In the November 4, 2015 Level I JBJS study by Kukkonen et al., patients over the age of 55 were randomized to one of three treatment arms for management of a rotator cuff tear—physical therapy alone and acromioplasty with and without rotator cuff repair. We learn that over a two-year follow up, treatment with physiotherapy produced results as clinically favorable as surgery in this “older” age group, although tear size was significantly smaller in the repair group than in the other two.
As Dr. Ken Yamaguchi points out in his commentary on the study, the average patient age for surgical repair of a rotator cuff tear is currently the mid-50s, and we know that the likelihood of repair failure with lack of healing increases in patients beyond their mid-60s. In fact, historic post-mortem studies have identified rotator cuff tears in 70% to 80% of all subjects, making this is a common wear-and-tear phenomenon among humans, akin to degenerative disc disease and declining hearing and vision.
So is the take-home message from Kukkonen et al. that any patient over the age of 55 should be treated with physiotherapy, with no discussion of surgical repair? I think not. The message is that we should be more supportive of a decision to start down the physiotherapy path with patients in their mid-50s than ones in their mid-40s. Although this study emphasizes the age factor, we should also remember that age is only one data point in a shared decision making discussion. An athletic, fit woman in her mid-50s who participates in yoga and zumba four days a week in addition to resistance training is a very different patient than the sedentary, deconditioned woman of the same age.
In the discussion of what is best for each patient, we need to leverage our knowledge regarding the musculoskeletal problem coupled with the wisdom to consider each patient’s functional demands and goals for activity return. As our population ages and the level of older-patient fitness hopefully increases, these discussions will take more time, but will result in higher-quality decisions for the individual patient.
Marc Swiontkowski, MD