What is the management of rotator cuff tendinopathy?

From the Guidelines

Management of rotator cuff tendinopathy should begin with conservative measures, including rest, activity modification, and a structured physical therapy program focusing on rotator cuff strengthening and scapular stabilization exercises for 6-12 weeks, as this approach has been shown to be effective in reducing pain and improving function, with moderate evidence supporting its use 1. The goal of treatment is to reduce pain, improve function, and restore normal shoulder biomechanics.

• Conservative management should include:
  • Rest and activity modification to avoid exacerbating the condition
  • A structured physical therapy program, including progressive resistance exercises targeting the supraspinatus, infraspinatus, teres minor, and subscapularis muscles
  • Pain relief with NSAIDs, such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily), for 1-2 weeks, as they have been shown to be effective in reducing pain and inflammation 1
  • Ice application for 15-20 minutes several times daily to reduce inflammation, particularly after activity
• Corticosteroid injections, such as methylprednisolone 40mg or triamcinolone 40mg mixed with lidocaine, may be considered for persistent pain, but should be limited to 2-3 injections per year due to potential tendon weakening, with moderate evidence supporting their short-term effectiveness 1
• If conservative management fails after 3-6 months, imaging (MRI or ultrasound) and surgical consultation may be warranted, with arthroscopic approach recommended whenever possible, as it is associated with reduced postoperative pain 1 The use of systemic analgesia, including paracetamol and NSAIDs, administered pre-operatively or intra-operatively and continued postoperatively, is also recommended, with opioids reserved as rescue analgesia in the postoperative period 1

From the Research

Management of Rotator Cuff Tendinopathy

The management of rotator cuff tendinopathy involves various conservative treatment options, including:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and inflammation 2, 3, 4
• Physical therapy to improve scapular mechanics and decrease dynamic impingement 2, 5, 3, 6
• Corticosteroid injections, which may provide short-term improvements in pain and function, especially when combined with physical therapist interventions 5
• Ultrasound-guided needle aspiration and lavage techniques, which can provide long-term improvement in pain and function 2
• Acetaminophen or ibuprofen for pain management, with ibuprofen showing improvement in pain severity and functional activity, and acetaminophen showing improvement in physical and environmental domains of quality of life 4

Treatment Approaches

Different treatment approaches may be effective for different patients, including:

• Conservative treatment with NSAIDs, corticosteroid injections, and physical therapy 2, 3
• Rehabilitation programs based on the evidence known about the pathoetiology of the tendinopathy, the extent of the local anatomic injury, and the local and distant physiological and biomechanical alterations 6
• Prehabilitation, or prospective exercises to minimize future rotator cuff loading stresses, as part of the return to function 6

Comparison of Treatment Options

Studies have compared the effectiveness of different treatment options, including:

• Corticosteroid injections versus physical therapist interventions, with corticosteroid injections showing some small to moderate improvements in pain and function at short term, but not at mid- and long-term follow-up assessments 5
• Acetaminophen versus ibuprofen, with ibuprofen showing improvement in pain severity and functional activity, and acetaminophen showing improvement in physical and environmental domains of quality of life 4