Without enough high-quality evidence to support almost any intervention for rotator cuff tears, the American Academy of Orthopaedic Surgeons engages in self-examination about the value of guidelines and expert opinion.
In the absence of adequate evidence, an American Academy of Orthopaedic Surgeons guideline recommends against surgery for rotator cuff tears that are asymptomatic, and finds only weak evidence to support surgery as "an option" for chronic, full-thickness, symptomatic tears.
The guideline also finds insufficient evidence to recommend any non-operative intervention, including exercise programs, subacromial injections, NSAIDs, activity modification, ice, heat, iontophoresis, massage, transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy, or ultrasound.
The rigorous evidence process sets up the committees draft guidelines to create statements that are "awkward, noncommittal, and bland," observes UCLA professor of orthopaedic surgery Robert A. Pedowitz in a commentary published alongside the guideline in the Journal of Bone and Joint Surgery.
The words "insufficient evidence" have different meanings to doctors, payors, and patients, he continues. "To me, the statement simply means that there is not sufficient proof, according to EBM [evidence-based medicine] rules, to make a declarative statement. Nothing more."
The fact that the rules of medical evidence to date fail completely for rotator cuff patients prompted Pedowitz to reflect that "sage advice from thoughtful experts and one's personal experience" are still the best guides to define the preferred treatment for individual patients. A response from four other orthopedists, published in the same issue of the journal, disagrees about the value of such expert advice.
They point out that many publications in the orthopedics literature are retrospective case series, which are limited by the fact that patients tend to seek treatment when they feel at their worst, for symptoms that might have regressed without any intervention.
As to the value of expert opinion, University of Rochester (NY) orthopedist James O. Sanders MD and his coauthors write that the experts may be biased by undisclosed conflicts of interest or a set of values about outcomes that differs from those of most patients. "While their clinical advice may be helpful, it cannot constitute evidence," they declare.
Then what should you say to a patient with a rotator cuff injury? Listen online as Dr. Pedowitz discusses the question, as well as reasons why many issues raised by guidelines can never be resolved.
How do you proceed when a guideline finds no good evidence on a treatment question? Should societies bother to publish guidelines that offer insufficient advice? Offer your own comments below.