Dr. Nicholas Cappello

Dr. James Andrews, a widely known sports medicine orthopedist in Gulf Breeze, Fla., wanted to test his suspicion that M.R.I.’s, the scans given to almost every injured athlete or casual exerciser, might be a bit misleading. So he scanned the shoulders of 31 perfectly healthy professional baseball pitchers.
Dr. James Andrews found that M.R.I.’s can mislead.
Steve Ganobcik nearly had unneeded knee surgery.
The pitchers were not injured and had no pain. But the M.R.I.’s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews says.

He and other eminent sports medicine specialists are taking a stand against what they see as the vast overuse of magnetic resonance imaging in their specialty.

M.R.I.’s can be invaluable in certain situations — finding serious problems like tumors or helping distinguish between competing diagnoses that fit a patient’s history and symptoms. They also can make money for doctors who own their own machines. And they can please sports medicine patients, who often expect a scan.

But scans are easily misinterpreted and can result in misdiagnoses leading to unnecessary or even harmful treatments.

For example, said Dr. Bruce Sangeorzan, professor and vice chairman of the department of orthopedics and sports medicine at the University of Washington, if a healthy, uninjured person goes out for a run, a scan afterward will show fluid in the knee bone. It is inconsequential. But in an injured person, fluid can be a sign of a bone that is stressed or even has a crack and is trying to heal.

“An M.R.I. is unlike any other imaging tool we use,” Dr. Sangeorzan said. “It is a very sensitive tool, but it is not very specific. That’s the problem.” And scans almost always find something abnormal, although most abnormalities are of no consequence.

“It is very rare for an M.R.I. to come back with the words ‘normal study,’ “ said Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. “I can’t tell you the last time I’ve seen it.”

In sports medicine, where injuries are typically torn muscles or tendons or narrow cracks in bones, specialists like Dr. Andrews and Dr. DiGiovanni say M.R.I.’s often are not needed — they usually can figure out what is wrong with just a careful medical history, a physical exam and, sometimes, a simple X-ray.

M.R.I.’s are not the only scans that are overused in medicine but, in sports medicine, where many injuries involve soft tissues like muscles and tendons, they rise to the fore.

In fact, one prominent orthopedist, Dr. Sigvard T. Hansen, Jr., a professor of orthopedics and sports medicine at the University of Washington, says he pretty much spurns such scans altogether because they so rarely provide useful information about the patients he sees — those with injuries to the foot and ankle.

“I see 300 or 400 new patients a year,” Dr. Hansen says. “Out of them, there might be one that has something confusing and might need a scan.”

The price, which medical facilities are reluctant to reveal, depends on where the scan is done and what is being scanned. One academic medical center charges $1,721 for an M.R.I. of the knee to look for a torn ligament. The doctor who interprets the scan gets $244. Doctors who own their own M.R.I. machines — and many do — can pocket both fees. Insurers pay less than the charges — an average of $150 to the doctor and $960 to the facility.

Steve Ganobcik is something of a poster child for what can go wrong with the scans. A salesman who turns 44 on Saturday, Mr. Ganobcik twisted his knee skiing in Colorado in February. He continued skiing anyway and skied again the next two days as well, not wanting to cut his vacation short.

When he got home to Cleveland, his knee still bothered him, so he saw a sports medicine orthopedist. The doctor immediately ordered an M.R.I. and said it showed a torn anterior cruciate ligament, or A.C.L. It is one of the most common — and most devastating — sports injuries. The standard treatment is surgery, with a difficult recuperation lasting six months to a year.

Mr. Ganobcik looked into surgical techniques and decided he wanted a different one than the one his doctor offered. So he saw another sports medicine orthopedist who, agreeing that Mr. Ganobcik’s ligament was torn, scheduled the operation.

Meanwhile, Mr. Ganobcik heard that Dr. Freddie H. Fu, chairman of the division of sports medicine at the University of Pittsburgh, had what might be an even better technique, so he went to see him.

To Mr. Ganobcik’s surprise, Dr. Fu told him his ligament was not torn after all. His pain was from a fracture in a long bone in the lower leg that the other doctors had also noticed was broken. An M.R.I. at the University of Pittsburgh confirmed it, showing a perfectly normal A.C.L. (Dr. Fu adds that Mr. Ganobcik’s original scans had an image that was ambiguous. He wanted a better one, to see if Mr. Ganobcik’s ligament had been partly torn and was healing or had never been torn at all. He would not need surgery with a partial tear, but he would need more careful recuperation.)

Dr. Fu’s suspicions were raised by Mr. Ganobcik’s story. He could never have continued skiing with a torn A.C.L. The diagnosis “made no sense,” Dr. Fu said.

And that, Dr. Fu says, illustrates a common problem: relying on an M.R.I.
instead of a history and an exam. Dr. Fu’s diagnosis “was a shock,” Mr. Ganobcik
said. “I thought he was going to talk about options for surgery.”

M.R.I.’s can be extremely useful in sports medicine, said Dr. Andrew
Green, the chief of shoulder and elbow surgery at Brown University. But, he
says, there is a fine line between appropriate use and overuse.

That, at least, is what he found in one of the few studies to address the
issue. The ideal study would randomly assign patients to have scans or not and
then assess their outcomes. Such a study has not been done. Instead, a few
researchers asked if scans made a difference for people who happened to have
them. They found they did not — at least in two common situations.

Dr. Green and his colleagues reviewed the records of 101 patients who had shoulder
pain lasting at least six weeks and that had not resulted from trauma, like
a fall. Forty-three arrived bearing M.R.I.’s from a doctor who had seen them
previously. The others did not have scans. In all cases, Dr. Green made a
diagnosis on the basis of a physical exam, a history, and regular X-rays.

A year later, Dr. Green re-assessed the patients. There was no difference in
the outcome of the treatment of the two groups of patients despite his knowledge
of the findings on the scans. M.R.I.’s, he said, are not needed for the initial
evaluation and treatment of many whose shoulder pain does not result from an
actual injury to the shoulder.

Dr. DiGiovanni did a similar study with foot and ankle patients, looking back
at 221 consecutive patients over a three-month period, 201 of whom did not have
fractures. More than 15 percent arrived with M.R.I.’s obtained by doctors they
had seen before coming to Dr. DiGiovanni. Nearly 90 percent of those scans were
unnecessary and half had interpretations that either made no difference to the
patient’s diagnosis or were at odds with the diagnosis.

“Patients often feel like they are getting better care if people are ordering
fancy tests, and there are some patients who come in demanding an M.R.I. —
that’s part of the problem,” he said.

Some doctors might also feel they are providing better care if they order the
scans, Dr. DiGiovanni said, and doctors often feel that they risk malpractice
charges if they fail to scan a patient and then miss a diagnosis.

Dr. Hansen teaches his fellows — doctors in training — to be careful with
scans and explains the risks of making the wrong diagnosis if they order them
unnecessarily. He also knows it is not easy to refrain from ordering an M.R.I.

It’s different for him, Dr. Hansen says. He is so eminent that patients tend
not to question him.

“When I say ‘You don’t need a scan,’ then it’s over,” Dr. Hansen said. His
fellows get a different response. Patients, he says, “look at them like, ‘You
don’t know what you’re doing.’ “

Experts in sports medicine say that if the technique’s early promise is fulfilled, it could eventually improve the treatment of stubborn injuries liketennis elbow and knee tendinitis for athletes of all types.

The method, which is strikingly straightforward and easy to perform, centers on injecting portions of a patient’s blood directly into the injured area, which catalyzes the body’s instincts to repair muscle, bone and other tissue. Most enticing, many doctors said, is that the technique appears to help regenerate ligament and tendon fibers, which could shorten rehabilitation time and possibly obviate surgery.

Research into the effects of platelet-rich plasma therapy has accelerated in recent months, with most doctors cautioning that more rigorous studies are necessary before the therapy can emerge as scientifically proven. But many researchers suspect that the procedure could become an increasingly attractive course of treatment for reasons medical and financial.

“It’s a better option for problems that don’t have a great solution — it’s nonsurgical and uses the body’s own cells to help it heal,” said Dr. Allan Mishra, an assistant professor of orthopedics at Stanford University Medical Center and one of the primary researchers in the field. “I think it’s fair to say that platelet-rich plasma has the potential to revolutionize not just sports medicine but all of orthopedics. It needs a lot more study, but we are obligated to pursue this.”

Dr. Neal ElAttrache, the Los Angeles Dodgers’ team physician, used platelet-rich plasma therapy in July on a partially torn ulnar collateral ligament in the throwing elbow of pitcher Takashi Saito. Surgery would have ended Mr. Saito’s season and shelved him for about 10 to 14 months; he instead returned to pitch in the September pennant race without pain.

Platelet-rich plasma is derived by placing a small amount of the patient’s blood in a filtration system or centrifuge that rotates at high speed, separating red blood cells from the platelets that release proteins and other particles involved in the body’s self-healing process, doctors said. A teaspoon or two of the remaining substance is then injected into the damaged area. The high concentration of platelets — from 3 to 10 times that of normal blood — often catalyzes the growth of new soft-tissue or bone cells. Because the substance is injected where blood would rarely go otherwise, it can deliver the healing instincts of platelets without triggering the clotting response for which platelets are typically known.

“This could be a method to stimulate wound healing in areas that are not well-vascularized, like ligaments and tendons,” said Dr. Gerjo van Osch, a researcher in the department of orthopedics at Erasmus University Medical Center in the Netherlands. “I call it a growth-factor cocktail — that’s how I explain it.”

Dr. van Osch and several other experts said they had used the procedure as a first option before surgery for reasons beyond its early results. There is little chance for rejection or allergic reaction because the substance is autologous, meaning it comes from the patient’s own body; the injection carries far less chance for infection than an incision and leaves no scar, and it takes only about 20 minutes, with a considerably shorter recovery time than after surgery.

Because of those apparent benefits, the consensus among doctors is that the procedure is worth pursuing. However, several doctors emphasized that platelet-rich plasma therapy as it stands now appeared ineffective in about 20 to 40 percent of cases, depending on the injury. But they added that because the procedure costs about $2,000 — compared with $10,000 to $15,000 for surgery — they expected that with more refinement, insurance companies would eventually not only authorize the use of PRP therapy but even require it as a first course of treatment.

Here’s a Q&A with Dr. Michael Hausman, a professor of orthopedic surgery and vice chairman of the Department of Orthopaedics at Mount Sinai School of Medicine in New York City, on Kobe Bryant’s torn lunotriquetral ligament in his right wrist. Bryant suffered the injury after landing awkwardly on his right wrist in Monday’s exhibition against the Clippers. Keep in mind that Bryant underwent an MRI exam and was examined by Dr. Steven Shin of the Kerlan-Jobe Orthopaedic Clinic. Hausman’s answers reflect the general nature of torn ligaments.

On what Hausman makes of Bryant’s original diagnosis:

He injured his ligament between the small bones and the wrist. But we don’t know the severity of the injury — is it a partial tear or full tear and whether or not there is instability between the little bones in the wrist. That shows whether it’s shifted out of the normal position and normal alignment. The prognosis is completely dependent on those factors.

How does that make a difference?

There are two wrist ligaments between the little bones that are commonly injured. There’s a ligament between the scaphoid bone and lunate bone called the scapholunate ligament. Then there’s the ligament between the lunate bone and triquetral ligament. That’s the one Kobe Bryant injured. Of the two, the potentially more serious injury is scapholunate injury, which he doesn’t have. The ligament that he did  injure, in general, has a somewhat better prognosis.

For orthopedic surgeons large bone defects still pose a major challenge. Porous scaffolds are expected to solve this problem and to speed the healing process. These porous scaffolds mimic the properties of trabecular bone, which is mainly present at the end of long bones, near joints, where implants would be expected. Compared to the other main bone type, compact bone, trabecular bone has a higher surface area but is less dense, softer, weaker, and less stiff. When seeded with human cells and bone growth stimulating molecules, it enhance bone healing.

Over the past 20 years a wide variety of materials including ceramics, glass, metals, polymers and composites have been studied to be applied as a porous scaffold material. A recently released study, conducted by the Flemish Institute for Technological Research (VITO) and the company Janssen Pharmaceutica NV, both based in Belgium, focused on metallic and ceramic materials. In collaboration with the universities of Ghent and Leuven as part of the ‘Guided Bone Engineering’ project, the researchers produced porous titanium (Ti) and calcium phosphate (CaP) scaffolds by different manufacturing routes, all starting from powders.

Three manufacturing routes, the PU replica method, gelcasting and the 3DFD method, were used to process porous scaffolds with properties comparable with trabecular bone. Scaffold design was another important topic in the study. The goal was not only to develop an optimized internal porous architecture but also to obtain an implant design with a custom external shape tailored for each patient. The surface-modification research concentrated on the coating of metallic scaffolds with a CaP layer. The experiments aimed at an increased bioactivity of the metallic scaffolds and the use of this porous CaP layer as a drug delivery system for bone infections.

The results of this study show that the three routes allow the production of porous structures from a wide variety of materials with high pore interconnectivity. For Ti and its alloys, the mechanical properties are tuned towards these of porous bone. The versatility of the CaP coatings deposited onto the metallic surface led to an increased bioactivity and the possibility to act as a drug delivery system.

Thus magnesium is proven to be a biocompatible and bio-absorbable material. As a next step, the researchers began the production porous magnesium scaffolds; however, preliminary results, while promising, suggested that there are still problems to overcome before porous magnesium can be considered the ideal scaffold.

For bone health, vitamin D and calcium go hand in hand, because the vitamin
must be present for calcium to be absorbed from the digestive tract. But who, if
anyone, needs supplements — and how much? Can you get enough from foods
naturally rich in these nutrients or fortified with them?

These are important questions, given the steady increase in life expectancy
and the already epidemic levels of osteoporosis
and fractures among older Americans, men and women alike. (Women are especially
vulnerable, because estrogen
loss at menopause
can cause a precipitous decline in bone density.)

The answers depend on three things, not to mention which experts you happen
to ask: the foods and drinks you regularly consume, your personal and family
history of broken bones, and habits that influence bone health.

Dr. Robert P. Heaney, a bone specialist at Creighton University in Omaha,
maintains that “at least one-third of all osteoporotic fractures have a
nutritional basis.”

What you eat and drink, from childhood on, is critical to the amount of
calcium in your bones. Dairy foods, especially milk, yogurt and cheese, are the
primary sources of calcium in the American diet, and consumption of milk has
been falling steadily for decades, especially in adolescence,
when most bone development occurs. A British study
concluded that frequent milk consumption before age 25 was an important
determinant of bone strength among middle-aged and elderly women.

Other foods are not nearly as rich in absorbable calcium, or the amounts
normally eaten do not come close to the calcium content of dairy products: 300
milligrams in a glass of milk, 400 milligrams in eight ounces of yogurt.

Sardines and canned salmon eaten with the bones are good sources, and almonds
are a fair source if you eat enough of them. And calcium-fortified foods like
orange juice, soy milk, breakfast cereals and tofu are now widely available.

Too Much of a Good Thing

But some other desirable foods are problematic, at least when it comes to
calcium: you’d have to eat so much broccoli to approach the level in milk that
it could be toxic to your thyroid gland. Other vegetables with calcium, like
spinach, collards, kale and beans, contain oxalates that block calcium
absorption.

For daily calcium intake, the institute now recommends 1,000 milligrams for
children 4 to 8, women and men 19 to 50, and men 51 to 70; 1,300 milligrams for
children 9 to 18; and 1,200 milligrams for women 51 and older and men 71 and
older. The upper limit of safety, the institute said, is 2,000 milligrams a day
for men and women over 51.

Thus, if you are a postmenopausal woman who typically consumes only one or
two servings a day of dairy, you may be hard put to get 1,200 milligrams of
calcium from the rest of your diet unless you take a supplement. Dr. Ethel
Siris, director of the osteoporosis clinic at Columbia
University Medical Center in New York, said such women could benefit from a
supplement of calcium carbonate (600 milligrams a day) or calcium citrate (500
milligrams a day).

Be sure to read the product label carefully — a usual “serving” is two
tablets. Calcium carbonate should be taken with meals to assure absorption, but
calcium citrate can be taken at any time and may cause fewer digestive problems.

Most calcium supplements now also contain vitamin D (usually as
cholecalciferol, or D3), supplying about 250 to 300 international units in two
tablets. The Institute of Medicine recommends 600 units a day for everyone from
age 1 to 70 and 800 units for men and women 71 and older, with a safe upper
limit for everyone over the age of 9 of 4,000 units.

Vitamin D has one advantage over calcium: It is fat-soluble and can be stored
in the body for later use. But getting enough of it can be tricky.

The body gets most of its vitamin D not from diet but from skin exposed to
the ultraviolet B radiation in sunlight. Unprotected skin on the arms and legs
may need about 15 minutes of sun exposure a day in spring, summer and fall to
make enough of the vitamin.

Alas, this production is effectively blocked if you follow current advice to
prevent skin
cancer and wrinkles
by always covering up or using ample amounts of sunscreen. Used properly,
sunscreens with an SPF of 8 or higher completely block UVB radiation and prevent
synthesis of vitamin D.

Also, people who are dark-skinned or housebound or who live in far northern
latitudes may fail to make enough vitamin D. And as people age, their bodies are
less able to convert the vitamin into the hormone that is its biologically
active form.

Milk is fortified with vitamin D at a level of 400 units per quart, and some
yogurts have it as well (check the label). Many breakfast cereals are also now
fortified. The only naturally rich dietary sources are oily fish from the sea
like salmon and mackerel, egg yolks, liver and fish liver oil.

Testing and Maintaining

An increasing number of physicians now routinely test vitamin D levels in the
blood of their female patients, and if it is below 30 nanograms per milliliter,
will suggest they take a supplement. The Institute of Medicine maintains that a
level of 20 nanograms is adequate, but other experts say it should be higher to
assure maximum calcium absorption and bone health.

In any event, unless you are a year-round sun worshiper, a daily supplement
of calcium with D, or even a separate supplement of 1,000 units of D, is likely
to keep you well below the institute’s upper safe limit. Based on current
evidence, unless you have a severe deficiency requiring temporary megadoses to
correct, there is no reason to go any higher.

At the same time, you’d be wise to get sufficient weight-bearing exercise and
avoid several bone-robbing habits: smoking; eating a lot of salty foods;
drinking more than two alcoholic drinks a day; consuming more than the caffeine
equivalent of two cups of coffee a day (about 300 milligrams); and eating too
little protein. As for soft drinks, Dr. Siris advises a daily limit of two
12-ounce cans, and she’d prefer that soda be only an occasional treat.

Shoulder pain due to the rotator cuff is one of the most common complaints presenting to an orthopedic surgeon’s office. Fortunately, most rotator cuff disease is really inflammation of the rotator cuff and surrounding tissue, not an actual tear. In most cases the inflammation will resolve with time, physical therapy, and injections. However, when a rotator cuff tear is found, much fear and trepidation occurs for patients. Do I need surgery? What happens if I don’t have the tear repaired? What does this mean for me in the long term?

In order to answer these questions, one first needs to understand that the rotator cuff is really four different muscles/tendons grouped together. Collectively, these four muscles help to center the ball portion of the shoulder in the socket. Further, these muscles help to raise the arm and rotate it in and out. The most commonly inflamed or torn muscle is the supraspinatus. This muscle helps to raise the arm forward and out to the side; it also prevents the ball from floating upward within the socket. When you hear physicians talk about rotator cuff tears, this is the tendon being talked about most of the time.

Another important distinction is the difference between a full thickness tear and a partial thickness tear. When the rotator cuff tendon attaches to the bone, it attaches not at just one point but over an area about as long and as wide as one of your fingers. The length of a tear is variable and has nothing to do with the term partial or full thickness. These terms indicate the width of the tendon that is torn off of the bone. In full thickness tears, the full width of the tendon is torn off of the bone. In partial thickness tears, some of the width of the tendon is torn off of the bone: low grade partial tears involve less than 50 percent of the width while in high grade tears more than 50 percent is torn.

How does this impact you? When a tear is a low grade partial tear, it behaves much like an inflamed but not torn rotator cuff. When the tear is more high grade, it tends to behave much like a full thickness tear. While it is uncommon for these partial tears to re-heal to the bone, true healing is not necessary for shoulder function to return to normal in most cases. A partial thickness tear can become a full thickness tear, though this does not happen in all cases. If it does become a full tear, it is treated just like any other full tear, which I will address next.

So you have a full thickness rotator cuff tear. What now? The true answer is that there is not one “correct” answer, which can cause a lot of confusion for patients. Each case is truly unique, and who needs an operation must be decided on a patient by patient basis. There are some important things to know regarding how I help my patients make this decision.

First, is the tear really causing your pain? A few studies have used either an ultrasound or an MRI to look at the rotator cuff of asymptomatic volunteers. One such study found that 28 percent of people over the age of 60 had a full tear and didn’t even know it.  Between the ages of 40 and 60 this number dropped to 4 percent. Another similar study found more than 50 percent of patients over the age of 70 had either a partial or a full tear without any symptoms. How many of these patients may or may not develop pain over time is unknown. The moral of this story is that a trial of physical therapy and injections is often the best first intervention for patients over the age of 60. In these cases, the pain may be just acute inflammation occurring in the setting of a chronic tear; i.e., the tear may have already been present for a long time and just an incidental finding. This is especially true in cases of atraumatic shoulder pain, which is usually the rule as opposed to the exception. A well designed multicenter trial comparing the results of operative versus nonoperative rotator cuff tear treatment is under way. At this time the results are still unpublished, but early data has shown very favorable results with physical therapy alone for atraumatic tears in patients over 60.

A second factor in whether or not to have surgery is my patient’s individual goals. A young patient who works overhead in construction is very different from a retired patient who only has to reach overhead to shower or reach into a cupboard. I am more likely to recommend an operation to the former patient than the later if therapy fails. Further, for patients that are simply scared to have surgery, have many other diseases that make surgery risky, or who cannot take the time to go through a postoperative recovery process, I would defer an operation. A rotator cuff tear is quite unlike appendicitis: a short delay prior to operating, if surgery is ever necessary, rarely has any long lasting ill effects.

A third factor in my operative decision making is the tear itself. Some large and retracted tears may not be possible to repair. Occasionally, in a shoulder that has not been used for a very long period of time, the muscle may be replaced by fat. In these very unusual cases, even if the tear is amenable to repair, the muscle can no longer work to move the shoulder: the engine can no longer move the piston. Also, if arthritis is present in the setting of a rotator cuff tear, a rotator cuff repair is unreliable in relieving pain, because the arthritis is still present. If a patient has any of these issues, even if he or she is quite young, I would start with conservative treatment first.

To conclude, the decision to operate on a rotator cuff tear must be tailored to each individual patient. My goal is to help a patient decide what will work best for him or her.  In general, in a patient under the age of 40 with an acute and traumatic tear, operative intervention is often indicated. In patients over the age of 60 with a chronic, atraumatic tear (the most common presentation), I always recommend a trial of physical therapy and/or injections first. In fact, I find it quite rare for surgery to be my first treatment recommendation. When I do perform surgery, I favor minimally invasive rotator cuff repairs done arthroscopically, and generally tell patients they will be in a sling for six weeks after the operation, and recovery will take approximately six months.Check out more on my Facebook,

Higher health care prices in the United States are a key reason that the nation’s health spending is so much higher than that  of other countries. A study compared physicians’ fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. Also compared physicians’  incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of                     payments per physician and of physician supply in the countries’ national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more  for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more  for private) than public and private payers paid these physicians’ counterparts in other countries. US primary care and orthopedic  physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. They conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main  drivers of higher US spending, particularly in orthopedics.

There was an E poster that I found very interesting that could be the future
for broken collar bones. It involves using a flexible implant into the canal of
the clavicle, and then with a few turns it becomes rigid with more strength then
a titanium plate. I have provided a link where Dr Carl Basamania is showing the
technique

What to do about partial Rotator Cuff Tears
by Dr. Chris Gerber , Patients
suspected of having a rotator cuff tear are divided into two treatment groups
initially: Each patient is initially a candidate for either operative or
non-operative treatment, however patients are re-evaluated throughout the
course of treatment and may move from one group to the other based on their
clinical response and findings on repeated examination.

Since many patients with partial
tears and some even with complete tears can respond to non-operative
management, generally conservative care is offered first. If a significant
trauma such as a shoulder dislocation, or fracture, or
high energy force is known to have been followed by complete to near complete
loss of rotator cuff- mediated motion and strength, then an operative work-up
is initiated with plans to proceed to surgery for repair, if confirmatory.