What is the recommended treatment for a rotator cuff injury?

Recommended Treatment for Rotator Cuff Injury

Begin with supervised physical therapy combined with NSAIDs and consider a single corticosteroid injection for short-term pain relief, reserving surgery only for patients who fail conservative management after 3-6 months or those with acute traumatic tears. 1

Initial Conservative Management Algorithm

All patients should start with supervised physical therapy as first-line treatment, as strong evidence demonstrates improved patient-reported outcomes in symptomatic patients with full-thickness rotator cuff tears. 1, 2 Supervised therapy is superior to unsupervised home exercise programs for rotator cuff pathology. 1, 2

Specific Physical Therapy Components:

• Restore range of motion first 3
• Address pectoralis minor and posterior capsule stiffness 3
• Restore motor control and strength to the scapula and rotator cuff 3
• Consider adding radial shockwave therapy or cryotherapy for additional benefit 1

Adjunctive Pain Management:

• Add NSAIDs concurrently with physical therapy for patients with rotator cuff-related symptoms, as moderate evidence shows beneficial effects in decreasing pain and improving function. 2
• Consider a single corticosteroid injection with local anesthetic for short-term improvement in both pain and function, supported by moderate evidence. 4, 1, 2
• Avoid multiple corticosteroid injections, as consensus opinion indicates they may compromise rotator cuff integrity and affect subsequent repair attempts. 1, 2

Treatments NOT Recommended:

• Do not routinely use platelet-rich plasma (PRP) for rotator cuff tendinopathy or partial tears, as limited evidence does not support its routine use. 4
• Do not use hyaluronic acid injections, as limited evidence does not support their use in nonsurgical management. 4, 2
• Avoid ice, heat, iontophoresis, massage, TENS, PEMF, and phonophoresis due to insufficient evidence. 2

Monitoring During Conservative Treatment

Important caveat: Tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management alone, highlighting the importance of regular monitoring. 1, 2 This means patients need periodic reassessment, not indefinite conservative treatment without follow-up imaging.

When to Consider Surgery

Indications for Surgical Referral:

• Failure of conservative treatment after 3-6 months of supervised physical therapy, NSAIDs, and corticosteroid injection 5
• Acute traumatic rotator cuff tears, particularly within 3 weeks of injury, where early surgical repair is an option 1
• High-grade partial-thickness tears that have failed physical therapy, as strong evidence supports conversion to full-thickness repair 4, 2
• Massive, unrepairable tears with pseudoparalysis after failed conservative treatment—these patients should proceed to reverse shoulder arthroplasty 5, 2

Prognostic Factors That Predict Worse Surgical Outcomes:

• Older age is associated with higher failure rates and poorer patient-reported outcomes after rotator cuff repair (strong evidence). 4, 5, 2
• Diabetes is associated with higher retear rates and poorer quality of life scores (moderate evidence). 4, 5
• Comorbidities are associated with poorer patient-reported outcomes (moderate evidence). 4

Surgical Technique Considerations (If Surgery Pursued)

• Single-row versus double-row repair: Strong evidence does not support double-row constructs improving patient-reported outcomes compared with single-row mattress repair. 4
• Platelet-derived products: Strong evidence does not support biological augmentation with platelet-derived products for improving outcomes, though limited evidence suggests liquid PRP may decrease retear rates. 4
• Marrow stimulation: Limited evidence suggests it does not improve outcomes but may decrease retear rates in larger tears. 4
• Dermal allografts: Limited evidence supports their use to augment repair of large and massive tears. 4

Post-Operative Rehabilitation (If Surgery Performed)

Strong evidence shows similar postoperative outcomes between early mobilization and delayed mobilization up to 8 weeks for small- to medium-sized full-thickness tears after arthroscopic repair. 4, 2 This means you can safely mobilize patients early without compromising outcomes, which may improve patient satisfaction and reduce stiffness.

Diagnostic Imaging

Use MRI, MR arthrography, or ultrasonography as adjuncts to clinical examination for identifying rotator cuff tears, as strong evidence supports their utility. 4, 1 Do not delay imaging when clinical suspicion is high, as early diagnosis guides appropriate treatment timing. 1

Evidence Quality Note

The strongest evidence comes from the 2020 American Academy of Orthopaedic Surgeons guidelines 4 and the 2025 Praxis Medical Insights summaries 1, 5, 2, which synthesize these guidelines. A 2017 meta-analysis of RCTs found no clinically significant difference between surgery and conservative treatment at 1-year follow-up, supporting the conservative-first approach. 6 Healed rotator cuff repairs do show improved outcomes compared with physical therapy alone and unhealed repairs, but this emphasizes the importance of patient selection and surgical technique. 1, 2