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Surgical Versus Nonsurgical Management of Rotator Cuff Tears: Predictors of Treatment Allocation
Christopher Kweon, Joel J. Gagnier, Christopher B. Robbins, Asheesh Bedi, James E. Carpenter and Bruce S. Miller
Am J Sports Med 2015 43: 2368 originally published online August 12, 2015
DOI: 10.1177/0363546515593954
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Surgical Versus Nonsurgical Management

of Rotator Cuff Tears
Predictors of Treatment Allocation
Christopher Kweon,* MD, Joel J. Gagnier,*y PhD, Christopher B. Robbins,* PhD,
Asheesh Bedi,* MD, James E. Carpenter,* MD, and Bruce S. Miller,*z MD, MS
Investigation performed at the University of Michigan, Ann Arbor, Michigan, USA
Background: Rotator cuff tears are a common shoulder disorder resulting in significant disability to patients and financial burden
on the health care system. While both surgical and nonsurgical management are accepted treatment options, there is a paucity of
data to support a treatment algorithm for care providers. Defining variables to guide treatment allocation may be important for
patient education and counseling, as well as to deliver the most efficient care plan at the time of presentation.
Purpose: To identify independent variables at the time of initial clinical presentation that are associated with preferred allocation
to surgical versus nonsurgical management for patients with known full-thickness rotator cuff tears.
Study Design: Case control study; Level of evidence, 3.
Methods: A total of 196 consecutive adult patients with known full-thickness rotator cuff tears were enrolled into a prospective
cohort study. Robust data were collected for each subject at baseline, including age, sex, body mass index (BMI), shoulder activity score, smoking status, size of cuff tear, duration of symptoms, functional comorbidity index, the American Shoulder and Elbow
Surgeons (ASES) score, the Western Ontario Rotator Cuff index (WORC), and the Veterans Rand 12-Item Health Survey (VR-12).
Logistic regression was performed to identify variables associated with treatment allocation, and the corresponding odds ratios
were calculated.
Results: Of the 196 patients enrolled, 112 underwent surgical intervention and 84 nonoperative management. With covariates controlled for, significant baseline patient characteristics predictive of eventual allocation to surgical treatment included younger age,
lower BMI, and durations of symptoms less than 1 year. Increasing age, higher BMI, and duration of symptoms longer than 1 year
were predictive of nonsurgical treatment. Factors that were not associated with treatment allocation included sex, tear size, functional
comorbidity score, or any of the patient-derived outcome scores at presentation (ASES, WORC, VR-12, shoulder activity score).
Conclusion: Patient demographics at the time of initial presentation for a symptomatic rotator cuff tear are more predictive of
treatment allocation to a surgical or nonoperative approach than the patient-derived outcome scores for activity level and shoulder disability. Further study is warranted to help define appropriate indications for treatment allocation in patients with rotator cuff
tears.
Keywords: rotator cuff; treatment allocation; predictors of surgery

Rotator cuff tears are a common shoulder disorder resulting

in significant disability to patients and financial burden on
the health care system.15,33 Evidence suggests that the
number of medical visits related to shoulder pain as well
as the number of rotator cuff procedures that are performed
in the United States will continue to grow.6 Early clinical
studies reported acceptable results with treating rotator
cuff tears nonoperatively.3,17,18,22,32,35,39 Numerous clinical
reports also describe favorable outcomes after surgical
treatment of rotator cuff tears regardless of varying patient
demographics, size or quality of tear, timing of surgery, or
operative techniques, implants, and approaches used.

Address correspondence to Bruce S. Miller, MD, MS, Department of

Orthopaedic Surgery, University of Michigan, MedSport, 24 Frank Lloyd
Wright Drive, Ann Arbor, MI 48106-0391, USA (email: bsmiller@med
.umich.edu).
*Department of Orthopaedic Surgery, University of Michigan, Ann
Arbor, Michigan, USA.
y
Department of Epidemiology, University of Michigan, Ann Arbor,
Michigan, USA.
Presented at the 40th annual meeting of the AOSSM, Seattle, Washington, July 2014.
One or more of the authors has declared the following potential conflict of interest or source of funding: This study was partly supported by
the Francis and Kenneth Eisenberg Research Fund.
The American Journal of Sports Medicine, Vol. 43, No. 10
DOI: 10.1177/0363546515593954
2015 The Author(s)

References 5, 8, 13, 14, 16, 19, 24, 25, 30, 34.

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Vol. 43, No. 10, 2015

Predictors of RCT Treatment Allocation

Despite the abundance of literature supporting both

surgical and nonsurgical management as accepted treatment options, few studies demonstrate how and why those
treatment options are used. The natural history of patients
with rotator cuff tears and the factors associated with
worsening of symptoms such as increasing tear size,
increased amount of fatty infiltration and muscle atrophy
of the rotator cuff, and increased length of follow-up have
been described.26,29 However, it is unclear to what extent
these factors are used to guide clinical practice. Defining
variables to guide treatment allocation may be important
for patient education and counseling, as well as to deliver
a rational and cost-effective plan of care at the time of presentation.38 The objective of this study was to identify
patient characteristics at the time of initial clinical presentation that are associated with allocation to surgical versus
nonsurgical management for patients with known fullthickness rotator cuff tears and to compare those identified
factors with existing clinical practice guidelines for treatment of rotator cuff tears.
It was hypothesized that the variables at the time of
clinical presentation associated with greater physical
demands and greater shoulder disability would be predictive of eventual allocation to surgical treatment while the
variables associated with less physical demands and shoulder disability would be predictive of allocation to an initial
trial of nonoperative management.

METHODS
Participant Selection
Institutional review board approval was obtained to conduct
a prospective observational study. All adult patients with
a known full-thickness rotator cuff tear treated by any of
3 high-volume shoulder surgeons (J.E.C., B.S.M., A.B.) at
our institution were offered enrollment in the study and
offered a US$50 gift card inducement for participation. Confirmation of full-thickness tear was determined with either
magnetic resonance imaging (MRI) or diagnostic musculoskeletal ultrasound. Exclusion criteria included age younger
than 18 years, presence of moderate to severe glenohumeral
arthritis, history of surgery, infection of the affected
shoulder, or history of fracture, adhesive capsulitis, or
inflammatory arthropathy. After inclusion in the study, no
alterations to each patients clinical course were made.
Eventual allocation to surgical or nonsurgical treatment
was determined individually while progressing along a standardized management protocol for rotator cuff disease.
Because of existing referral patterns and clinical structure,
all patients enrolled in the study who obtained surgical
consultation for evaluation had confirmed diagnosis of
full-thickness rotator cuff tear by advanced imaging. The
management protocol consisted of initial nonoperative
measures, which included activity modification, antiinflammatory drugs, physical therapy, and corticosteroid
injections. The surgical consultation involved a discussion
of risks and benefits of surgical and nonsurgical treatments
and a decision made by the patient to either continue with

2369

nonoperative measures or undergo surgery to repair the

rotator cuff. The specific contents of each discussion during
each patient encounter were not recorded. The duration of
nonoperative treatment before surgical consultation was
not obtainable due to initiation of treatment being started
in the majority of patients before surgical consultation at
outside institutions.

Data Collection
Robust data were collected for each patient at baseline and
included age, sex, body mass index (BMI), shoulder activity
score, current smoking status, size of cuff tear, duration of
symptoms, functional comorbidity index, treating surgeon,
the American Shoulder and Elbow Surgeons (ASES) score,27
the Western Ontario Rotator Cuff index (WORC),23 and the
Veterans Rand 12-Item Health Survey (VR-12).20 Allocation
to surgical or nonsurgical treatment was monitored over
a 2-year period (2012-2013) and recorded for each patient.
Age, BMI, shoulder activity score, functional comorbidity index, ASES score, WORC, and VR-12 scores were all
collected as continuous data, whereas sex, smoking status,
size of cuff tear, duration of symptoms, and treating surgeon were collected as categorical variables. Size of cuff
tear was based on MRI or ultrasound report and classified
based on the largest reported tear dimension in the
anterior to posterior direction as small (0-1 cm), medium
(1-3 cm), large (3-5 cm), and massive (5 cm). Duration
of symptoms was separated into 2 categories based on
the distribution of reported duration of symptoms of the
patients in the study group: greater than or less than 1
year. Each of the 3 surgeons was coded to control for and
evaluate the individual surgeons tendency for allocation
to surgical or nonsurgical treatment.

Statistical Analysis
All statistical analysis was performed using procedures
available in SPSS version 21 (SPSS, Inc). Demographic
and baseline scores were compared between patients allocated to surgical and nonsurgical treatment. Categorical
data were examined in contingency tables with inferential
testing by the x2 or Fisher exact test. The x2 test was used
for factors involving more than 2 possible observations.
Continuous data were analyzed using the Student t test
and summarized as means with standard deviations. Ordinary least squares logistic regression was performed to
identify independent variables that had a predictive effect
on treatment allocation, and the corresponding adjusted
odds ratios (ORs) were calculated. The confidence level
for rejecting null hypotheses was set at 95% (P  .05).
The dependent variable was set as surgery or no surgery.
The independent variables were age, sex, BMI, shoulder
activity score, smoking status, size of cuff tear, duration
of symptoms, functional comorbidity index, treating surgeon, ASES score, WORC index, and VR-12 physical and
mental component summary scores. No sample size calculations were performed.

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2370 Kweon et al

The American Journal of Sports Medicine

TABLE 1
Comparison of Surgical Versus Nonsurgical Group CharacteristicsContinuous Variablesa
Nonsurgical Group (n = 84)
Age, y
Body mass index, kg/m2
Functional comorbidity score
Shoulder activity level
ASES score
WORC index
VR-12
Physical CSS
Mental CSS

64
31.4
1.6
9.6
58
1070

6
6
6
6
6
6

Surgical Group (n = 112)

9.9
6.3
1.7
5.2
22.7
496

58
29.6
1.1
11
51
1243

38 6 11.0
50 6 11.6

P Value

9.0
6.4
1.2
4.6
18.4
368

\.001
.05
.01
.06
.04
.006

38 6 9.2
50 6 12.6

.641
.931

6
6
6
6
6
6

a
Results are reported as mean 6 SD. ASES, American Shoulder and Elbow Surgeons; CSS, component summary score; VR-12, Veterans
Rand 12-Item Health Survey; WORC, Western Ontario Rotator Cuff.

RESULTS
A total of 196 patients were consecutively enrolled, 80
women and 116 men. All patients offered enrollment
accepted. Of those enrolled, 112 (57%) ultimately underwent surgical intervention and 84 (43%) nonoperative
management. Demographic data of the study participants
based on treatment allocation are outlined in Tables 1
and 2. The mean 6 SD age of patients treated nonoperatively was 64 6 9.9 years (range, 34-85 years) versus 58
6 9.0 years (range, 37-76 years) in the surgically managed
group (P \ .001). Compared with the patients managed
nonoperatively, the surgically managed group averaged
higher baseline shoulder activity scores, 11.0 versus 9.6
(P = .06); lower ASES scores, 51 versus 58 (P = .04); and
higher (more symptomatic) WORC index scores, 1243 versus 1070 (P = .006). There were no statistically significant
differences in allocation to surgical or nonsurgical treatment between the 3 treating surgeons (P = .55).
To assess for covariance, we further analyzed all the
preoperative variables together. After regression analysis
with all 12 independent variables, statistically significant
baseline patient characteristics predictive of eventual decision of nonsurgical treatment included increasing age (OR,
0.884 [95% CI, 0.834-0.937]; P \ .001) and higher BMI
(OR, 0.894 [95% CI, 0.829-0.965]; P = .004). Duration of
symptoms less than 1 year (OR, 3.00 [95% CI, 1.22-7.42];
P = 0.017) was predictive of surgical treatment allocation.
Factors that were not associated with surgical or nonsurgical treatment included sex, tear size, treating surgeon,
functional comorbidity score, ASES score, WORC index,
VR-12, and shoulder activity score. The statistical analysis
performed on all independent factors is outlined in Table 3.

DISCUSSION
The results of this prospective study demonstrate that allocation to surgical or nonsurgical treatment is strongly associated with certain baseline demographic factors such as
age and BMI but not with clinical scores of disability at
the time of initial presentation. This was an unexpected
finding in that a perceived increased level of disability and

TABLE 2
Comparison of Surgical Versus Nonsurgical
Group CharacteristicsCategorical Variablesa
Nonsurgical
Group
(n = 84)

Surgical
Group
(n = 112)

44 (52)
40 (48)

72 (64)
40 (36)

10 (12)
74 (88)

15 (13)
97 (87)

53 (63)
31 (37)

81 (72)
31 (28)

Sex
Male
Female
Smoker
Yes
No
Duration of symptoms
\1 year
.1 year
Tear size
Small (\1 cm)
Medium (1-3 cm)
Large (3-5 cm)
Massive (.5 cm)
Surgeon
A
B
C

P Value
.11 (FET)

.466 (FET)

.214 (FET)

.258 (x2 = 4.03)

17
40
21
6

(20)
(48)
(25)
(7)

31
33
35
13

(28)
(30)
(31)
(12)
.555 (x2 = 1.18)

26 (31)
20 (24)
38 (45)

27 (24)
28 (25)
57 (51)

Results are reported as n (%). FET, Fisher exact test.

pain due to a rotator cuff tear did not lead to increased likelihood of pursuing surgical treatment. Of the subjective clinical scores that were analyzed, a higher (less favorable)
WORC index was the most predictive of surgical treatment
allocation, but this did not reach statistical significance. No
prior studies have demonstrated that patients of younger
age or lower BMI prefer surgical treatment of rotator cuff
disease. No qualitative or quantitative studies have suggested that orthopaedic surgeons prefer to perform surgery
on younger or lower BMI patients who have full-thickness
rotator cuff tears. While studies suggest that surgery performed for acute rotator cuff tears may have improved outcomes compared with chronic tears,1 it is still unclear if the
decision for surgery is affected by acuity of symptoms.3
Identification of factors at initial presentation that
predict allocation to surgical or nonsurgical treatment of

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Vol. 43, No. 10, 2015

Predictors of RCT Treatment Allocation

TABLE 3
Logistic Regression Analysis of Surgical
Allocation (N = 196)a
Independent Variable
Sex (reference = female)
Age, y
Body mass index, kg/m2
Nonsmoker
Symptom duration \1 year
Tear category (reference = massive)
Small
Medium
Large
Surgeon (reference = surgeon C)
A
B
Functional comorbidity index
Shoulder activity level
ASES score
WORC index
VR-12
Physical CSS
Mental CSS

95% CI

P Value

.442-2.65
.834-.937
.829-.965
.602-10.58
1.22-7.42

.255-1.74
.243-1.18
.687-1.30
.887-1.07
.973-1.04
1.00-1.004

.861
.000
.004
.205
.017
.808
.801
.850
.752
.615
.409
.418
.722
.544
.683
.075

.956-1.08
.981-1.06

.619
.262

.211-7.53
.149-4.81
.214-8.44

Bolded P values represent statistically significant baseline

patient characteristics predictive of eventual decision of nonsurgical treatment. ASES, American Shoulder and Elbow Surgeons;
CSS, component summary score; VR-12, Veterans Rand 12-Item
Health Survey; WORC, Western Ontario Rotator Cuff.

full-thickness rotator cuff tears is important, since this

may ultimately help to define care provider preferences
and thereby provide more efficient and cost-effective
care.38 Unfortunately, controversy still exists regarding
the appropriate surgical indications that warrant operative repair of the rotator cuff. Some variables that have
been implicated to affect healing and outcome after rotator
cuff surgery include age, activity level, history of trauma,
severity of fatty atrophy, and location or size of tear.||
The effect that length and severity of symptoms has on
the clinical outcomes after surgery has not been as well
studied.8,35 Wu et al36 used ultrasound in patients with
rotator cuff disease and found that the presence of a fullthickness tear was the only predictor of undergoing surgical treatment, but they did not analyze the subgroup of
patients with full-thickness tears to identify predictive factors for surgery. No correlation with age, sex, duration and
type of symptoms, or location and severity of tendon
damage on sonography was found.36 More recent work performed by Brophy et al4 demonstrates no clear relationship
between shoulder activity in patients with rotator cuff
tears and severity of shoulder symptoms, while Dunn
et al7 found no correlation between pain and rotator cuff
tear severity in patients with atraumatic tears. In addition, the effect that symptoms and disability when
assessed by validated clinical measures have on the decision to pursue surgery has not been elucidated in clinical

||

References 2, 5, 8, 10-14, 16, 19, 24, 25, 30, 34, 37.

2371

studies, thus preventing direct comparisons with the current study.

Limitations of this study include the observational
nature of the study. No causal relationships can be established from the findings, only associations. Potentially
important variables were identified before assessing data
and were selected based on previous clinical studies suggesting factors that may affect outcome after surgery.
However, other variables that were not selected to be
assessed in this study may potentially be important in predicting treatment for rotator cuff tears. Despite the large
number of patients in this well-defined cohort, it may still
be underpowered to demonstrate statistical significance in
some variables such as WORC and smoking status, since
these variables both trended toward significance.
Patient expectations have been found to correlate with
outcome after rotator cuff surgery.21 It was not examined
whether patient expectations correlated with treatment
choice since it is possible that a number of patients had
preconceived strong desires for or against surgery at the
time of presentation, which may have biased treatment
allocation. In addition, surgeon expectations were not specifically examined as factors affecting treatment decision.
The final treatment provided to each patient was open
to additional patient biases as well as surgeon preferences
and biases. While all patients were treated similarly with
the risks and benefits of each treatment option provided
in detail and informed decisions made by each patient,
more than 64% of the patients opted for surgical treatment. With recent literature supporting operative over
nonoperative treatment of rotator cuff tears, a strong
potential bias toward surgical treatment is possible.9,24,28,31 No association was found among the 3 surgeons with respect to treatment allocation, but it is
possible that clinical decision making was biased toward
one of the treatment groups but not detected in the analysis. It is also possible that the subset of patients who were
younger or had lower BMI was biased toward surgical
treatment by the treating surgeons irrespective of subjective reports of disability that led to the results of the study.

CONCLUSION
This prospective cohort study suggests that patient demographics are more predictive of treatment allocation for
patients with full-thickness rotator cuff tears than
patient-derived outcome scores measuring activity and disability at the time of initial presentation. Younger age,
lower BMI, and a more recent onset of symptoms were
all predictive of allocation to surgical treatment. Older
age, higher BMI, and symptoms being present greater
than 1 year were predictive of allocation to nonsurgical
treatment. Sex, shoulder activity score, smoking status,
size of cuff tear, functional comorbidity index, treating surgeon, and ASES, WORC, and VR-12 scores all were not.
Further study is warranted to help define appropriate indications for treatment allocation in patients with rotator
cuff tears.

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2372 Kweon et al

The American Journal of Sports Medicine

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