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Comparative Effectiveness of Nonoperative and Operative Treatments of Rotator Cuff Tears

• CME Information
• Faculty Biographies & Disclosures
• References
• Course Presentations
• CME Posttest

CME Information

Course Overview Educational Objectives Target Audience Method of Participation

Accreditation Statement Term of Approval Peer Review Program Director

Disclaimer Disclosure Acknowledgement of Support

Course Overview

The rotator cuff (RC) is comprised of four muscle-tendon units that stabilize the humeral head within the shoulder joint and aid in powering the movement of the upper extremity.¹ RC tears refer to a partial or full discontinuation of one or more of the muscles or tendons and may occur as a result of traumatic injury or degeneration over a period of years. The incidence of RC tears is related to increasing age; 54 percent of patients over the age of 60 years have a partial or complete RC tear when compared with only 4 percent of adults under 40 years of age.² Although not a life-threatening condition, RC tears may cause significant pain, weakness, and limitation of motion.¹ Both nonoperative and operative treatments are used in an attempt to relieve pain and restore movement and function of the shoulder.³ The majority of patients first undergo 6 weeks to 3 months of nonoperative treatment, which may consist of any combination of pain management (medications and injections), rest from activity, passive and active exercise, and modalities such as heat, cold, or ultrasound. When nonoperative treatment fails, the cuff may be surgically repaired by using an open, mini-open, or all-arthroscopic approach.

Alternatively, surgical repair may be indicated early on in the appropriate patient with a traumatic RC injury and a significant functional deficit.⁴ A variety of postoperative rehabilitation programs are used to restore range of motion, muscle strength, and function following operative treatment. Earlier operative treatment has been proposed to result in better patient outcomes, earlier return to work, and decreased costs;^5,6 therefore, patients and clinicians face the difficult decision of when to forego attempts at nonoperative treatment in favor of operative treatment. Moreover, the comparative effectiveness of the various nonoperative and operative treatment options for patients with RC tears remains uncertain.

This CME activity communicates the most relevant data from a systematic review and meta-analysis of existing research that was conducted by the University of Alberta Evidence-based Practice Center to evaluate the levels of evidence currently available for the effectiveness and safety of different operative and nonoperative interventions for the treatment of rotator cuff tears in adults.⁷

References

1. Crusher RH. Rotator cuff injuries. Accid Emerg Nurs 2000;8:129-33.
2.  Bartolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Related Res 1994;(308):90-7.
3.  Ghodadra NS, Provencher MT, Verma NN, et al. Open, mini-open and all-arthroscopic rotator cuff repair surgery: indications and implications for rehabilitations. J Orthop Sporsts Phys Ther 2009;39:81-9.
4. Bryant L, Shnier R, Bryant C, et al. A comparison of clinical estimation, ultrasonography, magnetic resonance imaging, and arthroscopy in determining the size of rotator cuff tears. J Shoulder Elbow Surg 2002;11:219-24.
5. Suenaga N, Minami A, Kaneda K. Postoperative subcoracoid impingement syndrome in patients with rotator cuff tear. J Shoulder Elbow Surg 2000;9:275-8.
6. Wittenberg RH, Rubenthaler F, Wolk T, et al. Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis--a matched-pair analysis of 100 patients. Arch Orthop Trauma Surg 2001;121(1-2):56-9.
7. Seida J, Schouten J, Mousavi S, et al. Comparative Effectiveness of Nonoperative and Operative Treatment for Rotator Cuff Tears, Comparative Effectiveness Review No. 22. (Prepared by the University of Alberta Evidence-based Practice Center under Contract No. 290-02-0023). Rockville, MD: Agency for Healthcare Research and Quality; July 2010. AHRQ Pub. No. 10-EHC050-EF.

Educational Objectives

At the conclusion of this activity, the participant should be able to:

• Understand the benefits and harms of nonoperative and operative interventions and postoperative rehabilitation in determining optimal treatment of rotator cuff tears in adults.
• Determine the needs of future clinical trials based on the current state of evidence for operative and nonoperative interventions for rotator cuff tears.

Target Audience

This CME activity is designed to meet the educational needs of primary care physicians and specialists who treat patients with rotator cuff tears.

Method of Participation

This activity is in PowerPoint file format and is accompanied by talking points and references linked to PubMed abstracts.

To receive a maximum of 1.0 AMA PRA Category 1 Credit(s)™ you should:

• View the presentations in this enduring material.
• Complete the posttest (you must answer 8 out of 10 questions correctly).
• Complete and submit the CME registration and evaluation forms.

The estimated time to complete this activity, including review of the materials, is 1.0 hour(s).

Hardware/software requirements: Activities should be run with recent versions of common browsers, including Internet Explorer, Firefox, and Google Chrome.

If you have questions about the participation process, please e-mail the Office of Continuing Medical Education, cme@bcm.edu or phone 713.798.8237.

Accreditation/Credit Designation

Baylor College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Baylor College of Medicine designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.    

Term of Approval

October 2010 through October 2013. Original release date: October 2010

Peer Review

In August 2010, this continuing medical education activity was reviewed by Frank J. Domino, M.D., an associate professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester, Massachusetts.

Disclosures: Nothing to disclose.

Program Director

Michael H. Heggeness, M.D., Ph.D. 
Professor and Chair 
Department of Orthopedic Surgery 
Baylor College of Medicine
Houston, Texas

Disclosures: Nothing to disclose.

Disclaimer

This CME activity is designed for use by healthcare professionals for educational purposes only. Information and opinion offered by the contributors represent their viewpoints. Conclusions drawn by the participant should be derived from careful consideration of all available scientific information. Prescription information and use of medical devices should be undertaken only after confirmation of information by consulting the FDA-approved uses and information.

Baylor College of Medicine makes every effort to have accurate information presented, no warranty, expressed or implied, is offered. The participant should use his/her clinical judgment, knowledge, experience, and diagnostic decision-making before applying any information, whether provided here or by others, for any professional use.

Links are provided to other Internet sites solely for the convenience of users. Once you link to another site, you are subject to the site's terms and conditions of use including copyright and licensing restrictions.

Disclosure

The Office of Continuing Medical Education (OCME) makes every effort to develop CME activities that are scientifically based, accurate, current, and objectively presented. In accordance with the Accreditation Council for Continuing Medical Education Standards for Commercial Support ^SM, Baylor College of Medicine (BCM) has implemented a mechanism requiring everyone in a position to control the content of an educational activity (e.g., directors, planning committee members, contributors, peer reviewers) to disclose any relevant financial relationships with commercial interests (drug/device companies) and manage/resolve any conflicts of interest prior to the activity. Individuals must disclose to participants the existence or non-existence of financial relationships: l) at the time of the activity or within 12 months prior; and 2) of their spouses/partners.

Baylor College of Medicine does not view the existence of interests or relationships with commercial entities as implying bias or decreasing the value of a presentation. It is up to the participants to determine whether the interests or relationships influence the presenter with regard to exposition or conclusions.

If at any time during this activity you feel that there has been commercial or promotional bias, please inform us by using the commercial bias comments box in the evaluation form. Please answer the questions about balance in the CME activity evaluation candidly.

The following individual(s) has/have reported no financial or other relationships with commercial entities whose products/services may relate to the educational content of this activity:

Michael H. Heggeness, M.D., Ph.D., Activity Director: nothing to disclose.
Charles A. Reitman, M.D., Contributor: nothing to disclose.
Jennifer C. Seida, B.H.Sc., M.P.H., Contributor: nothing to disclose.
Frank J. Domino, M.D., Peer Reviewer: nothing to disclose.

Some drugs/devices identified during this activity may have United States Food and Drug Administration (FDA) clearance for specific purposes only or for use in restricted research settings. The FDA has stated that it is the responsibility of the individual physician to determine the FDA status of each drug or device that he/she wishes to use in clinical practice and to use the products in compliance with the applicable law.

Baylor College of Medicine requires that all contributors disclose an unlabeled use or investigational use (not yet approved for any purpose) of pharmaceutical and medical device products, and provide adequate scientific and clinical justification for such use. Physicians are urged to fully review all the available data on products or procedures before using them to treat patients.

Acknowledgement of Support

This activity is supported by a contract, HHSA290200810015C, from the Agency for Healthcare Research and Quality.

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