What is the treatment for rotator cuff tendinopathy versus shoulder impingement?

Treatment of Rotator Cuff Tendinopathy vs Shoulder Impingement

For both rotator cuff tendinopathy and shoulder impingement, initial treatment should focus on conservative management with physical therapy, NSAIDs, and activity modification for 3-6 months before considering surgical intervention. 1

Understanding the Conditions

• Rotator Cuff Tendinopathy: Involves degeneration of the rotator cuff tendons (primarily supraspinatus), often due to overuse, aging, or poor biomechanics
• Shoulder Impingement: Occurs when the rotator cuff tendons are compressed between the humeral head and the acromion during shoulder movement

Note: These conditions often overlap, with impingement frequently leading to tendinopathy

Diagnostic Approach

• Imaging: MRI, MRA, and ultrasonography are strongly recommended as useful adjuncts to clinical examination for identifying rotator cuff tears 2
• Clinical Tests:
  • Hawkins' test (92% sensitive, 25% specific) - pain with forcible internal rotation with arm flexed forward at 90°
  • Neer's test (88% sensitive, 33% specific) - pain with full forward flexion between 70-120° 2

Treatment Algorithm

Step 1: Conservative Management (First 3-6 months)

1. Exercise Therapy (Moderate evidence)

   • Eccentric strengthening exercises to promote tendon healing
   • Supervised or home-based physical therapy 2, 1
   • Focus on rotator cuff strengthening and scapular stabilization

2. Pharmacological Management

   • NSAIDs/COX-2 inhibitors: First-line treatment for pain management 1
   • Acetaminophen: Regular administration to prevent pain escalation 1
   • Corticosteroid Injection: Moderate evidence supports a single injection with local anesthetic for short-term improvement in both pain and function 2
     • Caution: Multiple injections may compromise rotator cuff integrity 1

3. Activity Modification

   • Avoid overhead activities and positions that exacerbate symptoms
   • Technique modification for athletes and manual laborers 2

4. Adjunctive Therapies (Limited evidence)

   • Hyaluronic acid injections (limited evidence supports use) 2
   • Deep transverse friction massage to reduce pain 2
   • Ultrasound therapy (weak evidence) 2
   • Extracorporeal shock wave therapy (ESWT) - mixed results 2

Step 2: Persistent Symptoms (After 3-6 months of conservative treatment)

If symptoms persist despite appropriate conservative management:

1. Surgical Consultation

   • Recommended for:
     • Symptomatic tears unresponsive to conservative treatment
     • Traumatic acute tears, especially in young patients
     • Significant pain unresponsive to conservative management 1

2. Surgical Options

   • Arthroscopic Technique: Preferred when surgery is necessary 1
   • Rotator Cuff Repair: For chronic, symptomatic full-thickness tears 1
   • Subacromial Decompression: May be considered for impingement syndrome
   • Reverse Shoulder Arthroplasty: Salvage option for older patients with low functional demand and irreparable tears 1

Special Considerations

• Age: Strong evidence indicates older age is associated with higher failure rates and poorer outcomes after rotator cuff repair 2, 1
• Comorbidities: Moderate evidence supports association of poorer outcomes in patients with comorbidities 2
• Diabetes: Moderate evidence suggests higher retear rates and poorer quality of life after repair 2
• Night Pain: Often significant in rotator cuff pathology due to increased interstitial fluid in recumbent position 1

Postoperative Management

• Mobilization Timing: Strong evidence suggests similar outcomes between early mobilization and delayed mobilization (up to 8 weeks) for small to medium-sized tears 2, 1
• Pain Management: Interscalene brachial plexus block recommended as first-choice regional technique 1

Treatment Efficacy

• Approximately 80% of rotator cuff injuries fully recover within 3-6 months with appropriate conservative treatment 1
• One high-quality trial found no clinically important differences between manual therapy plus exercise versus placebo for rotator cuff disease 3

Caution: Avoid complete immobilization of the shoulder as it can lead to muscle atrophy and worsen outcomes 1