The MOON Shoulder Group Receives Kappa Delta Ann Doner Vaughn Award

The 2024 Kappa Delta Ann Doner Vaughn Award was presented to the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group for changing the way physicians treat patients with atraumatic, symptomatic rotator cuff tears. Their research determined that physical therapy (PT) was an effective treatment for more than 70 percent of these patients, improving pain and patient-reported outcome measures (PROMs) in a cohort that was followed for more than 10 years. This award recognizes research in musculoskeletal disease or injury with great potential to advance patient care.

Nearly 2 million people in the United States visit their doctors because of rotator cuff tears each year. This type of injury creates a significant economic burden to the United States healthcare system, as the prevalence of rotator cuff tears increases with age, and more than two-thirds of patients who have surgery are of working age.

“When I finished my training in 1994, we were taught that surgery was the preferred way to treat a rotator cuff tear,” said John E. Kuhn, MD, MS, FAAOS, chief of shoulder surgery and director of Vanderbilt Sports Medicine and director of the MOON Shoulder Group. “As the approach to treating rotator cuff tears remained unclear, we wanted a more thorough understanding of the disease to help define the indications for rotator cuff repair surgery and determine which patients would benefit from nonoperative treatment.”

Over the course of 10 years, the MOON Shoulder Group used their multicenter outcomes network to prospectively collect data on patients with rotator cuff disease to answer clinically important questions and better understand the natural history and treatment of rotator cuff disease.

The group developed a standard, evidence-based PT protocol that included a “gold standard” PT protocol, with elements derived from a systematic review. The cohort study enrolled patients aged 18 to 100 years with shoulder symptoms and MRI-documented, symptomatic, atraumatic, full-thickness rotator cuff tears (where the tendon was completely detached from the bone).

Patients were given two instructive rehabilitation books—one for physical therapists and another for home-based PT written at the eighth-grade level—with an accompanying DVD. The specific exercises included daily range of motion (postural exercises, active-assisted motion, active training of scapular muscles, and active range of motion), daily flexibility (anterior and posterior shoulder stretching), and strengthening three times per week (rotator cuff and scapula exercises). Therapists were instructed to provide manual mobilization exercises as needed based on evidence that supports their use in impingement and to progress the patient to a home therapy program when ready. Based on the systematic review, heat and cold were recommended as modalities but ultrasound was not.

Patient outcome scores were tracked at entry into the study and during each follow-up visit at weeks 6 and 12 and years 1, 2, 5, 7, and 10. At the 6-week mark, patients were given three options: no additional follow-up if they considered themselves “cured”; continued PT for 6 more weeks if they were “improved”; and, if they were “no better,” the option to have surgery. At any point during the study, patients could opt to have surgery. Results from the research include:

• At 10 years, PT was shown to be highly effective in more than 70 percent of patients with atraumatic, symptomatic, full-thickness rotator cuff tears in reducing pain and improving PROMs.
• Most patients who decided to have surgery within 6 months were driven primarily by their expectations of the effectiveness of PT. In other words, if they thought PT would work, it worked. If they did not believe it would work, it did not.
• When comparing those who had surgery before 6 months and those who had surgery between 6 months and 10 years, workers’ compensation status and activity level were more important in predicting the need for surgery after 6 months.
• Structural factors (e.g., tear size, retraction), visual analog pain score, and weakness were not predictors of surgery and are likely not helpful in determining surgical indications.
• There was no correlation between rotator cuff tear anatomy and pain, duration of symptoms, or patient activity level.

“Our team was shocked when so many patients in the cohort improved with physical therapy, because it’s not at all what we expected,” said Dr. Kuhn. “We’re also optimistic about the finding that low expectations for therapy drive patients to having surgery because we can modify this variable by educating patients that physical therapy can work.”

The MOON Shoulder Group and other surgeons are currently engaged in the Arthroscopic Rotator Cuff Trial, a multicenter, randomized trial funded by the Patient-Centered Outcomes Research Institute, where patients with symptomatic, atraumatic, full-thickness rotator cuff tears are randomized to either treatment with PT or surgical repair to help determine which treatment option might be best suited for particular patients.

In addition to Dr. Kuhn, the MOON Shoulder Group includes the following researchers: Warren R. Dunn, MD, MPH, FAAOS; Rosemary Sanders, BA; Keith M. Baumgarten, MD, FAAOS; Julie Y. Bishop, MD, FAAOS; Robert H. Brophy, MD, FAAOS; James L. Carey, MD, MPH, FAAOS; Brian G. Holloway, MD; Grant L. Jones, MD, FAAOS; C. Benjamin Ma, MD, FAAOS; Robert G. Marx, MD, MS, FAAOS; Eric C. McCarty, MD, FAAOS; Sourav K. Poddar, MD; Matthew V. Smith, MD, FAAOS; Edwin E. Spencer, MD, FAAOS; Armando F. Vidal, MD, FAAOS; Brian R. Wolf, MD, MS, FAAOS; and Rick W. Wright, MD, FAAOS.

The MOON group will be honored at the Your Academy event Wednesday morning.

Reference

1. Kuhn JE: Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg 2009;18(1):138-60.