From the Guidelines
The recommended treatment for a patient with a rotator cuff tear involving 3/4 muscles should start with physiotherapy, and if this approach fails after 6 months, a surgical consult should be considered. This approach is based on the principle of initially managing the condition conservatively before opting for surgical intervention, especially since the provided evidence does not strongly support immediate surgical repair for all cases of rotator cuff tears involving 3/4 muscles 1.
Initial Management
- The initial management should focus on physiotherapy to improve range of motion, strength, and function.
- Pain management is crucial and can include NSAIDs like ibuprofen or naproxen, possibly combined with acetaminophen for 1-2 weeks, as recommended by recent guidelines 1.
- For more severe pain, a short course of opioids may be prescribed for the first few days.
Surgical Consideration
- Surgical repair should be considered if there is no significant improvement after 6 months of physiotherapy, as large multi-tendon tears have high retear rates if left untreated, and the quality of the remaining rotator cuff tissue deteriorates over time, making delayed repair more difficult and less successful.
- The surgical approach usually involves arthroscopic repair with suture anchors to reattach the torn tendons to the humeral head.
- Post-operatively, patients should follow a structured rehabilitation protocol, which typically includes 4-6 weeks of immobilization in a sling, followed by passive range of motion exercises, then active-assisted motion, and finally strengthening exercises for 6-12 weeks.
Rehabilitation and Outcome
- Physical therapy is crucial and should continue for 3-6 months to restore function.
- Patients should understand that recovery is lengthy, typically requiring 6-12 months to regain full function, and adherence to the rehabilitation protocol is essential for optimal outcomes.
- The choice of surgical technique, such as arthroscopic repair, and the use of regional analgesic techniques like interscalene brachial plexus blockade, can help reduce postoperative pain and improve outcomes, as suggested by recent guidelines 1.
This approach prioritizes morbidity, mortality, and quality of life by initially avoiding the risks associated with surgery and reserving it for cases where conservative management fails, thereby optimizing the outcome for the patient.
From the Research
Treatment Approach for Rotator Cuff Tear
- The recommended treatment for a patient with a rotator cuff tear involving 3/4 muscles typically starts with conservative management, including physiotherapy and other nonoperative treatments 2, 3.
- Physiotherapy should focus on restoring range of motion, addressing any stiffness, and restoring motor control and strength to the scapula and rotator cuff 2.
- Other conservative treatments may include nonsteroidal anti-inflammatory drugs, corticosteroid injections, and platelet-rich plasma 2.
- If conservative management fails after 6 months, surgical consultation may be considered 2, 3.
Nonoperative Treatment Outcomes
- Studies have shown that nonoperative treatment can be effective for patients with rotator cuff tears, with significant improvements in functional outcome scores and strength 3.
- A synthesized nonoperative treatment protocol has been developed, which includes supervised physical therapy, corticosteroid injections, and nonsteroidal anti-inflammatory drugs 3.
- The overall success of nonoperative treatment can range from 32% to 96% 3.
Role of Nonsteroidal Anti-Inflammatory Drugs
- Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to reduce opioid requirements and decrease patient pain levels in the first week after arthroscopic rotator cuff repair 4, 5.
- NSAIDs do not appear to affect healing rate after arthroscopic rotator cuff repair, but they can improve postoperative pain and functional outcomes 5.
- The use of NSAIDs has been found to provide short-term pain relief for rotator cuff tendinopathy, but not functional improvement 6.