Initial Treatment Approach for Rotator Cuff Arthropathy

The initial treatment for rotator cuff arthropathy should be nonsurgical, using exercise programs and/or NSAIDs as first-line interventions. 1, 2

First-Line Nonsurgical Management

Paracetamol (acetaminophen) and NSAIDs should be administered as initial pain management for patients with rotator cuff tears 2
NSAIDs or COX-2 specific inhibitors should be used concurrently with paracetamol for more effective pain control 1, 2
Opioids should be reserved only for rescue analgesia when other methods fail 1, 2

Exercise programs have shown beneficial effects in decreasing pain and improving function in patients with rotator cuff-related symptoms 1
Several level II studies demonstrate significantly improved pain scores on visual analog scales after 8 weeks of treatment with exercise programs 1
Home exercise programs have shown significant improvements in pain at rest, pain at night, and functional scores after 3 months 1

Moderate evidence supports the use of a single injection of corticosteroid with local anesthetic for short-term improvement in both pain and function 1
However, evidence regarding subacromial corticosteroid injections is conflicting, with five level II studies reporting various results for outcomes of pain and function 1

For severe pain requiring additional intervention, interscalene brachial plexus blockade is recommended as the first-choice regional analgesic technique 1, 2
Suprascapular nerve block with or without axillary nerve block may be used as an alternative to interscalene block 1, 2
A single dose of intravenous dexamethasone can increase the analgesic duration of nerve blocks and provide additional pain relief 1

Limited evidence supports the use of hyaluronic acid injections in the nonsurgical management of patients with rotator cuff pathology 1, 3
Studies examining sodium hyaluronate and hyaluronic acid injections have shown notable improvements in shoulder function scores 3

Manual therapy combined with exercise has shown more improvement than placebo in function scores, though the difference may not always be clinically significant 4, 5
The inclusion of manual therapy in standard comprehensive physiotherapy for patients with chronic rotator cuff injuries significantly improves treatment effectiveness 5

Initial approach: Start with oral paracetamol and NSAIDs/COX-2 inhibitors for pain control 1, 2
Add exercise therapy: Implement a structured exercise program focusing on rotator cuff strengthening 1
If inadequate response: Consider a single corticosteroid injection with local anesthetic 1
For persistent severe pain: Consider regional anesthetic techniques (interscalene block or suprascapular nerve block) 1, 2
Advanced options: Consider hyaluronic acid injections or manual therapy combined with exercise if other approaches fail 1, 3, 5

Conservative management should be the initial approach before considering surgical options 6
There is limited evidence that surgery is not more effective in treating rotator cuff tears than conservative treatment alone 6
Older age is associated with higher failure rates and poorer outcomes after rotator cuff repair, which may influence treatment decisions 1
The effectiveness of other modalities such as ice, heat, iontophoresis, massage, TENS, or PEMF lacks sufficient evidence 1, 2

Rushing to surgical intervention before an adequate trial of conservative management 6
Relying solely on one treatment modality instead of a comprehensive approach 2
Overuse of corticosteroid injections, which should be limited to single injections for short-term relief 1
Using opioids as first-line treatment rather than reserving them for rescue analgesia 1, 2