RESEARCH

Rotator Cuff Injuries  

Surgery for rotator cuff tears is much more frequent than it was 20 years ago, and I credit the MRI for that.  Why?  Because many folks, especially men over 50 have rotator cuff tears even though they may have no pain!  I liken it to gray hair – a pretty normal age-related change. Dr. Gordon Waddell, a spine surgeon from Scotland, calls the MRI “a trap” in reference to low back pain evaluation; Dr. Ned Kuhn, chief of shoulder surgery at Vanderbilt calls it “the tool of the devil” in regards to rotator cuff tears, and I call it “the key to the cash drawer” in regards to rotator cuff tears. All one has to do is present with shoulder pain, and when the MRI is suggested, and you agree, you have stepped into the trap.  Just because the MRI shows a rotator cuff tear does not mean the tear is what is causing the pain, and multiple studies have shown tears to exist in folks that have NO pain. In one study published in 2017 they did an MRI of both the painful and non-painful shoulder.  They saw worse abnormalities in the rotator cuff in the non-painful shoulder in over 52% of the patients. Several years ago, I saw a patient who had complained of shoulder pain for over four months.  He had seen 5 different doctors, had injections and tried multiple medications, and had 10 PT and 10 OT visits.  None of this helped him.  I saw him once and resolved his pain and never touched his shoulder – that wasn’t the problem. On another occasion I saw a 72-year-old man who lifted an empty cardboard box overhead and suffered an onset of shoulder pain and arm weakness.  The MRI showed a rotator cuff tear and the surgeon called this a “traumatic tear”, after I suggested the patient likely had significant degeneration in the cuff prior to the onset of symptoms.  Three weeks after the onset of symptoms he was much better.  But he had the surgery that was recommended – it didn’t improve things. Below are some excerpts and the studies that they came from, that substantiate what I said above.  There are more.

Rotator Cuff Tears 

Reilly P, Macleod I, Macfarlane R, Windley J, Emery RJH. Dead men and radiologists don’t lie: a review of cadaveric and radiological studies of rotator cuff tear prevalence. Ann R Coll Surg Engl. 2006;88:116-121

Rotator cuff tears are common pathology and are frequently asymptomatic.  Rotator cuff tears demonstrated radiographically during the investigation of the shoulder may well not be responsible for the presenting symptoms.  It is important to correlate radiological and clinical findings in the shoulder.

Milgrom C, Schaffler M, Gilbert S, vanHolsbeck M. Rotator-cuff Changes In Asymptomatic Adults. The Jnl Bone and Joint Surg (Br). 1995;77-B:296-8.

(the) subject population……..had never sought medical advice for a shoulder problem and all were asymptomatic at the time of the ultrasound evaluation.

Our results indicate that rotator-cuff lesions may be regarded as a natural correlate of aging, with a statistically significant linear increase after the fifth decade of life.  All the lesions which we found were present without clinical symptoms.  The high incidence of rotator cuff lesions in the older asymptomatic population means that in this age group the initial treatment of suspected rotator-cuff lesions should be based on clinical judgment; reliance should not be placed on MR, sonographic or arthrographic imaging of the rotator cuff.

Gill TK, Shanahan ME, Allison D, Alcorn D, Hills CL.  Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults.  International Journal of Rheumatic Diseases 2014; 17: 863–871

Shoulder pathology is apparent in both symptomatic and asymptomatic shoulders and clinical symptoms may not match radiological findings. The cost burden of ordering MRI scans is significant and the relevance of the findings is questionable when investigating shoulder pain.

Clin Orthop Relat Res. 2017 Jun 9. DOI: 10.1007/s11999-017-5401-y. [Epub ahead of print]Liu TC, Leung N, Edwards L, Ring D, Bernacki E, Tonn MD Patients Older Than 40 Years With Unilateral Occupational Claims for New Shoulder and Knee Symptoms Have Bilateral MRI Changes.

MRI CHANGES MAY NOT BE RESPONSIBLE FOR SHOULDER PAIN

In a study of >40 y/o men and women published in June 2017 the authors did MRIs on the asymptomatic shoulders of workers that reported a work-related injury to the shoulder.  They found worse pathology in the asymptomatic shoulder in over 52% of the patients.  Abnormalities on the MRI were seen in 99% of the symptomatic shoulders and 98% of the asymptomatic shoulders.  They also looked at knee injuries and found similar results.

The author’s state:

Given that MRI signal changes of the shoulder and knee are increasingly prevalent with age regardless of symptomatology, considering newly symptomatic joints with MRI signal changes as injuries related to an acute traumatic event may not be accurate.

 

Worsening Trends In Back Pain Management

(The authors looked at 23, 918 patient visits for back or neck pain over a 12 year period)

A couple key points of the study found rather large increases in guideline discordant care that has not been shown to improve outcomes.

1) Referrals to other physicians: (over 100% increase)
2) Prescriptions for narcotics (nearly 50% increase)
3) Use of advanced imaging such as CT/MRI (nearly 60% increase)

The authors also found a decrease or no change in care concordant with guidelines:

1) Decrease in prescriptions of NSAIDs or use of OTC Acetaminophen (nearly 33% decrease)
2) No change in PT referrals

I believe the authors say it well in the final paragraph of their study:

Despite numerous published national guidelines, management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians, and use of narcotics, with a concomitant decrease in NSAID or acetaminophen use and no change in physical therapy referrals.

With health care costs soaring, improvements in the management of back pain represent an area of potential cost savings for the health care system while also improving the quality of care.

Ed Scott PT, DPT, OCS
September 2014

 

Worsening Trends in the Management and Treatment of Back Pain
JAMA Intern Med. 2013;173(17):1573-1581. doi:10.1001/jamainternmed.2013.8992

 

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