Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Robert H. Cofield, MD*,
Mayo Clinic, Rochester, Minnesota
Posted August 3, 2006
Ultrasonographic visualization of the rotator cuff has proven to be a very useful and relatively inexpensive tool for assessing rotator cuff tendons. It is quite accurate when used to assess the presence or absence of full-thickness tears but is less accurate when used to analyze partial-thickness tears. Because the authors of this article evaluated both shoulders of individuals who presented with unilateral disease, we are presented with a unique opportunity to learn more about the characteristics of symptomatic and asymptomatic shoulders.
The epidemiology of orthopaedic diseases and injuries is relatively understudied, and these types of studies can provide important insights into the overall analysis of patients and the recommendations for treatment. This study did identify tear size as an important factor in the development of pain. In terms of natural history, it did identify age (but not gender) as an important factor with regard to the presence or absence of substantive rotator cuff disease.
Interestingly, almost all unilateral rotator cuff tears were painful (ninety-three of ninety-seven with partial-thickness tears and 101 of 102 with full-thickness tears), a finding that reconfirms the belief that rotator cuff tearing can be highly associated with pain and is presumably the cause of the symptomatology. If there was a normal rotator cuff or only a partial tear on the painful side, the chance of there being a full-thickness tear on the opposite side was very low. On the other hand, if there was a full-thickness tear on the painful side, approximately one-third of those individuals also had a full-thickness tear on the opposite, nonpainful side. This is useful information that reminds us that our understanding of who might and might not have a clinically important level of symptoms is incompletely understood.
The author's concept of monitoring mildly symptomatic or asymptomatic full-thickness rotator cuff tears with ultrasonography for size progression over time is interesting, as is the suggestion concerning prophylactic treatment. Certainly, some individuals with a lesser degree of symptoms, when counseled, might opt for surgical treatment when the tear size is smaller so as to have continuation of substantive strength over time. However, most patients will not want to have preventative surgery if the level of pain, in and of itself, is not great enough to warrant surgical treatment. Perhaps patient follow-up should be approached along those very lines—if a patient requires considerable strength in the shoulder and is identified as having full-thickness rotator cuff tearing, then that patient should be carefully monitored over time. Those who don't require substantial shoulder strength would be advised to return for monitoring if the symptoms suggest surgery would be a strong consideration. This type of thinking and these sorts of questions are the product of studies such as this one and are good reasons to conduct similar investigations—not only of rotator cuff disease—but in other areas of orthopaedic surgery as well.
*The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
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