What is the initial step in managing a rotator cuff tear?

Initial Management of Rotator Cuff Tears

Begin with supervised physical therapy combined with paracetamol (acetaminophen) and NSAIDs for pain control, regardless of whether the tear is partial-thickness or full-thickness. 1, 2, 3

Immediate First Steps

Pain Management Protocol

• Start paracetamol immediately after diagnosis and continue regularly as the foundation of multimodal pain management 3
• Add NSAIDs or COX-2 specific inhibitors concurrently with paracetamol for more effective pain control 3
• Reserve opioids strictly for rescue analgesia when other methods fail 3
• Consider a single corticosteroid injection with local anesthetic for short-term improvement in pain and function if initial measures are insufficient 1, 2
  • Critical caveat: Avoid multiple steroid injections as they may compromise rotator cuff integrity and affect subsequent repair attempts 1, 2

Physical Therapy Initiation

• Supervised physical therapy is superior to unsupervised home exercise programs and should be the standard approach 1, 2
• Strong evidence demonstrates that patient-reported outcomes improve with physical therapy in symptomatic patients with full-thickness rotator cuff tears 2
• For patients with rotator cuff-related symptoms without full-thickness tears, exercise programs combined with NSAIDs show beneficial effects in decreasing pain and improving function 4

Evidence Quality and Nuances

The 2025 American College of Physicians guidelines provide the strongest recommendation for supervised physical therapy as initial treatment 1, superseding the 2011 AAOS guidelines which found inconclusive evidence for exercise programs in full-thickness tears 4. This evolution reflects improved evidence quality over time.

Important distinction by tear type:

• Partial-thickness tears: Exercise and NSAIDs have moderate evidence support 4
• Full-thickness tears: While older evidence was conflicting 4, newer guidelines strongly support supervised physical therapy as initial management 1, 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 2. This does not mean conservative treatment should be abandoned initially, but patients require monitoring.

Timing to transition to surgical consideration is indicated when a patient demonstrates increased weakness and loss of function not recoverable by physiotherapy 5. For acute traumatic full-thickness tears in younger patients, surgical repair should be considered earlier, ideally within 4 months of injury for optimal outcomes 6.

Common Pitfalls to Avoid

• Do not rely on unsupervised home exercises without proper instruction - supervised therapy yields better outcomes 2
• Do not use multiple corticosteroid injections - a single injection may help, but repeated injections compromise tissue integrity 1, 2
• Do not assume tear size correlates with symptoms - evidence suggests symptoms and tear size are not directly correlated with pain, function, or ultimate outcome 5
• Do not delay appropriate surgical referral in cases of progressive weakness unresponsive to therapy 5

Modalities Without Sufficient Evidence

The following cannot be recommended for or against due to insufficient or conflicting evidence: ice, heat, iontophoresis, massage, TENS, PEMF, phonophoresis, and hyaluronic acid injections 4, 2. While some research suggests potential benefits from PRP or collagen injections for partial-thickness tears 7, guideline-level evidence does not yet support their routine use.