What is the treatment for rotator cuff (RC) impingement?

Treatment of Rotator Cuff Impingement

Physical therapy should be the first-line treatment for rotator cuff impingement, with NSAIDs and activity modification, followed by corticosteroid injection if needed, and surgical intervention only after failure of conservative management for 8-12 weeks. 1

Initial Conservative Management (0-8 weeks)

Medications

• NSAIDs: First-line medication for pain and inflammation
  • Use lowest effective dose for shortest duration necessary
  • Consider patient's renal function, age, and comorbidities
• Acetaminophen (Paracetamol): Regular administration to prevent pain escalation
• Opioids: Reserve only for rescue analgesia when other methods fail 1

Physical Therapy

• Strong evidence supports that patient-reported outcomes improve with physical therapy 2
• Initial focus on gentle range of motion exercises
• Progress to strengthening exercises, particularly:
  • Rotator cuff strengthening
  • Scapular stabilization exercises
  • Eccentric strengthening exercises 1
• Supervised physical therapy is more effective than unsupervised home exercise for many patients 1

Activity Modification

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

Intermediate Management (If Initial Treatment Fails)

Corticosteroid Injections

• Moderate evidence supports a single corticosteroid injection with local anesthetic for short-term improvement in pain and function
• Use only if pain limits rehabilitation progress
• Caution: Potential adverse effects on tendon healing if surgical repair is anticipated 1

Hyaluronic Acid Injections

• Limited evidence supports their use in nonsurgical management of rotator cuff pathology 2

Advanced Management (After 8-12 Weeks of Failed Conservative Treatment)

Surgical Options

• Strong evidence supports that healed rotator cuff repairs show improved outcomes compared to physical therapy alone 2, 1
• Arthroscopic approach is preferred when surgery is necessary 1
• Moderate evidence does not support routine acromioplasty with rotator cuff repair 2, 1
• Strong evidence does not support double-row over single-row mattress repair constructs 1

Diagnostic Evaluation

Imaging

• Strong evidence supports that MRI, MRA, and ultrasonography are useful adjuncts to clinical examination for identifying rotator cuff tears 2, 1
• Simple radiography should include anteroposterior views in internal and external rotation, and an axillary or Y-view of the scapula 1

Clinical Tests

• Hawkins' test (92% sensitive, 25% specific)
• Neer's test (88% sensitive, 33% specific) 1

Prognostic Factors

• Age: Strong evidence that older age is associated with higher failure rates and poorer outcomes after rotator cuff repair 2, 1
• Tear Progression: Rotator cuff tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management 2, 1

Common Pitfalls to Avoid

1. Overuse of corticosteroid injections: May impair tendon healing 1
2. Complete immobilization: Can lead to muscle atrophy and worsen outcomes 1
3. Routine acromioplasty: Moderate evidence does not support its routine use with rotator cuff repair 2
4. Surgery for asymptomatic tears: Consensus recommendation against surgery for asymptomatic full-thickness rotator cuff tears 2
5. Inadequate pain management before bedtime: Can lead to sleep disruption and potential chronic pain development 1

Special Considerations

• For partial-thickness tears, strong evidence supports either conversion to full-thickness or repair 1
• Reverse shoulder arthroplasty is a salvage option for older patients with low functional demand and irreparable tears 1
• Limited evidence suggests that surgery may not be more effective than conservative treatment alone for rotator cuff tears 3