A remarkable multicenter group of 40 surgeons at 16 centers, organized as the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group, is the 2024 recipient of AAOS’s Kappa Delta Ann Doner Vaughn Award for creating meaningful change in the way physicians treat patients with atraumatic, symptomatic rotator cuff tears.
This award recognizes research in musculoskeletal disease or injury with great potential to advance patient care.
The MOON group’s award-winning research finding was that physical therapy is an effective treatment for over 70% of rotator cuff tear patients, improving pain and patient-reported outcome measures (PROMs) over an impressive 10-year follow-up period.
“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, M.D., M.S., 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.”
Prior to this study, we asked Dr. Kuhn, was physical therapy considered to be an effective treatment for a significant percentage, say 30% or 50% of rotator cuff tear patients?
According to Dr. Kuhn, not even 30%. “Before this work, very few surgeons would have thought physical therapy was effective in treating full thickness rotator cuff tears,” said Dr. Kuhn.
“Most surgeons were taught these need to have surgical repair. When we set up the study, we thought physical therapy might be effective in elderly, low demand patients, and thought that maybe 15% of our patients would do well. We were surprised to see how effective therapy was.”
The team set out to predict nonoperative treatment failure rates of rotator cuff tears. After creating a standard, evidence-based PT protocol that included a “gold standard” PT protocol, the researchers enrolled patients aged 18 to 100 years with shoulder symptoms and MRI-documented, symptomatic, atraumatic, full-thickness rotator cuff tears.
Partial findings include:
- Most patients who decided to have surgery within six months were driven primarily by their expectations of the effectiveness of physical therapy. In other words, if they thought PT would work, it worked. If they didn’t believe it would work, it didn’t.
- When comparing those who had surgery before six months and those who had surgery between six months and ten years, worker’s compensation status and activity level were more important in predicting the need for surgery after six months.
“As far as what we know about surgeons actually making the shift to treating patients with atraumatic, symptomatic rotator cuff tears using physical therapy, Dr. Kuhn told OTW, “surgery numbers are increasing over time, but that could reflect the population aging. A recent study demonstrated that only 19.8% of Medicare patients with atraumatic rotator cuff tears were treated initially with surgery, 38.8% with watchful waiting, and 41.3% with physical therapy, with surgery rates trending downward and physical therapy rates trending upward with time (Chapman et al 2018).”
“Additionally, many insurance companies now require an attempt at physical therapy in their clinical pathways before approving surgery.”
“Today, we know that physical therapy is very effective in treating atraumatic rotator cuff tears. We also know that surgery is effective. We do not know which treatment is best and for whom. Our MOON Group is involved in a randomized controlled trial led by Dr. Nitin Jain and funded by the Patient-Centered Outcomes Research Institute to help answer that question. The ARC Trial has just completed enrollment, and we should have some answers in the next few years!”
The MOON Shoulder Group also includes the following researchers: Warren R. Dunn, M.D., M.P.H., , Rosemary Sanders, B.A., Keith M. Baumgarten, M.D., , Julie Y. Bishop, M.D., Robert H. Brophy, M.D., James L. Carey, M.D., M.P.H., , Brian G. Holloway, M.D., Grant L. Jones, M.D., C. Benjamin Ma, M.D., Robert G. Marx, M.D., M.S., Eric C. McCarty, M.D., Sourav K. Poddar, M.D., Matthew V. Smith, M.D., Edwin E. Spencer, M.D., Armando F. Vidal, M.D., Brian R. Wolf, M.D., M.S., and Rick W. Wright, M.D.
