From the Guidelines
Management of rotator cuff tears should prioritize a systematic approach based on tear characteristics, patient factors, and functional demands, with initial management focusing on non-operative treatment and surgical intervention reserved for specific indications, as supported by the most recent and highest quality study 1.
Initial Management
Initial management for most tears should begin with non-operative treatment including:
- Activity modification
- NSAIDs (such as ibuprofen 400-600mg TID or naproxen 500mg BID for 2-4 weeks)
- Physical therapy focusing on rotator cuff and periscapular strengthening
- Possibly subacromial corticosteroid injections (40mg methylprednisolone with 4-5ml of 1% lidocaine), although the evidence for this is inconclusive 1 This conservative approach should typically be attempted for 3-6 months before considering surgery.
Surgical Intervention
Surgical intervention is indicated for:
- Acute traumatic tears, especially in younger patients (<65 years)
- Full-thickness tears >1cm with significant weakness or functional limitation
- Tears with significant retraction
- After failed conservative management Surgical options include arthroscopic repair, mini-open repair, or open repair depending on tear configuration, with the goal of anatomic footprint restoration using suture anchors with either single-row (for small tears <1cm) or double-row techniques (for larger tears >3cm) to maximize healing potential, as recommended by the most recent study 1.
Post-Operative Rehabilitation
Post-operative rehabilitation is crucial and typically involves:
- 4-6 weeks of immobilization in a sling
- Passive range of motion exercises
- Active assisted motion at 6-8 weeks
- Strengthening at 10-12 weeks Return to full activities usually occurs at 6 months.
Alternative Approaches
Massive irreparable tears may require alternative approaches such as:
- Partial repair
- Superior capsular reconstruction
- Tendon transfers (latissimus dorsi or lower trapezius)
- Reverse total shoulder arthroplasty in elderly patients with pseudoparalysis and glenohumeral arthritis Outcomes depend on patient age, tear size, tissue quality, fatty infiltration (Goutallier classification), and compliance with rehabilitation protocols, as noted in the literature 1.
From the Research
Management of Rotator Cuff Tears
- Rotator cuff tears are a common cause of chronic shoulder pain and disability, affecting the quality of life 2.
- The goals of conventional therapy are reduced pain and improved function, which can be achieved through relative rest, pain therapy, physical therapy, corticosteroid injections, and surgical intervention 2, 3.
Nonoperative Management
- Nonoperative management is appropriate for patients who have a positive response to conservative care, and may include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and functional rehabilitation therapy 4, 3.
- Exercise therapy can be effective in the conservative management of full-thickness tears of the rotator cuff, with improvements in outcome scores reported in observational studies 5.
- Subacromial injection of autologous platelet-rich plasma (PRP) may be considered as a good alternative to corticosteroid injection, especially in patients with a contraindication to corticosteroid administration 2.
Surgical Management
- Surgical repair is appropriate for symptomatic patients who have failed conservative treatment, and can provide a reliable treatment alternative 4, 6.
- Rotator cuff repair is recommended for patients with symptomatic tears, while reconstructive measures may be considered for patients with chronic massive tears 4.
- Arthroplasty may be considered for patients with painful pseudoparalysis and associated arthropathy, but has limited indications in the setting of rotator cuff tears 6.
Treatment Outcomes
- The outcome of rotator cuff tendon surgery in the elderly is generally poor, making conservative management a preferred option for this patient group 5.
- Recurrent tears after surgery can compromise outcomes, particularly for younger patients with physically demanding occupations, but revision surgery can provide satisfactory results 6.
- Addressing concomitant biceps pathology or performing partial repairs can reliably improve pain and potentially reverse pseudoparalysis in patients with irreparable tears 6.