Rehabilitation Approach for Rotator Cuff Tears
Physical therapy is strongly recommended as the initial treatment for rotator cuff tears, with supervised physical therapy being more appropriate than unsupervised home exercise for optimal outcomes. 1
Initial Non-Surgical Management
Physical Therapy
- Strong evidence supports that patient-reported outcomes improve with physical therapy in symptomatic patients with full-thickness rotator cuff tears 1
- Supervised physical therapy is preferred over unsupervised home exercise programs for most patients 1
- Physical therapy should focus on:
- Restoring range of motion
- Addressing pectoralis minor or posterior capsule stiffness
- Restoring motor control and strength to the scapula and rotator cuff 2
Pain Management
- Moderate evidence supports the use of a single injection of corticosteroid with local anesthetic for short-term improvement in both pain and function 1
- Multiple steroid injections should be avoided as they may compromise the integrity of the rotator cuff and affect subsequent repair attempts 1
- Limited evidence supports the use of hyaluronic acid injections in the nonsurgical management of rotator cuff pathology 1
- NSAIDs may be used for symptomatic relief, though evidence specifically for rotator cuff tears is limited 2
Monitoring During Conservative Treatment
- Important to note that rotator cuff tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management 1
- Transition to surgical treatment should be considered when a patient demonstrates increased weakness and loss of function not recoverable by physiotherapy 3
- Tear size and symptoms are not always correlated with pain, function, and ultimate outcome, making it safe to monitor symptomatic tears with appropriate rehabilitation 3
Surgical Considerations
- Strong evidence shows that healed rotator cuff repairs (particularly small to medium tears) demonstrate improved patient-reported and functional outcomes compared with physical therapy and unhealed repairs 1
- Older age is associated with higher failure rates and poorer outcomes after rotator cuff repair 1
- For partial-thickness tears that have failed physical therapy, repair of high-grade partial tears could improve outcomes 1
Special Considerations for Different Tear Types
Partial-Thickness Tears
- Conservative management including physical therapy, PRP injections, collagen injections, and hyaluronic acid injections has shown favorable clinical outcomes in the short term 4
- Eccentric rehabilitation exercises have shown improvements in pain and strength 4
Massive, Unrepairable Tears
- In patients with massive, unrepairable rotator cuff tears and pseudoparalysis who have failed conservative treatments, reverse arthroplasty can improve reported outcomes 1
- For unrepairable tears with glenohumeral joint arthritis, reverse shoulder arthroplasty can improve patient-reported outcomes after failure of conservative treatment 1
Post-Operative Rehabilitation
- Strong evidence suggests similar postoperative clinical outcomes for small to medium-sized full-thickness rotator cuff tears between early mobilization and delayed mobilization up to 8 weeks 1
- Moderate evidence supports the use of multimodal programs or non-opioid individual modalities for postoperative pain management 1
Common Pitfalls to Avoid
- Relying solely on unsupervised home exercises without proper instruction 1
- Using multiple corticosteroid injections, which may compromise rotator cuff integrity 1
- Delaying surgical intervention when progressive weakness and functional loss occur despite physical therapy 3
- Assuming that all rotator cuff tears require surgical intervention, as many patients can achieve satisfactory outcomes with conservative management 5