Rotator Cuff Tear / Further Readings and References
Rotator cuff tear has been a known entity for orthopaedic surgeons for more than two hundred years. Although the exact pathogenesis is controversial, a combination of intrinsic factors proposed by Codman as in a degenerative-microtrauma model and hypovascularity of the critical areas of the rotator cuff, and extrinsic factors theorized by Neer (abutment of the rotator cuff against the coracoacromial arch) is likely responsible for most rotator cuff tears.
The natural history of rotator cuff tears has been studied. Partial-thickness cuff tears can heal (10%) or become smaller (10%) but 52% propagate and 28% become full-thickness tears.  Full-thickness tears do not heal spontaneously and the majority (36-50%) progress in size gradually. An increase in tear size is associated with deterioration of the muscle by fatty replacement. This occurs after an average of 3 years and becomes severe after 5 years of cuff tear. [2, 3]
For chronic atraumatic full-thickness tears, there are largely three groups of patients:
Asymptomatic and functionally compensated
These tears are usually discovered by accident. They should be left alone and can be monitored under regular follow-up.
Mildly symptomatic but functionally compensated
Patients in this category present with pain but retain ability to elevate the arm actively enough to perform activities of daily living. Pain can be managed by activity modification, analgesics, steroid injection, and focused physical therapy aiming at strengthening the remaining normal cuff and scapular muscles. Once the pain subsides, these patients may not require any surgical intervention. However these patients should be informed about inevitable cuff tear enlargement in due course, which may be few months to years. 
Painful and functionally decompensated
They can be given a trial of analgesics and physical therapy for few weeks. If they fail to improve consider surgery.
1. Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff. A followup study by arthrography. Clin Orthop Relat Res. 1994:68e73.
2. Melis B, DeFranco MJ, Chuinard C, Walch G. Natural history of fatty infiltration and atrophy of the supraspinatus muscle in rotator cuff tears. Clin Orthop Relat Res. 2010;468:1498e1505.
3. Melis B, Nemoz C, Walch G. Muscle fatty infiltration in rotator cuff tears: descriptive analysis of 1688 cases. Orthop Traumatol Surg Res. 2009;95:319-324.
4. Mall NA, Kim HM, Keener JD, et al. Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and sonographic variables. J Bone Joint Surg Am. 2010;92:2623-2633.
Factors affecting the success of rotator cuff repair
Although there are variations in modern surgical technique in rotator cuff repair, the clinical results are by enlarge similar.
Patient factors and Tear characteristic have been showed to have major influence on the success rate.
Many studies have shown that the success of cuff repair decreases with advancing age (>65-70yrs). [5-9]
Size of the rotator cuff tears also matter. 87% healing rate in small/medium tears and 62% healing in large/massive tears has been reported. 
Wide retraction of the tear and heavily fatty infiltration along with atrophy of the torn muscle can render the tear irreparable.
Certain patient factors are known to have a negative impact on the rate of healing of a repair such as smoking, diabetes and obesity.
Recovery after surgery
Usually a shoulder sling is worn for about 6 weeks. Physiotherapy is required for about 3 to 4 months. 6 months before it may be safe to perform manual work and sports.
5. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87: 1229-1240.
6. Cho NS, Yi JW, Lee BG, Rhee YG. Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique. Am J Sports Med. 2010;38:664-671.
7. Choi S, Kim MK, Kim GM, Roh YH, Hwang IK, Kang H. Factors associated with clinical and structural outcomes after arthroscopic rotator cuff repair with a suture bridge technique in medium, large, and massive tears. J Shoulder Elbow Surg. 2014;23:1675-1681.
8. Le BT, Wu XL, Lam PH, Murrell GA. Factors predicting rotator cuff retears: an analysis of 1000 consecutive rotator cuff repairs. Am J Sports Med. 2014;42:1134-1142.
9. Rhee YG, Cho NS, Yoo JH. Clinical outcome and repair integrity after rotator cuff repair in patients older than 70 years versus patients younger than 70 years. Arthroscopy. 2014;30:546-554.
10. Jason L. Codding1 & Jay D. Keener1 Natural History of Degenerative Rotator Cuff Tears Current Reviews in Musculoskeletal Medicine (2018) 11:77–85
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