Purpose: The purpose of this study was to compare treatment benefits from surgical repair and from physiotherapy in the treatment of small and medium-sized rotator cuff tears.

Materials and Methods: One hundred and three patients with acute and chronic rotator cuff tears, with diameters not exceeding 3 cm, were randomly allocated to surgery or physiotherapy. Primary outcome measure was the Constant score, secondary outcome measures included the self report section of the American Shoulder and Elbow Surgeons score (ASES), the Short Form 36 Health Survey (SF-36) and subscores for shoulder motion, pain, strength and patient satisfaction. Scores were taken at baseline and after 6, 12 and 24 months by a blinded assessor. Patients with no effect from physiotherapy after at least 15 treatment sessions were offered secondary surgical treatment and scoring results from last follow-up before surgery were carried forward to analysis. Patients who crossed over to secondary surgery were followed as a separate group after secondary surgery.

Results: Analysis of between-group differences after one year showed significantly better results for the surgery group on the Constant scale (difference 13.0 points, p = 0.002), on the ASES scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8°, p = 0.003), for decrease of pain (difference on a visual analogue scale −1.7 cm, p < 0.0005), and for patient satisfaction (difference on a visual analogue scale −1.8 cm, p < 0.0005). Nine of 51 patients (18%) from the physiotherapy group were converted to secondary surgery. A preliminary two-year result (based on 96 of 103 patients) showed that treatment results on the Constant scale were stable in both groups. (Two-year follow-up will be complete in November 2009 and two-year results for all outcome measures will be presented at the EFORT meeting 2010).

Discussion: Treatment effect was demonstrated for both approaches, but results from surgery were superior to those from physiotherapy. Between group differences after 12 months were statistically significant and clinically important. On the other side, only 9 of 51 patients opted for cross-over to surgery and were effectively treated by secondary surgery. Therapeutic decisions for rotator cuff tears have to be made individually, on the basis of tear characteristics, symptoms, and patient expectations. But patients should be informed that medium-term treatment results for tears up to 3 cm, on average, are better after primary tendon repair.

In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment.

Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p − 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8°, p = 0.003) and for reduction in pain (difference on a visual analogue scale −1.7 cm, p < 0.0005).

We undertook clinical and ultrasonographic examination of the shoulders of 420 asymptomatic volunteers aged between 50 and 79 years. MRI was performed in selected cases. Full-thickness tears of the rotator cuff were detected in 32 subjects (7.6%). The prevalence increased with age as follows: 50 to 59 years, 2.1%; 60 to 69 years, 5.7%; and 70 to 79 years, 15%. The mean size of the tear was less than 3 cm and tear localisation was limited to the supraspinatus tendon in most cases (78%). The strength of flexion was reduced significantly in the group with tears (p = 0.01).

Asymptomatic tears of the rotator cuff should be regarded as part of the normal ageing process in the elderly but may be less common than hitherto believed.