What is the recommended treatment for a torn rotator cuff?

Treatment for Torn Rotator Cuff

Begin with supervised physical therapy as the primary treatment, combined with NSAIDs and a single corticosteroid injection if needed for pain control; reserve surgery for patients who fail conservative management after 3 months, particularly those with full-thickness tears who demonstrate persistent symptoms. 1, 2

Initial Conservative Management (First-Line Treatment)

Strong evidence supports that patient-reported outcomes improve with physical therapy in symptomatic patients with full-thickness rotator cuff tears. 3, 1 The American Academy of Orthopaedic Surgeons recommends this as the initial approach for all rotator cuff tears. 1, 2

Supervised Physical Therapy Protocol

• Supervised physical therapy is superior to unsupervised home exercise programs and should be the standard approach rather than simply giving patients exercises to do at home. 1, 2
• Moderate evidence confirms supervised therapy produces better outcomes than home-based programs. 2
• Physical therapy should include manual glenohumeral mobilizations and stretching exercises. 2

Pain Management During Conservative Treatment

• A single corticosteroid injection with local anesthetic provides short-term improvement in both pain and function (moderate evidence). 3, 1, 2
• NSAIDs or COX-2 inhibitors should be used concurrently with physical therapy. 3, 2
• Avoid multiple corticosteroid injections as they may compromise rotator cuff integrity and negatively affect subsequent surgical repair attempts. 1, 2, 4
• Hyaluronic acid injections have limited evidence and are not routinely recommended. 3
• Platelet-rich plasma (PRP) injections for partial-thickness tears have limited evidence and are not recommended for routine use. 3

When to Consider Surgery

Surgery should be considered after 3 months of failed conservative treatment, particularly for full-thickness tears. 5 A 2021 pragmatic randomized trial demonstrated that while non-surgical and surgical treatments provided equivalent results overall, surgery yielded superior improvement in pain (13-point difference, p=0.002) and function (7-point difference, p=0.008) specifically for full-thickness rotator cuff ruptures. 5

Surgical Indications

• Healed rotator cuff repairs (particularly small to medium tears) demonstrate improved patient-reported and functional outcomes compared with physical therapy alone and unhealed repairs (strong evidence). 1, 2
• For high-grade partial-thickness tears that have failed physical therapy, repair could improve outcomes. 1
• Early surgical repair within 3 weeks of acute traumatic injury is an option according to the American Academy of Orthopaedic Surgeons. 2

Surgical Technique Recommendations

• Arthroscopic technique is recommended as it reduces postoperative pain compared to open approaches. 3
• Strong evidence does not support double-row repair constructs over single-row mattress repair constructs for improving patient-reported outcomes. 3
• Strong evidence does not support biological augmentation with platelet-derived products for improving outcomes, though limited evidence suggests liquid PRP may decrease retear rates. 3

Prognostic Factors to Consider

Age

• Older age is associated with higher failure rates and poorer patient-reported outcomes after rotator cuff repair (strong evidence). 3, 1
• This should factor into the surgical decision-making process.

Comorbidities

• Patients with diabetes will have higher retear rates and poorer quality of life scores after rotator cuff repair (moderate evidence). 3, 4
• Metabolic disorders should be controlled before surgery. 4
• Moderate evidence supports that comorbidities in general are associated with poorer outcomes. 3

Natural History with Conservative Management

• Tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management alone. 1, 2
• Regular monitoring with imaging is important to track progression.

Postoperative Management (If Surgery Performed)

Mobilization Timing

• Strong evidence shows similar postoperative outcomes for small to medium-sized full-thickness tears between early mobilization and delayed mobilization up to 8 weeks. 3, 1, 4
• This allows flexibility in rehabilitation protocols without compromising outcomes.

Pain Management After Surgery

• Paracetamol and COX-2 inhibitors/NSAIDs should be administered pre-operatively or intra-operatively and continued postoperatively. 3
• Intravenous dexamethasone is recommended for increasing the analgesic duration of interscalene block and decreasing analgesic use. 3
• Interscalene brachial plexus block (continuous or single-shot) is the first-choice regional analgesic technique. 3
• Suprascapular nerve block with or without axillary nerve block may be used as an alternative to interscalene block. 3
• Opioids should be reserved for rescue analgesia only. 3

Special Situations

Massive, Unrepairable Tears

• In patients with massive, unrepairable rotator cuff tears and pseudoparalysis who have failed conservative treatments, reverse shoulder arthroplasty can improve reported outcomes. 1, 4
• For unrepairable tears with glenohumeral joint arthritis, reverse shoulder arthroplasty improves patient-reported outcomes after failure of conservative treatment. 1

Critical Pitfalls to Avoid

• Do not rely on unsupervised home exercises without proper instruction and follow-up; supervised therapy is superior. 1
• Do not give multiple corticosteroid injections as they compromise rotator cuff integrity and affect repair outcomes. 1, 2, 4
• Do not delay imaging when clinical suspicion is high as early diagnosis guides appropriate treatment timing. 2
• Do not assume all shoulder pain in trauma is rotator cuff injury; consider labral tears which require different management. 2