J Shoulder Elbow Surg (2017) 26, 1562–1565

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Anterior deltoid reeducation for irreparable

rotator cuff tears revisited
Edward H. Yian, MDa, Jeffrey F. Sodl, MDa, Emil Dionysian, MDa,
Alberto G. Schneeberger, MDb,*

a
Department of Orthopaedics, Southern California Permanent Medical Group, Anaheim, CA, USA
b
Endoclinic Zürich, Klinik Hirslanden, Zürich, Switzerland

Background: A previous study introduced a method of conservative treatment of irreparable rotator cuff
tears (RCTs) using a rehabilitation program (anterior deltoid reeducation [ADR]). The purposes of this
study were to present our experience with ADR and to compare our results with those of the previous
study.
Methods: Thirty consecutive elderly patients with irreparable RCTs were prospectively enrolled and taught
how to perform the home-based ADR program for a period of 3 months. Clinical and radiographic evalu-
ations were determined at the first visit. Clinical follow-up was available after 9 and 24 months. Failure
of the ADR program was defined as abandonment of the ADR program because of pain and/or a patient’s
decision to undergo surgery at any time or a less than 20-point improvement in the American Shoulder
and Elbow Surgeons score at last follow-up.
Results: Of the 30 patients, 9 did not complete the 3-month ADR program because of pain. Of the 21
patients who completed the ADR program, 3 were not satisfied with the outcome and went on to undergo
surgery. Eighteen of the 30 patients completed the program and had a follow-up at 24 months. Among
these 18 cases, there were significant mean improvements between pre-ADR and follow-up outcome scores
among all variables (P < .005). However, 6 of these 18 patients did not have an improvement in the Amer-
ican Shoulder and Elbow Surgeons score by at least 20 points. Overall, the ADR program had a success
rate of only 40%.
Conclusion: A 3-month ADR program had limited success to treat irreparable RCTs. We could not re-
produce the high rate of satisfactory results of 82% found in a previous study.
Levels of evidence: Level IV; Case Series; Treatment Study
© 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Deltoid; massive rotator cuff tear; rehabilitation; nonoperative treatment; elderly; conservative
treatment; shoulder

Elderly patients with chronic rotator cuff tears (RCTs) can

Approval authority: Kaiser Permanente Southern California Institutional
Review Board (No. 5393).
*Reprint requests: Alberto G. Schneeberger, MD, Endoclinic Zürich,
Klinik Hirslanden, Witellikerstrasse 40, Zürich CH-8032, Switzerland.
E-mail address: ags@schulter-ellbogen.ch (A.G. Schneeberger).
present with significant pain and disability. Massive irrepa-
rable RCTs pose a challenge to the treating orthopedic surgeon
because of the limited success of many nonoperative treat-
ment modalities and inconsistent results with reconstructive

1058-2746/$ - see front matter © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
http://dx.doi.org/10.1016/j.jse.2017.03.007

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Anterior deltoid reeducation
surgical options.4,6,16,17 Although reverse total shoulder ar-
throplasty (TSA) has shown reliable improvement of shoulder
function and pain, there remain medical risks with surgery
in this aged population.3,7 Anterior deltoid rehabilitation has
been proposed as an alternative treatment in part to counter
the altered biomechanics in a rotator cuff–deficient shoulder.14
The role and value of this specific method of nonoperative
treatment has not been clearly defined. Although anterior
deltoid rehabilitation has been shown to be helpful in the short
term, specifically in the debilitated elderly population, little
is known about the durability of its benefits and effects on
functional outcomes.14 In certain patients, nonoperative treat-
ment may be successful as the definitive treatment, whereas
in others, it may ultimately fail and lead to surgical options.
Clinically, it would be helpful to estimate the probability and
degree of improvement when counseling patients. It is im-
portant to understand what potential improvements a patient
may expect with this type of treatment and identify key prog-
nostic factors that can facilitate patient decision making with
the surgeon.
The hypothesis of this study was that anterior deltoid re-
education (ADR) would provide significant improvement in
patient outcome measurements after 2 years’ follow-up. In
addition, it was the aim of this study to compare our find-
ings with those of a previous study by Levy et al,14 who
presented a high success rate at 9 months. We also searched
for prognostic factors to identify those patients who are more
likely to succeed with the ADR protocol.
Patients and methods
From June 2009 to June 2010, 31 consecutive patients with a
minimum age of 55 years and the diagnoses of chronic irreparable
RCTs, were prospectively enrolled after patient consent. One patient
died during the course of the study and was excluded. There were
19 female and 11 male patients enrolled in the study. The average
patient age was 74 years (range, 55-89 years). The other exclusion
criteria were prior fracture malunion, cancer or metastatic lesion to
the shoulder, traumatic reparable RCT, or shoulder symptoms for
less than 6 months before study enrollment.
Shoulder function was determined using the American Shoul-
der and Elbow Surgeons (ASES) score. The Subjective Shoulder Value
(SSV)5 and the visual analog pain scale (from 0 to 10) were as-
sessed. Strength was evaluated using a handheld strength measurement
dynamometer (Lafayette Digital Dynamometer; Lafayette Instru-
ment, Lafayette, IN, USA). If 90° of forward elevation could not
be reached (pseudoparalysis), the strength was considered to be 0
kg.2 Range of motion (ROM) was measured in forward elevation
in the scapular plane. Abduction strength, ROM, the SSV, and the
ASES score were determined at the first visit and after 9 and 24
months of follow-up. RCT tendon involvement and the radio-
graphic Hamada score8,21 were determined at the first visit.
All patients had clinical, radiographic, and magnetic resonance
imaging confirmation of a massive (involving at least 2 tendons),
chronic, irreparable RCT. All patients had grade 3 retraction (ac-
cording to the Patte classification)18 and Goutallier grade 4 fatty
infiltration of the torn supraspinatus and/or infraspinatus muscles.
Those with subscapularis or teres minor tears had at least grade 3
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1563
fatty infiltration.9 The Hamada classification was grade 1 in 4 cases,
grade 2 in 11, grade 3 in 3, grade 4a in 7, grade 4b in 5, and grade
5 in 0. Glenohumeral arthritis was present in 12 shoulders. All pa-
tients had pain and significant functional weakness for at least 6
months before presentation, as well as medical comorbidities that
made them high-risk surgical candidates.
The exercise protocol using the ADR program has been previ-
ously described by the Reading Shoulder Unit, Reading, UK.14
Instruction was performed by a physician in the clinic, and a copy
of the instructions with diagrams was given to the patients. Pa-
tients were allowed to take nonsteroidal anti-inflammatory medications
or pain medications during the rehabilitation process, if needed.
Similar to the protocol established in a prior study, pain could be
controlled with a single subacromial injection of local anesthetic
and long-acting steroid only at the beginning of the study at the dis-
cretion of the physician.14 Ten patients received a steroid injection.
After the initial visit, the patients were seen at the following inter-
vals: 6 weeks, 3 months, 9 months, and 24 months. Patient compliance
with the ADR program was assessed by asking the patients if they
had performed the home-based exercise program 3 to 5 times a day
at the 6-week follow-up and 3-month follow-up visits. Photograph-
ic documentation of ROM was collected at time 0, at 9 months, and
at 2 years for each patient.
Failure of the ADR program was defined as patient abandon-
ment of the protocol because of pain and/or a patient’s decision to
undergo subsequent surgery (as recommended by Itoi11) or a less
than 20-point improvement in the ASES score at final follow-up (as
recommended by Kwon et al13). We analyzed whether there was a
statistically significant difference between pre- and post-ADR mea-
surements including pain, ROM, strength, SSV, and ASES score for
those patients who completed the rehabilitation program. We then
analyzed whether gender, age, and the pre-ADR factors—such as
pain score, ROM, SSV, ASES score, pseudoparalysis, number of
rotator cuff tendons involved, involvement of subscapularis or teres
minor, presence of glenohumeral arthritis, and Hamada grade—
could predict a successful outcome for the ADR program after 2
years.
Statistical analysis
Statistical analysis was performed using GraphPad Prism software
(version 7; GraphPad Software, San Diego, CA, USA) and SPSS
software (version 21; IBM, Armonk, NY, USA). To detect a differ-
ence at the .05 level of significance with 90% power while using a
difference in SD of 25, we calculated that 19 patients were suffi-
cient or, assuming a 35% dropout rate, 30 patients were sufficient.
The Fisher exact test was used to analyze a possible association of
pre-ADR factors with a successful outcome at 2 years. One-way
repeated-measures analysis of variance was used to analyze differ-
ences between the variables at the beginning of the study, after 9
months of follow-up, and after 2 years of follow-up. These analy-
ses were limited to those patients who finished the study without
dropout. All statistical tests were 2 sided; the level of significance
was set at P < .05.
Results
Only 21 of 30 patients were compliant. The 9 noncompliant
patients were not able to complete the ADR program because
1564
of pain and persistent symptoms. Of these 9 patients, 5 went
on to undergo reverse TSA and 1 underwent partial rotator
cuff repair. Twenty-one patients completed the 3-month ADR
program. Of these 21 patients, 3 were not satisfied with the
outcome at 3 months and went on to undergo reverse TSA
(2 cases) or partial rotator cuff repair (1 case). Eighteen of
the 30 patients completed the program and underwent follow-
up at 9 and 24 months.
Failure of the ADR program occurred in the 9 aforemen-
tioned patients who could not perform the ADR program, in
3 patients who completed the program but went on to undergo
reverse TSA or partial rotator cuff repair, and in 6 patients
who completed the program but did not have an improve-
ment in the ASES score of at least 20 points. Overall, the ADR
program had a success rate of only 40% (12 of 30) at the
2-year follow-up.
Among the 18 patients who completed the ADR program,
the average ASES score improved from 39 points to 65 points
at 9 months (P < .001) and to 62 points at 2 years (P = .001).
The pain score improved from 6.7 points to 3.3 points at 9
months (P < .001) and to 3.7 points at 2 years (P < .001).
Strength increased from 1.1 kg to 2.1 kg at 9 months (P < .001)
and to 1.9 kg at 2 years’ follow-up (P = .03). The SSV in-
creased from 45% to 65% at 9 months (P < .001) and to 60%
at 2 years (P = .01). Forward flexion increased from 101° to
141° at 9 months (P < .001) and to 129° at 2 years (P = .01).
There were no significant differences between any scores at
9 months versus 2 years.
Pre-ADR factors associated with successful
outcome
With the number of patients available, we could not detect
an association between any of the pre-ADR factors ana-
lyzed and a successful outcome at 2 years’ follow-up, except
for ROM. Forward flexion of less than 50° at the beginning
of the ADR program was significantly associated with an un-
successful outcome at 2 years compared with forward flexion
of 50° or more at the beginning of the ADR program
(P = .022).
Discussion
ADR has been suggested as an alternative nonsurgical treat-
ment option for older patients presenting with irreparable
RCTs.10,14 Biomechanical studies have shown that compen-
satory increases in force of the deltoid and the remaining
rotator cuff are required to achieve improvements of shoul-
der function.9,10,15,19,22 This includes rehabilitation of the anterior
deltoid muscle to resist superior escape forces.22 There are
limited clinical studies, however, that have specifically ex-
amined patient functional outcomes after ADR in the chronic
irreparable cuff tear setting.1,15 However, this information would
be important in that it would allow patients to understand the
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E.H. Yian et al.
likelihood of improvement with this specific nonoperative re-
habilitation protocol.
Levy et al14 first described a prospective cohort of debili-
tated, pseudoparalytic, elderly patients with anterosuperior
RCTs who underwent ADR and noted improvement in the
Constant score from 26 to 63 after 9 months’ follow-up. All
of their patients were able to complete the rehabilitation
program and had improvements in ROM. Mean forward el-
evation improved from 40° (range, 30°-60°) at presentation
to 160° (range, 150°-180°) after the ADR program. Only 3
of 17 patients did not have adequate improvement at 9 months’
follow-up, indicating a success rate of 82%.14
We were unable to reproduce the positive results of Levy
et al14 with the ADR protocol. In contrast to the success rate
of 82% at 9 months in their original series, our series had a
success rate of only 40% at 2 years’ follow-up and failure
was more likely for patients with pre-rehabilitation forward
flexion of less than 50°. Of 30 patients, 9 (30%) could not
complete the ADR program, primarily because of pain. Our
patients seemed to be slightly younger (mean age, 74 years)
than those of Levy et al (mean, 80 years). The patients in our
series had chronic symptoms for a minimum of 6 months
without a traumatic event, whereas in the series of Levy et
al, the duration of symptoms was not specified.
Few studies have evaluated predictive factors for success
after conservative treatment.12,20 It is difficult to compare these
studies because of differences in the inclusion criteria for RCT
size and atrophy, rehabilitation protocols, and definitions of
success. Tanaka et al20 identified multiple factors that pre-
dicted improved response using a broad-based physical therapy
regimen to treat RCTs, including increased pretreatment ex-
ternal rotation and lack of supraspinatus muscle atrophy on
magnetic resonance imaging. However, they included small-
to large-sized tears and excluded patients with massive (>5 cm)
RCTs. Ainsworth1 proposed an anterior deltoid rehabilita-
tion program that included strengthening of the anterior deltoid
and teres minor muscles. The author suggested that patients
with improved teres minor recruitment would have better out-
comes. Our study found that only pre-rehabilitation forward
elevation less than 50° predicted a lower chance of success
after the ADR protocol. We defined the success criteria as rec-
ommended by several authors in the scientific literature, and
we did not find any predictive correlation with teres minor
tear involvement before treatment and functional outcome after
the ADR protocol.
Although this is a prospectively enrollment study, there
are limitations. There is no control group without treatment
for comparison. Although all of the patients in the study were
retired, we did not assess physical activity scores, which may
have affected patient perception of improvement. There may
be different cultural or social perceptions that caused the pa-
tients to withdraw from the ADR program or choose to pursue
surgical treatment. Lastly, as ADR consists of a home-
based program and patients were not under supervision during
the exercises, exact compliance and correctness of the exer-
cises were not precisely determined.
Anterior deltoid reeducation
Conclusion
In non-debilitated elderly patients, a 3-month ADR pro-
tocol to treat symptomatic chronic irreparable RCTs had
limited success at 2 years’ follow-up. Success was less
likely for those with pretreatment active forward flexion
of less than 50°.
Acknowledgments
We thank Raoul Burchette, MA, MS, biostatistician, for
his help with the statistical analysis.
Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not re-
ceived any financial payments or other benefits from any
commercial entity related to the subject of this article.
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