Factors associated with failed conservative treatment in patients with degenerative full-thickness supraspinatus...

The conservative treatment of degenerative full-thickness supraspinatus tears yields satisfactory results in most patients. However, identifying those likely to require surgery remains difficult. The aim of this study was to evaluate the effectiveness of conservative treatment and identify the characteristics of the patient or the size of the tear which are associated with treatment failure.

This prospective study included patients with degenerative full-thickness supraspinatus tears treated with a standardized physiotherapy protocol. Exclusion criteria were patients aged > 75 years, those with traumatic or massive tears, cuff arthropathy, those without MRI scans, or with < two years of follow-up. The patients were reviewed at three, six and 12 months and annually thereafter. Outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and pain using a visual analogue scale (VAS). Failure of treatment was defined as the need for surgery. The tears were classified from MRI scans according to the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine criteria. The mean follow-up was 30.5 months (SD 6.2). The study included 348 patients with a mean age of 63.4 years (SD 7.6); 230 (66.1%) were female, the dominant side was affected in 234 (67%), and 170 (49%) were manual workers. A total of 171 tears (49%) were grade C1, 131 (38%) were C2, and 46 (13%) were C3. Partial infraspinatus tears occurred in 162 (46.6%) and 243 (69.8%) had subscapularis involvement (Lafosse I to II).

At the final follow-up, 268 patients (77%) had a satisfactory outcome without surgery. Mean improvements were: ASES +31.3 (SD 20); SSV +35.6 (SD 24); and VAS -4.3 (SD 2.7) (all p < 0.001). There were no significant differences in final outcomes between those who had surgery and those who did not. The surgical group were significantly younger (58.7 years (SD 8) vs 64.8 years (SD 6.8); p < 0.001), significantly more likely to be manual workers (62.5% (50/80) vs 44.8% (120/268); p = 0.008), had significantly higher BMI, lower initial ASES and SSV scores, previous contralateral shoulder surgery, and significantly larger sagittal tears (14.7 mm (SD 5) vs 13.5 mm (SD 5); p = 0.021).

Conservative treatment was effective in 77% of patients with a degenerative supraspinatus tear. Younger patients, manual workers, those with more painful shoulders, and those with a history of previous surgery in the contralateral shoulder were at a significantly increased risk of requiring surgery.