Who should a patient with a suspected rotator cuff tear consult for diagnosis and treatment?

Who to See for a Rotator Cuff Tear

Start with your primary care physician or a sports medicine specialist for initial evaluation and imaging, then proceed to an orthopedic surgeon specializing in shoulder surgery if conservative management fails after 3-6 months or if you have a traumatic tear requiring early surgical consideration. 1, 2

Initial Evaluation Pathway

Primary Care or Sports Medicine Physician First

• Begin with a primary care physician or sports medicine specialist who can perform the clinical examination and order appropriate imaging 3, 2
• Plain radiographs (AP views in internal and external rotation plus axillary or scapular Y view) must be obtained first to exclude fractures, dislocations, and osseous pathology 3, 2
• If radiographs are normal or nonspecific and rotator cuff pathology is suspected, MRI shoulder without IV contrast should be ordered as the next step, as it is "generally considered the best modality for adequately assessing most soft tissue injuries" including rotator cuff pathology 3

When to Proceed Directly to Orthopedic Surgery

• Traumatic tears in younger patients (<40 years) should be referred promptly to orthopedic surgery, as these represent a distinct entity with better healing potential and benefit from early surgical intervention 4, 5
• Persistent pain or dysfunction after shoulder dislocation warrants urgent orthopedic evaluation, especially in contact or overhead athletes, patients older than 40 years, or those with nerve injury 4
• Pseudoparalysis (inability to actively elevate the arm) indicates a massive tear requiring orthopedic surgical consultation 6

Conservative Management Trial (3-6 Months)

Who Manages This Phase

• Primary care physicians or sports medicine specialists can manage the initial 3-6 month conservative treatment period for chronic, symptomatic full-thickness tears 1, 2
• Physical therapy should be structured and focused on rotator cuff, periscapular muscles, and core strengthening with capsular flexibility exercises 3, 2

Treatment Components

• Structured physical therapy for 3-6 months is the cornerstone of initial treatment for both partial-thickness and small full-thickness tears 2
• Subacromial corticosteroid injection may be used as an adjunct for localized inflammation, though evidence is inconclusive regarding superiority over placebo 1
• NSAIDs and functional rehabilitation are appropriate initial measures 3

Orthopedic Surgery Referral Criteria

Mandatory Referral Situations

• No improvement in pain or function after 3-6 months of structured physical therapy requires orthopedic surgery referral 2
• Traumatic tears in younger patients should be referred early, as surgical repair in this population results in improved pain relief and patient satisfaction compared to nonoperative management 4, 7
• Massive irreparable tears in elderly patients with glenohumeral osteoarthritis and low-demand lifestyles may benefit from reverse total shoulder arthroplasty 6

Evidence Supporting Surgical Referral

• Patients who undergo rotator cuff repair report significantly better outcomes than matched patients treated nonoperatively, with mean ASES scores of 86.1 versus 76.2 and pain VAS scores of 14.4 versus 27.8 at final follow-up 7
• Eighty-one percent of surgical patients reported excellent results compared with 37% with nonsurgical treatment in chronic, symptomatic full-thickness tears 1
• Repair of the rotator cuff along with concomitant capsulolabral lesions helps restore shoulder stability in post-dislocation tears 4

Critical Pitfalls to Avoid

• Do not proceed directly to orthopedic referral without advanced imaging, as MRI is essential to confirm the diagnosis, characterize tear extent, assess tendon retraction, muscle atrophy, and fatty infiltration to guide appropriate treatment planning 3
• Do not perform surgery for asymptomatic full-thickness rotator cuff tears, as asymptomatic rotator cuff disease is highly prevalent in older populations, and the morbidity and risks of repair are not warranted in the absence of symptoms 1
• Do not delay surgical referral beyond 4 months in appropriate surgical candidates, as delayed rotator cuff repair up to 4 months has not shown adverse outcomes, but further delays may compromise healing potential 3
• Do not use ultrasound as the sole diagnostic modality for partial-thickness tears, as it has variable interobserver agreement and is less reliable than MRI for this indication 3