- Dr David Colvin
Rotator cuff repair in an ageing workforce
It is well documented that our workforce is ageing. The retirement age went to 67 recently, and there is already talk of pushing it further.
“One consequence of this is the increasing prevalence of degenerative (age-related) conditions contributing to work-related injuries and workers compensation claims.”
Dr David Colvin, Shoulder Surgeon Perth
I have previously written about osteoarthritis of the knee and degenerative meniscal tears in this context.
“The other very common injury in this category is rotator cuff tearing of tendons at the shoulder.”
Dr David Colvin, Shoulder Surgeon Perth
So who should have surgery for a rotator cuff tear?
Where do we draw the line on reconstructive surgery in older patients ?
Firstly, let’s start with the case for non-operative treatment.
There is a high incidence of pain free rotator cuff tears in older age groups.
A low estimate based on ultrasound studies is 10% of people in their 60’s, 20% in their 70’s and 40% in their 80’s.
The actual numbers may be much higher.
It is possible to have a pain free, well functioning shoulder, with a degenerative rotator cuff tear.
That tear may have evolved over many years.
Furthermore, post-operative ultrasound studies have historically shown that many people who have had rotator cuff repair surgery have a good result even when the repair has failed.
“It begs the question – if the surgery succeeds without achieving its primary objective, would the patient’s condition have improved regardless? ”
Dr David Colvin, Shoulder Surgeon Perth
As much as anecdotal evidence is poor science, I can say that I have seen many elderly patients with painful rotator cuff tears settle over time with conservative treatment. The emphasis is ‘over time’. Things don’t happen quickly with orthopaedic rehab.
On the flip side, what are the risks of doing nothing?
In a nutshell, the pain might continue, function may not improve and we might ‘miss the boat’ in terms of repair. Tendons retract, muscles waste away, and the fixable may become unfixable. This is a big problem, as there are no good alternatives once the tear becomes irrepairable. ‘The bail-out’ may be shoulder replacement. Outcomes for a successful repair will be vastly better in a high functioning worker.
There is way too much dogma about orthopaedic surgery online today.
” All shoulder impingement can be treated non-operatively”.
“ All ACL tears can treated with physio”.
The truth is rarely ever black and white in medicine, that’s why we talk about the ‘art’ of medicine.
There is nothing conservative about not operating on a young patient with a full thickness rotator cuff tear.
In fact, it would be radical at the very least, but probably negligent.
It is important to understand all tears are not the same. Rotator cuff tears can be –
A. Acute – meaning recent, traumatic, from injury
B. Chronic – long-standing, degenerative
C. Acute on chronic – injury has increased the size of a pre existing tear, or caused it to become painful.
So here is the algorithm I use to decide who should have surgery.
• Is it fixable? – MRI scans allows us to pick winners.
A big chronic retracted tear with wasted muscle is a non-starter.
Acute tears will do much better.
There is a grey zone in the middle; acute on chronic.
• Biological age – 80 doesn’t rule you out if you look 60 and the corollary.
• Co-morbidities – Diabetes is a big one.
It comes with increased risks of infection, frozen shoulder and poor tendon healing.
Same for smokers.
• Pain and function – Night pain and loss of sleep will test your sanity.
Paralysis from a big acute tear is catastrophic.
These factors might push us towards surgery.
• Patient expectations – Even if I think we are heading to surgery, a short period of non- operative treatment might help decision making.
Partial tears or those not retracted can be rescanned in six months without significant risk.
My final point – more than any other operation, the success of rotator cuff repair surgery depends on good rehab. It’s an unforgiving operation. Patients need a clear understanding of the rehab timeline and targets, and ‘constructive feedback’ if they are not meeting those targets!