What is the management for rotator cuff tendinitis?

Management of Rotator Cuff Tendinitis

The management of rotator cuff tendinitis should follow a multimodal approach including NSAIDs, acetaminophen, physical therapy, and limited corticosteroid injections, with surgical intervention reserved for cases that fail conservative management after 8-12 weeks. 1

Initial Conservative Management (0-4 weeks)

• Pain Management:

  • NSAIDs at lowest effective dose for shortest duration (consider patient's renal function, age, comorbidities)
  • Regular acetaminophen to prevent pain escalation
  • Avoid opioids except as rescue analgesia when other methods fail 1

• Activity Modification:

  • Avoid overhead activities and positions that exacerbate symptoms
  • Technique modification for athletes and manual laborers 1

• Physical Therapy:

  • Gentle range of motion exercises
  • Focus on rotator cuff strengthening and scapular stabilization 1

Intermediate Phase (4-8 weeks)

• Continue medications as needed

• Progress Physical Therapy:

  • Advance to strengthening exercises
  • Eccentric strengthening exercises
  • Supervised physical therapy is more appropriate than unsupervised home exercise for many patients 1

• Consider Corticosteroid Injection:

  • Moderate evidence supports a single injection with local anesthetic for short-term improvement in pain and function
  • Use only if pain limits rehabilitation progress
  • Be cautious about potential adverse effects on tendon healing if surgical repair is anticipated 2, 1

Advanced Phase (8-12 weeks)

• Evaluate Response to Conservative Treatment:

  • Continue physical therapy for at least 8-12 weeks for optimal results 1
  • Consider alternative injections if improvement is inadequate:
    • Limited evidence supports hyaluronic acid injections 2
    • Limited evidence does not support routine PRP for tendinopathy or partial tears 2

• Consider Surgical Consultation:

  • If persistent pain and functional limitation occur despite conservative management 1
  • Strong evidence supports that healed rotator cuff repairs show improved outcomes compared to physical therapy alone 2

Surgical Options (when conservative management fails)

• Arthroscopic Approach:
  • Preferred when surgery is necessary 1
  • For partial-thickness tears, strong evidence supports either conversion to full-thickness or repair 2
  • Moderate evidence does not support routine acromioplasty with repair 2
  • Strong evidence does not support double-row over single-row mattress repair constructs for improved outcomes 2

Prognostic Considerations

• Age: Strong evidence indicates older age is associated with higher failure rates and poorer outcomes 2, 1

• Comorbidities: Moderate evidence suggests patients with comorbidities, especially diabetes, will have higher retear rates and poorer outcomes 2, 1

• Natural History: With non-surgical management, tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years 2, 1

Potential Pitfalls

• Overuse of corticosteroid injections may impair tendon healing 1

• Complete immobilization of the shoulder can lead to muscle atrophy and worsen outcomes 1

• Inadequate pain management before bedtime can lead to sleep disruption and potential chronic pain development 1

• Delayed rehabilitation may lead to stiffness and prolonged recovery

• Failure to address biomechanical factors contributing to impingement and tendinopathy may lead to recurrence

By following this structured approach to rotator cuff tendinitis management, clinicians can optimize outcomes while minimizing complications and the need for more invasive interventions.