Initial Treatment for Presumed Mild Rotator Cuff Injury
Start with supervised physical therapy as the primary treatment, supplemented by NSAIDs or acetaminophen for pain control, and consider a single corticosteroid injection if pain significantly limits function or therapy participation. 1
Primary Treatment Approach
Physical therapy is the cornerstone of initial management with strong evidence supporting improvement in patient-reported outcomes for symptomatic rotator cuff tears. 2, 1 The American Academy of Orthopaedic Surgeons specifically recommends supervised physical therapy over unsupervised home exercise programs for optimal outcomes. 1
Supervised vs. Home Exercise
- Supervised physical therapy is strongly preferred over home-based programs for most patients with rotator cuff pathology. 1
- Unsupervised home exercises without proper instruction represent a common pitfall that should be avoided. 1
Pain Management Strategy
First-Line Pharmacologic Options
- NSAIDs and acetaminophen are appropriate initial analgesics for managing rotator cuff pain. 3
Corticosteroid Injections
- A single corticosteroid injection with local anesthetic provides short-term improvement in both pain and function with moderate strength evidence. 2, 1
- Avoid multiple steroid injections as they compromise rotator cuff integrity and may negatively affect subsequent repair attempts if surgery becomes necessary. 1, 4
- This is a critical pitfall: repeated injections can worsen the underlying pathology. 1
Alternative Injection Therapies
- Hyaluronic acid injections have limited evidence and should not be routinely used, though they may be considered based on clinical judgment and patient preference. 2, 1
- Platelet-rich plasma (PRP) has limited evidence for rotator cuff tendinopathy or partial tears and is not routinely recommended. 2
Monitoring During Conservative Treatment
Be aware that rotator cuff tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management alone. 2, 1 This doesn't mean conservative treatment fails, but rather that structural changes can occur even as symptoms improve.
When to Consider Imaging
If the clinical diagnosis is uncertain or if symptoms fail to improve with initial conservative management, MRI, MRA, or ultrasonography are useful adjuncts to clinical examination for identifying rotator cuff tears. 2
Duration and Expectations
- Most rotator cuff injuries respond to conservative management with the regimen of NSAIDs, possible corticosteroid injection, and functional rehabilitation therapy. 3
- Surgical management is reserved for refractory cases that have exhausted conservative measures. 3
- For a presumed mild injury, expect to trial conservative therapy for at least several months before considering surgical options. 3, 5
Evidence Supporting Conservative Approach
Meta-analysis shows no clinically significant difference between surgery and active physiotherapy at 1-year follow-up in improving shoulder function or reducing pain. 5 Given that physiotherapy has fewer complications and lower cost than surgery, conservative treatment is advocated as the initial modality. 5