The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 13, 2019
RESEARCH ARTICLE

Prognostic Factors for Conservative Treatments of Atraumatic Rotator Cuff Tears



Takuya Sekiguchi1, Junichiro Hamada2, *, Yoshihiro Hagiwara3, Akira Ando4, Takashi Watanabe5, Mitsukuni Yamaguchi6, Kiyohisa Ogawa7
1 Department of Orthopaedic Surgery, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Iwate 020-0066, Japan
2 Department of Orthopaedic Surgery, Kuwano Kyoritsu Hospital, 2-9-18, Shima, Koriyama, Fukushima 963-8034, Japan
3 Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
4 Department of Orthopaedic Surgery, Matsuda Hospital, 17-1, Tatsutayashiki, Sanezawa, Izumi-ku, Sendai, Miyagi 981-3217, Japan
5 Department of General Health, Japan Community Health Care Organization Sendai Hospital, 3-16-1, Tsutsumi-machi, Aoba-ku, Sendai, Miyagi 981-8501, Japan
6 Therapy Laboratory, 1-1-5 Dobashi, Miyamae-ku, Kawasaki, Kanagawa 216-0005, Japan
7 Department of Orthopaedic Surgery, Eijyu General Hospital, 2-23-16, Higashiueno, Taito-ku, Tokyo 110-8645, Japan

Abstract

Background:

Little consensus has been achieved on conservative treatments in patients with Rotator Cuff Tears (RCTs).

Objective:

To determine whether anatomical severities of RCTs were poor prognostic factors in conservative treatments.

Method:

This study included 102 shoulders with atraumatic RCTs diagnosed by magnetic resonance imaging. Partial-thickness tears were identified in 15 shoulders and full-thickness tears in 87 shoulders. Three patients had a concomitant subscapularis (SSC) tendon tear. All patients were treated conservatively with the administration of non-steroidal anti-inflammatory drugs and physical therapy. The visual analog scale (VAS), Constant scores, and active range of motion were evaluated as clinical outcomes. Pearson’s chi-square test and Student’s t test, Mann-Whitney U test, one-way analysis of variance (ANOVA), or Kruskal-Wallis test was performed to compare the participant’s characteristics and clinical data. Treatment effectiveness among the tear size groups and with/without SSC tear groups was assessed using a two-factor repeated measures ANOVA.

Results:

Larger tears were associated with less improvement in VAS (p = 0.032). At the initial and final visits, larger tears showed lower constant scores (p = 0.014 and p < 0.001, respectively) and restricted forward elevation (FE) (p = 0.042 and p = 0.013, respectively). Shoulders with SSC tear showed higher VAS, lower constant scores, and lower FE at the final visit (p = 0.002, p = 0.001, and p=0.019, respectively). Patients with SSC tear underwent surgery more frequently than those without tear (p < 0.001).

Conclusion:

Larger RCTs and concomitant SSC tear are poor prognostic factors for the conservative treatment of atraumatic RCTs.

Keywords: Rotator cuff tears, Conservative treatment, Tear size, Tear pattern, Shoulder disorder, Anatomical severities.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 26
Last Page: 31
Publisher Id: TOORTHJ-13-26
DOI: 10.2174/1874325001913010026

Article History:

Received Date: 05/09/2018
Revision Received Date: 18/12/2018
Acceptance Date: 11/01/2019
Electronic publication date: 31/1/2019
Collection year: 2019

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 770
Abstract HTML Views: 498
PDF Downloads: 211
ePub Downloads: 148
Total Views/Downloads: 1627

Unique Statistics:

Full-Text HTML Views: 505
Abstract HTML Views: 363
PDF Downloads: 141
ePub Downloads: 96
Total Views/Downloads: 1105
Geographical View

© 2019 Sekiguchi et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this Department of Orthopaedic Surgery, Kuwano Kyoritsu Hospital, 2-9-18, Shima, Koriyama, Fukushima 963-8034, Japan; Tel: +81-24-933-5422; Fax: +81-24-923-6169;
E-mail: i-hamada@koriyama-h-coop.or.jp





1. INTRODUCTION

Rotator Cuff Tears (RCTs) are a common shoulder disorder mainly affecting people older than 50 years and has a prevalence of approximately 20% in the general population [1Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. J Orthop 2013; 10(1): 8-12.[http://dx.doi.org/10.1016/j.jor.2013.01.008] [PMID: 244037 41] -3Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999; 8(4): 296-9.[http://dx.doi.org/10.1016/S1058-2746(99)90148-9] [PMID: 1047 1998] ]. Treatment options for symptomatic RCTs are operative intervention and conservative treatments including administration of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), corticosteroid injections to the glenohumeral joint or subacromial bursa, and physical therapy. Although the benefit of surgical treatments for patients with symptomatic RCTs has been proposed, other treatment options remain controversial [4Oh LS, Wolf BR, Hall MP, Levy BA, Marx RG. Indications for rotator cuff repair: A systematic review. Clin Orthop Relat Res 2007; 455(455): 52-63.[http://dx.doi.org/10.1097/BLO.0b013e31802fc175] [PMID: 1717 9786] , 5Marx RG, Koulouvaris P, Chu SK, Levy BA. Indications for surgery in clinical outcome studies of rotator cuff repair. Clin Orthop Relat Res 2009; 467(2): 450-6.[http://dx.doi.org/10.1007/s11999-008-0585-9] [PMID: 1894 9526] ]. Numerous factors that affect clinical outcomes of RCTs have been described [5Marx RG, Koulouvaris P, Chu SK, Levy BA. Indications for surgery in clinical outcome studies of rotator cuff repair. Clin Orthop Relat Res 2009; 467(2): 450-6.[http://dx.doi.org/10.1007/s11999-008-0585-9] [PMID: 1894 9526] , 6Huisstede BM, Koes BW, Gebremariam L, Keijsers E, Verhaar JAN. Current evidence for effectiveness of interventions to treat rotator cuff tears. Man Ther 2011; 16(3): 217-30.[http://dx.doi.org/10.1016/j.math.2010.10.012] [PMID: 21146 445] ], including anatomical severities, such as tear size and quality of torn cuff muscles, a history of trauma, duration of symptoms, and duration and/or failure of conservative treatments [5Marx RG, Koulouvaris P, Chu SK, Levy BA. Indications for surgery in clinical outcome studies of rotator cuff repair. Clin Orthop Relat Res 2009; 467(2): 450-6.[http://dx.doi.org/10.1007/s11999-008-0585-9] [PMID: 1894 9526] , 6Huisstede BM, Koes BW, Gebremariam L, Keijsers E, Verhaar JAN. Current evidence for effectiveness of interventions to treat rotator cuff tears. Man Ther 2011; 16(3): 217-30.[http://dx.doi.org/10.1016/j.math.2010.10.012] [PMID: 21146 445] ].

Many researchers have reported various outcomes with regard to conservative treatments for symptomatic full-thickness RCTs. Success rates of conservative treatments vary widely. Some investigators described a rate of approximately 50% or less [7Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. J Bone Joint Surg Am 1974; 56(1): 14-26.[http://dx.doi.org/10.2106/00004623-197456010-00002] [PMID: 4812 158] -9Tanaka M, Itoi E, Sato K, et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. Ups J Med Sci 2010; 115(3): 193-200.[http://dx.doi.org/10.3109/03009734.2010.493246] [PMID: 20636254] ], whereas others reported over 70% [10Bartolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Relat Res 1994; (308): 90-7.[PMID: 7955708] -13Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop Relat Res 1993; (294): 103-10.[PMID: 8358901] ]. This variation is attributed to the difference in the participants’ characteristics (e.g., a history of trauma and anatomical features, such as tear size, with or without subscapularis [SSC] tendon tear) and types of conservative treatments (e.g., home exercise program, physical therapy by physical therapists) [8Goldberg BA, Nowinski RJ, Matsen FA III. Outcome of nonoperative management of full-thickness rotator cuff tears. Clin Orthop Relat Res 2001; (382): 99-107.[http://dx.doi.org/10.1097/00003086-200101000-00015] [PMID: 111 54011] -10Bartolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Relat Res 1994; (308): 90-7.[PMID: 7955708] , 12Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin Orthop Relat Res 1992; (275): 165-73.[PMID: 1735208] , 14Maman E, Harris C, White L, Tomlinson G, Shashank M, Boynton E. Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging. J Bone Joint Surg Am 2009; 91(8): 1898-906.[http://dx.doi.org/10.2106/JBJS.G.01335] [PMID: 19651947] -19Hawkins RH, Dunlop R. Nonoperative treatment of rotator cuff tears. Clin Orthop Relat Res 1995; (321): 178-88.[PMID: 7497666] ].

Progression of tear size is one of the most important factors from asymptomatic to symptomatic tears [20Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am 2006; 88(8): 1699-704.[http://dx.doi.org/10.2106/JBJS.E.00835] [PMID: 16882890] , 21Mall NA, Kim HM, Keener JD, et al. Symptomatic progression of asymptomatic rotator cuff tears: A prospective study of clinical and sonographic variables. J Bone Joint Surg Am 2010; 92(16): 2623-33.[http://dx.doi.org/10.2106/JBJS.I.00506] [PMID: 21084574] ]. The anatomical severities of RCTs are associated with a failure rate of conservative treatments [9Tanaka M, Itoi E, Sato K, et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. Ups J Med Sci 2010; 115(3): 193-200.[http://dx.doi.org/10.3109/03009734.2010.493246] [PMID: 20636254] , 10Bartolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Relat Res 1994; (308): 90-7.[PMID: 7955708] , 15Safran O, Schroeder J, Bloom R, Weil Y, Milgrom C. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med 2011; 39(4): 710-4.[http://dx.doi.org/10.1177/0363546510393944] [PMID: 21310 940] ]. However, recent studies have indicated that symptomatic RCTs are not associated with anatomical features, pain, or functions [18Dunn WR, Kuhn JE, Sanders R, et al. Symptoms of pain do not correlate with rotator cuff tear severity: A cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am 2014; 96(10): 793-800.[http://dx.doi.org/10.2106/JBJS.L.01304] [PMID: 24875019] , 22Curry EJ, Matzkin EE, Dong Y, Higgins LD, Katz JN, Jain NB. Structural characteristics are not associated with pain and function in rotator cuff tears: The ROW cohort study. Orthop J Sports Med 2015; 3(5): 2325967115584596.[http://dx.doi.org/10.1177/2325967115584596] [PMID: 26675 985] , 23Brophy RH, Dunn WR, Kuhn JE. Shoulder activity level is not associated with the severity of symptomatic, atraumatic rotator cuff tears in patients electing nonoperative treatment. Am J Sports Med 2014; 42(5): 1150-4.[http://dx.doi.org/10.1177/0363546514526854] [PMID: 24658 346] ]. Curry et al. stated that pain and functional status in patients with RCTs with operative and conservative treatments were not associated with tear size or thickness, fatty infiltration, or muscle atrophy [22Curry EJ, Matzkin EE, Dong Y, Higgins LD, Katz JN, Jain NB. Structural characteristics are not associated with pain and function in rotator cuff tears: The ROW cohort study. Orthop J Sports Med 2015; 3(5): 2325967115584596.[http://dx.doi.org/10.1177/2325967115584596] [PMID: 26675 985] ]. The MOON Shoulder Group demonstrated that shoulder pain and activity level were not associated with anatomical severities of atraumatic RCTs [18Dunn WR, Kuhn JE, Sanders R, et al. Symptoms of pain do not correlate with rotator cuff tear severity: A cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am 2014; 96(10): 793-800.[http://dx.doi.org/10.2106/JBJS.L.01304] [PMID: 24875019] , 23Brophy RH, Dunn WR, Kuhn JE. Shoulder activity level is not associated with the severity of symptomatic, atraumatic rotator cuff tears in patients electing nonoperative treatment. Am J Sports Med 2014; 42(5): 1150-4.[http://dx.doi.org/10.1177/0363546514526854] [PMID: 24658 346] ]. Correlations between anatomical severities and conservative treatments of atraumatic RCTs are still controversial. In the present study, we aimed to determine whether anatomical severities, such as tear size and patterns at the initial visit, could be prognostic factors in conservative treatments for atraumatic RCTs.

2. MATERIALS AND METHODS

2.1. Participants

This study included 102 shoulders in 101 patients (50 men and 51 women; mean age, 70.1 ± 8.5 years) who met the inclusion criteria and visited the senior author’s clinic between April 2010 and August 2014. The inclusion criteria were as follows: shoulder pain at rest and/or during motion, 50 years or older, positive supraspinatus test [24Kelly BT, Kadrmas WR, Speer KP. The manual muscle examination for rotator cuff strength. An electromyographic investigation. Am J Sports Med 1996; 24(5): 581-8.[http://dx.doi.org/10.1177/036354659602400504] [PMID: 88 83676] ], and RCTs diagnosed by magnetic resonance imaging. The exclusion criteria were the history of trauma or previous surgery on the affected shoulder joint or girdle; history of chronic arthritis involving the shoulder joint, such as osteoarthritis and rheumatoid arthritis; systemic disorders, such as diabetes mellitus and thyroid disorder; neurological disorders, such as cervical myelopathy, radiculopathy, and stroke; or a recent intra-articular corticosteroid injection. All patients were followed up closely, and the median duration of conservative treatment was 3.1 months (Interquartile Range [IQR], 2.2-5.9 months).

Partial-thickness tears were identified in 15 shoulders and full-thickness tears in 87. Shoulders with full-thickness tears were classified by their greatest diameter using the system of DeOrio and Cofield [25DeOrio JK, Cofield RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am 1984; 66(4): 563-7.[http://dx.doi.org/10.2106/00004623-198466040-00011] [PMID: 6707 035] ]. Twenty-two shoulders were classified as small tears (<1 cm), 41 as medium (1-3 cm), 19 as large (3-5 cm), and 5 as massive tears (≥5 cm). The partial, small, medium, and large and massive tear groups were categorized as the study groups.

2.2. Conservative Treatments

All patients were treated with physical therapy such as mobilization of the sternoclavicular and sternocostal joints, restoration of thoracic spine and rib motion, static and dynamic exercises for the scapula and glenohumeral movement, and stretching the periscapular and rotator cuff muscles. NSAIDs were administered to patients with severe pain. As abnormal posture and scapular kinema tics were associated with patients with RCTs, the motion of the scapula, clavicle, and thoracic spine was intensified [26Yamamoto A, Takagishi K, Kobayashi T, et al. The impact of faulty posture on rotator cuff tears with and without symptoms. J Shoulder Elbow Surg 2015; 24(3): 446-52.[http://dx.doi.org/10.1016/j.jse.2014.07.012] [PMID: 254415 65] -28McClure PW, Michener LA, Karduna AR. Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Phys Ther 2006; 86(8): 1075-90.[PMID: 16879042] ]. Physical therapy was performed twice a week by physical therapists specializing in shoulder problems, and they provided the patients with a daily home-exercise program [29Endo K, Hamada J, Suzuki K, Hagiwara Y, Muraki T, Karasuno H. Does scapular motion regress with aging and is it restricted in patients with idiopathic frozen shoulder? Open Orthop J 2016; 10: 80-8.[http://dx.doi.org/10.2174/1874325001610010067] [PMID: 27733880] ]. The two senior doctors (J.H. and Y.H.) assessed the range of motion, and scapular motion, and evaluated Visual Analog Scale (VAS).

2.3. Outcome Assessment and Goal Setting

VAS and Constant scores [30Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987; (214): 160-4.[PMID: 3791738] ] were used for clinical outcomes. Active Range of Motion (AROM) including Forward Elevation (FE), External Rotation with the arm at side (ER), and Internal Rotation (IR) as the hand behind the back was also evaluated. In seven patients who underwent arthroscopic rotator cuff repairs, the condition of the torn cuff and intra-articular findings were recorded to reveal the reason for recalcitrance to conservative treatment. The goal of the conservative treatment for responders was set as follows: significant improvement in pain during daily living, work, and sports activities. For non- or weak responders, limitation of the conservative treatment was set as follows: restriction of their daily living, work, and sports activities with pain even after the conservative treatment.

2.4. Statistical Analysis

Categorical variables were summarized as percentages and continuous variables as means with standard deviation or medians with IQR. Participant’s characteristics and clinical data were compared using Pearson’s chi-square test for categorical variables, and using Student’s t-test, Mann-Whitney U test, one-way analysis of variance (ANOVA), or Kruskal-Wallis test for continuous variables. Treatment effectiveness with regard to the study’s continuous dependent variables (e.g., VAS, Constant scores, AROM [FE and ER]) among the anatomical feature groups (e.g., four tear size groups, with /without SSC tear groups) was assessed using a two-factor repeated measures ANOVA (RMANOVA). The generalized estimating equations for repeated measures were used to analyze the change of IR in AROM among the groups, since IR was an ordinal variable. All statistical tests were conducted at a significance level of 0.05. Statistical analyses were performed with SPSS for Windows version 23.0 (SPSS Inc., Chicago, IL, USA).

3. RESULTS

Basic characteristics among the partial, small, medium, and large and massive tear groups at the initial visit are summarized in Table 1. SSC tendon tear was concomitant in three shoulders. Significant differences were not found among the four groups in age (p = 0.13), sex (p = 0.58), affected shoulder (p = 0.88), or presence of SSC tendon tear (p = 0.31).

The clinical characteristics of the four groups at the initial and final visits are listed in Table 2. After the conservative treatment, the clinical outcomes greatly improved in 95 shoulders, whereas little improvement was noted in 7 shoulders. Seven patients (1 in the partial, 3 in the medium, and 3 in the large and massive tear groups) underwent arthroscopic rotator cuff repairs. The duration of the treatment and the number of operated shoulders were not statistically significant among the groups (p = 0.82 and p = 0.42, respectively). Larger tears showed less improvement in VAS (group * time interaction by RMANOVA: p = 0.032). Significant differences in effectiveness of conservative treatment were not observed for the Constant scores or AROM (FE, ER, and IR) among the four groups (group * time interaction: Constant score, p = 0.33; FE, p = 0.54; ER, p = 0.68; IR, p = 0.65). At both the initial and final visits, larger tears showed lower Constant scores (p = 0.014 and p < 0.001, respectively) and restriction of FE (p = 0.042 and p = 0.013, respectively). No significant differences were found in ER or IR among the four groups.

Table 1
Basic characteristics of study participants.


Table 2
Clinical characteristics among the four tear size groups.


Table 3
Clinical characteristics of the groups with and without SSC tears.


Significant differences were not observed in the effectiveness of conservative treatment between the two groups with or without SSC tendon tears (Table 3). Significant differences in VAS, Constant scores, and FE at the initial visit were not identified. However, the group with SSC tear showed higher VAS, lower Constant scores, and smaller range of FE at the final visit (p = 0.002, p = 0.001, and p = 0.019, respectively). Patients with SSC tendon tear had a tendency to have surgery than those without (p < 0.001).

4. DISCUSSION

The important findings of this study were as follows. First, larger RCTs tended to be recalcitrant to the conservative treatment. Second, the presence of SSC tendon tear had poor outcomes for the conservative treatment.

Although the anatomical features of RCTs have been speculated to be one of the most important factors for surgical repairs, the association between the anatomical severities of RCTs (e.g., tear size, quality of the torn rotator cuff muscle) and pain, function, and effectiveness of conservative treatments is controversial [9Tanaka M, Itoi E, Sato K, et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. Ups J Med Sci 2010; 115(3): 193-200.[http://dx.doi.org/10.3109/03009734.2010.493246] [PMID: 20636254] , 10Bartolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Relat Res 1994; (308): 90-7.[PMID: 7955708] , 15Safran O, Schroeder J, Bloom R, Weil Y, Milgrom C. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med 2011; 39(4): 710-4.[http://dx.doi.org/10.1177/0363546510393944] [PMID: 21310 940] , 18Dunn WR, Kuhn JE, Sanders R, et al. Symptoms of pain do not correlate with rotator cuff tear severity: A cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am 2014; 96(10): 793-800.[http://dx.doi.org/10.2106/JBJS.L.01304] [PMID: 24875019] , 22Curry EJ, Matzkin EE, Dong Y, Higgins LD, Katz JN, Jain NB. Structural characteristics are not associated with pain and function in rotator cuff tears: The ROW cohort study. Orthop J Sports Med 2015; 3(5): 2325967115584596.[http://dx.doi.org/10.1177/2325967115584596] [PMID: 26675 985] , 23Brophy RH, Dunn WR, Kuhn JE. Shoulder activity level is not associated with the severity of symptomatic, atraumatic rotator cuff tears in patients electing nonoperative treatment. Am J Sports Med 2014; 42(5): 1150-4.[http://dx.doi.org/10.1177/0363546514526854] [PMID: 24658 346] ]. Recent studies have indicated that symptomatic RCTs are not associated with anatomical features on pain or function [18Dunn WR, Kuhn JE, Sanders R, et al. Symptoms of pain do not correlate with rotator cuff tear severity: A cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am 2014; 96(10): 793-800.[http://dx.doi.org/10.2106/JBJS.L.01304] [PMID: 24875019] , 22Curry EJ, Matzkin EE, Dong Y, Higgins LD, Katz JN, Jain NB. Structural characteristics are not associated with pain and function in rotator cuff tears: The ROW cohort study. Orthop J Sports Med 2015; 3(5): 2325967115584596.[http://dx.doi.org/10.1177/2325967115584596] [PMID: 26675 985] , 23Brophy RH, Dunn WR, Kuhn JE. Shoulder activity level is not associated with the severity of symptomatic, atraumatic rotator cuff tears in patients electing nonoperative treatment. Am J Sports Med 2014; 42(5): 1150-4.[http://dx.doi.org/10.1177/0363546514526854] [PMID: 24658 346] ]. Dunn et al. reported that anatomical severities, such as tear size, superior migration of the humeral head, and fatty infiltration of rotator cuff muscles, were not related to pain severity [18Dunn WR, Kuhn JE, Sanders R, et al. Symptoms of pain do not correlate with rotator cuff tear severity: A cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am 2014; 96(10): 793-800.[http://dx.doi.org/10.2106/JBJS.L.01304] [PMID: 24875019] ]. Curry et al. also described that pain and functional status did not correspond with anatomical features (e.g., tear size and thickness, fatty infiltration, muscle atrophy) [22Curry EJ, Matzkin EE, Dong Y, Higgins LD, Katz JN, Jain NB. Structural characteristics are not associated with pain and function in rotator cuff tears: The ROW cohort study. Orthop J Sports Med 2015; 3(5): 2325967115584596.[http://dx.doi.org/10.1177/2325967115584596] [PMID: 26675 985] ]. Brophy et al. documented that the activity levels of patients with atraumatic RCTs were not associated with tear size, but with age, sex, and occupation [23Brophy RH, Dunn WR, Kuhn JE. Shoulder activity level is not associated with the severity of symptomatic, atraumatic rotator cuff tears in patients electing nonoperative treatment. Am J Sports Med 2014; 42(5): 1150-4.[http://dx.doi.org/10.1177/0363546514526854] [PMID: 24658 346] ]. However, in this study, relieving pain from larger RCTs was difficult by conservative treatment and these RCTs exhibited lower function and FE. In addition, RCTs with SSC tendon tear showed higher VAS, lower Constant scores and FE at the final visit, and more shoulder surgeries than those without. The rotator cuff muscles can stabilize the humeral head centered in the glenoid cavity and move the humerus in multiple directions. Throughout the shoulder motion, the compressive joint force in the transverse plane contributes to joint stability [31Parsons IM, Apreleva M, Fu FH, Woo SLY. The effect of rotator cuff tears on reaction forces at the glenohumeral joint. J Orthop Res 2002; 20(3): 439-46.[http://dx.doi.org/10.1016/S0736-0266(01)00137-1] [PMID: 12038 616] ]. Patients with larger RCTs might present with the instability of the humeral head in the glenoid cavity and limited shoulder motion due to loss of the transverse plane force couple [32Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy 1994; 10(4): 363-70.[http://dx.doi.org/10.1016/S0749-8063(05)80186-0] [PMID: 7945631] ]. Therefore, larger RCTs and the combination of an SSC tendon tear appear to decrease the stability of the humerus and would be recalcitrant to the conservative treatment, which corresponded well with some reports [9Tanaka M, Itoi E, Sato K, et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. Ups J Med Sci 2010; 115(3): 193-200.[http://dx.doi.org/10.3109/03009734.2010.493246] [PMID: 20636254] , 10Bartolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Relat Res 1994; (308): 90-7.[PMID: 7955708] , 15Safran O, Schroeder J, Bloom R, Weil Y, Milgrom C. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med 2011; 39(4): 710-4.[http://dx.doi.org/10.1177/0363546510393944] [PMID: 21310 940] ]. Although surgical procedure should be recommended to such patients, this category of RCTs has a higher rate of re-rupture [33Kim JH, Hong IT, Ryu KJ, Bong ST, Lee YS, Kim JH. Retear rate in the late postoperative period after arthroscopic rotator cuff repair. Am J Sports Med 2014; 42(11): 2606-13.[http://dx.doi.org/10.1177/0363546514547177] [PMID: 2518 6830] , 34Le BT, Wu XL, Lam PH, Murrell GA. Factors predicting rotator cuff retears: An analysis of 1000 consecutive rotator cuff repairs. Am J Sports Med 2014; 42(5): 1134-42.[http://dx.doi.org/10.1177/0363546514525336] [PMID: 24748 610] ]. To provide an appropriate treatment protocol, further high quality research would be needed on the treatment of symptomatic RCTs.

The success rate of conservative treatments varies from less than 50% to 80% [7Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. J Bone Joint Surg Am 1974; 56(1): 14-26.[http://dx.doi.org/10.2106/00004623-197456010-00002] [PMID: 4812 158] -13Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop Relat Res 1993; (294): 103-10.[PMID: 8358901] ]. In this study, seven patients had poor improvement in their clinical symptoms and poor satisfaction after the conservative treatment, which meant a success rate of 93%. This result is better than those in previous studies because of the following reasons. First, a small number of massive RCTs and SSC tendon tear were included. This may lead to overestimation of the effectiveness of the conservative treatment. Second, we excluded patients with traumatic episodes and/or systemic disorders, such as diabetes mellitus, in this study. Complications of diabetes mellitus have a worse effect on shoulder pain in frozen shoulder [35Ando A, Sugaya H, Hagiwara Y, et al. Identification of prognostic factors for the nonoperative treatment of stiff shoulder. Int Orthop 2013; 37(5): 859-64.[http://dx.doi.org/10.1007/s00264-013-1859-8] [PMID: 2350 3671] ]. Finally, the frequency of physical therapy in this study was higher than that in other studies [11Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: A multicenter prospective cohort study. J Shoulder Elbow Surg 2013; 22(10): 1371-9.[http://dx.doi.org/10.1016/j.jse.2013.01.026] [PMID: 235405 77] ], and all therapies were performed by physical therapists specializing in shoulder problems. This physical therapy program might result in a high success rate in conservative treatments [36Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: A prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2007; 15(7): 915-21.[http://dx.doi.org/10.1007/s00167-007-0288-x] [PMID: 1733 3123] ].

We have to consider short-term follow-up (the median duration of conservative treatment was 3.1 months). Kuhn et al. conservatively treated 452 patients with atraumatic full-thickness RCTs using physical therapy protocol. They found that patient-reported outcomes improved significantly at 6 and 12 weeks and most failures occur within the first 12 weeks [11Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: A multicenter prospective cohort study. J Shoulder Elbow Surg 2013; 22(10): 1371-9.[http://dx.doi.org/10.1016/j.jse.2013.01.026] [PMID: 235405 77] ]. However, deterioration after the completion of conservative treatments remains a possibility [16Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: A longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg 2001; 10(3): 199-203.[http://dx.doi.org/10.1067/mse.2001.113086] [PMID: 114088 98] , 37Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff. A followup study by arthrography. Clin Orthop Relat Res 1994; 304(304): 68-73.[PMID: 8020236] ].

Yamamoto et al. reported that RCTs were present in 20.7% of a rural population in Japan, in which 35% was painful and 65% was asymptomatic RCTs [2Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg 2010; 19(1): 116-20.[http://dx.doi.org/10.1016/j.jse.2009.04.006] [PMID: 195407 77] ]. Tempelhof et al. stated that the rate of RCTs increasing with age was a normal condition, but the reasons for changing asymptomatic to symptomatic RCTs are unclear [3Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999; 8(4): 296-9.[http://dx.doi.org/10.1016/S1058-2746(99)90148-9] [PMID: 1047 1998] ]. This suggested that the presence of RCTs themselves was not only a substantial cause. However, other factors, such as extra-articular factors (i.e., scapular dyskinesis, scapular dysfunction, stiffness of the sternoclavicular joint, and weakness of the shoulder muscles), intra-articular factors (i.e., thickened glenohumeral ligaments and coracohumeral ligament), and factors related to RCTs (i.e., tear size and patterns or muscle weakness due to large or massive tears), might influence the phenomenon. Physical therapy is a treatment option targeting the extra-articular factors, but it shows little efficacy to the intra-articular factors and the factors related to RCTs are unknown. Arthroscopic findings in the seven patients demonstrated attachment of torn supraspinatus tendons to the deltoid muscle in one patient, large or massive tears and combined SSC tendon tear in three patients, and decreased mobility of SSC, supraspinatus, and infraspinatus tendons by the thickened coracohumeral ligament and superomedial capsule in three patients. From these findings, surgical treatment was recommended for patients with intra-articular factors and/or factors related to RCTs [38Koide M, Hamada J, Hagiwara Y, Kanazawa K, Suzuki K. A thickened coracohumeral ligament and superomedial capsule limit internal rotation of the shoulder joint: Report of three cases. Case Rep Orthop 2016; 9384974.[http://dx.doi.org/10.1155/2016/9384974] [PMID: 27123353] ]. Further study is needed with regard to the three factors to choose appropriate treatment options.

This study has several limitations. The first limitation is the small number of massive tears, a combination of SSC tendon tears, and operated shoulders included. The second limitation is the short-term follow-up. Deterioration after the completion of conservative treatment is possible and may lead to overestimation of the effectiveness of the treatment [16Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: A longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg 2001; 10(3): 199-203.[http://dx.doi.org/10.1067/mse.2001.113086] [PMID: 114088 98] , 37Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff. A followup study by arthrography. Clin Orthop Relat Res 1994; 304(304): 68-73.[PMID: 8020236] ]. The third limitation is that we could not evaluate the function of the extra-articular factors. Finally, our study was performed at a single center hospital. Furthermore, as there was no information about the demand level of the shoulder, such as work and sports activities, ruling out information bias would be difficult.

CONCLUSION

Larger RCTs and a combination of SSC tendon tears are predisposing factors for recalcitrant conservative treatment.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for the studies that are basis of this research.

CONSENT FOR PUBLICATION

Informed consent was obtained from all the participants prior to publication.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. J Orthop 2013; 10(1): 8-12.[http://dx.doi.org/10.1016/j.jor.2013.01.008] [PMID: 244037 41]
[2] Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg 2010; 19(1): 116-20.[http://dx.doi.org/10.1016/j.jse.2009.04.006] [PMID: 195407 77]
[3] Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999; 8(4): 296-9.[http://dx.doi.org/10.1016/S1058-2746(99)90148-9] [PMID: 1047 1998]
[4] Oh LS, Wolf BR, Hall MP, Levy BA, Marx RG. Indications for rotator cuff repair: A systematic review. Clin Orthop Relat Res 2007; 455(455): 52-63.[http://dx.doi.org/10.1097/BLO.0b013e31802fc175] [PMID: 1717 9786]
[5] Marx RG, Koulouvaris P, Chu SK, Levy BA. Indications for surgery in clinical outcome studies of rotator cuff repair. Clin Orthop Relat Res 2009; 467(2): 450-6.[http://dx.doi.org/10.1007/s11999-008-0585-9] [PMID: 1894 9526]
[6] Huisstede BM, Koes BW, Gebremariam L, Keijsers E, Verhaar JAN. Current evidence for effectiveness of interventions to treat rotator cuff tears. Man Ther 2011; 16(3): 217-30.[http://dx.doi.org/10.1016/j.math.2010.10.012] [PMID: 21146 445]
[7] Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. J Bone Joint Surg Am 1974; 56(1): 14-26.[http://dx.doi.org/10.2106/00004623-197456010-00002] [PMID: 4812 158]
[8] Goldberg BA, Nowinski RJ, Matsen FA III. Outcome of nonoperative management of full-thickness rotator cuff tears. Clin Orthop Relat Res 2001; (382): 99-107.[http://dx.doi.org/10.1097/00003086-200101000-00015] [PMID: 111 54011]
[9] Tanaka M, Itoi E, Sato K, et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. Ups J Med Sci 2010; 115(3): 193-200.[http://dx.doi.org/10.3109/03009734.2010.493246] [PMID: 20636254]
[10] Bartolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Relat Res 1994; (308): 90-7.[PMID: 7955708]
[11] Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: A multicenter prospective cohort study. J Shoulder Elbow Surg 2013; 22(10): 1371-9.[http://dx.doi.org/10.1016/j.jse.2013.01.026] [PMID: 235405 77]
[12] Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin Orthop Relat Res 1992; (275): 165-73.[PMID: 1735208]
[13] Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop Relat Res 1993; (294): 103-10.[PMID: 8358901]
[14] Maman E, Harris C, White L, Tomlinson G, Shashank M, Boynton E. Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging. J Bone Joint Surg Am 2009; 91(8): 1898-906.[http://dx.doi.org/10.2106/JBJS.G.01335] [PMID: 19651947]
[15] Safran O, Schroeder J, Bloom R, Weil Y, Milgrom C. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med 2011; 39(4): 710-4.[http://dx.doi.org/10.1177/0363546510393944] [PMID: 21310 940]
[16] Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: A longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg 2001; 10(3): 199-203.[http://dx.doi.org/10.1067/mse.2001.113086] [PMID: 114088 98]
[17] Longo UG, Franceschi F, Berton A, Maffulli N, Droena V. Conservative treatment and rotator cuff tear progression. Med Sport Sci 2012; 57: 90-9.[http://dx.doi.org/10.1159/000328910] [PMID: 21986048]
[18] Dunn WR, Kuhn JE, Sanders R, et al. Symptoms of pain do not correlate with rotator cuff tear severity: A cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am 2014; 96(10): 793-800.[http://dx.doi.org/10.2106/JBJS.L.01304] [PMID: 24875019]
[19] Hawkins RH, Dunlop R. Nonoperative treatment of rotator cuff tears. Clin Orthop Relat Res 1995; (321): 178-88.[PMID: 7497666]
[20] Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am 2006; 88(8): 1699-704.[http://dx.doi.org/10.2106/JBJS.E.00835] [PMID: 16882890]
[21] Mall NA, Kim HM, Keener JD, et al. Symptomatic progression of asymptomatic rotator cuff tears: A prospective study of clinical and sonographic variables. J Bone Joint Surg Am 2010; 92(16): 2623-33.[http://dx.doi.org/10.2106/JBJS.I.00506] [PMID: 21084574]
[22] Curry EJ, Matzkin EE, Dong Y, Higgins LD, Katz JN, Jain NB. Structural characteristics are not associated with pain and function in rotator cuff tears: The ROW cohort study. Orthop J Sports Med 2015; 3(5): 2325967115584596.[http://dx.doi.org/10.1177/2325967115584596] [PMID: 26675 985]
[23] Brophy RH, Dunn WR, Kuhn JE. Shoulder activity level is not associated with the severity of symptomatic, atraumatic rotator cuff tears in patients electing nonoperative treatment. Am J Sports Med 2014; 42(5): 1150-4.[http://dx.doi.org/10.1177/0363546514526854] [PMID: 24658 346]
[24] Kelly BT, Kadrmas WR, Speer KP. The manual muscle examination for rotator cuff strength. An electromyographic investigation. Am J Sports Med 1996; 24(5): 581-8.[http://dx.doi.org/10.1177/036354659602400504] [PMID: 88 83676]
[25] DeOrio JK, Cofield RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am 1984; 66(4): 563-7.[http://dx.doi.org/10.2106/00004623-198466040-00011] [PMID: 6707 035]
[26] Yamamoto A, Takagishi K, Kobayashi T, et al. The impact of faulty posture on rotator cuff tears with and without symptoms. J Shoulder Elbow Surg 2015; 24(3): 446-52.[http://dx.doi.org/10.1016/j.jse.2014.07.012] [PMID: 254415 65]
[27] Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther 2009; 39(2): 90-104.[http://dx.doi.org/10.2519/jospt.2009.2808] [PMID: 191940 22]
[28] McClure PW, Michener LA, Karduna AR. Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Phys Ther 2006; 86(8): 1075-90.[PMID: 16879042]
[29] Endo K, Hamada J, Suzuki K, Hagiwara Y, Muraki T, Karasuno H. Does scapular motion regress with aging and is it restricted in patients with idiopathic frozen shoulder? Open Orthop J 2016; 10: 80-8.[http://dx.doi.org/10.2174/1874325001610010067] [PMID: 27733880]
[30] Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987; (214): 160-4.[PMID: 3791738]
[31] Parsons IM, Apreleva M, Fu FH, Woo SLY. The effect of rotator cuff tears on reaction forces at the glenohumeral joint. J Orthop Res 2002; 20(3): 439-46.[http://dx.doi.org/10.1016/S0736-0266(01)00137-1] [PMID: 12038 616]
[32] Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy 1994; 10(4): 363-70.[http://dx.doi.org/10.1016/S0749-8063(05)80186-0] [PMID: 7945631]
[33] Kim JH, Hong IT, Ryu KJ, Bong ST, Lee YS, Kim JH. Retear rate in the late postoperative period after arthroscopic rotator cuff repair. Am J Sports Med 2014; 42(11): 2606-13.[http://dx.doi.org/10.1177/0363546514547177] [PMID: 2518 6830]
[34] Le BT, Wu XL, Lam PH, Murrell GA. Factors predicting rotator cuff retears: An analysis of 1000 consecutive rotator cuff repairs. Am J Sports Med 2014; 42(5): 1134-42.[http://dx.doi.org/10.1177/0363546514525336] [PMID: 24748 610]
[35] Ando A, Sugaya H, Hagiwara Y, et al. Identification of prognostic factors for the nonoperative treatment of stiff shoulder. Int Orthop 2013; 37(5): 859-64.[http://dx.doi.org/10.1007/s00264-013-1859-8] [PMID: 2350 3671]
[36] Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: A prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2007; 15(7): 915-21.[http://dx.doi.org/10.1007/s00167-007-0288-x] [PMID: 1733 3123]
[37] Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff. A followup study by arthrography. Clin Orthop Relat Res 1994; 304(304): 68-73.[PMID: 8020236]
[38] Koide M, Hamada J, Hagiwara Y, Kanazawa K, Suzuki K. A thickened coracohumeral ligament and superomedial capsule limit internal rotation of the shoulder joint: Report of three cases. Case Rep Orthop 2016; 9384974.[http://dx.doi.org/10.1155/2016/9384974] [PMID: 27123353]

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents



Webmaster Contact: info@benthamopen.net
Copyright © 2019 Bentham Open