title: Clinical and structural outcomes of nonoperative management of massive rotator cuff tears.
abstract: BACKGROUND
  The natural history of massive rotator cuff tears is not well known. The purpose of this study was to determine the clinical and structural mid-term outcomes in a series of nonoperatively managed massive rotator cuff tears.
  
  
  METHODS
  Nineteen consecutive patients (twelve men and seven women; average age, sixty-four years) with a massive rotator cuff tear, documented by magnetic resonance imaging, were identified retrospectively. There were six complete tears of two rotator cuff tendons and thirteen complete tears of three rotator cuff tendons. All patients were managed exclusively with nonoperative means. Nonoperative management was chosen when a patient had low functional demands and relatively few symptoms and/or if he or she refused to have surgery. For the purpose of this study, patients were examined clinically and with standard radiographs and magnetic resonance imaging.
  
  
  RESULTS
  After a mean duration of follow-up of forty-eight months, the mean relative Constant score was 83% and the mean subjective shoulder value was 68%. The score for pain averaged 11.5 points on a 0 to 15-point visual analogue scale in which 15 points represented no pain. The active range of motion did not change over time. Forward flexion and abduction averaged 136 degrees; external rotation, 39 degrees; and internal rotation, 66 degrees. Glenohumeral osteoarthritis progressed (p = 0.014), the acromiohumeral distance decreased (p = 0.005), the size of the tendon tear increased (p = 0.003), and fatty infiltration increased by approximately one stage in all three muscles (p = 0.001). Patients with a three-tendon tear showed more progression of osteoarthritis (p = 0.01) than did patients with a two-tendon tear. Four of the eight rotator cuff tears that were graded as reparable at the time of the diagnosis became irreparable at the time of final follow-up.
  
  
  CONCLUSIONS
  Patients with a nonoperatively managed, moderately symptomatic massive rotator cuff tear can maintain satisfactory shoulder function for at least four years despite significant progression of degenerative structural joint changes. There is a risk of a reparable tear progressing to an irreparable tear within four years.
authors.affiliation: Department of Orthopaedics, University of Zurich, Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland.
authors.forename: P O
authors.initials: PO
authors.lastname: Zingg
authors.forename: B
authors.initials: B
authors.lastname: Jost
authors.forename: A
authors.initials: A
authors.lastname: Sukthankar
authors.forename: M
authors.initials: M
authors.lastname: Buhler
authors.forename: C W A
authors.initials: CW
authors.lastname: Pfirrmann
authors.forename: C
authors.initials: C
authors.lastname: Gerber
mesh_terms: D000174:Acromion / Q000473:pathology; D000273:Adipose Tissue / Q000473:pathology; D000368:Aged; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006811:Humerus / Q000473:pathology; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000473:pathology; D010003:Osteoarthritis / Q000503:physiopathology; D010147:Pain Measurement; D016059:Range of Motion, Articular / Q000502:physiology; D012189:Retrospective Studies; D012307:Risk Factors; D012399:Rotation; D017006:Rotator Cuff / Q000473:pathology / Q000503:physiopathology; D000070636:Rotator Cuff Injuries; D012785:Shoulder Joint / Q000503:physiopathology; D020069:Shoulder Pain / Q000503:physiopathology; D016896:Treatment Outcome