What is the approach to management of a rotator cuff tear?

Management of Rotator Cuff Tears

Signs and Symptoms

Patients with symptomatic rotator cuff tears typically present with shoulder pain (particularly at night and during overhead activities), weakness in abduction and external/internal rotation, reduced range of motion, and altered shoulder mechanics including decreased glenohumeral elevation and scapulothoracic posterior tilt. 1

Key clinical features include:

• Pain during range of motion and at rest/night 2
• Weakness in abduction, external rotation, and internal rotation compared to the unaffected side 1
• Reduced active range of motion in multiple planes 1
• Functional limitations in activities of daily living 3

Physical Examination

Diagnosis requires a cluster of physical examination tests rather than relying on a single maneuver. 4

Critical examination findings:

• Strength testing reveals deficits in abduction, external rotation, and internal rotation 1
• Range of motion assessment demonstrates limitations compared to the contralateral shoulder 1
• Scapular mechanics show reduced posterior tilt during elevation 1
• Acromiohumeral distance may be decreased 1

Diagnostic Imaging

Strong evidence supports that MRI, MRI arthrography, and ultrasonography are useful adjuncts to clinical examination for identifying rotator cuff tears. 5

Imaging approach:

• MRI is the most commonly used imaging technique for confirming rotator cuff tears 4, 6
• Ultrasound represents an effective alternative imaging modality 5, 4
• Plain radiographs can be helpful but are insufficient for definitive diagnosis 4

Management Algorithm

Initial Conservative Management (First-Line Treatment)

Physical therapy is the initial treatment for rotator cuff tears, with supervised physical therapy being more appropriate than unsupervised home exercise for optimal outcomes. 3

Pain Management Protocol:

1. Start with paracetamol (acetaminophen) and NSAIDs as initial pain management 7
2. Paracetamol should be administered immediately after diagnosis and continued regularly 7
3. NSAIDs or COX-2 specific inhibitors should be used concurrently with paracetamol for more effective pain control 7
4. Consider a single corticosteroid injection with local anesthetic for short-term improvement in pain and function 3
5. Avoid multiple steroid injections as they may compromise rotator cuff integrity and affect subsequent repair attempts 3
6. Reserve opioids only for rescue analgesia when other methods fail 7

Physical Therapy Components:

• Restoring range of motion is the initial focus 4
• Address pectoralis minor or posterior capsule stiffness if present 4
• Scapular stabilization exercises are essential 2
• Rotator cuff strengthening should be progressively implemented 2
• Restore motor control and strength to both scapula and rotator cuff 4

Monitoring During Conservative Treatment

Important caveat: Rotator cuff tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management. 5, 3

When Conservative Treatment Fails

If pain persists despite 6-8 weeks of appropriate conservative management:

• Consider regional anesthetic techniques (interscalene brachial plexus blockade as first choice, or suprascapular nerve block with/without axillary nerve block as alternative) 7
• Single dose of intravenous dexamethasone can increase analgesic duration of nerve blocks 7
• Obtain advanced imaging if not already done to assess tear characteristics 2
• Proceed to surgical consultation for persistent pain and functional limitations 2

Surgical Indications

Strong evidence shows that healed rotator cuff repairs (particularly small to medium tears) demonstrate improved patient-reported and functional outcomes compared with physical therapy and unhealed repairs. 3

Clear Surgical Indications:

• Full-thickness tears in younger patients (especially acute traumatic tears) should be managed with surgical repair as soon as possible, with better outcomes when repaired within 4 months of injury 6
• Chronic, symptomatic full-thickness tears when conservative treatment fails after appropriate trial period 2
• High-grade partial-thickness tears that have failed physical therapy 3
• Significant functional limitations despite well-managed conservative treatment 2

Special Surgical Considerations:

• Massive, unrepairable tears with pseudoparalysis that have failed conservative treatment: consider reverse arthroplasty 3
• Unrepairable tears with glenohumeral joint arthritis: reverse shoulder arthroplasty can improve outcomes 3
• Do NOT surgically repair asymptomatic full-thickness rotator cuff tears 2

Surgical Technique Considerations

Moderate strength evidence does not support the routine use of acromioplasty as concomitant treatment compared with arthroscopic repair alone for small- to medium-sized full-thickness rotator cuff tears. 5

Post-Operative Management

Strong evidence suggests similar postoperative clinical outcomes for small to medium-sized full-thickness rotator cuff tears between early mobilization and delayed mobilization up to 8 weeks. 5, 3

Post-operative approach:

• Mobilization timing (early vs. delayed up to 8 weeks) can be individualized without compromising outcomes 5
• Multimodal programs or non-opioid individual modalities are supported for postoperative pain management 3

Prognostic Factors

Strong evidence supports that older age is associated with higher failure rates and poorer patient-reported outcomes after rotator cuff repair. 5, 3, 2

Additional prognostic considerations:

• Comorbidities are associated with poorer outcomes 2
• Tear size influences surgical success rates 3
• Timing of repair affects outcomes, with earlier repair (within 4 months) showing better results for acute tears 6

Common Pitfalls to Avoid

• Relying solely on unsupervised home exercises without proper instruction 3
• Using multiple corticosteroid injections, which may compromise rotator cuff integrity 3
• Overreliance on corticosteroid injections may lead to tendon weakening and potential rupture 2
• Neglecting exercise therapy, which forms the cornerstone of conservative management 2
• Operating on asymptomatic tears where risks outweigh benefits 2

Modalities with Insufficient Evidence

Current guidelines cannot definitively recommend for or against:

• Subacromial corticosteroid injections due to conflicting evidence 7
• Hyaluronic acid injections (limited evidence only) 5, 3
• Platelet-rich plasma for rotator cuff tendinopathy or partial tears 2
• Ice, heat, iontophoresis, massage, TENS, or PEMF lack sufficient evidence 7, 2