What are the evidence-based guidelines for treating a chronic rotator cuff tear that occurred in 2013?

From the Guidelines

Evidence-based treatment for a chronic rotator cuff tear from 2013 typically begins with conservative management before considering surgical options. Initial treatment should include physical therapy focusing on strengthening the rotator cuff muscles and improving shoulder mechanics, typically 2-3 sessions per week for 6-12 weeks 1. Pain management may include NSAIDs such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 2-4 weeks, with consideration of gastric protection if used long-term.

Key Considerations

• Corticosteroid injections (such as methylprednisolone 40mg or triamcinolone 40mg mixed with lidocaine) may provide temporary relief but should be limited to 2-3 injections per year due to potential tendon weakening 1.
• If conservative measures fail after 3-6 months, surgical repair may be considered, with arthroscopic techniques generally preferred for better visualization and less tissue damage 1.
• However, for tears present since 2013, tissue quality may be compromised, potentially affecting surgical outcomes.
• Factors influencing treatment decisions include the patient's age, activity level, tear size, and degree of muscle atrophy or fatty infiltration, which can be assessed through MRI 1.

Rehabilitation and Recovery

• Rehabilitation following any intervention is crucial for restoring function, with expected recovery taking 6-12 months to achieve maximum improvement.
• The use of platelet-derived products for biological augmentation of rotator cuff repair is not strongly supported by evidence, although limited evidence suggests liquid platelet–rich plasma may decrease retear rates 1.
• Postoperative pain management should include paracetamol, non-steroidal anti-inflammatory drugs, dexamethasone, and a regional analgesic technique, with opioids reserved for rescue analgesia 1.

From the Research

Treatment Options for Chronic Rotator Cuff Tears

• Nonoperative care, including physical therapy and conservative treatment, may be appropriate for patients with chronic rotator cuff tears, especially if they have had a positive response to conservative care 2.
• Repair of symptomatic tears is often recommended when conservative treatment fails 2.
• Reconstructive measures may be considered for patients with chronic massive tears 2.
• Arthroplasty may be an option for healthy patients with pseudoparalysis and chronic massive tears 2.

Role of Biologic Injections

• Biologic injections, such as platelet-rich plasma (PRP), may provide short-term therapeutic benefits for patients with partial-thickness rotator cuff tears, but their effects tend to diminish after 1 year 3.
• The efficacy and safety of PRP preparations and concentrations can vary, and the optimal biologic injectable and formulation is unknown 3.

Comparison of Surgery and Conservative Treatment

• A meta-analysis found that surgery was not significantly more effective than conservative treatment in reducing pain and improving function in patients with rotator cuff tears, and that a conservative approach may be advocated as the initial treatment modality 4.
• Exercise rehabilitation and physical therapy may be a viable alternative to surgical repair for selected patients with rotator cuff tears, with studies showing high satisfaction, improvement in function, and success in avoiding surgery 5.

Surgical Indications

• Surgical treatment may be indicated for patients with partial rotator cuff tears that are more than 50% of the thickness or with substantial thinning of the rotator cuff 6.
• The technique and postoperative rehabilitative regimen for arthroscopic surgery for partial rotator cuff tears have been described, with the goal of increasing blood supply to the rotator cuff and diminishing the chance of extension to a complete tear 6.