What is the best treatment approach for rotator interval tears?

Treatment Approach for Rotator Interval Tears

The best treatment approach for rotator interval tears is conservative management with physical therapy as the first-line treatment, focusing on gentle range of motion exercises progressing to strengthening exercises, along with appropriate pain management. 1

Initial Assessment and Diagnosis

• MRI, MRA, and ultrasonography are strongly supported as useful adjuncts to clinical examination for identifying rotator cuff tears, including rotator interval tears 1
• Clinical tests for diagnosis include:
  • Hawkins' test (92% sensitivity, 25% specificity)
  • Neer's test (88% sensitivity, 33% specificity) 1
• Simple radiography should include anteroposterior views in internal and external rotation, and an axillary or Y-view of the scapula 1

Treatment Algorithm

Phase 1: Initial Treatment (0-4 weeks)

1. Pain Management:

   • NSAIDs and acetaminophen as first-line medications
   • Local cold therapy for pain relief
   • NSAIDs should be used at the lowest effective dose for the shortest duration 1

2. Activity Modification:

   • Avoid activities that exacerbate pain
   • No significant clinical data supports specific timeframes for shoulder immobilization 1

3. Physical Therapy:

   • Gentle range of motion exercises
   • Avoid complete immobilization as it can lead to muscle atrophy 1

Phase 2: Intermediate Treatment (4-8 weeks)

1. Progress Physical Therapy:

   • Advance to strengthening exercises
   • Include rotator cuff strengthening
   • Add scapular stabilization exercises
   • Incorporate eccentric strengthening exercises 1, 2

2. Pain Management:

   • Continue medications as needed
   • Consider a single corticosteroid injection if pain limits rehabilitation progress
   • Caution: multiple injections may compromise rotator cuff integrity 1

Phase 3: Advanced Treatment (8-12 weeks)

1. Evaluate Response:

   • Reassess in 4-6 weeks to evaluate response to physical therapy
   • If improvement is inadequate, consider platelet-rich plasma (PRP) injection 1, 2

2. Surgical Consideration:

   • Consider surgical consultation if persistent pain and functional limitation occur after 8-12 weeks of conservative management 1, 3
   • Anterosuperior rotator cuff lesions (which may include rotator interval tears) often respond poorly to physiotherapy due to biceps tendon instability and may require earlier surgical intervention 3

Special Considerations

Factors Favoring Conservative Management

• Older age (associated with higher failure rates after surgical repair) 1, 4
• Presence of comorbidities like diabetes 1
• Limited evidence shows no clinically significant difference between surgery and active physiotherapy in 1-year follow-up 4

Factors Favoring Surgical Intervention

• Young, active patients with high functional demands 5
• Failure of conservative management after 8-12 weeks 1
• Anterosuperior rotator cuff tears with biceps tendon instability 3
• Deep partial tears (≥6 mm) of the subscapularis or supraspinatus 3

Potential Complications and Pitfalls

• 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
• Retear risk: Most retears occur between 6-26 weeks post-repair, with peak incidence around 19 weeks, requiring careful progression during rehabilitation 1

Advanced Treatment Options

• For persistent symptoms:

  • Platelet-rich plasma (PRP) injections have shown significant improvements in pain scores 2
  • Hyaluronic acid injections have demonstrated notable improvements in shoulder function 2
  • Collagen injections may provide pain relief and functional improvement 2

• Surgical options when conservative management fails:

  • Tendon repair for repairable tears
  • Decompression may provide short-term pain relief, though effects may deteriorate over time 5
  • Biceps tenodesis or tenotomy is necessary for tears with biceps tendon instability 3