Curr Orthop Pract. 2016;27(3):281-290.
Rotator cuff pathology is a major contributor to shoulder dysfunction, particularly in the elderly population. Elderly individuals have shown an increasing desire to remain physically active and have high expectations of treatment. The ideal method to provide pain relief and restore function is controversial, with some surgeons advocating conservative measures and others preferring surgical management. The purpose of this article was to highlight the factors that influence decisionmaking when treating elderly individuals with rotator cuff pathology. Current treatment recommendations with their reported clinical outcomes and possible future developments are discussed.
Rotator cuff pathology is a major contributor to shoulder dysfunction, particularly in the elderly population.[1,2] This elderly population (persons 65 yr of age and older) represented approximately 45 million of the U.S. population in the year 2013, which accounted for about one in every seven Americans.[3,4] More than 20% of the elderly population has a full-thickness rotator cuff tear, of which more than a third will clinically manifest.[5,6] This represents approximately 9 million elderly U.S. residents with a full-thickness rotator cuff tear, of which at least 3 million will be symptomatic over time. Due to an aging population and the increasing prevalence of rotator cuff tears with age, the total number of patients with shoulder dysfunction is expected to rise even more in the future.[7,8]
The importance of physical activity in maintaining health and function has been highlighted in the context of ''aging successfully''.[8,9] Moreover, individuals have an increasing desire to remain physically active and have high expectations of returning to high levels of function after treatment. However, the ideal treatment method that provides both pain relief and restores function in elderly individuals is controversial; some surgeons advocate conservative treatment and others support surgical management. In the context of rotator cuff tear in ''the elderly'', it is often stated that patients must be ''appropriately or carefully selected'' for successful treatment outcome.[10,11] However, how is ''appropriately or carefully selected'' defined? The purpose of this article was to highlight key factors to be considered in decision-making when treating elderly individuals with rotator cuff pathology. Furthermore, suggested treatment options with their reported clinical outcomes and possible future developments are discussed.
The etiology of rotator cuff tear in an elderly person is often very different from that of a younger individual.[12] In elderly people, the pathogenesis usually is degenerative, resulting from overuse and progressive tendinopathy. Most are atraumatic in onset. Additionally, elderly patients tend to have more severe tears, in terms of tear size, when compared to younger patients and tend to have tears with less capability for healing and higher degrees of muscle atrophy and fatty infiltration.[13] Gumina et al.[13] found that patients older than 60 yr old were twice as likely to experience a large tear and three times as likely to experience a massive tear compared to younger subjects.
The authors of a recent study concluded that ''rotator cuff tears in senior athletes are often not painful and may not need to be repaired for successful participation in athletics.''[14] However, in the elderly population, there is also a high prevalence of asymptomatic partial and full-thickness tears that progress into symptomatic tears, even without specific inciting incidents. Patients over the age of 70 with asymptomatic rotator cuff tear have a 50% risk of developing symptoms at a mean of 3 yr after diagnosis.[15] A major challenge is, therefore, to identify the patients who will progress and will need treatment for rotator cuff tear, so that patients will ultimately benefit from the appropriate treatment path.[7]
Regardless of whether rotator cuff tears are symptomatic or asymptomatic, patients with full-thickness tears have significantly reduced shoulder function compared to patients without tears.[2] Correspondingly, activities of daily living are significantly impaired in patients with untreated, symptomatic rotator cuff tear.[5] In addition, the degenerative process of the rotator cuff progresses more in patients with nonreconstructed, full-thickness tears.[16,17]
Comorbid conditions are more common in elderly patients as is referred pain. It is particularly important in elderly patients to fully assess the cervical spine to exclude referred pain from cervical spondylosis, radiculopathy, or stenosis.[18]A careful examination of the shoulder will usually lead to the correct diagnosis.[19] Additional confirmatory imaging studies, such as plain radiographs with anteroposterior, axillary, and outlet views, as well as MRIs should be obtained to rule out other pathology and confirm the diagnosis (Figures 1 and 2). Plain radiographs in patients with rotator cuff tear may show degenerative changes at the tuberosity and the acromion, calcific tendinitis, or superior migration of the humeral head, with secondary arthropathy seen in advanced cases. Furthermore, larger critical shoulder angles (>35 degrees) are associated with rotator cuff tears.[20,21] MRI provides a detailed view of the rotator cuff tendons and allows for characterization of tear chronicity, retraction, muscle atrophy, lamellar dissection, and fatty infiltration.
The goal of treatment is to restore the functional capacity and reduce or eliminate pain. Acute rotator cuff tear in the setting of trauma should often be treated surgically, but a trial of conservative treatment may be warranted when acute-onchronic tears occur or when other comorbid factors are considered. Conservative management is typically suggested as the initial treatment for most chronic tears in elderly patients. This usually consists of a combination of physical therapy, antiinflammatory medications, and local corticosteroid injections. Physical therapy involves exercises directed at pain control, improving range of motion, and strengthening of the periscapular muscles, with recommendations varying from 3–18mo.[30] The typical minimum physical therapy program is 6–12wk, and the last phase of strengthening can be carried out until the desired results are achieved.[31] Based on experience, the senior author recommends a trial of 6–12wk of physical therapy to evaluate if this option can provide satisfactory results for the patient. If there is no improvement in function or if there is continued pain, then surgery can be considered. Also, if the patient deteriorates significantly or is dissatisfied with the physical therapy program, then surgery can be considered.
In 2007, Ainsworth and Lewis[30] published a systematic review looking at exercise therapy for full-thickness tears in the elderly and found that there was some evidence supporting its use with therapy providing relief in some cases. However, they concluded that there is the definite need for well-planned, prospective, randomized controlled trials comparing surgical and conservative treatment for full-thickness tears. The short-term results of two such studies have recently been published.[31–33] Kukkonen et al.[33] randomly allocated 180 shoulders with symptomatic full-thickness tears to three different treatment groups and concluded ''that at 1-year follow-up, operative treatment is no better than conservative treatment with regard to nontraumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.'' In a similar study, Heerspink et al.[32] found no difference in Constant-Murley Score and Dutch Simple Shoulder Test 1 yr after treatment after randomly treating degenerative full-thickness rotator cuff tears by either conservative protocol or surgery.[32] However, the study also found that surgical treatment resulted in significant improvements in pain on visual analog scale and disability scores compared to conservative treatment.
These short-term results after conservative treatment are encouraging but must be interpreted cautiously, as an unrepaired rotator cuff tear continues to undergo degeneration with atrophy and fatty infiltration, which can become irreversible.[17,22–24] Thus, more studies on the mid-term to long-term outcomes after conservative treatment for large full-thickness rotator cuff tears are needed to consider the consequences of factors such as muscle atrophy, fatty infiltration, and cuff tear arthropathy. A recent study comparing 5-year results of surgical with conservative treatment of small and medium-sized rotator cuff tears found repair to be associated with better outcomes than physiotherapy (PT).[34] In the PT group, tear size increased, and this was accompanied by inferior outcomes in one-third of the patients. Although presently there are comparable short-term outcomes with repair and conservative management, this may come at the cost of an increased incidence of rotator cuff tear arthropathy in 5–10 yr.
Before the era of arthroscopy, open rotator cuff repair was the gold standard for symptomatic, full-thickness rotator cuff tears, and this treatment has been shown to be beneficial in patients aged 65 yr and older.[35,36]
Currently, arthroscopic rotator cuff repair is preferred because of the better visualization, less injury to the deltoid, and lower complications. Arthroscopic debridement, without repair, combined with biceps tenotomy has been shown to result in significant functional improvements in elderly patients with irreparable rotator cuff tear.[37] Because of the minimally invasive nature of this intervention, this treatment option may be considered suitable in some elderly patients with irreparable full-thickness tears. Partial repair may also be considered and has in some studies resulted in more favorable outcomes than debridement alone.[38] In 2013, results of a multicenter, prospective, randomized study that compared decompression alone with decompression and arthroscopic rotator cuff repair in 154 patients aged 70 yr and older demonstrated that repair was significantly better than decompression alone for all clinical outcomes, even in patients over 75 yr of age.[39] Currently, even massive rotator cuff tears can be repaired arthroscopically with excellent outcomes.[40]
Between 2009 and 2015, at least nine independent groups of authors have reported results of arthroscopic rotator cuff repairs in elderly patients.[10,11,41–47] All authors have reported significant clinical improvements at follow-up when compared to the preoperative status (). In some series, results in elderly patients after rotator cuff repair have been similar to younger age groups (). In a recent study from the senior author's group, out of 49 shoulders in elderly recreational athletes who underwent arthroscopic rotator cuff repair, 77% were able to return to their preinjury level of sport at a minimum follow-up of 2 yr after repair.[45] In summary, arthroscopic rotator cuff repair in elderly patients is a safe and effective treatment for full-thickness tears that significantly improves functional outcome with comparable results to younger age groups.
The senior author's preferred technique for arthroscopic rotator cuff repair in the elderly patient is a knotless, interconnected, double-row procedure (Figure 3).[45,51] The biomechanical advantages of this type of repair are helpful for structural healing (Figure 4) in the biologically challenged environments frequently seen in patients in this age group. The surgical steps of this repair result in a self-reinforcing, interconnected construct that distributes the force of the repair with no point loading or spot welds:
Two-year postoperative T1-weighted MRI showing knotless, interconnected, double-row repair of a full-thickness supraspinatus tendon tear in a 69-year-old man.
Although intrinsic tissue healing is qualitatively diminished in elderly patients with rotator cuff tears, age does not seem to influence the outcome after arthroscopic repair.[61] Recently, Kweon et al.[62] evaluated predictors of treatment allocation for surgical and conservative management of rotator cuff tears. The authors found that younger age, lower body mass index, and duration of symptoms less than 1 yr were predictive of eventual allocation to surgical treatment. Other authors found that a higher American Society of Anesthesiologist (ASA) grade as well as duration of symptoms of 3 yr or more to be negative predictors for results of arthroscopic rotator cuff repair.[36] According to Goutallier et al.,[23] fatty infiltration (grade 3 or 4) has been identified as negative prognostic indicator for repair. In addition, proximal migration of the humeral head can be associated with different stages of cuff tear arthropathy.[63] Hamada grades 3 and higher do not seem to be suitable for arthroscopic rotator cuff repair in elderly patients. Retear rates are associated with tear sizes in elderly individuals, and functional results are best in patients with tears limited to the supraspinatus tendon.[41,46]
Considering these findings, we have developed the ''Rule of 3's'' for predicting successful arthroscopic rotator cuff repair in elderly patients (). Ideal candidates for repair are symptomatic patients who fit these criteria, independent of the chronological age.
| Preoperative patient prognostic factors | Criteria for predicting successful outcome |
|---|---|
| Duration of symptoms | <3yr |
| Fatty infiltration of supraspinatus and infraspinatus | <Goutallier grade 3 |
| Cuff tear arthropathy | <Hamada grade 3 |
| Body mass index | <30 |
| American Society of Anesthesiologists (ASA) grade | <3 |
| Number of tendons involved | <3 |
With partial tears of the rotator cuff, conservative treatment usually is preferred, and this is supported by data from recent short-term studies that advocate primary conservative treatment.[32,33] In patients in whom there is little clinical improvement and symptoms persist, arthroscopic treatment should be considered. However, in the context of the elderly, there is little data to support decision making, which can include debridement or arthroscopic rotator cuff repair. In either case, the biceps tendon should be assessed and liberally treated as indicated.
For massive rotator cuff tears, retear rates are higher and functional outcomes are inferior when compared to smaller tears, but the results of both open and arthroscopic studies support repair of these tears, even in the elderly.[35,36,41,44,45] Although there are no studies specifically discussing arthroscopic repair of massive tears in elderly patients, we suggest using the same rule of 3's as described above to help identify the best surgical candidates. For massive rotator cuff tears that are technically irreparable, partial repair, or debridement combined with biceps tenotomy should be considered in those in whom conservative treatment fails.[37,38] In properly selected patients who have symptomatic and disabling rotator cuff deficiency, reverse total shoulder arthroplasty can result in life-changing improvements in pain, motion, function, and patient satisfaction.[64] Because of the deterioration both clinically and radiographically with time, reverse shoulder arthroplasty should be used judiciously.[65] Future comparative studies of different treatment options for irreparable, massive rotator cuff tears in elderly patients will hopefully help to clarify the optimal surgical decision-making when treating these patients.
Recognition of a more active elderly population with rotator cuff tears has recently led to the development of a new instrument to measure the activity profile of elderly patients with shoulder pathology.[66] How this instrument may help to identify the best treatment choice for each patient will certainly be the focus of future studies. As the elderly population (>65 to 100 yr and more) includes a wide range of patient ages and activity levels, it might be helpful to distinguish between age subgroups, even among elderly patients. Not only chronological age but physiologic age is also an important factor for the surgeon to consider when considering surgery in elderly patients.
Because of some of the biological challenges that we face when trying to get rotator cuff tears to heal successfully, different means of augmenting the healing process have been considered, such as stem cells, platelet rich plasma, and synthetic or biologic scaffolds (patches).[67–69] Although the outcomes from some of these adjunctive techniques are still preliminary, they are showing promising results in some series.[70,71] For patients with irreparable rotator cuff tears, superior capsule reconstruction, which is a new arthroscopic biological technique, could be a promising treatment alternative.[72] Since bone osteopenia of the greater tuberosity is more common in elderly patients and in cases of chronic rotator cuff tears, some researchers have been experimenting with suture anchor augmentation using cement as a means to improve the anchor fixation in poor quality bone.[73–75] Although as yet with limited clinical data, these new techniques offer a lot of promise as we face the growing demographic tidal wave of elderly patients with symptomatic rotator cuff tears.
Rotator cuff disease is an extremely important topic in the field of orthopaedic surgery, particularly with the rapidly increasing number of elderly patients, many of whom will suffer from symptomatic rotator cuff tears. Although rotator cuff tears in the elderly can be more challenging to treat than rotator cuff tears in younger patients because of a variety of factors that were discussed in this article, the results of surgical treatment can be quite good with pain relief, improvements in function, high degrees of patient satisfaction, and return to sport. From today's perspective, arthroscopic repair must be considered the gold standard for treatment of most rotator cuff tears in elderly patients. Excellent results can be achieved with careful patient selection, skillful surgery, and appropriate postoperative rehabilitation. Although surgery for elderly patients with acute onset of symptoms after trauma may be considered, most probably a trial of conservative treatment is in order, particularly if the tear is acute-on-chronic. When the rotator cuff tear is chronic and degenerative, there should be consideration as to the level of the patient's current symptoms, chronologic and physiologic age, comorbid conditions, desired activity level as well as the pathomorphologic and biologic predictors of success of repair. If a patient's individual circumstances favor the chances of successful repair, as determined by the surgeon's expertise and the prognostic factors mentioned, then rotator cuff repair is worthwhile. If not, then there may be a place for conservative treatment or alternative palliative surgical techniques.
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