Manual Therapy 16 (2011) 217e230

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Manual Therapy
journal homepage: www.elsevier.com/math

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 a b s t r a c t

Article history: In this systematic review we assessed effectiveness of non-surgical and (post)surgical interventions for
Received 1 April 2010 symptomatic rotator cuff tears (RotCuffTear). The Cochrane Library, PubMed, Embase, Cinahl, and Pedro
Received in revised form were searched for relevant systematic reviews and randomized controlled trials (RCTs). Two reviewers
9 October 2010
independently selected relevant studies, extracted data and assessed the methodological quality.
Accepted 25 October 2010
Three Cochrane reviews (7 RCTs) and 14 RCTs were included (3 non-surgery, 10 surgery, 8 post-
surgery).
Keywords:
For small or medium RotCufftears, moderate evidence was found in favour of surgery versus
Rotator cuff
Shoulder
physiotherapy in mid- and long-term. In surgery, tendon-to-bone fixation with one metal suture
Therapy anchor loaded with double sutures (TB) was more effective (moderate evidence) than a side-to-side
Surgery 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 firm evidence-based conclusions for
effectiveness of non-surgical or (post)surgical interventions to treat RotCuffTears. More research is
clearly needed.
Ó 2010 Elsevier Ltd. Open access under the Elsevier OA license.

1. Introduction 2010). Therefore, it remains unclear which conditions convert an

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 influ-
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.,
* 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.: þ31 10 7034228; fax: þ31 10 7033843.
E-mail address: b.huisstede@erasmusmc.nl (B.M.A. Huisstede).
asymptomatic RotCuffTear into a painful symptomatic tear. On the
basis of imaging findings 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 defined (Schibany
et al., 2004).
RotCuffTears are one of the 23 specific disorders included in the
CANS model, a consensus model that describes terminology and
definition 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

1356-689X Ó 2010 Elsevier Ltd. Open access under the Elsevier OA license.
doi:10.1016/j.math.2010.10.012
218 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230
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 fulfilled 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 defi-
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).
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?
Each item was scored as “yes”, “no”, or “don’t know”. High quality
was defined 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 significance was
reported. The results of the study were labeled significant if one
of the three outcome measures (pain, function, improvement)
reported significant results. The levels of evidence for effectiveness
are ranked as follow:
1. Strong evidence: consistent* positive (significant) findings
within multiple high-quality RCTs.
2. Moderate evidence: consistent positive (significant) findings
within multiple low-quality RCTs and/or one high-quality RCT.
3. Limited evidence: positive (significant) findings within one
low-quality RCT.
4. Conflicting evidence: provided by conflicting (significant)
findings in the RCTs (<75% of the studies reported consistent
findings)
5. No evidence: RCT(s) available, but no (significant) differ-
ences between intervention and control groups were
reported.
6. No systematic review or RCT found.
*When 75% of the trials report the same findings.
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
 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230
SEARCH
Cochrane PubMed Embase
Potential relevant articles identified: reviews: 6 / RCTs: 364
Articles retrieved for more detailed
evaluation: reviews: 6 / RCTs: 29
Appropriate articles included:
reviews: 3 / RCTs: 14
Fig. 1. Flowchart of the literature search.
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
219
Cinahl Pedro
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
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 significant 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 ¼ 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
220 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230

Table 2
Methodological quality scores of the included RCTs and RCTs included in the Cochrane reviews.

Reference 1. Adequate 2. Allocation 3. 4. 5. 6. 7. 8. Free of 9. Similarity 10.

randomization? concealment? Blinding? Blinding? Blinding? Incomplete Incomplete Suggestions of of baseline Co-interventions
Patients? Caregiver? Outcome outcome outcome selective characteristics? avoided or
assessors? data data? outcome similar?
addressed? ITT reporting?
Drop-outs? analysis?
Included recent and additional RCTsa:
Moosmayer et al. (2010) þ þ e e þ þ þ þ þ e
Milano et al. (2007) þ þ ? e ? þ e þ þ þ
Mohtadi et al. (2008) þ þ e e þ þ e þ þ þ
Hayes et al. (2004) þ ? þ e þ þ e þ þ ?
Michael et al. (2005) þ þ þ e þ þ e þ ? ?
Bigoni et al. (2009) þ ? ? e þ þ þ þ ? ?
Burks et al. (2009) þ ? ? e þ þ þ þ ? ?
Franceschi et al. (2007) þ ? ? e ? þ þ þ ? þ
Iannotti et al. (2006) þ ? ? e þ þ e þ þ e
Abbot et al. (2009) þ ? ? e þ e ? þ ? ?
Grasso et al. (2009) þ þ ? e ? þ e þ ? ?
Blum et al. (2009) e e þ e e þ þ e ? ?
Klintberg et al. (2009) þ þ e e ? e e þ ? ?
Roddey et al. (2002) þ ? e e ? e e þ þ ?
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) ? ? ? þ# þ

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) þ ? þ ? þ# ?
Gartsman and O’Connor þ ? þ ? ?# þ
(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. þ: 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-specific modification 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 (þ: 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.

dexamethasone versus placebo in 13 patients with a persistent 3.7. Effectiveness of surgery

rotator cuff lesion. At 12-weeks follow-up, night pain and pain with
movement, and active abduction, flexion 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
A high-quality study (Moosmayer et al., 2010) (n ¼ 103) studied the
effectiveness of surgery (mini-open or open rotator cuff repair INS>
(RCR)) versus physiotherapy (exercise therapy) and found significant
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 significant differences
between the groups were found in favour of surgery at 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.
3.7.1. 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 O’Connor, 2004; Boehm et al., 2005) reported on
interventions for RotCuffTear. A low-quality RCT (Boehm et al.,
2005) (n ¼ 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 modified Mason Allen sutures was compared to
an open RCR with 1.0 mm absorbable polydioxane cord using
modified Kessler sutures. No significant 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 O’Connor, 2004)
(n ¼ 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.
 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 221

11. 12. Timing of In and exclusion Interventions Outcome Diagnostic Surveillance Score Score % Quality
Compliance the outcome criteria clearly clearly measures tests active and max study of the study
acceptable in assessment defined? defined? clearly useful? appropriate?
all groups? similar? defined?

? þ 12 8 67 High
n.a. þ 11 7 64 High
n.a. e 11 7 64 High
e þ 12 7 58 High
? e 12 6 50 High
n.a. þ 11 6 55 High
n.a. þ 11 6 55 High
n.a. e 11 5 45 Low
n.a. e 11 5 45 Low
n.a. þ 11 4 36 Low
n.a. e 11 4 36 Low
? þ 12 4 33 Low
? þ 12 4 33 Low
e þ 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

3.7.2. Recent RCTs
Eight recent RCTs on surgery were found.
A high-quality study (Milano et al., 2007) (n ¼ 80) studied
arthroscopic RCR with and without subacromial decompression.
Similar to the results reported by Gartsman and O’Connor (2004),
no significant 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 significant differences
between the groups were found at 3 and 6-months and 1 and 2-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 significant differences between the groups were
found on the Constant Score, strength or the DASH.
Another low-quality study (Franceschi et al., 2007) (n ¼ 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 significant differences on the UCLA scores, rates of
healing or MRI arthrography were found.
A third high-quality study (Burks et al., 2009) (n ¼ 40) that
compared the effectiveness of single-row versus double-row
anchors in full-thickness arthroscopic RCR did not find significant
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 ¼ 50) studied side-
to-side with permanent sutures (SS) versus tendon-to-bone fixation
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 significant results on the
Constant score and internal and external rotator peak torque
were found at 3- and 6-months follow up. At 12-months follow-up,
significant results between the groups in favour of TB on the
Constant Score and in favour of SS on the strength scores were found.
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 significant). No significant
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 ¼ 24) was treated with arhroscopic RCR, subacromial
decompression and debridement of their type II SLAP tears (Debrid)
and the other group (n ¼ 24) with arthroscopic RCR, subacromial
decompression anchor replacement and suture repair of their type
II SLAP tears (Repair). After 2 years significant better results were
found in favour of the Debrid group on the UCLA score. Also
significant 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 flexion.
We conclude that there is moderate evidence for effectiveness in
favour of tendon-to-bone fixation with 1 metal suture anchor loaded
222 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230

Table 3
CANS: evidence for effectiveness of interventions for the rotator cuff tear.

Physiotherapy Non-surgical treatment Surgical treatment

Oral Injection Other non-surgical

treatment
Non-surgery vs surgery X Intra-articular corticosteroid Suprascapular nerve block Surgery:
injections compared:
<Physiotherapy (exercise < Corticosteroid vs < Suprascapular nerve block with In open RCR:
therapy) vs surgerya: Hyaluronate: dexamethosone vs placebo:
Mid-term: þþ Short-term (4 weeks): NE Short-term: NE < Use of Ethibond vs PDS:
Long-term: þþ 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: þþ
< Debrid* vs Repair
Long-term: þ
< 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; þ: limited evidence found; þþ: 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 fixation
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.

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
compared to anchor replacement and suture 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 review of 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 ¼ 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 significant differences between the interventions on the
outcome ‘no improvement on pain’.
Another high-quality RCT (Watson, 1985) (n ¼ 89) studied RCR
and splinting in abduction versus RCR resting the arm at the side.
Only the outcome ‘poor response’ was studied and no significant
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 significant 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
 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230
the CPM plus physiotherapy group compared to 43 days in the
physiotherapy alone group (p ¼ 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 significant 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 (Blum et al., 2009) studied the effectiveness of
Repetitive H-Wave device stimulation (HWDS) versus placebo
HWDS and found significant 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
significant 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 found no evidence for the effectiveness of splinting
in abduction versus resting the arm at 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 review of Ainsworth and Lewis (2007) focused on
exercise therapy in the management of full-thickness RotCuffTears.
Only observation studies were included and, similar to the findings
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 benefit, no firm 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
223
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 significant 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. Defining 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 benefit 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 difficult to understand. First, tendinitis and bursitis of the
shoulder are difficult 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 specificity of 67e89% compared with findings at arthroscopy.
(Shellock et al., 2001; Teefey et al., 2004), although, as stated before,
on the basis 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 definite 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 influence the decrease of shoulder
function in patients with a RotCuffTear. Both atrophy and fatty
infiltration (identifying degenerative changes) are reported to give
poor prognosis for the return of rotator cuff function in these patients
(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 difficult to make an appropriate selec-
tion of patients who may (or may not) benefit 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
infiltration of the rotator cuff muscle(s). According to Zingg et al.
224 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230

(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 field of musculoskeletal disorders
when statistical pooling is not feasible or clinically viable (van
Tulder et al., 2003).
Secondly, for the included recent and additional 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 confirmed they were associated with bias. This list is
constructed to assess interventions in the field of neck and back
disorders, but can also be used and appears very suitable in other
fields (Verhagen et al., 1998; Boutron et al., 2005). Thirdly, we
adopted the quality score and definition 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 significant
results, our final 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
fixation 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 firm 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 definitely needed. Future large-scale studies should also
concentrate on prognostic factors and on subgroup analyses with
regard to the different types of RotCuffTears.
Conflict of Intrest
There are no conflicts 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. Treatment Placebo Control/comparison Outcome measures Effect size
of patients (n) (n) (total follow-up time)
Corticosteroid injections
Buchbinder 78 Intra-articular steroid Intra-articular Satisfaction treatment RR 0.89 (95% CI 0.52e1.54)
et al., 2003 injection (n ¼ 40) hyaluronate (4 weeks)
injections (n ¼ 38)
1 RCT (out of 26
RCTs)a
Suprascapulair nerve block
Ejnisman Dexamethasone suprascapular (n: Night pain (VAS) Treatment: 2.2 (1.8) (mean change
et al., 2004 nerve block (n: unclear) unclear) (12 weeks) (SE)) vs placebo: 1 (0.7)d
1 RCT (out of 8 Movement pain (VAS) Treatment: 4 (0.6) (mean change (SE))
RCTs)b (12 weeks) vs placebo: 0.3 (0.4)
ROM e active abduction Treatment: 28 (21) (mean change (SE)) vs
(degrees) (12 weeks) placebo: 8 (8)d
ROM e active flexion Treatment: 2 (23) (mean change (SE)) vs
(degrees) (12 weeks) placebo: 22 (9)d
ROM e active external Treatment: 11 (8) (mean change (SE)) vs
rotation (degrees) placebo: 2 (3)d
(12 weeks)
Surgery
Coghlan et al., 191 (out Open repair of rotator Open repair of
2008 of 829) cuff using rotator cuff
2 RCTs (out of polydioxane suture using Ethibond
14 RCTs)c suture
n ¼ 40/48 n ¼ 41/50 Outcome rated as good or RR 1.02 (95% CI 0.85e1.22)
excellent (2 years)
n ¼ 18/44 n ¼ 11/49 Rate of re-tear RR 1.82 (95% CI 0.97e3.42)
(on sonography, 2 years)
n ¼ 40/44 n ¼ 45/49 Constant score > 75 RR 0.99 (95% CI 0.87e1.12)
(follow-up time not
reported)

RCT: randomized clinical trial; n: number ; RR: relative risk; CI; confidence 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 225

Appendix 1B

Data extraction e RCTs of rotator cuff tear.

Author Treatment Placebo Control/comparison Outcome measures Results e Results
Type of RotCuffTears (n) (total follow-up statistical
time)
Non-surgery vs surgery
Moosmayer et al., Surgery (standard, i.e. mini- Physiotherapy (12 weeks 2x/ Constant score Between group differences:
2010 open or open tendon repair) week, followed by 6e12 (12 months)
Small and medium- (n ¼ 52) weeks with increased 6 months:
sized RotCuffTears intervals of exercise therapy) NS No exact data given
1
and 2 (n ¼ 51) 12 months:
p ¼ 0.002 13.0 (95% CI 4.9e21.1) in favour
ASES score Between group differences:
(12 months)
Age: 59 (44e75) (mean (range)) Age: 61 (46e75) 6 months:
Men-women: 37e15 Men-women; 36e15 p ¼ 0.005 11.4 (95% CI 3.6e19.1) in favour of
surgery
Duration: 12.3 (18.7) (mean Duration: 9.8 (9.8) 12 months:
(sd))
p < 0.0005 16.1 (95% CI 8.2e23.9) in favour of
surgery
Surgery
Milano et al., 2007 Arthroscopic RCR with Arthroscopic RCR without Constant score (2 Not 103.6 vs 96.1
subacromial decompression subacromial decompression years) significant
Full-thickness (n ¼ 40) (n ¼ 40) (p-value
RotCuffTear1 and not given)
type 2 or 3 DASH score (2 Not 18.2 vs 23.1
acromion 4 years) significant
(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 ¼ 30) Arthroscopic acromio-plasty ASES score (2 years) Baseline:
Small/Medium/ with mini-open Repair p ¼ 0.25 48.2 (40.7e55.6) (mean 95% CI) vs 53.8
Large/Massive (n ¼ 32) (47.1e60.5)
full-thickness 3 months follow-up:
RotCuffTear 1 or 2 Age: 56.2 (44e77) (mean Age: 57.0 (33e82) p ¼ 0.48 61.8 (54.8e68.7) vs 71.7 (64.4e79.1)
or 3 (range))
Men-women: 22-8 Men-women: 20-13 6 months follow-up:
Duration: not given Duration: not given p ¼ 0.16 68.9 (61.7e76.1) vs 80.7 (74.2e87.3)
1 year follow-up:
p ¼ 0.84 85.2 (79.5e90.9) vs 86.1 (79.9e92.2)
2 years follow-up:
p ¼ 0.49 87.5 (81.9e93.1) vs 89.9 (85.4e94.4)
SRQ score (2 years) Baseline:
p ¼ 0.33 46.7 (41.3e52.1) (mean 95% CI) vs 50.3
(45.2e55.4)
3 months follow-up:
p ¼ 0.17 63.3 (57.5e69.1) vs 69.4 (62.6e76.3)
6 months follow-up:
p ¼ 0.10 73.6 (68.2e79.1) vs 79.8 (74.7e84.9)
1 year follow-up:
p ¼ 0.59 83.4 (78.1e88.8) vs 85.2 (81.2e89.2)
2 years follow-up:
p ¼ 0.81 85.1 (80.2e90.1) vs 85.9 (81.7e90.0)
RC-QOL Baseline to 3 months:
p ¼ 0.5 13.9 (5.9e21.9) MD (95% CI) vs 25.4
(16.5e34.3)
Baseline to 6 months:
p ¼ 0.81 33.3 (23.9e42.7) vs 34.9 (25.5e44.3)
Baseline to 1 year:
p ¼ 0.91 43.7 (37.4e50.1) vs 44.3 (36.3e52.4)
Baseline to 2 year:
p ¼ 0.43 45.6 (39.9e51.2) vs 41.5 (32.7e50.2)
Grasso et al., 2009 Arthroscopic RCR with single Arthroscopic RCR with Constant Score p ¼ 0.378 Single row: 100.5 (17.8) (mean (sd)) vs
row anchor (n ¼ 40) double row anchor double row: 104.9 (21.8)
(n ¼ 40)
Full-thickness Mean follow-up (95% CI 13.695 to 5.267))
RotCuffTear1 24.8 (1.4) mean (sd)
months
Muscle strength (lb) p ¼ 0.382 Single row: 12.7 (5.7) (mean (sd)) vs
Age: 58.3 (10.3) (mean (sd)) Age: 55.2 (6.5) double row: 12.9 (7.0)
Men-women: 16-21 Men-women: 18-17 (95% CI 13.695 to 5.267))
(continued on next page)
226 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230

(continued )

Author Treatment Placebo Control/comparison Outcome measures Results e Results

Type of RotCuffTears (n) (total follow-up statistical
time)
Mean follow-up
24.8 (1.4) mean (sd)
months
Duration: not given Duration: not given DASH questionnaire p ¼ 0.482 Single row: 15.4 (15.6) (mean (sd)) vs
Mean follow-up double row: 12.7 (10.1)
24.8 (1.4) mean (sd) (95% CI 4.057 to 8.512)
months
Franceschi et al., Arthroscopic RCR with single- Arthroscopic RCT with double- UCLA shoulder score (range)) pre-operative to 32.9 (29e35)
2007 row anchor (n ¼ 30) row anchor (n ¼ 30) (2 years) post-operative vs dubble-row: 10.1 (5
e14) pre-operative to 33.3 (30e35)
post-operative
Large/massive full- Age: 63.5 (43e76) (mean Age: 59.6 (45e80) ROM e forward p > 0.06 Single row: 110 (30e140) (mean
thickness tear1 of (range)) flexion (degrees) (2 (range)) pre-operative to 159 (150
the supraspinatur, Men-women: 12-14 Men-women: 16-10 years) e170) post-operative vs dubble-row:
infraspinatus or Duration: at least 3 months Duration: at least 3 months 100 (30e150) pre-operative to 156
subscapularis1 (140e170) post-operative
and 4
ROM e external p > 0.05 Single row: 83.2 (65e95) (mean
rotation (2 years) (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 p > 0.05 Single row: 27.3 (20e33) (mean
rotation (2 years) (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 p > 0.05 Single-row 10 vs double-row 7
defect
Full-thickness p > 0.05 Single-row 2 vs double-row 1
defect
Burks et al., 2009 Arthroscopic RCR with single- Arthroscopic RCR with Pre-operative (mean (sd)) to 1 year
row anchor (n ¼ 20) double-row anchor (n ¼ 20) follow-up:
Full-thickness Age: 56 (43e74) (mean (range)) Age: 57 (41e81) Constant Score (1 p ¼ 0.980 Single-row: 44.1 (18.8)e77.8 (9.0) vs
RotCufftear (no year) double-row: 45.6 (20.3)e74.4 (18.4)
significant Men-women: not given Men-women: not given ASES (1 year) p ¼ 0.673 Single-row: 41.0 (21.5)e85.9 (14.0) vs
subscapularis Duration (total population): 16.8 double-row: 37.6 (19.3)e85.5 (20.0)
tear)1 (1 weeke12 years)
UCLA (1year) p ¼ 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 p ¼ 0.862 Single-row: 8.7 (4.6)e17.2 (7.7) vs
rotation (N.m) double-row: 9.6 (6.0)e16.7 (7.5)
Strength e internal p ¼ 0.687 Single-row: 15.8 (7.9)e28.1 (13.8) vs
rotation (N.m) double-row: 18.1 (11.6)e28.8 (14.4)
Bigoni et al., 2009 Arthroscopic RCR side-to-side Arthroscopic RCR tendon-to- Constant Score (12 (mean (range))
Small/medium/large with permanent sutures (SS) bone with 1 metal suture months) Pre-operative:
full-thickness (n ¼ 25) anchor loaded with double p-value SS: 32 (22e40) vs TB: 30 (22e38)
supraspinatus tear sutures (TB) (n ¼ 25) not given
(intact 3 months:
subscapularis)5 p-value SS: 41 (32e52) vs TB: 46 (38e53)
not given
6 months:
Age: (inclusion 50e65), Age: (inclusion 50e65), p-value SS: 70 (58e80) vs TB: 73 (58e83)
not given
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 (Mean (range))
internal rotation (%) Pre-operative:
(12 months) p-value SS: 34 (25e40) vs TB: 32 (27e37)
not given
3 months:
p-value SS: 30 (26e55) vs TB: 25 (10e32)
not given
6 months:
p-value SS: 25 (18e35) vs TB: 14 (5e20)
not given
12 months:
p < 0.05 SS: 17 (12e30) vs TB: 9 (8 to 20)
Peak torque e (mean (range))
external rotation (%) Pre-operative:
(12 months) SS: 39 (32e56) vs TB: 25 (19e32)
 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 227

(continued )

Author Treatment Placebo Control/comparison Outcome measures Results e Results

Type of RotCuffTears (n) (total follow-up statistical
time)
p-value
not given
3 months:
p-value SS: 34 (38e47) vs TB: 32 (26e44)
not given
6 months:
p-value SS: 28 (22e38) vs TB: 24 (16e33)
not given
12 months:
p < 0.05 SS: 21 (12e30) vs TB: 12 (22 to 26)
Iannotti et al., 2006 Open RCR with augmentation Open RCR without UPenn score p ¼ 0.07 Augmentation group: 83 (81e91)
Large/massive with porcine small intestine Augmentation (n ¼ 15) (average 14 (median (interquartile range)) vs
chronic tear mucosa (n ¼ 15) months) control group: 91 (81e99)
supra- and Healed rotator cuff p ¼ 0.11 uugmentation group: 4 of 15 vs Control
Infraspinatus1 Age: 58 (mean) Age: 57 (MRI) group: 9 of 15
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 Arthroscopic RCR, subacromial UCLA (2 years) p < 0.001 From baseline to 2 years follow-up:
Concomitant decompression and decompression and anchor Debrid*: from 17.4 (2.8) (mean (sd) to
Supraspinatus debridement of the type II SLAP replacement and suture repair 34 (2.1) vs Repair: 17.9 (3.8)e31 (2.7)
tear and type II tears (Debrid) (n ¼ 24) of the type II SLAP tears in favour of debrid
SLAP tears1 (Repair) (n ¼ 24) ROM e internal no p-value Baseline: no data given
rotation (2 years) 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 Age: 52.6 (47e60) p < 0.001 2 years: Debrid: 69.8 (11.8) vs Repair:
(range)) 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 no p-value Baseline: no data given
rotation (2 years) 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 no p-value Baseline: no data given
flexion (2 years) given
p ¼ 0.05 1 year: Debrid: 166.0 (4.8) (mean (sd))
vs Repair: 161.9 (10.5)
p ¼ 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) Traditional physiotherapy (T) Pain during activity Median (range)
Repaired full- after RCR (i.e. activation (active after RCR (i.e. 6 weeks (VAS) (24 months) Baseline:
thickness and passive range of motion) of immobilized followed by P and T: P: 73 (54e98) vs T: 60 (0e77) #
RotCufftear* the rotator cuff the day after passive range of motion only) p > 0.05
surgery) (n ¼ 9) (n ¼ 9) 3 months:
P and T: P: 24 (0e66) vs T: 11 (2e52) #
p > 0.05
6 months:
P and T: P: 28 (8e52) vs T: 7 (0e50) #
p > 0.05
Total population: 12 months:
Age: 55 (40e64) (mean (range)) P and T: P: 10 (5e50) vs T: 7 (0e76) #
p > 0.05
Men-women: 9-5 24 months:
Duration: nog given P: P: 2 (0e7) vs T: 0 (0e40) #
p < 0.05;
T: p > 0.05
Pain at rest (VAS) Median (range)
(24 months) Baseline:
P and T: P: 27 (12e64) vs T: 4 (0e97) #
p > 0.05
3 months:
P and T: P: 4 (0e22) vs T: 2 (0e57) #
p > 0.05
6 months:
P and T: P: 1 (0e27) vs T: 0 (0e15) #
p > 0.05
12 months:
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(continued )

Author Treatment Placebo Control/comparison Outcome measures Results e Results

Type of RotCuffTears (n) (total follow-up statistical
time)
P: P: 0 (0e0) vs T: 0 (0e38) #
p < 0.05;
T: p > 0.05
24 months:
P: P: 0 (0e3) vs T: 0 (0e12) #
p < 0.05;
T: p > 0.05
Constant Score, Baseline:
75 points (12 no p-value P: 35 (20e55) vs T: 45 (24e75) #
months) given
6 months:
no p-value P: 51 (43e70) vs T: 67(21e74) #
given
12 months:
no p-value P: 69 (57e75) vs T: 71 (45e75) #
given
Michael et al., 2005 Continuous passive motion Physiotherapy alone Constant score no p-value Treatment group: from 39 (mean)
Repaired full- (CPM) plus physiotherapy after after RCR (n ¼ 21) (56 days) given at baseline to 69 after 56 days vs
thickness tear RCR (n ¼ 40) control group: 36 at baseline to 66
of the after 56 days #
supraspinatus* Age: inclusion criteria: 30e70, Age: inclusion criteria: Pain during loading no p-value Treatment group: from 62 (mean) at
no further data given 30e70, no further data given (VAS) (20 days) given baseline to 42 after 20 days vs control
Men-women: not given Men-women: not given group: 62 at Baseline to 28 after 20
Duration: not given Duration: not given days #
ROM e patient can p ¼ 0.292 Treatment group: after 31 days vs
reach 90 degrees control group: after 43 days
active abduction
Hayes et al., 2004 Individualised physiotherapy Standardized home exercise Between groups differences (mean
after RCR (n ¼ 26) program after RCR (n ¼ 32) (95% CI):
Complete repaired ROM e flexion (24 Not 12 weeks: 5 (11 to 21)
small/ medium/ weeks) significant
large/massive tear (No p- 24 weeks: 6 (8 to 20)
ofthe rotator cuff* value
given)
Age: 58 (10) (mean (sd)) Age: 62 (11) ROM e abduction Not 12 weeks: 6 (12 to 24)
(24 weeks) significant
Men-women: 20-6 Men-women: 20-12 (No p- 24 weeks: 12 (6 to 30)
value
given)
Duration: 12 (16) Duration: 19 (27) ROM e external Not 12 weeks: 1 (9 to 11)
(mean (sd)) rotation (24 weeks) significant
(No p- 24 weeks: 8 (0e16)
value
given)
Muscle force e Not 12 weeks: 0 (0e0)
internal rotation significant
(24 weeks) (No p- 24 weeks: 0 (0e0)
value
given)
Muscle force e Not 12 weeks: 0 (0.5e0)
external rotation significant
(24 weeks) (No p- 24 weeks: 0 (0e0)
value
given)
Muscle force e Not 12 weeks: 0 (0.5e0)
elevation significant
(24 weeks) (No p- 24 weeks: 0 (0e0)
value
given)
Disability e physical Not 12 weeks: 4 (16 to 8)*
symptoms (%) (24 significant
weeks) (No p- 24 weeks: 15 (27 to 3)*
value
given)
Disability e overall Not 12 weeks: 6 (20 to 8)*
shoulder status (24 significant
weeks) (No p- 24 weeks: 18 (30 to 6)*
value
given)
Roddey et al., 2002 Home exercise program Individual instruction by Video group vs physio group
Repaired full- using a videotape after a physiotherapist for a home (Mean (SD)):
thickness RCR (n ¼ 54) exercise program after RCR SPADI (52 weeks) p ¼ 0.06 Baseline:
RotCuffTear1 (n ¼ 54) 60.4 (22.1) vs 52.3 (21.6)
 B.M.A. Huisstede et al. / Manual Therapy 16 (2011) 217e230 229

(continued )

Author Treatment Placebo Control/comparison Outcome measures Results e Results

Type of RotCuffTears (n) (total follow-up statistical
time)
p ¼ 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 ¼ 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 ¼ 0.99 52 weeks:
12.3 (14.2) vs 12.4 (14.4)
UPenn (52 weeks) p ¼ 0.34 baseline:
37.9 (15.7) vs 40.9 (16.3)
p ¼ 0.32 12 weeks:
62.6 (17.7) vs 66.2 (17.5)
p ¼ 0.95 24 weeks:
79.4 (15.5) vs 79.6 (17.3)
p ¼ 0.94 52 weeks:
85.6 (13.8) vs 85.9 (16.7)
Blum et al., 2009 Repetitive H-Wave Device Placebo HDWS One hour/2 ROM e External Difference compared to baseline:
Repaired moderate Stimulator (HWDS) One hour/2 days for 90 days rotation (arm at 45 days:
to severe days for 90 days Physiotherapy Physiotherapy started 8 weeks slide) (degrees) (90 p ¼ 0.0079 HWDS: loss of 22.75 degrees vs
RottCuffTear* started 8 weeks after open RCR after open RCR (n ¼ 10) days) p ¼ 0.007 placebo: loss of 33.00 degrees #
(n ¼ 12) 90 days:
p ¼ 0.007 HDWS: loss of 11.67 degrees vs
p ¼ 0.007 Placebo: loss of 21.64 degrees #
Age: not given Age: not given ROM e internal Difference compared to baseline:
Men-women: not given Men-women: not given rotation (arm at 90 45 days:
Duration: not given Duration: not given degrees) (degrees) p ¼ 0.007 HWDS: loss of 23.75 degrees vs
(90 days) p ¼ 0.007 Placebo: loss of 33.00 degrees #
90 days:
p ¼ 0.006 HDWS: loss of 13.33 degrees vs
p ¼ 0.0062 Placebo: loss of 23.25 degrees #
ROM e other, i.e. Not 45 days and 90 days:
significant
Forward elevation, No p-value HDWS vs placebo: no exact data given
external rotation given
(arm at 90 degrees),
internal rotation
(arm at slide)

RotCuffTear ¼ rotator cuff tear

* ¼ instrument used to make diagnose not given
Duration ¼ duration of complaints (before surgery) in months
Small/medium/Large/Massive tear ¼ <1 cm / 1e3 cm / >3e5 cm / >5 cm
# ¼ no comparison made between the groups
RCR ¼ rotator cuff repair
RotCuffTear ¼ Rotator cuff tear
ASES ¼ American Shoulder and Elbow Surgeons
DASH ¼ Disability of the Arm, Shoulder and Hand
SRQ ¼ Shoulder Rating Questionnaire
RC-QOL ¼ rotator cuff quality of life
UCLA ¼ University of California, Los Angeles
ROM ¼ range of motion
SPADI ¼ Shoulder Pain and Disability Index
UPenn ¼ University of UPennsylvania
1
¼ MRI used to diagnose
2
¼ ultrasound used to diagnose
3
¼ arthrogram used to diagnose
4
¼ radiograph used to diagnose
5
¼diagnostic arthroscopy

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