Recommended Treatment for Rotator Cuff Injury
For rotator cuff injuries without full-thickness tears, begin with supervised physical therapy combined with NSAIDs as first-line treatment; for full-thickness tears, supervised physical therapy remains the initial approach, with surgical repair reserved for chronic symptomatic tears that fail conservative management after an appropriate trial period.
Initial Treatment Approach Based on Tear Type
Partial-Thickness Tears or Rotator Cuff Symptoms Without Full-Thickness Tear
Start with supervised physical therapy plus NSAIDs as the primary treatment, which has moderate-grade evidence showing significant improvements in pain reduction and functional outcomes 1, 2.
Exercise programs demonstrate significant pain improvements on visual analog scales after 8 weeks, with particularly strong results when combining exercise with manual therapy 1.
Patients show significant improvements in pain at rest, nighttime pain, and Constant-Murley scores after 3 months of structured exercise programs 1.
Supervised physical therapy is superior to unsupervised home exercise programs for achieving optimal outcomes 2, 3.
Full-Thickness Tears
Begin with supervised physical therapy as initial management, which shows strong evidence for improving patient-reported outcomes even in symptomatic patients with full-thickness rotator cuff tears 2, 3.
Conservative management remains the gold standard approach initially, incorporating comprehensive rehabilitation, anti-inflammatories, and selective use of corticosteroid injections 4.
Physical therapy demonstrates high patient satisfaction, functional improvement, and success in avoiding surgery in selected cases 5.
Pain Management Strategy
Initiate paracetamol (acetaminophen) immediately after diagnosis and continue regularly 3.
Add NSAIDs or COX-2 specific inhibitors concurrently with paracetamol for more effective pain control 3.
Consider a single corticosteroid injection with local anesthetic for short-term improvement in both pain and function, supported by moderate evidence 2, 3.
Avoid multiple steroid injections, as they may compromise rotator cuff integrity and negatively affect subsequent surgical repair attempts 2, 3.
Exercise Prescription Specifics
Prescribe loaded resistance exercises including open chain resisted band exercises and closed chain exercises, which show significant improvements in pain and function at 6 weeks 3.
Use 3 sets of 8-12 repetitions for isotonic exercises with loads of 8 repetition maximum, adjusted every 2-3 weeks, achieving approximately 96 seconds total time under tension per session 3.
Surgical Indications
Consider surgical repair when:
Chronic, symptomatic full-thickness tears fail conservative treatment after an appropriate trial period 3.
High-grade partial-thickness tears have failed physical therapy 2, 3.
Strong evidence shows healed rotator cuff repairs (particularly small to medium tears) demonstrate superior patient-reported and functional outcomes compared with physical therapy alone and unhealed repairs 2, 3.
Timing Considerations for Acute Traumatic Tears
Early surgical repair within 3 weeks is an option for acute traumatic injuries, though this carries only weak-grade evidence 1.
Patients repaired within 3 weeks of acute injury show better results than those repaired after 3 weeks, though acute rotator cuff injuries represent less than 10% of all rotator cuff repairs 1.
Prognostic Factors Affecting Outcomes
Increasing age correlates with higher failure rates and poorer outcomes after rotator cuff surgery, affecting both healing rates and strength recovery 1, 2, 3.
Rotator cuff tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management 2.
Workers' compensation status and MRI tear characteristics also correlate with less favorable surgical outcomes 1.
Post-Operative Rehabilitation (If Surgery Performed)
Early mobilization versus delayed mobilization up to 8 weeks produces similar clinical outcomes for small to medium-sized full-thickness tears, allowing flexibility in rehabilitation timing 2, 3.
Use multimodal programs or non-opioid individual modalities for postoperative pain management 2.
Treatment Modalities with Insufficient Evidence
The American Academy of Orthopaedic Surgeons cannot recommend for or against the following due to inconclusive or absent evidence 1, 2:
- Iontophoresis, phonophoresis, TENS, ice, heat, massage
- Pulsed electromagnetic field therapy (PEMF) - conflicting study results
- Hyaluronic acid injections - limited evidence
- Activity modification alone
Critical Pitfalls to Avoid
Do not rely on unsupervised home exercises without proper instruction, as supervised therapy produces superior outcomes 2.
Never use multiple corticosteroid injections, which compromise rotator cuff integrity 2, 3.
Do not delay appropriate surgical referral for chronic symptomatic full-thickness tears that fail conservative management, as tear progression and muscle changes worsen over time 2.
Do not assume age alone disqualifies surgical candidacy, though older patients should be counseled about higher failure rates and potentially poorer outcomes 1, 2, 3.