Rotator cuff disease is a fascinating clinical entity. Despite decades of treating rotator cuff tears, the evidence keeps mounting that the exact etiology of symptoms and the predictors of success after treatment are still not entirely known.

The purpose of the study by Russell et al. was to review the highest level of evidence available on the correlation between structural integrity of the rotator cuff after surgical repair and patient outcome measures. A combination of meta-analysis and systematic review methodology was utilized to examine this question. This study examines how well the two most commonly reported end points in rotator cuff surgery, patient clinical outcome measures and radiographic healing, correlate with each other.

There can be great power in meta-analyses and systematic reviews. The level of evidence of these studies is determined by the level of evidence of the included research. In this study, the authors included only Level-I and Level-II studies. Hence, these studies represent high-level evidence on a large number of patients. The authors only included studies with a minimum of one year of follow-up, at least one outcome measure, and imaging evaluation of healing using magnetic resonance imaging, computed tomographic arthography, or ultrasound. Overall, fourteen studies (five Level-I studies and nine Level-II studies) met inclusion criteria with an impressive combined total of 861 patients.

Russell et al. pooled studies that used similar outcome measures. Four studies used the Constant score, five studies used the American Shoulder and Elbow Surgeons (ASES) score, four studies used the University of California Los Angeles (UCLA) shoulder score, and three studies used the visual analog scale (VAS) score. Two studies examined shoulder external rotation strength, and three studies examined forward flexion strength. Overall, 78% of the rotator cuff repairs were healed on postoperative imaging. A significant improvement was noted for the Constant, VAS, and UCLA scores in patients with intact rotator cuff repairs. The ASES score was not significantly different. However, despite achieving significance, the results did not meet known benchmarks for meeting the minimal clinically important difference. Validated outcome measures have minimal clinically important difference values that allow for the determination of whether numerical differences in scores can be deemed significant. The UCLA and Constant scores are not validated. However, the differences seen between intact repairs and recurrent tears did not meet levels that would be considered clinically important. The validated VAS and ASES scores did not meet the minimal clinically important difference benchmarks either.

The included studies do seem to support that a healed rotator cuff repair is associated with increased forward flexion strength of approximately five pounds. There is no minimal clinically important difference for strength. However, this is useful information to pass along to patients considering rotator cuff surgery, especially if regaining strength is a priority for the patient.

This study summarizes what many in orthopaedics have recognized over the years. The vast majority of patients are subjectively improved after rotator cuff repair surgery, despite evidence that a variable percentage of repairs either do not heal or do retear. However, the current study demonstrates that the presence of an intact repair does not lead to a significantly improved clinical outcome based on patient outcome measures. Taking a step back, these results also call into question whether the rotator cuff tear itself is solely responsible for the symptoms that led a patient to undergo an operation. It is possible that the underlying cause for a patient’s pain and dissatisfaction that contribute to patient-related outcome measures is something other than the rotator cuff tear itself, given that patient outcome measures are similar whether the repair is intact or not after surgery.

Again, rotator cuff disease is fascinating. It is known that a substantial portion of the population has asymptomatic rotator cuff tears. It has also been shown that patients with an atraumatic, full-thickness rotator cuff tear can be successfully managed with conservative treatment. Yet failure of conservative measures, patient activity levels, and expectations often lead to surgical management to repair symptomatic patients with rotator cuff tears.