What is the initial management for rotator cuff injuries?

Initial Management of Rotator Cuff Injuries

Physical therapy is strongly recommended as the first-line treatment for rotator cuff injuries, with strong evidence supporting its effectiveness in improving patient-reported outcomes. 1

Diagnostic Evaluation

• Imaging: MRI, MRA, and ultrasonography are strongly recommended as useful adjuncts to clinical examination for identifying rotator cuff tears 2, 1
• Clinical tests:
  • Hawkins' test (92% sensitive, 25% specific)
  • Neer's test (88% sensitive, 33% specific) 1
• Radiography: Should include anteroposterior views in internal and external rotation, and an axillary or Y-view of the scapula 1

Treatment Algorithm

Phase 1 (0-4 weeks)

1. Pain management:

   • NSAIDs (ibuprofen, naproxen) at lowest effective dose
   • Acetaminophen (paracetamol) administered regularly
   • Avoid opioids except as rescue analgesia 1

2. Activity modification:

   • Avoid overhead activities and movements that exacerbate pain
   • Gentle range of motion exercises 1

Phase 2 (4-8 weeks)

1. Continue medications as needed
2. Progress to strengthening exercises:
   • Rotator cuff strengthening
   • Scapular stabilization exercises
   • Eccentric strengthening exercises 1
3. Consider a single corticosteroid injection with local anesthetic if pain limits rehabilitation progress
   • Moderate evidence supports short-term improvement in pain and function 2, 1
   • Caution: Multiple injections may compromise rotator cuff integrity 1

Phase 3 (8-12 weeks)

1. Evaluate response to conservative treatment
2. Consider additional interventions if improvement is inadequate:
   • Hyaluronic acid injections (limited evidence supports use) 2
   • Platelet-rich plasma (limited evidence, not routinely recommended) 2, 3
3. Assess need for surgical consultation if persistent pain and functional limitation 1

Prognostic 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 shows poorer outcomes in patients with comorbidities, particularly diabetes 2, 1
• Natural history: Tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with non-surgical management 2, 1

Surgical Considerations

• Surgical management should be reserved for cases that fail conservative measures after 8-12 weeks 4
• Patients with large retracted tears and muscle atrophy may have poor healing potential with surgical repair 1
• Strong evidence does not support routine use of acromioplasty as a concomitant treatment compared with arthroscopic repair alone for small to medium-sized full-thickness tears 2

Common Pitfalls to Avoid

• Overuse of corticosteroid injections: May impair tendon healing if surgical repair is anticipated 1
• Complete immobilization: Can lead to muscle atrophy and worsen outcomes 1
• Inadequate pain management: Particularly before bedtime, can lead to sleep disruption and potential chronic pain development 1
• Premature surgical intervention: Most rotator cuff injuries can be treated conservatively 4