Shoulder Pain Does Not Parallel Rotator Cuff Tear Size—What Does That Tell Us?: Commentary on an article by Warren R. Dunn, MD, MPH, et al.: “Symptoms of Pain Do Not Correlate with Rotator Cuff Tear Severity. A Cross-Sectional Study of 393 Patients with a

It is simultaneously critical and refreshing to read an article that keeps our focus on the patient. This is especially true in the very confusing world of rotator cuff tears, where recent articles have claimed, on the one hand, that rotator cuff repair “is cost-effective for all patients” and that “the estimated lifetime societal savings of the approximately 250,000 rotator cuff repairs performed in the U.S. each year was $3.44 billion”and, on the other hand, that “the clinical outcomes after the operation [cuff repair] did not differ significantly between the patients who had healing of the tear and those who did not (p = 0.438, p = 0.625, and p = 0.898 for the UCLA, ASES, and Constant-Murley scores, respectively).”Even the American Academy of Orthopaedic Surgeons Clinical Practice Guideline on Optimizing the Management of Rotator Cuff Problems is replete with recommendations of limited or inconclusive strength.

Taking a new tack, the authors of this paper conducted a multicenter study examining 393 subjects with an atraumatic symptomatic full-thickness rotator cuff tear with respect to their self-reported pain and the severity of their cuff disease in terms of tear size, retraction, superior head migration, and rotator cuff muscle atrophy. Seventy-two percent of the patients had a supraspinatus-only tear, 48% had minimal retraction, and 16% had superior humeral head migration. In these 393 patients, anatomic indicators of rotator cuff tear severity (e.g., number of tendons torn, degree of retraction, and degree of fatty degeneration) were not associated with the pain level. In contrast, increased comorbidities (p = 0.002), lower education level (p = 0.004), and race (p = 0.041) were significantly associated with pain on presentation. We may draw three conclusions from these results: (1) none of these three pain-associated factors will be changed by an attempt at surgical repair, (2) these three factors need to be included in studies of the effectiveness of rotator cuff surgery in reducing pain, and (3) patients who have an atraumatic tear and substantial pain may benefit from a thorough search for factors other than the cuff tear as the cause of the pain.