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Cochrane in CORR ®: Surgery for Rotator Cuff Disease (Review)

Importance of the Topic

Rotator cuff disease is one of the most common musculoskeletal disorders [9]. According to MRI scans, as many as 54% (25/46) of asymptomatic volunteers older than 60 years of age have partial or complete tears of the rotator cuff [18]. Usually degenerative, rotator cuff tears occasionally are associated with high-velocity trauma and a more favorable prognosis [9]. Shoulder pain negatively impacts quality of life, physical function, and leads to occupational disability [21]. In the United States alone, the diagnosis and management of rotator cuff disease presents a financial burden estimated at 300,000 procedures and USD 3 billion annually [2].

Symptomatic patients typically describe pain with overhead tasks and pain with daily activities [20]. Surgical management generally is reserved for those who fail to improve with conservative treatment, which often includes a combination of subacromial débridement or decompression, débridement and/or repair of partial tears, and generally repair of full thickness tears [20]. Surgery can be performed using open surgery or arthroscopic approaches, but there has recently been a dramatic increase in the number of patients treated arthroscopically [20]. Purported advantages of arthroscopy include rapid recovery and decreased morbidity [7]. However, controversy persists with regards to optimal management of rotator cuff disease [1]. This Cochrane review evaluated all randomized and quasirandomized controlled trials of operative and nonoperative interventions for rotator cuff disease.

Upon Closer Inspection

Intention-to-treat analysis tallies the results of participants according to the group to which they were randomized, regardless of their adherence to assigned intervention [8]. The goals of intention-to-treat are to maintain the balance of prognostic factors between groups created by randomization and to include noncompliance or protocol deviations that reflect real-world treatment effectiveness [5, 16]. In this Cochrane review, 11 of 14 trials failed to perform or report intention-to-treat analyses, and one of the trials reported that a significant number of crossovers were not analyzed in their original group [15]. Failure to employ intention-to-treat analyses typically results in an inflation of the apparent benefits of treatment; because of this, in the studies included in this Cochrane review, the benefits of surgery or other invasive interventions may have been overestimated as a result of failure to use intention-to-treat approaches.

Differential expertise bias is a unique feature of surgical randomized trials that suggests the performance of a novel or alternative procedure by a less-experienced surgeon may lead to inferior outcomes [17]. Expertise-based trial designs attempt to minimize bias and improve validity, feasibility, and ethical integrity by randomizing patients between surgeons with expertise in the intervention of interest [17]. Six of the included trials found no differences in pain or function between arthroscopic and open management of rotator cuff tears, but none adequately described surgeon expertise.

Take-Home Messages

This Cochrane review finds no difference in either functional outcome scores or pain relief between surgical and active nonoperative treatment for impingement syndrome based on three of the 14 included trials at high-risk of bias. Additionally, the review further concluded that no differences exist with regards to pain or functional outcomes between open or arthroscopic subacromial decompression based on six of the 14 trials reporting this comparison.

This Cochrane review demonstrates the need for large, rigorously designed, and well-executed randomized trials [8, 19]. Significant methodological deficiencies preclude firm conclusions regarding the effectiveness of open versus arthroscopic surgical approaches and conservative management for rotator cuff disease. The results of this review are echoed in a recent American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guideline Summary [13]. Nineteen of the 31 recommendations were inconclusive due to lack of high quality evidence.

Future studies can enhance the transparency of their methodological quality by emphasizing clear reporting [6, 11]. The Consolidated Standards of Reporting Trials statement was developed to guide the reporting of randomized controlled trials [12], and modified as the Checklist to Evaluate a Report of a Nonpharmacological Trial to address the unique methodological issues inherent to surgical trials [3] Low-quality reporting has been identified in the orthopaedic literature using these guidelines [6, 10, 14]. Clear reporting of outcomes will allow readers to appropriately evaluate bias and safeguard in future studies [4, 6, 11].

Uniform reporting of patient-important outcomes, as well as objective clinical evaluation of specific rotator cuff muscle strength, and standardized measurement of ROM have been inconsistent and will be critical to fully understand differences between groups. Clinicians must also consider variance in patient’s goals, desires, and expectations. Published studies tend to group older and younger patients together despite the fact that younger patients generally have a better prognosis and desire improved performance, whereas older patients generally desire pain relief.


  1. 1.

    Aleem AW, Brophy RH. Outcomes of rotator cuff surgery: what does the evidence tell us? Clin Sports Med. 2012;31:665–674.

    PubMed  Article  Google Scholar 

  2. 2.

    Bedi A. Torn rotator cuff. Available at: Accessed: Aug. 30, 2013.

  3. 3.

    Boutron I, Moher D, Tugwell P, Giraudeau B, Poiraudeau S, Nizard R, Ravaud P. A checklist to evaluate a report of a nonpharmacological trial (CLEAR NPT) was developed using consensus. J Clin Epidemiol. 2005;58:1233–1240.

    PubMed  Article  Google Scholar 

  4. 4.

    Brand RA. Standards of reporting: The CONSORT, QUORUM, and STROBE guidelines. Clin Orthop Relat Res. 2009;467:1393–1394.

    PubMed  Article  PubMed Central  Google Scholar 

  5. 5.

    Campbell F, Hollis S. What is meant by intention to treat? Survey of published randomised controlled trials. BMJ. 1999;319:670–674.

    PubMed  Article  PubMed Central  Google Scholar 

  6. 6.

    Chan S, Bhandari M. The quality of reporting of orthopaedic randomized trials with use of a checklist for nonpharmacological therapies. J Bone Joint Surg Am. 2007;89:1970–1978.

    PubMed  Article  Google Scholar 

  7. 7.

    Colvin A, Egorova N, Harrison A, Moskowitz A, Flatow E. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94:227–233.

    PubMed  Article  PubMed Central  Google Scholar 

  8. 8.

    Guyatt GH, Sackett DL, Cook DJ. Users’ guides to the medical literature. II. How to use an article about therapy or prevention. A. Are the results of the study valid? Evidence-based medicine working group. JAMA. 1993;270:2598–2601.

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Iannotti J. Full-thickness rotator cuff tears: Factors affecting surgical outcome. J Am Acad Orthop Surg. 1994;2:87–95.

    PubMed  Google Scholar 

  10. 10.

    Jacquier I, Boutron I, Moher D, Roy C, Ravaud P. The reporting of randomized clinical trials using a surgical intervention is in need of immediate improvement: a systematic review. Ann Surg. 2006;244:677–683.

    PubMed  Article  PubMed Central  Google Scholar 

  11. 11.

    Leopold SS, Porcher R. Reporting statistics in abstracts in Clinical Orthopaedics and Related Research®. Clin Orthop Relat Res. 2013;471:1739–1740.

    PubMed  Article  PubMed Central  Google Scholar 

  12. 12.

    Moher D, Schulz K, Altman D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel group randomized trials. BMC Medical Research Methodology. 2001;1:2.

    PubMed  Article  CAS  PubMed Central  Google Scholar 

  13. 13.

    Pedowitz RA, Yamaguchi K, Ahmad CS, Burks RT, Flatow EL, Green A, Ianotti JP, Miller BS, Tashjian RZ, Watters WC 3rd, Weber K, Turkelson CM, Wies JL, Anderson S, St Andre J, Boyer K, Raymond L, Sluka P, McGowan R, American Academy of Orthoapedic Surgeons. Optimizing the management of rotator cuff problems. J Am Acad Orthop Surg. 2011;19:368–379.

  14. 14.

    Poolman RW, Struijs PA, Krips R, Sierevelt IN, Lutz KH, Bhandari M. Does a “Level I Evidence” rating imply high quality of reporting in orthopaedic randomised controlled trials? BMC Med Res Methodol. 2006;6:44.

    PubMed  Article  PubMed Central  Google Scholar 

  15. 15.

    Rahme H, Solem-Bertoft E, Westerberg CE, Lundberg E, Sorensen S, Hilding S. The Subacromial Impingement Syndrome. A study of results of treatment with special emphasis on predictive factors and pain-generating mechanisms. Scandinavian Journal of Rehabilitation Medicine 1998;30:253–262.

    PubMed  Article  CAS  Google Scholar 

  16. 16.

    Scharfstein DO, Hogan J, Herman A. On the prevention and analysis of missing data in randomized clinical trials: The state of the art. J Bone Joint Surg Am. 2012;94 Suppl 1:80–84.

    PubMed  Article  PubMed Central  Google Scholar 

  17. 17.

    Scholtes VA, Nijman TH, van Beers L, Devereaux PJ, Poolman RW. Emerging designs in orthopaedics: expertise-based randomized controlled trials. J Bone Joint Surg Am. 2012

  18. 18.

    Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77:10–15.

    PubMed  CAS  Google Scholar 

  19. 19.

    SPRINT Investigators, Bhandari M, Tornetta P,3rd, Rampersad SA, Sprague S, Heels-Ansdell D, Sanders DW, Schemitsch EH, Swiontkowski M, Walter S. (Sample) size matters! An examination of sample size from the SPRINT trial study to prospectively evaluate reamed intramedullary nails in patients with tibial fractures. J Orthop Trauma. 2013;27:183–188.

  20. 20.

    Wolf B, Dunn W, Wright R. Indications for repair of full-thickness rotator cuff tears. Am J Sports Med. 2007;35:1007–1016.

    PubMed  Article  Google Scholar 

  21. 21.

    Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease: A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88:1699–1704.

    PubMed  Article  Google Scholar 

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Author information



Corresponding author

Correspondence to Moin Khan MD.

Additional information

A Note from the Editor-in-Chief: We are pleased to publish the next installment of Cochrane in CORR® , our partnership between CORR®, The Cochrane Collaboration® , and McMaster University’s Evidence-Based Orthopaedics Group. In it, we will identify an abstract originally published in The Cochrane Library that we think is especially important, and researchers from McMaster University will provide expert perspective on it.

(Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD005619. DOI: 10.1002/14651858.CD005619.pub2.)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Reproduced with permission.

The authors certify that they, or any member of their immediate families, have no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or the Association of Bone and Joint Surgeons®.

Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library ( should be consulted for the most recent version of the review.

This Cochrane in CORR ® column refers to the abstract available at: DOI: 10.1002/14651858.CD005619.pub2.




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Khan, M., Simunovic, N. & Provencher, M. Cochrane in CORR ®: Surgery for Rotator Cuff Disease (Review). Clin Orthop Relat Res 472, 3263–3269 (2014).

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  • Rotator Cuff
  • Cochrane Review
  • Rotator Cuff Tear
  • Rotator Cuff Muscle
  • Full Thickness Tear