Developing a treatment algorithm for people presenting to primary care with symptomatic large to massive rotator cuff tendon tears: the CALMeR cuff pathway

Background: Shoulder pain is highly prevalent accounting for one-third of all musculoskeletal presentations managed in primary care. Full-thickness rotator cuff tears account for almost 1 in 4 of these presentations with the incidence and size of the tear positively correlated with increasing age. Patients can often present with pain, especially at night, significant muscle weakness, and loss of function. The prognosis is highly uncertain with 50% of patients reporting persistent pain and disability that lasts >6 months. Some of this uncertainty is created due to the high variability in first-line treatment which is often based on age, tear morphology and characteristics, and patient expectations. Managing shoulder pain at the primary care level is challenged further when a lack of clinician confidence is combined with many shoulder disorders exhibiting similar clinical features, and a lack of consensus on diagnostic criteria and concordance in clinical assessment. As a result, a great debate exists within the current literature around the prognostic outcomes of non-surgical versus surgical repair for large to massive rotator cuff tears (LMRCTTs). To address these evidence-practice gaps, the overarching aim of this thesis is to develop a treatment algorithm to assist in the provision of care for people presenting with LMRCTTs. The overall aim is achieved through the conduct of four objectives, underpinned by the Medical Research Council Framework for the Development and Evaluation of Complex Interventions.