AAOS releases clinical practice guideline to treat rotator cuff tears

The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors approved and released a clinical practice guideline for treating rotator cuff tears.  The rotator cuff is a group of muscles and their associated tendons which holds the humerus (upper arm bone) stable in the shoulder joint, allowing the arm to rotate and elevate.  Rotator cuff tears are a common cause of pain and disability among adults, occurring often as a consequence of aging, because of tendon degeneration.  Tears can also occur following injury from sports or acute trauma.

Clinical practice guidelines, based on the highest quality evidence-based research available, are an educational and learning tool for Academy members, can assist orthopaedic surgeons and patients in potential treatment recommendations, and also serve to improve the design of future clinical studies. In this case, an arduous review of the literature up through 2008 identified 74 studies to be included in the guideline.  Robert Pedowitz, MD, chair, and Ken Yamaguchi, MD, co-chair, of the Academy work group developing this guideline, state that although a large number of lower evidence studies exist, they were surprised at the absence of more high quality prospective studies to support many commonly used interventions.

"Although there is a tremendous amount of research on the rotator cuff, much of it does not reach the quality levels necessary to be considered definitive," says Yamaguchi.  "Thus, we cannot say that there were recommendations that could be unequivocally supported."  

That said, Yamaguchi points out that the AAOS work group has recommended 14 interventions for treating rotator cuff tears.  There is a consensus opinion among the work group for the following recommendation:

• In the absence of reliable evidence, it is the opinion of the work group that surgery not be performed for asymptomatic full thickness rotator cuff tears.  By "asymptomatic," the work group refers to a patient without symptoms.  The primary indication for rotator cuff repair is significant pain or dysfunction affecting the quality of life.

Rotator cuff repair is an option to treat both symptomatic acute and chronic tears.  There was no Level 1 evidence, however, to demonstrate a difference in outcome from one type of surgical approach to another.

Dr. Yamaguchi mentioned that many of the common practices for repairing acute tears or chronic tears that have failed conservative management are considered viable options today.  The work group found no evidence to refute most of these common treatment practices.  It is entirely probable, they believe, that future, good evidence will substantiate current opinion.  

"In our opinion, the guideline process taken by the Academy is a valuable exercise that has focused our awareness on what precisely are the modern standards for good evidence," says Yamaguchi.  "This process clearly demonstrates the need for higher quality research and should hasten the progression toward more sophisticated studies in the future."