What is the management of a rotator cuff tear?

Management of Rotator Cuff Tears

Physical therapy should be the first-line treatment for most rotator cuff tears, as strong evidence supports that patient-reported outcomes improve with physical therapy in symptomatic patients with full-thickness rotator cuff tears, though tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management. 1

Diagnostic Approach

Strong evidence supports using imaging as an adjunct to clinical examination:

• MRI
• MR arthrography
• Ultrasonography

These modalities are highly effective in identifying rotator cuff tears 1.

Treatment Algorithm

1. Initial Management (Non-Surgical)

For symptomatic rotator cuff tears, begin with:

• Physical therapy

  • Both supervised and home exercise programs may be beneficial
  • Focus on rotator cuff strengthening and scapular stabilization
  • Strong evidence supports improvement in pain and function 1

• Pain management options

  • NSAIDs (though evidence is inconclusive specifically for rotator cuff tears) 1
  • Single corticosteroid injection with local anesthetic (moderate evidence supports short-term improvement) 1
  • Avoid multiple steroid injections as they may compromise rotator cuff integrity 1
  • Hyaluronic acid injections (limited supporting evidence) 1

• Activity modification to avoid provocative movements

2. Surgical Management Considerations

Surgical repair should be considered in the following scenarios:

• Acute traumatic tears

  • Especially in younger patients
  • Better outcomes when repaired within 4 months of injury 2
  • Typically from falls on outstretched hand or glenohumeral dislocations

• Chronic symptomatic full-thickness tears

  • When conservative management fails (weak evidence) 1
  • Note that surgery has not conclusively demonstrated superior outcomes compared to conservative treatment in some studies 3

• Partial-thickness tears

  • Repair recommended if involving >50% of tendon thickness 4
  • Debridement for articular-sided tears <50% thickness
  • More aggressive approach for bursal-sided tears even if <50% 4

3. Special Considerations

• Age factors

  • Strong evidence shows older age is associated with higher failure rates and poorer outcomes after repair 1
  • Incidence increases with age (25% in 60s, >50% in 80s) 5

• Massive, irreparable tears

  • Biceps tenotomy or tenodesis can provide symptomatic improvement 4
  • Reverse shoulder arthroplasty may be considered for irreparable tears with pseudoparalysis or glenohumeral arthritis 1

• Post-operative rehabilitation

  • Strong evidence shows similar outcomes between early mobilization and delayed mobilization (up to 8 weeks) 1
  • Multimodal non-opioid pain management is supported by moderate evidence 1

Clinical Pitfalls and Caveats

1. Asymptomatic tears should not be treated surgically as:

   • They are highly prevalent in older populations
   • No reliable evidence shows surgery prevents clinical deterioration
   • Healing rates are inconsistent in elderly patients
   • Surgical risks outweigh benefits in absence of symptoms 1

2. Acromioplasty is not routinely recommended with rotator cuff repair for small to medium-sized tears (moderate evidence) 1

3. Platelet-rich plasma (PRP) is not supported by evidence for rotator cuff tendinopathy or partial tears 1

4. Multiple steroid injections may compromise rotator cuff integrity and affect subsequent repair attempts 1

5. Surgical vs. conservative treatment shows limited evidence that surgery is not significantly more effective than conservative treatment alone, with differences below clinically important thresholds 3