For a probable rotator cuff injury, should you mobilize the extremity or refer to an orthopedic specialist?

Management of Probable Rotator Cuff Injuries: Mobilization vs. Orthopedic Referral

For a probable rotator cuff injury, early mobilization with appropriate physical therapy is recommended, with orthopedic referral reserved for cases that fail to improve with conservative management or show signs of complete tears. 1

Initial Assessment and Management

• Strong evidence supports that MRI, MR arthrography, and ultrasonography are useful adjuncts to clinical examination for identifying and characterizing rotator cuff tears 1
• Pain located in the anterior or anterolateral aspect of the shoulder that worsens with overhead activities is highly sensitive (88%) for rotator cuff pathology 2
• Decreased range of motion, particularly during abduction with external or internal rotation, is a common finding in patients with rotator cuff injury 2

Conservative Management Approach

• Strong evidence supports that patient-reported outcomes improve with physical therapy in symptomatic patients with full-thickness rotator cuff tears 1
• First-line treatment for rotator cuff injuries consists of conservative non-operative management with appropriate rest, anti-inflammatory medications, followed by a specific rehabilitation program 3, 4
• Early mobilization after rotator cuff injury is associated with better early mobility and functional scores compared to immobilization 5
• Conservative management should include:
  • Rotator cuff and scapular stabilizer strengthening
  • Re-establishing proper mechanics of the shoulder and spine
  • Restoring range of motion 1

Mobilization Timing and Protocols

• Strong evidence suggests similar postoperative clinical outcomes between early mobilization and delayed mobilization for patients who have undergone arthroscopic rotator cuff repair 1
• A randomized controlled trial showed that three weeks of immobilization was non-inferior to six weeks of immobilization after repair of small to medium rotator cuff tears 6
• In patients without surgical repair, early mobilization with appropriate physical therapy is beneficial for maintaining range of motion and preventing stiffness 3

Indications for Orthopedic Referral

• Orthopedic referral is recommended for:
  • Failure to improve with 4-6 weeks of conservative management 3
  • Evidence of complete tears, especially in younger patients 4
  • Progressive worsening of symptoms despite appropriate therapy 1
  • Significant functional limitations affecting quality of life 1
  • Athletes requiring expedited return to high-level performance 4

Special Considerations

• In youth/adolescent patients, rotator cuff injuries often result from atraumatic microinstability and weak rotator cuff muscles 1
• Older age is associated with higher failure rates and poorer outcomes after rotator cuff repair, which may influence the decision between continued conservative management versus surgical referral 1
• Muscular imbalance, with weakened posterior shoulder musculature and overdeveloped anterior musculature, increases injury risk and should be addressed in rehabilitation 2

Common Pitfalls to Avoid

• Prolonged immobilization can lead to shoulder stiffness and decreased function 5
• Failure to distinguish between primary impingement and secondary impingement may lead to inappropriate treatment 2
• Ignoring scapular dyskinesis, which contributes significantly to rotator cuff injury 2
• Neglecting to address the entire kinetic chain in rehabilitation programs 3