Appropriate Use Criteria (AUC) for the Management of Rotator Cuff Pathology

The American Academy of Orthopaedic Surgeons (AAOS) released an AUC to report on the optimal management of symptomatic full-thickness rotator cuff tears based on expert experience and review of the literature as an appropriate use document. The treatment scenarios provided by this AUC stem from the recommendations in the Clinical Practice Guideline (CPG) issued by the AAOS in March 2019.

OVERVIEW
This AUC is intended to offer guidance on decision factors for adults with rotator cuff tears. The AUC online tool provides clinicians algorithms on how to optimally evaluate the condition based on a patient’s various indications, including injury or degeneration. It recommends specific next steps and procedures to ensure optimal recovery. The target patient group is assumed to have a:

• Clinical history such as anterolateral shoulder pain not radiating past the elbow;
• Physical examination such as weakness with testing rotator cuff strength, positive lift off or belly press test, external rotation lag, positive drop arm test, and/or pain relief but sustained weakness after impingement test;
• Imaging findings (MRI or ultrasound) all consistent with a full-thickness rotator cuff tear.

For surgical candidates with any other concomitant diagnoses, such as biceps tendonitis, labral fraying/tearing, and acromioclavicular arthritis with osteophytes, these AUC may still be applicable if the candidate meets both of the following conditions:

1. After the history, exam, and imaging review, the clinician determines that the rotator cuff tear accounts for the majority of the symptoms. 
2. Treatment of this secondary pathology is necessary as part of the surgical procedure to treat potential pain generators and relieve pathology that may deteriorate the surgical outcome.

CONDITIONS NOT COVERED WITHIN THIS DOCUMENT
The conditions listed below are specifically not addressed in these AUC:

• Rotator cuff re-tears/history of previous rotator cuff repair
• Partial-thickness tears or rotator cuff tendonitis/ rotator cuff bursitis
• Secondary diagnosis that the surgeon determines is more likely to be the relevant pathology creating pain such as: Glenohumeral Arthrosis, calcific tendinitis, plexopathy, radiculopathy or muscle weakness from SSN nerve compression, isolated clinically symptomatic AC joint arthritis

INTENDED AUC USERS
The new AUC is geared towards the needs of sports medicine and shoulder and elbow orthopaedic surgeons; however, healthcare professionals other than orthopaedic surgeons, including but not limited to adult primary care physicians, adult medicine specialists, physical therapists, occupational therapists, physician assistants, nurse practitioners who routinely see this patient population in various practice settings may benefit from this tool. This AUC tool is not intended for use as a benefits determination document.

FOR MORE INFORMATION
The AUC tool offers accepted approaches to treatment and/or diagnosis and is not intended to be a fixed protocol. Patient care and treatment should always be based on a clinician’s independent medical judgment, giving the individual patient’s specific clinical circumstances.

The full AUC for the evaluation of psychosocial factors influencing recovery from adult orthopaedic trauma is available through AAOS’ OrthoGuidelines website and free mobile app. For more information on the development process for AAOS clinical practice guidelines, please reference the Clinical Practice Guideline Methodology.

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