AAOS Appropriate Use Criteria: Management of Rotator Cuff Pathology

The American Academy of Orthopaedic Surgeons approved Appropriate Use Criteria (AUC) for the treatment of rotator cuff pathology to assist clinicians in caring for these injuries.1 The AUC is largely based on the recommendations of the current clinical practice guidelines (CPG)2 published in 2019. Rotator cuff pathology is highly prevalent and is encountered frequently by musculoskeletal providers, with an estimated 4.5 million patient visits because of shoulder pain on a yearly basis.1 The CPG provided a thorough, rigorous, evidence-based review of treatment principles for rotator cuff pathology and serves as a robust guideline for the management of these injuries. Several assumptions were made by the AUC panel. Specifically, patients were expected to have a history, clinical examination, and imaging studies consistent with a full-thickness rotator cuff tear. Several mitigating or aggravating factors, including patient age, activity level, and concomitant pathology, were not considered. Whereas the CPG identifies several patient factors that affect the likely healing rate or clinical outcome of rotator cuff tears, ranging from diabetes to workers' compensation status, we are unable to quantify the effect of these factors on the outcomes, and so the AUC panel elected to combine these into an either/or dialectic for the purposes of limiting the number of possible clinical scenarios. It was also felt that some combinations, for example, an acute, small cuff tear with a high level of fatty atrophy, were clinically unlikely and so were eliminated. Here, we present several clinical scenarios and treatment options to demonstrate how the AUC can be used to aid in the decision-making process. The AUC writing panel developed 180 unique clinical scenarios that were tested and evaluated by the voting panel, with 900 treatment options to determine which treatments or diagnostic studies were appropriate. These scenarios address common situations and those in which the AUC provide guidance that may either differ from the previous CPG or be considered controversial. Although the AUC scenarios represent patients that a clinician is likely to encounter, independent medical judgment and a patient's clinical circumstances and preferences should always guide patient care and treatment. Case 1 A 70-year-old man presented with chronic right shoulder pain. He had intermittent right shoulder pain and decreased range of motion for as many years as he can remember. Other than an occasional over-the-counter anti-inflammatory drug, he had no prior treatment of this shoulder. His main complaint today is some pain with range of motion and worsening pain when he tries to sleep on that side. His medical history is notable for poorly controlled diabetes (past A1C was 8.5%) and hypertension. On physical examination, his active range of motion (ROM) is decreased (forward flexion and abduction 110°, external rotation 30°, and internal rotation is normal) but passively has full motion with increased pain at the extremes of motion. He has positive Neer and Hawkins signs along with a positive drop arm test. There is no evident muscular atrophy, but there is weakness, associated with pain, demonstrated by 4/5 strength in the supraspinatus, infraspinatus, and teres minor with normal (5/5) subscapularis strength. He has a normal neurological examination. Plain radiographs show superior migration of the humeral head with a 2-mm acromiohumeral interval but no femoralization of the humeral head or acetabularization of the acromion. MRI shows a massive, 6-cm tear involving the entire supraspinatus and infraspinatus tendons with retraction to the glenoid rim. There is notable atrophy and fatty infiltration (Goutallier stage 3 to 4) of the rotator cuff musculature. Minimal glenohumeral arthrosis is appreciated. This patient has a chronic, massive rotator cuff tear (C4) with notable muscle atrophy and fatty infiltration with overall mild symptoms and factors that may negatively affect healing and outcome. Based on the criteria in this clinical scenario, the highest recommendation is formal or supervised home-based physical therapy, scoring 8/9. This case demonstrates the panel's view that a chronic, massive cuff tear with notable atrophy, but only mild symptoms, in a patient with risk factors for poor healing, may be treated nonsurgically. In this case, a primary repair is rarely appropriate, scoring 3/9, given the low likelihood of success. A partial repair, reconstructive procedure, or reverse total shoulder arthroplasty may be appropriate in certain situations, each scoring 5/9. Case 2 A 55-year-old carpenter presented with acute left shoulder pain that started when he caught himself falling off a ladder at work. He has a long history of chronic, mild, left shoulder pain, but it has markedly worsened in the past month since the incident. He is otherwise very healthy. He saw his primary care provider a week after the incident, and oral NSAIDs and home-based exercises were prescribed with no relief. Another orthopaedic surgeon conducted a subacromial injection, which the patient says gave him relief for only a few days. He was referred for additional management. On physical examination, his active ROM is slightly decreased (forward flexion and abduction 120°, external rotation 50°, and internal rotation is normal) because of pain. Passively, his ROM is full, although he guards flexion beyond 120°. He has a positive Hawkins test, but his drop arm test is negative. There is no muscular atrophy, and there is minimal discernible weakness, although the patient is fairly demonstrative throughout the examination. Neurological examination of the cervical spine and the upper extremities are normal. Plain radiographs are overall normal. MRI shows a small, 2-cm tear in the supraspinatus tendon with no retraction and no notable atrophy or fatty infiltration (Goutallier stage 1 to 2) of the rotator cuff musculature. This patient has moderate symptoms with an acute exacerbation of their chronic shoulder pain. They have an MRI scan confirming a small tear in a single tendon without atrophy or fatty infiltration. The patient is healthy and did not respond to other treatments, but worker's compensation status remains a negative prognostic factor. Based on the criteria in this clinical scenario, the highest recommendation is for either a primary repair or supervised physical therapy, both scoring 8/9. A partial repair may also be appropriate, assuming that the tear is more extensive or uncompliant than anticipated, scoring 5/9. Arthroplasty and reconstructive procedures are rarely appropriate in these clinical scenarios. This scenario underscores that the option to repair any small symptomatic rotator cuff tear is reasonable, given the likelihood of progression over time, but that physical therapy remains a mainstay of conservative treatment. Case 3 A 60-year-old right-hand–dominant woman presented with 4 months of markedly worsening right shoulder pain. She has had right shoulder pain for approximately 25 years ever since a motor vehicle accident with occasional exacerbations. She denies any acute trauma. The symptoms have gotten worse, and she has had to curtail her exercise program because of decreased range of motion and pain. She is a predominantly right-side sleeper, making it harder to sleep because of pain. Overall, her quality of life is moderately worsened because of her shoulder pain, and because she is otherwise healthy, she would like it treated. She has been doing some home exercises that worked for her in the past, but they do not seem to be helping currently. NSAIDs help the pain, temporarily, but she must take them round the clock or else her pain markedly worsens. A subacromial injection 3 months ago gave her moderate symptomatic improvement, but her symptoms returned subsequently. On physical examination, her active ROM is markedly decreased (forward flexion and abduction 80°, external rotation 20°, and internal rotation is decreased compared with her left side). Passive range of motion is minimally better than active range of motion but still markedly decreased because of pain. She has a painful Neer and Hawkins sign. There is some muscular atrophy in the supraspinatus fossa, and there is obvious weakness, demonstrated by 3/5 strength in the supraspinatus and 4/5 in external rotation with normal (5/5) subscapularis strength. Neurological examination of the cervical spine and the upper extremities are normal. MRI shows a massive tear of the supraspinatus and infraspinatus with extension to the teres minor and retraction to the glenohumeral joint. There is notable atrophy and fatty infiltration (Goutallier stage 3 to 4) of the rotator cuff musculature. No notable glenohumeral arthrosis is noted. Discussion This otherwise healthy patient has a chronic, massive rotator cuff tear (C4) with notable muscle atrophy and fatty infiltration that is at least moderately symptomatic and not responding to treatment. Based on the criteria in this clinical scenario, the highest recommendation is either physical therapy or arthroplasty (8/9), with reconstructive procedures or partial repair also being reasonable (7/9). Primary repair is likely to fail and thus considered less appropriate but still a potential option (5/9). For irreparable tears of the rotator cuff, the CPG is limited to consensus statements suggesting that reverse arthroplasty, partial repair, and reconstructive procedures, including tendon transfer and superior capsular reconstruction, may improve outcomes. Given the lack of clarity in the current scientific literature, the AUC panel could not consistently recommend one of these treatments over another. This scenario thus represents the current limitations of our knowledge base and additional studies are warranted. Conclusion The American Academy of Orthopaedic Surgeons Appropriate Use Criteria for rotator cuff pathology are based on the current clinical practice guidelines and provide a decision-making tool for practitioners based on the best available evidence. Many clinical scenarios remain controversial, given the paucity of high-level comparative literature, and in those cases, the AUC panel has generally considered multiple treatment options as reasonable. Given the many assumptions of the AUC and the variety of clinical scenarios, care should be taken to individuate appropriate treatment. The AUC are meant to be a general guide, not to supersede clinician expertise and judgment. Management of Rotator Cuff Pathology Writing Panel: John Tokish, MD, FAAOS; William Kibler, MD, FAAOS; Albert Lin, MD, FAAOS; Paula Ludewig, PT, PhD; Surena Namdari, MD, FAAOS; Brian Galienat, MD, MBA, FAAOS; Siddharth Joglekar, MD; Christopher Roach, MD, FAAOS; and Robert Waltrip, MD, FAAOS. Voting Panel: Derek Papp, MD, FAAOS; Shawn Kane, MD; Rudolph Mason, MD; Michael Cusick, MD, FAAOS; Sarah Edwards, MD, FAAOS; Charles Thigpen, PT, PhD, ATC; Kent Jason Lowry, MD, FAAOS; Henry Bone Ellis, MD, FAAOS; Gautam P. Yagnik, MD, FAAOS; and Michael Angeline, MD, FAAOS. Voting Panel Moderator: Noah Matthew Raizman, MD, FAAOS. AAOS Staff: Jayson Murray, MA; Kaitlyn Sevarino, MBA, CAE; Ryan Pezold, MA; and Jennifer Rodriguez. The complete Appropriate Use Criteria for the Management of Rotator Cuff Pathology, including all tables, figures, and appendices, as well as the details of the methods used to prepare this AUC are available at https://www.aaos.org/rcauc. Visit https://www.orthoguidelines.org/ to view the 2019 Management of Rotator Cuff Injuries or the 2020 Appropriate Use Criteria for Management of Rotator Cuff Pathology.