What medications are used to treat pain in rotator cuff tears?

Medications for Pain Management in Rotator Cuff Tears

For pain management in rotator cuff tears, a multimodal approach using paracetamol (acetaminophen) and NSAIDs/COX-2 inhibitors should be used as first-line treatment, with opioids reserved only for rescue analgesia when other methods fail. 1, 2

First-Line Pharmacological Options

• Paracetamol (acetaminophen) should be administered regularly as part of the baseline pain management strategy 1, 2
• NSAIDs or COX-2-specific inhibitors should be used concurrently with paracetamol for more effective pain control 1
• Ibuprofen (400-800mg every 6-8 hours) has been shown to provide better improvement in pain severity and functional activity compared to acetaminophen in rotator cuff-related shoulder pain 3
• These medications should be started pre-operatively or immediately after diagnosis and continued regularly 1, 2

Second-Line Options for Severe Pain

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

Corticosteroid Injections

• A single injection of corticosteroid with local anesthetic may provide short-term improvement in both pain and function 4
• Multiple steroid injections should be avoided as they may compromise the integrity of the rotator cuff and affect subsequent repair attempts 1, 4
• Evidence regarding subacromial corticosteroid injections is conflicting, with some studies showing benefit while others show no significant difference compared to placebo 1, 2

Rescue Medication

• Opioids should be reserved only for rescue analgesia when other methods fail 1, 2
• They should not be used as a first-line or regular treatment option 1, 2

Pain Management Algorithm

1. Start with regular paracetamol and NSAIDs/COX-2 inhibitors 1, 2
2. If pain persists despite optimal oral medication, consider:
   • Single corticosteroid injection (with caution) 4, 2
   • Regional anesthetic techniques for severe pain (interscalene block or suprascapular nerve block) 1
3. Use opioids only as rescue medication when all other options fail 1

Common Pitfalls to Avoid

• Relying solely on opioids for pain management 1, 2
• Using multiple corticosteroid injections, which may compromise rotator cuff integrity 1, 4
• Failing to implement a multimodal approach combining medications with physical therapy 4, 5
• Not addressing pain adequately, which may impair rehabilitation efforts and potentially affect long-term outcomes 1, 4

Special Considerations

• For elderly patients, NSAIDs should be used with caution due to increased risk of gastrointestinal, renal, and cardiovascular side effects 6
• When surgical repair is planned, pain management should be optimized to facilitate early rehabilitation 1
• Whenever possible, rotator cuff repair should be performed using an arthroscopic approach, as it is associated with reduced postoperative pain 1