low-quality RCT.
4. Conicting evidence: provided by conicting (signicant)
ndings in the RCTs (<75% of the studies reported consistent
ndings)
5. No evidence: RCT(s) available, but no (signicant) differ-
ences between intervention and control groups were
reported.
6. No systematic review or RCT found.
*When 75% of the trials report the same ndings.
3. Results
3.1. Characteristics of the included studies
The initial literature search resulted in 6 potentially relevant
(Cochrane) reviews and 364 RCTs. Finally, 3 Cochrane reviews and
Table 1
Methodological quality assessment, list of Furlan.
Sources of risk of bias
Item
A 1. Was the method of randomization adequate?
B 2. Was the treatment allocation concealed?
C Was knowledge of the allocated interventions adequately prevented during
the study?
3. Was the patient blinded to the intervention?
4. Was the care provider blinded to the intervention?
5. Was the outcome assessor blinded to the intervention?
D Were incomplete outcome data adequately addressed?
6. Was the drop-out rate described and acceptable?
7. Were all randomized participants analysed in the group to which they were
allocated?
E 8. Are reports of the study free of suggestion of selective outcome reporting?
F Other sources of potential bias:
9. Were the groups similar at baseline regarding the most important
prognostic indicators?
10. Were co-interventions avoided or similar?
11. Was the compliance acceptable in all groups?
12. Was the timing of the outcome assessment similar in all groups?
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 218
14 RCTs met our inclusion criteria. Fig. 1 shows the process of
identifying the relevant articles. The three reviews studied effec-
tiveness of corticosteroid injections for shoulder pain (Buchbinder
et al., 2003), surgery for rotator cuff disease (Coghlan et al., 2008),
and interventions (conservative, surgical and post-surgical) for
RotCuffTears (Ejnisman et al., 2004). We excluded the results on
surgery and corticosteroid injections found in the review of
Ejnisman et al. (2004), because these treatments are also studied in
the more recent reviews of Coghlan et al. (2008) and Buchbinder
et al. (2003) respectively. The characteristics of the included
studies are listed in Appendix 1A and 1B.
3.2. Methodological quality of the included studies
The methodological scores of the included studies are reported
in Table 2.
To assess the quality of the included 14 recent and additional
RCTs we used the list of Furlan et al. (2009). Seven of the 14
included recent and additional RCTs were of high quality; 13 of
the 14 RCTs performed adequate randomization and were free of
suggestions of selective outcome reporting. In none of the RCTs
the care provider was blinded. We adopted the quality assessment
of the included Cochrane reviews. All assessed the quality of the
included RCTs in different ways (Table 2). In the Cochrane review
of Buchbinder et al. (2003) 5 quality items were scored. The RCT
of Shibata et al. scored 2 of these items as positive and 3 items
as unclear; therefore, this latter RCT was scored as low quality.
Ejnisman et al. (2004) assessed 12 items to study the quality of the
included RCTs; all 4 RCTs on RotCuffTear were of high quality (>50%
of the items scored positive). The Cochrane review of Coghlan et al.
(2008) on surgery included 2 RCTs on RotCuffTear. Both RCTs scored
3 of the 6 items positive (in both studies the randomization was
adequate and the patients were blinded), and 3 items as unclear (in
both studies the concealment of allocation and blinding of the
outcome assessor was unclear). According to Coglan et al. these
RCTs are of low quality.
For all included RCTs (recent, additional and included in the
Cochrane reviews) the concealment of the allocation and intention-
to-treat was assessed and was scored positive in about 50%.
3.3. Effectiveness of interventions of the RotCuffTear
Table 3 showed an overview of the evidence found for effec-
tiveness of interventions to treat RotCuffTears.
3.4. Effectiveness of corticosteroid injections
3.4.1. Systematic reviews
Buchbinder et al. (2003) studied the effectiveness of cortico-
steroid injections for shoulder pain. Only one low-quality RCT
(Shibata et al., 2001) reported on RotCuffTears: 78 full-thickness
RotCuffTears were treated with intra-articular corticosteroid or
hyaluronate injections. After 4 weeks, no signicant differences
regarding satisfaction with improvement due to the treatment
were found.
We conclude that there is no evidence for the effectiveness of
corticosteroid injections in the short-term (4 weeks).
3.5. Effectiveness of a suprascapular nerve block
3.5.1. Systematic review
As mentioned above, the Cochrane review of Ejnisman et al.
(2004) examined non-surgical and surgical interventions for Rot-
CuffTears. Eight trials (n 455) were included. Data of 393 patients
were analysed. One high-quality study (Vecchio et al., 1993)
reported on the effectiveness of a suprascapular nerve block with
SEARCH
Potential relevant articles identified: reviews: 6 / RCTs: 364
Appropriate articles included:
reviews: 3 / RCTs: 14
Cochrane PubMed Embase Cinahl Pedro
Articles retrieved for more detailed
evaluation: reviews: 6 / RCTs: 29
Excluded based on title
and/or abstract:
reviews: 0 / RCTs: 335
Excluded, did not met
inclusion criteria:
review: 3 / RCTs: 15
Articles retrieved by
screening references: 0
Fig. 1. Flowchart of the literature search.
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 219
dexamethasone versus placebo in 13 patients with a persistent
rotator cuff lesion. At 12-weeks follow-up, night pain and pain with
movement, and active abduction, exion and external rotation
were better in the treatment group. No comparisons between the
groups were made.
Therefore, we found no evidence for the effectiveness a supra-
scapular nerve block with dexamethosone versus placebo for
treating the RotCuffTear in the short-term.
3.6. Effectiveness of non-surgery versus surgery
3.6.1. Additional RCTs
Ahigh-qualitystudy(Moosmayeret al., 2010) (n103) studiedthe
effectiveness of surgery (mini-open or open rotator cuff repair INS>
(RCR)) versus physiotherapy (exercise therapy) and found signicant
differences between the groups in favour of surgery on the Constant
Score at 12-months follow-up (13.0 (95% CI 4.9e21.1)) but not at
6-months follow-up. On the ASES score signicant differences
betweenthegroups were foundinfavour of surgeryat 6-months (11.4
(95%CI 3.6e19.1)) and 12-months (16.1 (95%CI 8.2e23.9)) follow-up.
We conclude that there is moderate evidence that surgery is
more effective than physiotherapy (exercise therapy) in patients
with RotCuffTears in the mid- and long-term.
3.7. Effectiveness of surgery
3.7.1. Systematic reviews
The Cochrane review of Coghlan et al. (2008) studied surgery
for rotator cuff disease and included 14 studies. Two of these
(Gartsman and OConnor, 2004; Boehm et al., 2005) reported on
interventions for RotCuffTear. A low-quality RCT (Boehm et al.,
2005) (n 100) studied repairable non-traumatic full-thick-
ness Bateman types 1 or 3 tears of the rotator cuff (i.e.1e5 cm).
In this trial, an open RCR with non-absorbable braided No.3
Ethibond using modied Mason Allen sutures was compared to
an open RCR with 1.0 mm absorbable polydioxane cord using
modied Kessler sutures. No signicant differences were found
on the outcome rated as good or excellent at 2-years follow-
up. Also, no differences were found between the groups for re-
tear of the rotator cuff on sonography and the Constant
score >75.
Another low-quality study (Gartsman and OConnor, 2004)
(n 93) studied arthroscopic RCR with and without subacromial
decompression with an isolated repairable or a full-thickness
supraspinatus tear. No differences between the groups on the
American Shoulder and Elbow Score (ASES) were found at
12-months follow-up.
Table 2
Methodological quality scores of the included RCTs and RCTs included in the Cochrane reviews.
Reference 1. Adequate
randomization?
2. Allocation
concealment?
3.
Blinding?
Patients?
4.
Blinding?
Caregiver?
5.
Blinding?
Outcome
assessors?
6.
Incomplete
outcome
data
addressed?
Drop-outs?
7.
Incomplete
outcome
data?
ITT
analysis?
8. Free of
Suggestions of
selective
outcome
reporting?
9. Similarity
of baseline
characteristics?
10.
Co-interventions
avoided or
similar?
Included recent and additional RCTs
a
:
Moosmayer et al. (2010) e e e
Milano et al. (2007) ? e ? e
Mohtadi et al. (2008) e e e
Hayes et al. (2004) ? e e ?
Michael et al. (2005) e e ? ?
Bigoni et al. (2009) ? ? e ? ?
Burks et al. (2009) ? ? e ? ?
Franceschi et al. (2007) ? ? e ? ?
Iannotti et al. (2006) ? ? e e e
Abbot et al. (2009) ? ? e e ? ? ?
Grasso et al. (2009) ? e ? e ? ?
Blum et al. (2009) e e e e e ? ?
Klintberg et al. (2009) e e ? e e ? ?
Roddey et al. (2002) ? e e ? e e ?
Total positive per item 13 6 3 0 8 10 5 13 6 3
RCT included in CR of Buchbinder et al. (2003)
b
:
Shibata et al. (2001) ? ? ? #
RCTs included in CR of Ejnisman et al. (2004)
c
Vecchio et al. (1993) 1 2 2 2
Lastayo et al. (1998) 0 0 2 2
Raab et al. (1996) 1 0 2 2
Watson (1985) 0 0 0 2
RCTs included in CR of Coghlan et al. (2008)
d
Boehm et al. (2005) ? ? # ?
Gartsman and OConnor
(2004)
? ? ?#
Overall validity: A: low risk of bias: all criteria met; B: moderate risk of bias: one or more criteria partly met; C: high risk of bias: one or more criteria not met; empty cells:
item not assessed.
a
Quality criteria adopted from Furlan et al. : yes: : no:?: unclear/unsure; n.a.: not applicable (in a non-time intervention, such as surgery, compliance is not an issue);
a score 50% of the items is called a high-quality study.
b
Quality criteria adopted from the Cochrane Reviewers Handbook (Clarke M, Oxman AD editors. Cochrane Reviewers Handbook 4.0 [updated July 1999]. In: The
Cochrane Library [database on CDROM]. The Cochrane Collaboration. Oxford: Update Software; 2000, Issue 2 1999), a score >50% of the items is called a high-quality study.
c
Quality criteria using a piloted, subject-specic modication of the generic evaluation tool developed by the Cochrane Musculoskeletal Injuries GroupScores consisting
of 9 criteria; per item: 0 (: no), 1 (: partly true) or 2 (: yes); a score >50% of the items is called a high-quality study.
d
The methodological quality was assessed based upon whether the trials met 6 key methodological criteria.
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 220
3.7.2. Recent RCTs
Eight recent RCTs on surgery were found.
A high-quality study (Milano et al., 2007) (n 80) studied
arthroscopic RCR with and without subacromial decompression.
Similar to the results reported by Gartsman and OConnor (2004),
no signicant differences between the groups were reported on the
Constant score or the DASH score at 2-years follow-up.
Another high-quality study (Mohtadi et al., 2008) compared
open to arthroscopic acromioplasty with mini-open RCR in 62
patients with a full-thickness RotCuffTear. No signicant differences
betweenthegroups werefoundat 3and6-months and1and2-years
follow-up on the ASES score, the Shoulder Rating Questionnaire
(SRQ), or the Rotator Cuff-Quality of Life (RC-QOL) measure.
A low-quality study (Grasso et al., 2009) studied the effective-
ness of arthroscopic full-thickness RCR with single-row versus
double-row anchors in 80 patients. At follow-up (24.8 (1.4) mean
(sd) months) no signicant differences between the groups were
found on the Constant Score, strength or the DASH.
Another low-quality study (Franceschi et al., 2007) (n 60) also
compared the effectiveness of arthroscopic single-row to double-
row suture anchor repair of a full-thickness RotCuffTear. At 2-years
follow-up no signicant differences on the UCLA scores, rates of
healing or MRI arthrography were found.
A third high-quality study (Burks et al., 2009) (n 40) that
compared the effectiveness of single-row versus double-row
anchors in full-thickness arthroscopic RCR did not nd signicant
results between the groups either on the Constant Score, ASES,
UCLA and strength 1 year after surgery.
A high-quality study (Bigoni et al., 2009) (n 50) studied side-
to-side withpermanent sutures (SS) versus tendon-to-bone xation
with 1 metal suture anchor loaded with double sutures (TB)
in arthroscopic full-thickness supraspinatus tear repair. From
the study it is not clear whether or not signicant results on the
Constant score and internal and external rotator peak torque
were found at 3- and 6-months followup. At 12-months follow-up,
signicant results between the groups in favour of TB on the
Constant Scoreandinfavour of SS onthestrengthscores werefound.
Another low-quality study (Iannotti et al., 2006) examined the
use of porcine small intestine submucosa to augment repairs of
the rotator cuff (supra- or infraspinatus). It was hypothesized
that augmentation would reduce re-tears after RCR. A total of 30
patients was treated using open RCR by performing a Neer acro-
mioplasty. Half of the patients were treated with augmentation. In
4 of the 15 shoulders in the augmentation group and in 9 of the 15
patients in the control group the rotator cuff was healed at follow-
up (average 14 months after surgery, non signicant). No signicant
differences were found with regard to the UPenn questionnaire.
A low-quality study (Abbot et al., 2009) reported on patients
with concomitant supraspinatus tear and type II SLAP tears. One
group (n 24) was treated with arhroscopic RCR, subacromial
decompression and debridement of their type II SLAP tears (Debrid)
and the other group (n 24) with arthroscopic RCR, subacromial
decompression anchor replacement and suture repair of their type
II SLAP tears (Repair). After 2 years signicant better results were
found in favour of the Debrid group on the UCLA score. Also
signicant better results were found for internal and external
rotation in favour of the Debrid group (no baseline scores reported)
at 1- and 2-years follow-up, but not for forward exion.
We conclude that there is moderate evidence for effectiveness in
favour of tendon-to-bone xation with 1 metal suture anchor loaded
11.
Compliance
acceptable in
all groups?
12. Timing of
the outcome
assessment
similar?
In and exclusion
criteria clearly
dened?
Interventions
clearly
dened?
Outcome
measures
clearly
dened?
Diagnostic
tests
useful?
Surveillance
active and
appropriate?
Score
max
Score
study
% Quality
of the study
? 12 8 67 High
n.a. 11 7 64 High
n.a. e 11 7 64 High
e 12 7 58 High
? e 12 6 50 High
n.a. 11 6 55 High
n.a. 11 6 55 High
n.a. e 11 5 45 Low
n.a. e 11 5 45 Low
n.a. 11 4 36 Low
n.a. e 11 4 36 Low
? 12 4 33 Low
? 12 4 33 Low
e 12 4 33 Low
0 9
5 2 40 Low
1 2 1 1 2 24 16 67 High
2 2 2 2 2 24 16 67 High
2 2 2 2 2 24 17 71 High
1 2 2 2 2 24 13 54 High
6 3 50 C: low
6 3 50 C: low
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 221
with TB compared to side-to-side with SS in full-thickness supra-
spinatus tear repair in the long-term; limited evidence for effec-
tiveness was found in favour of debridement of the type II SLAP tears
comparedtoanchor replacement andsuture repair or the type II SLAP
tear in RCR with subacromial decompression in the long-term.
Further, there is no evidence for the effectiveness of the use of
Ethibond compared to polydioxane in an open RCR in the long-
term, in favour of arthroscopic RCR with or without subacromial
decompression in the long-term, or an open compared to an
arthroscopic acromioplasty with mini-open RCR in the short-, mid-
and long-term. Moreover, no evidence was found in favour of either
one-row or double-row suture anchor in arthroscopic RCR, or for
the effectiveness of the use of augmentation with porcine small
intestine submucosa in open RCR in the long-term.
3.8. Effectiveness of interventions after RCR
3.8.1. Systematic review
In the Cochrane reviewof Ejnisman et al. (2004) on non-surgical
and surgical interventions for a RotCuffTear, 3 studies that focused
on post-operative programs after an RCR were included. Two high-
quality RCTs (Raab et al., 1996; Lastayo et al., 1998) (n 28) studied
RCR and continuous passive motion (CPM) versus RCR and manual
passive ROM exercises after 3 or 24 months follow-up. Pooled data
showed no signicant differences between the interventions on the
outcome no improvement on pain.
Another high-quality RCT (Watson, 1985) (n 89) studied RCR
and splinting in abduction versus RCR resting the arm at the side.
Only the outcome poor response was studied and no signicant
differences were found at 5-weeks follow-up.
3.8.2. Recent RCTs
Five recent RCTs that studied interventions after an RCR were
found.
A low-quality RCT (Klintberg et al., 2009) compared progressive
physiotherapy (i.e. early loading of the rotator cuff (active and
passive motion)) to traditional physiotherapy (i.e. immobilization
of 6 weeks followed by only passive motion). Only the progressive
group showed signicant within group results on the pain
outcomes at 12 and 24 months follow-up. However, no compari-
sons between the groups were made.
A high-quality study (Michael et al., 2005) compared RCR and
CPM plus physiotherapy with RCR and physiotherapy alone. ROM
(90

active abduction of the shoulder) was managed after 31 days in

Table 3
CANS: evidence for effectiveness of interventions for the rotator cuff tear.
Physiotherapy Non-surgical treatment Surgical treatment
Oral
treatment
Injection Other non-surgical
Non-surgery vs surgery X Intra-articular corticosteroid
injections compared:
Suprascapular nerve block Surgery:
<Physiotherapy (exercise
therapy) vs surgery
a
:
<Corticosteroid vs
Hyaluronate:
< Suprascapular nerve block with
dexamethosone vs placebo:
In open RCR:
Mid-term: Short-term (4 weeks): NE Short-term: NE <Use of Ethibond vs PDS:
Long-term: Long-term: NE
<Use of augmentation with porcine small intestine
submucosa vs no augmentation: NE
Long-term: NE
In arthroscopic RCR:
<With vs without subacromial decompression:
Long-term: NE
<One-row vs double-row suture anchor:
Long-term: NE
<SS vs TB*:
Long-term:
<Debrid* vs Repair
Long-term:
<Open RCR vs arthroscopic acromioplasty with mini-
open RCR:
Short-term:NE
Mid-term:NE
Long-term:NE
After RCR:
<Progressive vs traditional physiotherapy:
Long-term: NE
<CPM as additive to physiotherapy:
Short-term: NE
Mid-term: NE
Long-term: NE
<Physiotherapy vs home exercise program:
Long-term: NE
<Instructions by using videotape vs individual
instructions by a physiotherapist:
Short-term: NE
Mid-term: NE
Long-term: NE
<HWDS vs placebo:
Short-term: NE
X: No systematic review(SR) or randomized clinical trial (RCT) found; : limited evidence found; : moderate evidence found; NE: no evidence found for effectiveness of the
treatment: RCT(s) available, but no differences between intervention and control groups were found or reported.
a
In favour of; RCR: rotator cuff repair; PDS: Polydioxane; CPM: continuous passive motion; SS: repair side-to-side with permanent sutures; TB: tendon-to-bone xation
with 1 metal suture anchor loaded with double sutures; Debrid: arthroscopic RCR, subacromial decompression and debridement of their II SLAP tears; Repair: arthroscopic
RCR, subacromial decompression anchor replacement and suture repair of their type II SLAP tears; HWDS: H-Wave device stimulation.
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 222
the CPM plus physiotherapy group compared to 43 days in the
physiotherapy alone group (p 0.292).
Another high-quality study of Hayes et al. (2004) compared
individualized physiotherapy to a standardized home exercise
program after RCR and found no signicant differences between
the groups for any passive ROM, muscle force or overall shoulder
status at 12- and 24-weeks follow-up.
A low-quality study (Roddey et al., 2002) compared two
instructional approaches to a home exercise program after RCR:
a videotape versus personal instruction by a physiotherapist. No
differences between the treatment groups were found on the
Shoulder Pain and Disability Index (SPADI) and UPenn Shoulder
Scale at 12-weeks, 24-weeks and 1-year follow-up.
A low-quality RCT (Blumet al., 2009) studied the effectiveness of
Repetitive H-Wave device stimulation (HWDS) versus placebo
HWDS and found signicant within group results for both groups
for external rotation (arm at slide) and internal rotation (arm at
90

) at 90 days follow-up; the HWDS group improved most. No

signicant within group results were found for the other ROM
measurements. No comparisons were made between the groups.
We found no evidence for the effectiveness of progressive
compared to traditional physiotherapy, in the long-term or for
the effectiveness of CPM as additive to physiotherapy after RCR.
Furthermore, we foundnoevidence for the effectiveness of splinting
inabductionversus restingthe armat the side, physiotherapy versus
a standardized home exercise program, instructional approaches
versus a home exercise program (videotape), or H-wave device
stimulation versus placebo after RCR.
4. Discussion
This study focused on the effectiveness of non-surgical and
surgical interventions for treating RotCuffTears not caused by acute
traumata or systemic diseases.
4.1. Non-surgical interventions
Neri et al. (2009) stated that in patients with a massive Rot-
CuffTear presenting minimal pain, non-surgical treatment can be
considered to improve the function of the shoulder by training
muscle strength, coordination and proprioception, or by judicious
use of corticosteroid injections. We found only two RCTs that
studied non-surgical treatments. In one study (Shibata et al., 2001)
intra-articular corticosteroid injections were compared to an hya-
luronate injection, but no evidence in favour of one of these
treatments was found. In the other RCT (Vecchio et al., 1993) no
evidence was found for the effectiveness of a suprascapular nerve
block with dexamethosone versus placebo to treat RotCuffTear.
The systematic reviewof Ainsworth andLewis (2007) focused on
exercise therapy in the management of full-thickness RotCuffTears.
Only observation studies were included and, similar to the ndings
in our systematic review, no RCTs investigating effectiveness of
exercise therapy were found. Although it was concluded that exer-
cise therapy (either in isolation or given as part of non-operative
treatment) has some benet, no rm conclusions could be drawn.
Therefore, evidence-based conclusions regarding the effective-
ness of non-surgical interventions for treating the RotCuffTear
remain elusive.
4.2. Surgical interventions
RCR should compare favourably with other medical interven-
tions and improve quality of life. (Adla et al., 2010). We only found
one RCT that compared non-surgical to surgical interventions.
Moderate evidence for effectiveness was found in favour of surgery
compared to physiotherapy (exercise therapy) for were small
(<1 cm) or medium sized (1e3 cm) symptomatic RotCuffTears
(Moosmayer et al., 2010). More high-quality RCTs are needed to
study non-surgical versus surgical treatments to treat RotCuffTears.
Various surgical approaches and techniques to treat RotCuff-
Tears have been described. We included 10 RCTs regarding surgical
repair of the RotCuffTear. Moderate evidence was found in favour
of TB versus SS. Limited evidence in favour of Debrid versus Repair
was found and no signicant differences (thus no evidence) were
found in favour of any one of all other surgical or anchor tech-
niques. None of the included RCTs studied an optimal timing
strategy for surgery. Dening the timing of surgery may play an
important role with regard to good results of surgery; future
studies should explore this aspect.
4.3. Post-operative treatment options
Eight of our included RCTs concentrated on post-operative
treatments. In these trials, different exercise therapies, or different
immobilization techniques used after RCR, were compared to each
other. However, no benet in favour of any one of the treatments
was found. None of these trials focused on immobilization versus
exercise therapy.
There are several reasons why treatment of RotCuffTears is rela-
tively difcult to understand. First, tendinitis and bursitis of the
shoulder are difcult to differentiate from one another. (Huisstede
et al., 2007) To identify a RotCuffTear, the patients should be
referred for magnetic resonance imaging (MRI). MRI is one of the
most accurate non-invasive tools to detect a RotCuffTear, with
a specicity of 67e89% compared with ndings at arthroscopy.
(Shellock et al., 2001; Teefey et al., 2004), although, as stated before,
onthebasis of imaging alone it is impossible to differentiate between
symptomatic and asymptomatic tears (Shibata et al., 2001). There-
fore, other (non tendinous) sources causing the symptoms should
also be taken into account before making the denite diagnosis.
Second, little is known about the natural history of symptomatic
or asymptomatic RotCuffTears. Therefore, more studies are needed
to elucidate the long-term natural history of the different types of
RotCuffTears.
Third, various factors may inuence the decrease of shoulder
function in patients with a RotCuffTear. Both atrophy and fatty
inltration (identifying degenerative changes) are reported to give
poor prognosis for thereturnof rotator cuff functioninthesepatients
(Schaefer et al., 2002; Goutallier et al., 2003). Furthermore, a massive
RotCuffTear can cause cuff tear arthropathy (Feeley et al., 2009).
Mechanical as well as nutritional factors may also play a role in this
process (Neer et al., 1983). The head of the humerus may migrate
upward and may wear into acromion/acromio-clavicular joint and
coracoid, resulting in cuff tear (mechanical) arthopathy or reduced
motion (Neer et al., 1983). With disuse this can lead to osteoporosis
and biochemical changes in the cartilage and cuff tear (nutritional)
arthopathy (Jensen et al., 1999). Surgery might serve to stop this
destructive process, but it is difcult to make an appropriate selec-
tion of patients who may (or may not) benet from a surgical
procedure based on the existing literature (Feeley et al., 2009).
Additional studies are needed to identify pre-operative clinical
prognostic factors in order to decide which patients are likely to
respond to either non-surgical or surgical treatment. Moreover,
information is needed that allows predicting which tears will
progress and may need surgical intervention. One retrospective
study (Maman et al., 2009) reported that progression of symp-
tomatic RotCuffTear in patients treated non-surgical (physio-
therapy, activity restriction, and selective corticosteroid injection)
is associated with age over 60 years, a full-thickness tear, and fatty
inltration of the rotator cuff muscle(s). According to Zingg et al.
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 223
(2007), satisfactory shoulder function in patients with a non-
operatively managed, moderate, symptomatic massive RotCuffTear
can be maintained for at least four years.
Additional knowledge about pre-operative prognostic factors
and outcome of non-operative treatment options of RotCuffTears
may help professionals to decide which treatment may be most
suitable for each individual patient.
Some limitation of this review and its conclusions need to be
addressed. First, we refrained from statistical pooling of the results
of the individual trials; this was done because of the high hetero-
geneity of the trials. A single-point estimate of the effect of the
interventions included for a RotCuffTear would probably not do
justice to the differences between the trials regarding patient
characteristics, interventions and outcome measures. Use of a best-
evidence synthesis is a next best solution and is a transparent
method commonly applied in the eld of musculoskeletal disorders
when statistical pooling is not feasible or clinically viable (van
Tulder et al., 2003).
Secondly, for the includedrecent andadditional RCTs we assessed
the methodological quality using the list of Furlan et al. (2009). This
list includes minimum criteria for which either empirical evidence
existed that conrmed they were associated with bias. This list is
constructed to assess interventions in the eld of neck and back
disorders, but can also be used and appears very suitable in other
elds (Verhagen et al., 1998; Boutron et al., 2005). Thirdly, we
adopted the quality score and denition of high/low quality for the
RCTs included in the three Cochrane reviews. This choice is arbitrary.
However, because these included RCTs did not reported signicant
results, our nal conclusions remain unchanged if would have used
the quality list of Furlan et al. (2009).
In conclusion, we found moderate evidence in favour of surgery
compared to physiotherapy in the mid- and long-term to treat
small or medium sizes RotCuffTears. In surgery, tendon-to-bone
xation with 1 metal suture anchor loaded with TB was more
effective than a side-to-side repair with SS, but further no
unequivocal evidence was found that one surgical treatment is
superior to the other in treating the RotCuffTear. Further, it remains
unclear whether immobilization, or perhaps some form of exercise
therapy, is most effective after surgery.
Therefore, at present, it is hard to draw rm evidence-based
conclusions about the effectiveness of either non-surgical or
surgical interventions for RotCuffTears. The whole area of treat-
ment options for RotCuffTears remains mostly unclear and more
research is denitely needed. Future large-scale studies should also
concentrate on prognostic factors and on subgroup analyses with
regard to the different types of RotCuffTears.
Conict of Intrest
There are no conicts of interest for any authors.
Acknowledgement
The authors thank M.S. Randsdorp, MD, for her participation in
the methodological quality assessment.
Appendix 1A
Author Total no.
of patients
Treatment Placebo
(n)
Control/comparison
(n)
Outcome measures
(total follow-up time)
Effect size
Corticosteroid injections
Buchbinder
et al., 2003
78 Intra-articular steroid
injection (n 40)
Intra-articular
hyaluronate
injections (n 38)
Satisfaction treatment
(4 weeks)
RR 0.89 (95% CI 0.52e1.54)
1 RCT (out of 26
RCTs)
a
Suprascapulair nerve block
Ejnisman
et al., 2004
Dexamethasone suprascapular
nerve block (n: unclear)
(n:
unclear)
Night pain (VAS)
(12 weeks)
Treatment: 2.2 (1.8) (mean change
(SE)) vs placebo: 1 (0.7)
d
1 RCT (out of 8
RCTs)
b
Movement pain (VAS)
(12 weeks)
Treatment: 4 (0.6) (mean change (SE))
vs placebo: 0.3 (0.4)
ROM e active abduction
(degrees) (12 weeks)
Treatment: 28 (21) (mean change (SE)) vs
placebo: 8 (8)
d
ROM e active exion
(degrees) (12 weeks)
Treatment: 2 (23) (mean change (SE)) vs
placebo: 22 (9)
d
ROM e active external
rotation (degrees)
(12 weeks)
Treatment: 11 (8) (mean change (SE)) vs
placebo: 2 (3)
d
Surgery
Coghlan et al.,
2008
191 (out
of 829)
Open repair of rotator
cuff using
Open repair of
rotator cuff
2 RCTs (out of
14 RCTs)
c
polydioxane suture using Ethibond
suture
n 40/48 n 41/50 Outcome rated as good or
excellent (2 years)
RR 1.02 (95% CI 0.85e1.22)
n 18/44 n 11/49 Rate of re-tear
(on sonography, 2 years)
RR 1.82 (95% CI 0.97e3.42)
n 40/44 n 45/49 Constant score > 75
(follow-up time not
reported)
RR 0.99 (95% CI 0.87e1.12)
RCT: randomized clinical trial; n: number ; RR: relative risk; CI; condence interval; ROM: range of motion; SE: standard error
a
1 out of 26 RCTs included in this review on shoulder pain reported on rotator cuff tear
b
1 out of 8 RCTs included in this review reported on non-surgical treatments other than corticosteroid injections to treat the rotator cuff tear
c
2 out of 14 RCTs included in this review on rotator cuff disease reported on rotator cuff tear
d
no comparison made between the groups
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 224
Appendix 1B
Data extraction e RCTs of rotator cuff tear.
Author
Type of RotCuffTears
Treatment Placebo
(n)
Control/comparison Outcome measures
(total follow-up
time)
Results e
statistical
Results
Non-surgery vs surgery
Moosmayer et al.,
2010
Surgery (standard, i.e. mini-
open or open tendon repair)
(n 52)
Physiotherapy (12 weeks 2x/
week, followed by 6e12
weeks with increased
intervals of exercise therapy)
(n 51)
Constant score
(12 months)
Between group differences:
Small and medium-
sized RotCuffTears
1
and
2
6 months:
NS No exact data given
12 months:
p 0.002 13.0 (95% CI 4.9e21.1) in favour
ASES score
(12 months)
Between group differences:
Age: 59 (44e75) (mean (range)) Age: 61 (46e75) 6 months:
Men-women: 37e15 Men-women; 36e15 p 0.005 11.4 (95% CI 3.6e19.1) in favour of
surgery
Duration: 12.3 (18.7) (mean
(sd))
Duration: 9.8 (9.8) 12 months:
p < 0.0005 16.1 (95% CI 8.2e23.9) in favour of
surgery
Surgery
Milano et al., 2007 Arthroscopic RCR with
subacromial decompression
(n 40)
Arthroscopic RCR without
subacromial decompression
(n 40)
Constant score (2
years)
Not
signicant
103.6 vs 96.1
Full-thickness
RotCuffTear
1
and
type 2 or 3
acromion
4
(p-value
not given)
DASH score (2
years)
Not
signicant
18.2 vs 23.1
(p-value
not given)
Age: 61.0 (7.0) (mean (sd)) Age: 59.7 (9.7)
Men-women: 20e14 Men-women: 19e18
Duration: not given Duration: not given
Mothadi et al., 2008 Open surgical RCR (n 30) Arthroscopic acromio-plasty
with mini-open Repair
(n 32)
ASES score (2 years) Baseline:
Small/Medium/
Large/Massive
full-thickness
RotCuffTear
1 or 2
or
3
p 0.25 48.2 (40.7e55.6) (mean 95% CI) vs 53.8
(47.1e60.5)
3 months follow-up:
Age: 56.2 (44e77) (mean
(range))
Age: 57.0 (33e82) p 0.48 61.8 (54.8e68.7) vs 71.7 (64.4e79.1)
Men-women: 22-8 Men-women: 20-13 6 months follow-up:
Duration: not given Duration: not given p 0.16 68.9 (61.7e76.1) vs 80.7 (74.2e87.3)
1 year follow-up:
p 0.84 85.2 (79.5e90.9) vs 86.1 (79.9e92.2)
2 years follow-up:
p 0.49 87.5 (81.9e93.1) vs 89.9 (85.4e94.4)
SRQ score (2 years) Baseline:
p 0.33 46.7 (41.3e52.1) (mean 95% CI) vs 50.3
(45.2e55.4)
3 months follow-up:
p 0.17 63.3 (57.5e69.1) vs 69.4 (62.6e76.3)
6 months follow-up:
p 0.10 73.6 (68.2e79.1) vs 79.8 (74.7e84.9)
1 year follow-up:
p 0.59 83.4 (78.1e88.8) vs 85.2 (81.2e89.2)
2 years follow-up:
p 0.81 85.1 (80.2e90.1) vs 85.9 (81.7e90.0)
RC-QOL Baseline to 3 months:
p 0.5 13.9 (5.9e21.9) MD (95% CI) vs 25.4
(16.5e34.3)
Baseline to 6 months:
p 0.81 33.3 (23.9e42.7) vs 34.9 (25.5e44.3)
Baseline to 1 year:
p 0.91 43.7 (37.4e50.1) vs 44.3 (36.3e52.4)
Baseline to 2 year:
p 0.43 45.6 (39.9e51.2) vs 41.5 (32.7e50.2)
Grasso et al., 2009 Arthroscopic RCR with single
row anchor (n 40)
Arthroscopic RCR with
double row anchor
(n 40)
Constant Score p 0.378 Single row: 100.5 (17.8) (mean (sd)) vs
double row: 104.9 (21.8)
Full-thickness
RotCuffTear
1
Mean follow-up
24.8 (1.4) mean (sd)
months
(95% CI 13.695 to 5.267))
Muscle strength (lb) p 0.382 Single row: 12.7 (5.7) (mean (sd)) vs
double row: 12.9 (7.0) Age: 58.3 (10.3) (mean (sd)) Age: 55.2 (6.5)
Men-women: 16-21 Men-women: 18-17 (95% CI 13.695 to 5.267))
(continued on next page)
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 225
(continued)
Author
Type of RotCuffTears
Treatment Placebo
(n)
Control/comparison Outcome measures
(total follow-up
time)
Results e
statistical
Results
Mean follow-up
24.8 (1.4) mean (sd)
months
Duration: not given Duration: not given DASH questionnaire p 0.482 Single row: 15.4 (15.6) (mean (sd)) vs
double row: 12.7 (10.1) Mean follow-up
24.8 (1.4) mean (sd)
months
(95% CI 4.057 to 8.512)
Franceschi et al.,
2007
Arthroscopic RCR with single-
row anchor (n 30)
Arthroscopic RCT with double-
row anchor (n 30)
UCLA shoulder score
(2 years)
(range)) pre-operative to 32.9 (29e35)
post-operative vs dubble-row: 10.1 (5
e14) pre-operative to 33.3 (30e35)
post-operative
Large/massive full-
thickness tear
1
of
the supraspinatur,
infraspinatus or
subscapularis
1
and 4
Age: 63.5 (43e76) (mean
(range))
Age: 59.6 (45e80) ROM e forward
exion (degrees) (2
years)
p > 0.06 Single row: 110 (30e140) (mean
(range)) pre-operative to 159 (150
e170) post-operative vs dubble-row:
100 (30e150) pre-operative to 156
(140e170) post-operative
Men-women: 12-14 Men-women: 16-10
Duration: at least 3 months Duration: at least 3 months
ROM e external
rotation (2 years)
p > 0.05 Single row: 83.2 (65e95) (mean
(range)) pre-operative to 132.4 (90
e140) post-operative vs dubble-row:
79.6 (62e93) pre-operative to 131.3
(85e137) post-operative
ROM e internal
rotation (2 years)
p > 0.05 Single row: 27.3 (20e33) (mean
(range)) pre-operative to 37.3 (27e42)
post-operative vs dubble-row: 28.6 (22
e35) pre-operative to 40.3 (26e43)
post-operative
MRI arthroscopic: (2
years)
Intact p > 0.05 Single-row 14 vs double-row 18
Partial-thickness
defect
p > 0.05 Single-row 10 vs double-row 7
Full-thickness
defect
p > 0.05 Single-row 2 vs double-row 1
Burks et al., 2009 Arthroscopic RCR with single-
row anchor (n 20)
Arthroscopic RCR with
double-row anchor (n 20)
Pre-operative (mean (sd)) to 1 year
follow-up:
Full-thickness
RotCufftear (no
signicant
subscapularis
tear)
1
Constant Score (1
year)
p 0.980 Single-row: 44.1 (18.8)e77.8 (9.0) vs
double-row: 45.6 (20.3)e74.4 (18.4)
Age: 56 (43e74) (mean (range)) Age: 57 (41e81)
Men-women: not given Men-women: not given ASES (1 year) p 0.673 Single-row: 41.0 (21.5)e85.9 (14.0) vs
double-row: 37.6 (19.3)e85.5 (20.0) Duration (total population): 16.8
(1 weeke12 years)
UCLA (1year) p 0.165 Single-row: 12.1 (3.9)e28.6 (3.6) vs
double-row: 13.6 (4.6)e29.5 (5.6)
Strength e external
rotation (N.m)
p 0.862 Single-row: 8.7 (4.6)e17.2 (7.7) vs
double-row: 9.6 (6.0)e16.7 (7.5)
Strength e internal
rotation (N.m)
p 0.687 Single-row: 15.8 (7.9)e28.1 (13.8) vs
double-row: 18.1 (11.6)e28.8 (14.4)
Bigoni et al., 2009 Arthroscopic RCR side-to-side
with permanent sutures (SS)
(n 25)
Arthroscopic RCR tendon-to-
bone with 1 metal suture
anchor loaded with double
sutures (TB) (n 25)
Constant Score (12
months)
(mean (range))
Small/medium/large
full-thickness
supraspinatus tear
(intact
subscapularis)
5
Pre-operative:
p-value
not given
SS: 32 (22e40) vs TB: 30 (22e38)
3 months:
p-value
not given
SS: 41 (32e52) vs TB: 46 (38e53)
6 months:
Age: (inclusion 50e65), Age: (inclusion 50e65), p-value
not given
SS: 70 (58e80) vs TB: 73 (58e83)
no further data given no further data given 12 months:
Men-women: not given Men-women: not given p < 0.05 SS: 78 (71e87) vs TB: 88 (81e94)
Duration: not given Duration: not given Peak torque e
internal rotation (%)
(12 months)
(Mean (range))
Pre-operative:
p-value
not given
SS: 34 (25e40) vs TB: 32 (27e37)
3 months:
p-value
not given
SS: 30 (26e55) vs TB: 25 (10e32)
6 months:
p-value
not given
SS: 25 (18e35) vs TB: 14 (5e20)
12 months:
p < 0.05 SS: 17 (12e30) vs TB: 9 (8 to 20)
Peak torque e
external rotation (%)
(12 months)
(mean (range))
Pre-operative:
SS: 39 (32e56) vs TB: 25 (19e32)
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 226
(continued)
Author
Type of RotCuffTears
Treatment Placebo
(n)
Control/comparison Outcome measures
(total follow-up
time)
Results e
statistical
Results
p-value
not given
3 months:
p-value
not given
SS: 34 (38e47) vs TB: 32 (26e44)
6 months:
p-value
not given
SS: 28 (22e38) vs TB: 24 (16e33)
12 months:
p < 0.05 SS: 21 (12e30) vs TB: 12 (22 to 26)
Iannotti et al., 2006 Open RCR with augmentation
with porcine small intestine
mucosa (n 15)
Open RCR without
Augmentation (n 15)
UPenn score
(average 14
months)
p 0.07 Augmentation group: 83 (81e91)
(median (interquartile range)) vs
control group: 91 (81e99)
uugmentation group: 4 of 15 vs Control
group: 9 of 15
Large/massive
chronic tear
supra- and
Infraspinatus1
Healed rotator cuff
(MRI)
p 0.11
Age: 58 (mean) Age: 57
Men-women: 11-4 Men-women: 12-3
Duration: at least 3 months Duration: at least 3 months
Abbot et al., 2009 Arthroscopic RCR, subacromial
decompression and
debridement of the type II SLAP
tears (Debrid) (n 24)
Arthroscopic RCR, subacromial
decompression and anchor
replacement and suture repair
of the type II SLAP tears
(Repair) (n 24)
UCLA (2 years) p < 0.001 From baseline to 2 years follow-up:
Concomitant
Supraspinatus
tear and type II
SLAP tears
1
Debrid*: from 17.4 (2.8) (mean (sd) to
34 (2.1) vs Repair: 17.9 (3.8)e31 (2.7)
in favour of debrid
ROM e internal
rotation (2 years)
no p-value
given
Baseline: no data given
p < 0.001 1 year: Debrid: 69.3 (11.3) (mean (sd))
vs Repair: 36.1 (23.9) in favour of
debrid
Age: 51.2 (45e60) (mean
(range))
Age: 52.6 (47e60) p < 0.001 2 years: Debrid: 69.8 (11.8) vs Repair:
37.8 (23.8) in favour of debrid
Men-women: not given Men-women: not given
Duration: not given Duration: not given
ROM e external
rotation (2 years)
no p-value
given
Baseline: no data given
p < 0.001 1 year: Debrid: 84.3 (9.8) (mean (sd))
vs Repair: 68.6 (12.8) in favour of
debrid
p < 0.001 2 years: Debrid: 84.8 (9.0) vs Repair:
69.7 (12.5) in favour of debrid
ROM e forward
exion (2 years)
no p-value
given
Baseline: no data given
p 0.05 1 year: Debrid: 166.0 (4.8) (mean (sd))
vs Repair: 161.9 (10.5)
p 0.08 2 years: Debrid: 166.5 (4.9) vs Repair:
163.1 (10.0)
Post-surgical interventions
Klintberg et al., 2009 Progressive physiotherapy (P)
after RCR (i.e. activation (active
and passive range of motion) of
the rotator cuff the day after
surgery) (n 9)
Traditional physiotherapy (T)
after RCR (i.e. 6 weeks
immobilized followed by
passive range of motion only)
(n 9)
Pain during activity
(VAS) (24 months)
Median (range)
Repaired full-
thickness
RotCufftear*
Baseline:
P and T:
p > 0.05
P: 73 (54e98) vs T: 60 (0e77) #
3 months:
P and T:
p > 0.05
P: 24 (0e66) vs T: 11 (2e52) #
6 months:
P and T:
p > 0.05
P: 28 (8e52) vs T: 7 (0e50) #
Total population: 12 months:
Age: 55 (40e64) (mean (range)) P and T:
p > 0.05
P: 10 (5e50) vs T: 7 (0e76) #
Men-women: 9-5 24 months:
Duration: nog given P:
p < 0.05;
T: p > 0.05
P: 2 (0e7) vs T: 0 (0e40) #
Pain at rest (VAS)
(24 months)
Median (range)
Baseline:
P and T:
p > 0.05
P: 27 (12e64) vs T: 4 (0e97) #
3 months:
P and T:
p > 0.05
P: 4 (0e22) vs T: 2 (0e57) #
6 months:
P and T:
p > 0.05
P: 1 (0e27) vs T: 0 (0e15) #
12 months:
(continued on next page)
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 227
(continued)
Author
Type of RotCuffTears
Treatment Placebo
(n)
Control/comparison Outcome measures
(total follow-up
time)
Results e
statistical
Results
P:
p < 0.05;
T: p > 0.05
P: 0 (0e0) vs T: 0 (0e38) #
24 months:
P:
p < 0.05;
T: p > 0.05
P: 0 (0e3) vs T: 0 (0e12) #
Constant Score, Baseline:
75 points (12
months)
no p-value
given
P: 35 (20e55) vs T: 45 (24e75) #
6 months:
no p-value
given
P: 51 (43e70) vs T: 67(21e74) #
12 months:
no p-value
given
P: 69 (57e75) vs T: 71 (45e75) #
Michael et al., 2005 Continuous passive motion
(CPM) plus physiotherapy after
RCR (n 40)
Physiotherapy alone
after RCR (n 21)
Constant score
(56 days)
no p-value
given
Treatment group: from 39 (mean)
at baseline to 69 after 56 days vs
control group: 36 at baseline to 66
after 56 days #
Repaired full-
thickness tear
of the
supraspinatus* Age: inclusion criteria: 30e70,
no further data given
Age: inclusion criteria:
30e70, no further data given
Pain during loading
(VAS) (20 days)
no p-value
given
Treatment group: from 62 (mean) at
baseline to 42 after 20 days vs control
group: 62 at Baseline to 28 after 20
days #
Men-women: not given Men-women: not given
Duration: not given Duration: not given
ROM e patient can
reach 90 degrees
active abduction
p 0.292 Treatment group: after 31 days vs
control group: after 43 days
Hayes et al., 2004 Individualised physiotherapy
after RCR (n 26)
Standardized home exercise
program after RCR (n 32)
Between groups differences (mean
(95% CI):
Complete repaired
small/ medium/
large/massive tear
ofthe rotator cuff*
ROM e exion (24
weeks)
Not
signicant
12 weeks: 5 (11 to 21)
(No p-
value
given)
24 weeks: 6 (8 to 20)
Age: 58 (10) (mean (sd)) Age: 62 (11) ROM e abduction
(24 weeks)
Not
signicant
12 weeks: 6 (12 to 24)
Men-women: 20-6 Men-women: 20-12 (No p-
value
given)
24 weeks: 12 (6 to 30)
Duration: 12 (16)
(mean (sd))
Duration: 19 (27) ROM e external
rotation (24 weeks)
Not
signicant
12 weeks: 1 (9 to 11)
(No p-
value
given)
24 weeks: 8 (0e16)
Muscle force e
internal rotation
(24 weeks)
Not
signicant
12 weeks: 0 (0e0)
(No p-
value
given)
24 weeks: 0 (0e0)
Muscle force e
external rotation
(24 weeks)
Not
signicant
12 weeks: 0 (0.5e0)
(No p-
value
given)
24 weeks: 0 (0e0)
Muscle force e
elevation
(24 weeks)
Not
signicant
12 weeks: 0 (0.5e0)
(No p-
value
given)
24 weeks: 0 (0e0)
Disability e physical
symptoms (%) (24
weeks)
Not
signicant
12 weeks: 4 (16 to 8)*
(No p-
value
given)
24 weeks: 15 (27 to 3)*
Disability e overall
shoulder status (24
weeks)
Not
signicant
12 weeks: 6 (20 to 8)*
(No p-
value
given)
24 weeks: 18 (30 to 6)*
Roddey et al., 2002 Home exercise program
using a videotape after
RCR (n 54)
Individual instruction by
a physiotherapist for a home
exercise program after RCR
(n 54)
Video group vs physio group
Repaired full-
thickness
RotCuffTear1
(Mean (SD)):
SPADI (52 weeks) p 0.06 Baseline:
60.4 (22.1) vs 52.3 (21.6)
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 228
References
Abbot AE, Li X, Busconi BD. Arthroscopic treatment of concomitant superior labral
anterior posterior (SLAP) lesions and rotator cuff tears in patients over the age
of 45 years. Am J Sports Med 2009;37:1358e62.
Adla DN, Rowsell M, Pandey R. Cost-effectiveness of open versus arthroscopic
rotator cuff repair. J Shoulder Elbow Surg 2010;19:258e61 [Epub Jul.
2009].
Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full
thickness tears of the rotator cuff: a systematic review. Br J Sports Med
2007;41:200e10.
Bigoni M, Gorla M, Guerrasio S, Brignoli A, Cossio A, Grillo P, et al. Shoulder eval-
uation with isokinetic strength testing after arthroscopic rotator cuff repairs. J
Shoulder Elbow Surg 2009;18:178e83.
Blum K, Chen AL, Chen TJ, Waite RL, Downs BW, Braverman ER, et al. Repetitive H-
wave device stimulation and program induces signicant increases in the range
of motion of post operative rotator cuff reconstruction in a double-blinded
randomized placebo controlled human study. BMC Musculoskelet Disord
2009;10:132.
Boehm TD, Werner A, Radtke S, Mueller T, Kirschner S, Gohlke F. The effect of suture
materials and techniques on the outcome of repair of the rotator cuff:
a prospective, randomised study. J Bone Jt Surg Br 2005;87:819e23.
Boutron I, Moher D, Tugwell P, Giraudeau B, Poiraudeau S, Nizard R, et al. A checklist
to evaluate a report of a nonpharmacological trial (CLEAR NPT) was developed
using consensus. J Clin Epidemiol 2005;58:1233e40.
Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain.
Cochrane Database Syst Rev 2003;(1). CD004016.
Burkhart SS. Arthroscopic treatment of massive rotator cuff tears. Clinical results
and biomechanical rationale. Clin Orthop Relat Res 1991;267:45e56.
Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of
irreparable rotator cuff tears. Arthroscopy 1994;10:363e70.
Burks RT, Crim J, Brown N, Fink B, Greis PE. A prospective randomized clinical trial
comparing arthroscopic single- and double-row rotator cuff repair: magnetic
(continued)
Author
Type of RotCuffTears
Treatment Placebo
(n)
Control/comparison Outcome measures
(total follow-up
time)
Results e
statistical
Results
p 0.17 12 weeks:
32.0 (19.7) vs 26.7 (18.8)
Age: 58.7 (10.6) (mean (sd)) Age: 57.2 (9.1) p 0.40 24 weeks:
Men-women: 36-18 Men-women: 33-21 18.1 (16.1) vs 15.3 (15.2)
Duration: not given Duration: not given p 0.99 52 weeks:
12.3 (14.2) vs 12.4 (14.4)
UPenn (52 weeks) p 0.34 baseline:
37.9 (15.7) vs 40.9 (16.3)
p 0.32 12 weeks:
62.6 (17.7) vs 66.2 (17.5)
p 0.95 24 weeks:
79.4 (15.5) vs 79.6 (17.3)
p 0.94 52 weeks:
85.6 (13.8) vs 85.9 (16.7)
Blum et al., 2009 Repetitive H-Wave Device
Stimulator (HWDS) One hour/2
days for 90 days Physiotherapy
started 8 weeks after open RCR
(n 12)
Placebo HDWS One hour/2
days for 90 days
Physiotherapy started 8 weeks
after open RCR (n 10)
ROM e External
rotation (arm at
slide) (degrees) (90
days)
Difference compared to baseline:
Repaired moderate
to severe
RottCuffTear*
45 days:
p 0.0079 HWDS: loss of 22.75 degrees vs
p 0.007 placebo: loss of 33.00 degrees #
90 days:
p 0.007 HDWS: loss of 11.67 degrees vs
p 0.007 Placebo: loss of 21.64 degrees #
Age: not given Age: not given ROM e internal
rotation (arm at 90
degrees) (degrees)
(90 days)
Difference compared to baseline:
Men-women: not given Men-women: not given 45 days:
Duration: not given Duration: not given p 0.007 HWDS: loss of 23.75 degrees vs
p 0.007 Placebo: loss of 33.00 degrees #
90 days:
p 0.006 HDWS: loss of 13.33 degrees vs
p 0.0062 Placebo: loss of 23.25 degrees #
ROM e other, i.e. Not
signicant
45 days and 90 days:
Forward elevation,
external rotation
(arm at 90 degrees),
internal rotation
(arm at slide)
No p-value
given
HDWS vs placebo: no exact data given
RotCuffTear rotator cuff tear
* instrument used to make diagnose not given
Duration duration of complaints (before surgery) in months
Small/medium/Large/Massive tear <1 cm / 1e3 cm / >3e5 cm / >5 cm
# no comparison made between the groups
RCR rotator cuff repair
RotCuffTear Rotator cuff tear
ASES American Shoulder and Elbow Surgeons
DASH Disability of the Arm, Shoulder and Hand
SRQ Shoulder Rating Questionnaire
RC-QOL rotator cuff quality of life
UCLA University of California, Los Angeles
ROM range of motion
SPADI Shoulder Pain and Disability Index
UPenn University of UPennsylvania
1
MRI used to diagnose
2
ultrasound used to diagnose
3
arthrogram used to diagnose
4
radiograph used to diagnose
5
diagnostic arthroscopy
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 229
resonance imaging and early clinical evaluation. Am J Sports Med
2009;37:674e82.
Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff
disease. Cochrane Database Syst Rev 2008;(1). CD005619.
Ejnisman B, Andreoli CV, Soares BG, Fallopa F, Peccin MS, Abdalla RJ, et al. Inter-
ventions for tears of the rotator cuff in adults. Cochrane Database Syst Rev
2004;(1). CD002758.
Feeley BT, Gallo RA, Craig EV. Cuff tear arthropathy: current trends in diagnosis and
surgical management. J Shoulder Elbow Surg 2009;18:484e94.
Franceschi F, Ruzzini L, Longo UG, Martina FM, Zobel BB, Maffulli N, et al. Equivalent
clinical results of arthroscopic single-row and double-row suture anchor repair
for rotator cuff tears: a randomized controlled trial. Am J Sports Med
2007;35:1254e60.
Furlan AD, Pennick V, Bombardier C, van Tulder M. 2009 updated method guide-
lines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa
1976) 2009;34:1929e41.
Gartsman GM, OConnor DP. Arthroscopic rotator cuff repair with and without
arthroscopic subacromial decompression: a prospective, randomized study of
one-year outcomes. J Shoulder Elbow Surg 2004;13:424e6.
Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S. Inuence of cuff
muscle fatty degeneration on anatomic and functional outcomes after simple
suture of full-thickness tears. J Shoulder Elbow Surg 2003;12:550e4.
Grasso A, Milano G, Salvatore M, Falcone G, Deriu L, Fabbriciani C. Single-row versus
double-row arthroscopic rotator cuff repair: a prospective randomized clinical
study. Arthroscopy 2009;25:4e12.
Gwilym SE, Watkins B, Cooper CD, Harvie P, Auplish S, Pollard TC, et al. Genetic
inuences in the progression of tears of the rotator cuff. J Bone Jt Surg Br
2009;91:915e7.
Hayes K, Ginn KA, Walton JR, Szomor ZL, Murrell GA. A randomised clinical trial
evaluating the efcacy of physiotherapy after rotator cuff repair. Aust J Physi-
other 2004;50:77e83.
Huisstede BM, Miedema HS, Verhagen AP, Koes BW, Verhaar JA. Multidisciplinary
consensus on the terminology and classication of complaints of the arm, neck
and/or shoulder. Occup Environ Med 2007;64:313e9.
Iannotti JP, Codsi MJ, Kwon YW, Derwin K, Ciccone J, Brems JJ. Porcine small intestine
submucosa augmentation of surgical repair of chronic two-tendon rotator cuff
tears. A randomized, controlled trial. J Bone Jt Surg Am 2006;88:1238e44.
Jensen KL, Williams Jr GR, Russell IJ, Rockwood Jr CA. Rotator cuff tear arthropathy.
J Bone Jt Surg Am 1999;81:1312e24.
Klintberg IH, Gunnarsson AC, Svantesson U, Styf J, Karlsson J. Early loading in physio-
therapy treatment after full-thickness rotator cuff repair: a prospective random-
ized pilot-study with a two-year follow-up. Clin Rehabil 2009;23:622e38.
Lastayo PC, Wright T, Jaffe R, Hartzel J. Continuous passive motion after repair of the
rotator cuff. A prospective outcome study. J Bone Jt Surg Am 1998;80:1002e11.
Maman E, Harris C, White L, Tomlinson G, Shashank M, Boynton E. Outcome of
nonoperative treatment of symptomatic rotator cuff tears monitored by
magnetic resonance imaging. J Bone Jt Surg Am 2009;91:1898e906.
Michael JW, Konig DP, Imhoff AB, Martinek V, Braun S, Hubscher M, et al. Effektivitat
der postoperativen Behandlung mittels motorisierter Bewegungsschienen
(CPM) bei Patienten mit Ruptur der Rotatorenmanschette [[Efciency of
a postoperative treatment after rotator cuff repair with a continuous passive
motion device (CPM)]]. Z Orthop Ihre Grenzgeb 2005;143:438e45.
Milano G, Grasso A, Salvatore M, Zarelli D, Deriu L, Fabbriciani C. Arthroscopic
rotator cuff repair with and without subacromial decompression: a prospective
randomized study. Arthroscopy 2007;23:81e8.
Milgrom C, Schafer M, Gilbert S, van Holsbeeck M. Rotator-cuff changes in
asymptomatic adults. The effect of age, hand dominance and gender. J Bone Jt
Surg Br 1995;77:296e8.
Mohtadi NG, Hollinshead RM, Sasyniuk TM, Fletcher JA, Chan DS, Li FX. A
randomized clinical trial comparing open to arthroscopic acromioplasty with
mini-open rotator cuff repair for full-thickness rotator cuff tears: disease-
specic quality of life outcome at an average 2-year follow-up. Am J Sports Med
2008;36:1043e51.
Moosmayer S, Lund G, Seljom U, Svege I, Hennig T, Tariq R, et al. Comparison
between surgery and physiotherapy in the treatment of small and medium-
sized tears of the rotator cuff: a randomised controlled study of 103 patients
with one-year follow-up. J Bone Jt Surg Br 2010;92:83e91.
Neer 2nd CS, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Jt Surg Am
1983;65:1232e44.
Neri BR, Chan KW, Kwon YW. Management of massive and irreparable rotator cuff
tears. J Shoulder Elbow Surg 2009;18:808e18.
Raab MG, Rzeszutko D, OConnor W, Greatting MD. Early results of continuous
passive motion after rotator cuff repair: a prospective, randomized, blinded,
controlled study. Am J Orthop 1996;25:214e20.
Roddey TS, Olson SL, Gartsman GM, Hanten WP, Cook KF. A randomized controlled
trial comparing 2 instructional approaches to home exercise instruction
following arthroscopic full-thickness rotator cuff repair surgery. J Orthop Sports
Phys Ther 2002;32:548e59.
Schaefer O, Winterer J, Lohrmann C, Laubenberger J, Reichelt A, Langer M. Magnetic
resonance imaging for supraspinatus muscle atrophy after cuff repair. Clin
Orthop Relat Res; 2002:93e9.
Schibany N, Zehetgruber H, Kainberger F, Wurnig C, Ba-Ssalamah A, Herneth AM,
et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasono-
graphic screening study. Eur J Radiol 2004;51:263e8.
Shellock FG, Bert JM, Fritts HM, Gundry CR, Easton R, Crues 3rd JV. Evaluation of the
rotator cuff and glenoid labrum using a 0.2-Tesla extremity magnetic resonance
(MR) system: MR results compared to surgical ndings. J Magn Reson Imaging
2001;14:763e70.
Shibata Y, Midorikawa K, Emoto G, Naito M. Clinical evaluation of sodium hyalur-
onate for the treatment of patients with rotator cuff tear. J Shoulder Elbow Surg
2001;10:209e16.
Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K.
Detection and quantication of rotator cuff tears. Comparison of ultrasono-
graphic, magnetic resonance imaging, and arthroscopic ndings in seventy-one
consecutive cases. J Bone Jt Surg Am 2004;86:708e16.
Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in
asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296e9.
Van Rijn RM, Huisstede BM, Koes BW, Burdorf A. Associations between work-related
factors and specic disorders of the shoulder-a systematic review of the liter-
ature. Scand J Work Environ Health 2010;36:189e201.
van Tulder M, Furlan A, Bombardier C, Bouter L. Updated method guidelines for
systematic reviews in the Cochrane collaboration back review group. Spine
2003;28:1290e9.
Vecchio PC, Adebajo AO, Hazleman BL. Suprascapular nerve block for persistent
rotator cuff lesions. J Rheumatol 1993;20:453e5.
VerhagenAP, de Vet HC, de Bie RA, Kessels AG, Boers M, Knipschild PG. Balneotherapy
andqualityassessment: interobserver reliabilityof the Maastricht criteria list and
the need for blinded quality assessment. J Clin Epidemiol 1998;51:335e41.
Watson M. Major ruptures of the rotator cuff. The results of surgical repair in 89
patients. J Bone Jt Surg Br 1985;67:618e24.
Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural
history of asymptomatic rotator cuff tears: a longitudinal analysis of asymp-
tomatic tears detected sonographically. J Shoulder Elbow Surg 2001;10:
199e203.
Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, et al.
Prevalence and risk factors of a rotator cuff tear in the general population.
J Shoulder Elbow Surg 2010;19:116e20.
Zingg PO, Jost B, Sukthankar A, Buhler M, Prrmann CW, Gerber C. Clinical and
structural outcomes of nonoperative management of massive rotator cuff tears.
J Bone Jt Surg Am 2007;89:1928e34.
B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 230