Shoulder pain and dysfunction are common presentations in the older age group. Presentations may be atraumatic or precipitated by ‘minor’ trauma. Patients will usually wait a few weeks or months before seeking treatment in hope symptoms settle.
Today’s ‘older age group’ comprises a heterogeneous group of patients ranging from the extremely fit, strong, active and mobile to the frail with multiple medical comorbidities. Individualised management based on the patient’s needs and demands is needed.
Plain x-rays and ultrasound scans, commonly performed, will frequently report full thickness rotator cuff tears causing concern for both the patient and the treating doctor. While the rotator tear may be the cause of the patients’ symptoms, there is a reported rate of 20-40% of rotator cuff tears in the asymptomatic population aged 60-80.
Judgment needed
If the patient falls into the fit active ‘high demand group’ then early referral to a shoulder specialist for consideration of surgical repair should be considered. This should be no different to the usual treatment algorithms in young patients with full thickness rotator cuff tears.
If the patient is lower demand, in poorer physiological condition with medical comorbidities, then a more conservative approach may be reasonable.
Initial non-operative treatment could include:
- Giving the patient time to recover as functional improvement can be significant in the first 6-12 weeks or even longer
- Non steroid anti-inflammatory drugs
- Local anaesthetic and steroid injections into the subacromial space
- Good quality shoulder rehabilitation with a musculoskeletal physiotherapist with an interest in shoulder rehabilitation.
Physiotherapy with an experienced shoulder physiotherapist is important as ineffective and prolonged therapy with little improvement can be expensive and disillusioning for the patient, leading to the statement that ‘physio does not work’.
In patients failing non-operative treatment, referral to a shoulder specialist surgeon may be appropriate.
Once the patient reaches the surgeon, consideration is needed to establish if the patient is a surgical candidate and, if so, what surgery may be appropriate.
This is usually done (in addition to clinical examination) with an MRI scan which gives useful information that a plain x-ray and an USS may not. The MRI scan can provide information on the size of the tendon tear and also the quality of the rotator cuff muscle bellies. Generally, rotator cuff tears involving more than two tendons, that are larger (>3-4cm) and retracted to the glenoid with muscle belly atrophy have a poorer prognosis after repair (with poorer outcome). They also have a higher re-rupture rate after repair.
The MRI scan may also show other soft tissue pathology (e.g., inflamed or subluxed biceps tendon) and glenohumeral joint degeneration.
Surgical procedures that may be considered in this age group:
- Arthroscopic debridement and biceps tenotomy for irreparable rotator cuff tears in which pain relief the main goal
- Arthroscopic rotator cuff repair in ‘smaller’ tears with good quality muscle bellies in which a good outcome from surgery can be predicted
- Reverse total shoulder replacement is a good option in patients with irreparable rotator cuff tears, particularly with glenohumeral joint degeneration
All surgeries have pros and cons. Arthroscopic surgery may be ‘low risk’ but may also be ‘low yield’ particularly in poorly selected patients. Recovery from rotator cuff repair can be prolonged, taking three to six months to get a reasonable result and up to 12 months for maximal improvement. So, it is important the surgery ‘works’.
Reverse total shoulder replacement is being done with increasing frequency. It is particularly useful in cases where there is glenohumeral joint degeneration and irreparable rotator cuff tendons where attempted repair would lead to a predictably poor outcome.
Recovery from reverse total shoulder replacement can seem much quicker than rotator cuff repair, with two to four weeks in a sling and a good outcome by three months post-surgery in most cases. However, the surgery is no panacea as even a good result of a reverse total shoulder replacement does not produce a normal shoulder. There is also a small risk of a serious adverse outcome including fracture and infection.
We all need to choose wisely and endeavour to get the treatment right the first time.
Key messages
- Full thickness rotator cuff tears are common in over 65s and symptoms may vary
- The rotator cuff tendons and articular cartilage may be markedly degenerate and of poor quality
- Individualised treatment is needed and several options exist.
Author competing interests – nil