What is the treatment for rotator cuff pain?

Treatment for Rotator Cuff Pain

For rotator cuff pain, a multimodal approach including paracetamol, NSAIDs, physical therapy, and regional anesthesia techniques is recommended, with arthroscopic surgical repair reserved for cases that fail conservative management. 1

First-Line Conservative Management

Medications

• Paracetamol (acetaminophen): Regular administration to prevent significant increases in pain 1, 2
• NSAIDs/COX-2 inhibitors: First-line pharmacological treatment 1, 2
  • Ibuprofen (400-800mg every 6-8 hours) has shown better improvement in pain severity and functional activity compared to acetaminophen 3
• Timing: Take medications approximately 30 minutes before bedtime to manage night pain 2

Physical Therapy

• Exercise programs: Moderate evidence supports exercise for decreasing pain and improving function, especially for patients without full-thickness tears 1
• Focus areas:
  • Eccentric strengthening exercises to promote tendon healing 2
  • Range of motion restoration
  • Addressing pectoralis minor or posterior capsule stiffness
  • Motor control/strength restoration to scapula and rotator cuff 4

Adjunctive Treatments

• Cryotherapy: Recommended for short-term pain relief 2
• Corticosteroid injections: May be more effective than NSAIDs in the acute phase, but evidence is conflicting 1, 2
  • Caution: Overuse can lead to tendon weakening 2

Regional Anesthesia (For Severe Pain or Post-Surgical Management)

• Interscalene brachial plexus block: Recommended as first-choice regional technique 1
  • Available as continuous or single-shot options
• Suprascapular nerve block: Alternative when interscalene block is contraindicated 1
• IV dexamethasone: Recommended to increase analgesic duration of nerve blocks 1

Surgical Management

• Indication: Significant pain that doesn't respond to conservative treatment, especially with full-thickness tears 2
• Approach: Arthroscopic technique is recommended when surgery is necessary 1
• Post-surgical pain management: Same multimodal approach with emphasis on regional anesthesia 1

Treatment Algorithm

1. Initial treatment (0-6 weeks):

   • Regular paracetamol and NSAIDs
   • Physical therapy with focus on eccentric strengthening
   • Cryotherapy for acute pain

2. If inadequate response (6-12 weeks):

   • Consider corticosteroid injection
   • Continue physical therapy with modified protocol
   • Optimize pain medication regimen

3. Persistent symptoms (>3 months):

   • Consider MRI to assess tear severity
   • Evaluate for surgical candidacy if conservative measures fail

Prognosis

• Approximately 80% of rotator cuff injuries fully recover within 3-6 months with appropriate conservative treatment 2
• Complete immobilization should be avoided as it can lead to muscle atrophy and worsen outcomes 2
• Limited evidence suggests no clinically significant difference between surgery and active physiotherapy in 1-year follow-up 5

Common Pitfalls to Avoid

• Inadequate pain management before bedtime can lead to sleep disruption and potential chronic pain development 2
• Overreliance on corticosteroid injections can weaken tendons over time 2
• Neglecting physical therapy in favor of medication-only approaches reduces chances of full recovery 4, 6
• Complete immobilization of the shoulder leading to muscle atrophy 2