Acute rotator cuff tearsBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5366 (Published 11 December 2017) Cite this as: BMJ 2017;359:j5366
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To the editor,
With great interest we read the article entitled “Acute rotator cuff tears” by Craig et al. (BMJ 2017;359:j5366). We agree with the authors that rotator cuff tears are easily missed. However, the conclusions may be premature and should first be followed by a control-study and a study proving the potential benefit from additional imaging and consequent treatment. At this point, subjecting patients to routine soft tissue imaging may lead to misdiagnosis and overuse of diagnostic and therapeutic modalities.
In order to enhance the diagnosis and (surgical) treatment of acute rotator cuff tears after injury, the authors plead for urgent imaging when patients are aged over 40 years, or when patients are unable to abduct their arm above 90° for longer than two weeks. In addition, the authors advise that clinicians differentiate between chronic and acute rotator cuff tears for clinical decision-making. In practice, however, this may be difficult and it may even be doubted whether indeed such difference exists. The authors cite incidence rates of acute tears between 49-54% in patients aged 40-89 years. Looking at the prevalence of these same tears in 1366 healthy shoulders, it shows that full-thickness tears are part of normal ageing, and occur in up to 50% of individuals older than 80 years of age. Thus, when performing soft tissue imaging in patients with shoulder injury, especially when they are aged over 40 year, pre-existent full thickness tears may easily be mistaken for acute pathology.
The high prevalence of rotator cuff tears in asymptomatic participants also proves that rotator cuff tears do not necessarily lead to symptoms. The size of the tear, but also the magnitude in terms of involved tendons determines whether patients will develop complaints. Biomechanical and clinical studies show that when the subscapularis and/or infraspinatus is torn, glenohumeral stability is compromised, and shoulder function will be impaired. In contrast, tears of the supraspinatus have little biomechanical consequence and will hence not likely give symptoms. The authors accordingly state that clinical assessment of the individual rotator cuff muscles is desirable, however difficult, because the utility of clinical tests in isolation is limited, referring to a systematic review by Gismervik et al.. Indeed, clinical tests for supraspinatus pathology are little specific and hence not very useful in isolation. In contrast, and as explicitly stated by Gismervik et al., functional tests for the diagnosis of subscapularis and infraspinatus tears show good sensitivity and specificity and thus are useful in clinical practice. We highly recommend the use of clinical tests such as the lift-off or rotation lag sign test, to triage patients for additional soft tissue imaging and prevent overuse of diagnostic modalities.
In case an acute rotator cuff tear is confirmed, the authors advocate urgent referral to a specialist surgeon to discuss potential surgical repair. It should be noted that the benefits of early surgery are not as likely as in the referred younger population with a clinical relevant acute tear. In fact, recent studies show that surgical repair has no beneficial outcome compared to conservative management in a less than medium sized single tendon full thickness tear.
In light of the above arguments, we recommend that diagnostic and treatment strategies should be highly dependent on patients age, risk factors, clinical performance and type of rotator cuff tear. Follow-up studies are recommended to substantiate the conclusions drawn by the authors.
Paul Burgers, MD, PhD
Celeste Overbeek, MD
Jochem Nagels, MD, orthopaedic surgeon
Department of orthopaedic surgery, Leiden University Medical Center, Leiden, The Netherlands
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Competing interests: No competing interests