Arthroscopic rotator cuff repair is an effective procedure through which to decrease pain and increase strength, with favorable long-term outcomes demonstrated in older patient populations with full-thickness rotator cuff tears. The long-term outcomes after this procedure in younger, higher-demand patients, however, is not as clearly defined.
Purpose:
To report on the long-term outcomes after arthroscopic rotator cuff repair of traumatic full-thickness rotator cuff tears in active duty military patients under the age of 40 years at the time of surgery.
Study Design:
Case series; Level of evidence, 4.
Methods:
Preoperative, midterm, and final evaluations were collected, including scores on the visual analog scale for pain, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons shoulder form. A total of 42 patients were screened for inclusion: 3 underwent additional surgical procedures on the operative shoulder and 2 were lost to follow-up, leaving 37 patients with mean follow-up of 104.51 months available for analysis. A subgroup analysis was performed comparing outcomes between patients with Southern California Orthopaedic Institute grade 1 or 2 tears and those with grade 3 or 4 tears.
Results:
At final follow-up, pain per the visual analog scale decreased to 1.16 from 8.03 (P < .0001); the Single Assessment Numeric Evaluation score increased to 87.32 from 48.24 (P < .0001); and the American Shoulder and Elbow Surgeons score increased to 88.68 from 41.00 (P < .0001). There was no statistically significant difference in outcome scores or range of motion between midterm and final follow-up. Improvement in outcome scores and range of motion at final follow-up did not vary between patients with small and large tears. Of 42 patients, 37 (88.1%) were able to return to full unrestricted active duty and sporting activity, while 5 (11.9%) were medically separated from the military.
Conclusion:
Active duty military patients under the age of 40 years with traumatic full-thickness rotator cuff tears had statistically and clinically significant increases in outcome scores and decreases in pain after arthroscopic rotator cuff repair at long-term follow-up.
AgerALRoyJSGamacheFHebertLJ. The effectiveness of an upper extremity neuromuscular training program on the shoulder function of military members with a rotator cuff tendinopathy: a pilot randomized controlled trial. Mil Med. 2019;184(5-6):e385-e393.
2.
BenjaminiYKriegerrAMYekutieliD. Adaptive linear step-up procedures that control the false discovery rate. Biometrika. 2006;93(3): 491-507.
3.
BjörnssonHCNorlinRJohanssonKAdolfssonLE. The influence of age, delay of repair, and tendon involvement in acute rotator cuff tears: structural and clinical outcomes after repair of 42 shoulders. Acta Orthop. 2011;82(2):187-192.
4.
BokshanSLKotchmanHMLiLTDeFrodaSFCameronKLOwensBD. Incidence of posterior shoulder instability in the United States military: demographic considerations from a high-risk population. Am J Sports Med. 2021;49(2):340-345.
5.
BurkhartSS. Internal impingement of the shoulder. Instr Course Lect. 2006;55:29-34.
6.
BurnsJPSnyderSJ. Arthroscopic rotator cuff repair in patients younger than fifty years of age. J Shoulder Elbow Surg. 2008;17(1): 90-96.
7.
Centre for Swedish National Musculoskeletal Competence. National Indications for Shoulder Surgery. Centre for Swedish National Musculoskeletal Competence; 2006.
8.
CvetanovichGLGowdAKLiuJN, et al. Establishing clinically significant outcome after arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2019;28(5):939-948.
9.
DeBerardinoTMArcieroRATaylorDC. Arthroscopic stabilization of acute initial anterior shoulder dislocation: the West Point experience. J South Orthop Assoc. 1996;5(4):263-271.
10.
DickensJFKilcoyneKGHaniukEOwensBD. Combined lesions of the glenoid labrum. Phys Sportsmed. 2012;40(1):102-108.
11.
DumontGDGolijaninPProvencherMT. Shoulder instability in the military. Clin Sports Med. 2014;33(4):707-720.
12.
DwyerTRazmjouHHoltbyR. Full-thickness rotator cuff tears in patients younger than 55 years: clinical outcome of arthroscopic repair in comparison with older patients. Knee Surg Sports Traumatol Arthrosc. 2015;23(2):508-513.
13.
EnadJGKurtzCA. Isolated and combined type II SLAP repairs in a military population. Knee Surg Sports Traumatol Arthrosc. 2007;15(11):1382-1389.
14.
FlintJHPickettAOwensBD, et al. Recurrent shoulder instability in a young, active, military population and its professional implications. Sports Health. 2018;10(1):54-59.
15.
FuchsBWeishauptDZanettiMHodlerJGerberC. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8(6):599-605.
16.
GoutallierDPostelJMBernageauJLavauLVoisinMC. Fatty muscle degeneration in cuff ruptures: pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78-83.
17.
GutmanMJJoyceCDPatelMS, et al. Early repair of traumatic rotator cuff tears improves functional outcomes. J Shoulder Elbow Surg. 2021;30(11):2475-2483.
18.
HantesMEKaridakisGKVlychouMVaritimidisSDailianaZMalizosKN. A comparison of early versus delayed repair of traumatic rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. 2011;19(10):1766-1770.
19.
HeHBWangTWangMC, et al. Tendon-to-bone healing after repairing full-thickness rotator cuff tear with a triple-loaded single-row method in young patients. BMC Musculoskelet Disord. 2021;22(1):305.
20.
HijiokaASuzukiKNakamuraTHojoT. Degenerative change and rotator cuff tears: an anatomical study in 160 shoulders of 80 cadavers. Arch Orthop Trauma Surg. 1993;112(2):61-64.
21.
HsiaoMSCameronKLTuckerCJBenigniMBlaineTAOwensBD. Shoulder impingement in the United States military. J Shoulder Elbow Surg. 2015;24(9):1486-1492.
22.
KampaRJClasperJ. Incidence of SLAP lesions in a military population. J R Army Med Corps. 2005;151(3):171-175.
23.
KrishnanSGHarkinsDCSchiffernSCPenningtonSDBurkheadWZ. Arthroscopic repair of full-thickness tears of the rotator cuff in patients younger than 40 years. Arthroscopy. 2008;24(3):324-328.
24.
KukkonenJKaukoTVirolainenPAarimaaV. The effect of tear size on the treatment outcome of operatively treated rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. 2015;23(2):567-572.
25.
LazaridesALAlentorn-GeliEChoiJH, et al. Rotator cuff tears in young patients: a different disease than rotator cuff tears in elderly patients. J Shoulder Elbow Surg. 2015;24(11):1834-1843.
26.
MacKechnieMAChahalJWassersteinDTheodoropoulosJSHenryPDwyerT. Repair of full-thickness rotator cuff tears in patients aged younger than 55 years. Arthroscopy. 2014;30(10): 1366-1371.
27.
MillettPJWilcoxRB3rdO’HolleranJDWarnerJJ. Rehabilitation of the rotator cuff: an evaluation-based approach. J Am Acad Orthop Surg. 2006;14(11):599-609.
28.
MurrayMLangeBNornbergBRSogaardKSjogaardG. Specific exercise training for reducing neck and shoulder pain among military helicopter pilots and crew members: a randomized controlled trial protocol. BMC Musculoskelet Disord. 2015;16:198.
29.
NhoSJYadavHShindleMKMacgillivrayJD. Rotator cuff degeneration: etiology and pathogenesis. Am J Sports Med. 2008;36(5): 987-993.
30.
OwensBDDawsonLBurksRCameronKL. Incidence of shoulder dislocation in the United States military: demographic considerations from a high-risk population. J Bone Joint Surg Am. 2009;91(4):791-796.
31.
OwensBDDuffeyMLNelsonBJDeBerardinoTMTaylorDCMountcastleSB. The incidence and characteristics of shoulder instability at the United States Military Academy. Am J Sports Med. 2007;35(7):1168-1173.
32.
ParkILeeHJChoiYHKimYS. Arthroscopic repair of large to massive rotator cuff tears in patients younger than 60 years. J Orthop Sci. 2020;25(1):104-109.
33.
ParnesNBartoszewskiNRDefrancoMJ. Arthroscopic repair of full-thickness rotator cuff tears in active patients younger than 40 years: 2- to 5-year clinical outcomes. Orthopedics. 2018;41(1):e52-e57.
34.
ParnesNDunnJCCzajkowskiHDeFrancoMJGreenCKScanaliatoJP. Biceps tenodesis as an attractive alternative to superior labral anterior-posterior (SLAP) repair for type II SLAP lesions in active-duty military patients younger than 35 years. Am J Sports Med. 2021;49(14):3945-3951.
35.
ParnesNPerrineJDeFrancoMJ. Outcomes of simultaneous arthroscopic rotator cuff repair and inferior labral repair among active patients younger than 40 years. Orthopedics. 2021;44(3): e326-e330.
36.
PiperCCHughesAJMaYWangHNeviaserAS. Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2018;27(3):572-576.
37.
ProvencherMTMannavaSTokishJMRogersJP. Traumatic anterior shoulder instability: the US military experience. Am J Orthop (Belle Mead NJ). 2017;46(4):184-189.
38.
RammeAJRobbinsCBPatelKA, et al. Surgical versus nonsurgical management of rotator cuff tears: a matched-pair analysis. J Bone Joint Surg Am. 2019;101(19):1775-1782.
39.
RandelliPSMenonANocerinoE, et al. Long-term results of arthroscopic rotator cuff repair: initial tear size matters: a prospective study on clinical and radiological results at a minimum follow-up of 10 years. Am J Sports Med. 2019;47(11):2659-2669.
40.
RossyWSanchezGSanchezAProvencherMT. Superior labral anterior-posterior (SLAP) tears in the military. Sports Health. 2016;8(6):503-506.
41.
ShimSBJeongJYYumTHYooJC. A comparative study to evaluate the risk factors for medium-sized rotator cuff tear in patients younger than 50 years of age. Arthroscopy. 2018;34(11):2971-2979.
42.
SnyderS. Arthroscopic classification of rotator cuff lesions and surgical decision making. In: Shoulder Arthroscopy. Lippincott Williams & Wilkins, eds; 2003:201-207.
43.
SongADeClercqJAyersGD, et al. Comparative time to improvement in nonoperative and operative treatment of rotator cuff tears. J Bone Joint Surg Am. 2020;102(13):1142-1150.
44.
SperlingJWCofieldRHSchleckC. Rotator cuff repair in patients fifty years of age and younger. J Bone Joint Surg Am. 2004;86(10): 2212-2215.
45.
SprossCBehrensGDietrichTJ, et al. Early arthroscopic repair of acute traumatic massive rotator cuff tears leads to reliable reversal of pseudoparesis: clinical and radiographic outcome. Arthroscopy. 2019;35(2):343-350.
46.
TashjianRZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clin Sports Med. 2012;31(4):589-604.
47.
TashjianRZShinJBroschinskyK, et al. Minimal clinically important differences in the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores after arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2020;29(7):1406-1411.
48.
TempelhofSRuppSSeilR. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296-299.
49.
WalsworthMKDoukasWCMurphyKPBimsonWMielcarekBJMichenerLA. Descriptive analysis of patients undergoing shoulder surgery at a tertiary care military medical center. Mil Med. 2009;174(6):642-644.
50.
WatermanBOwensBDTokishJM. Anterior shoulder instability in the military athlete. Sports Health. 2016;8(6):514-519.
51.
WatermanBRCameronKLHsiaoMLangstonJRClarkNJOwensBD. Trends in the diagnosis of SLAP lesions in the US military. Knee Surg Sports Traumatol Arthrosc. 2015;23(5):1453-1459.
52.
Witney-LagenCMazisGBrugueraJAtounESforzaGLevyO. Do elderly patients gain as much benefit from arthroscopic rotator cuff repair as their younger peers?J Shoulder Elbow Surg. 2019;28(6): 1056-1065.
53.
WolfeJAChristensenDLMauntelTCOwensBDLeClereLEDickensJF. A history of shoulder instability in the military: where we have been and what we have learned. Mil Med. 2018;183(5-6):e158-e165.
54.
WorlandRLLeeDOrozcoCGSozaRexFKeenanJ. Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. J South Orthop Assoc. 2003;12(1):23-26.
55.
YamaguchiKTetroAMBlamOEvanoffBATeefeySAMiddletonWD. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg. 2001;10(3):199-203.
56.
YowBGWadeSMBedrinMDRueJHLeClereLE. The incidence of posterior and combined AP shoulder instability treatment with surgical stabilization is higher in an active military population than in the general population: findings from the US Naval Academy. Clin Orthop Relat Res. 2021;479(4):704-708.
57.
ZinggPOJostBSukthankarABuhlerMPfirrmannCWGerberC. Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am. 2007;89(9):1928-1934.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
