From the Guidelines
Surgical repair using an arthroscopic approach is the recommended treatment for full thickness rotator cuff tears of subscapularis and supraspinatus tendon, as it is associated with reduced postoperative pain. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of minimizing postoperative pain to improve patient outcomes 1.
Key Considerations
- The procedure involves reattaching the torn tendons to the humeral head using suture anchors.
- Post-surgery, patients follow a structured rehabilitation protocol beginning with 4-6 weeks of immobilization in a sling, followed by passive range of motion exercises.
- Active motion begins around 6-8 weeks, with strengthening exercises introduced at 8-12 weeks.
- Full recovery typically takes 6-12 months.
Preoperative and Postoperative Management
- Systemic analgesia should include paracetamol and non-steroidal anti-inflammatory drugs (NSAID) administered pre-operatively or intra-operatively and continued postoperatively 1.
- Interscalene brachial plexus blockade is recommended as the first-choice regional analgesic technique, with suprascapular nerve block as an alternative 1.
- A single dose of intravenous (i.v.) dexamethasone is recommended for its ability to increase the analgesic duration of interscalene brachial plexus block, decrease analgesic use, and provide anti-emetic effects 1.
- Opioids should be reserved as rescue analgesia in the postoperative period 1.
Conservative Management
- Prior to surgery, conservative management may include oral NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for pain control, along with activity modification and physical therapy focusing on scapular stabilization and rotator cuff strengthening.
- Corticosteroid injections are generally avoided as they can weaken tendon tissue and compromise surgical repair.
The choice between arthroscopic and open repair techniques is guided by the most recent evidence, which suggests that arthroscopic repair is associated with reduced postoperative pain 1. While an earlier study found no conclusive evidence to recommend one technique over the other 1, the more recent guideline prioritizes arthroscopic approaches for their benefits in pain management.
From the Research
Treatment Options for Full Thickness Rotator Cuff Tears
- The treatment for full thickness rotator cuff tears of the subscapularis and supraspinatus tendon can involve various methods, including operative repair and non-operative treatment 2, 3, 4, 5, 6.
- Operative repair can be performed using an arthroscopic-plus-open approach, which involves arthroscopic repair of the posterosuperior rotator cuff followed by an open subscapularis repair 2.
- Arthroscopic repair with use of the suture anchor technique is a safe and effective procedure for the treatment of combined rotator cuff tears involving the subscapularis tendon 5.
- Non-operative treatment, including exercises with or without glucocorticoid injections, may be effective for some patients, but the evidence is uncertain regarding its effectiveness compared to operative repair 4.
Factors Affecting Treatment Outcomes
- Patient age and the degree of tendon retraction can affect the integrity of the repair and the clinical outcomes 5.
- The presence of concomitant pathology, such as tears of the infraspinatus tendon, can also impact the treatment outcomes 2, 5.
- The use of reconstructive options, including tendon transfers, capsular reconstruction, and reverse shoulder arthroplasty, may be considered when tears of the subscapularis are irreparable 6.
Clinical Outcomes
- Operative repair can result in significant improvements in shoulder function, pain, and quality of life 2, 5.
- However, the evidence is uncertain regarding the long-term benefits of operative repair compared to non-operative treatment, and further studies are needed to determine the optimal treatment approach 4.