What is the recommended treatment for a patient with right shoulder pain and positive empty can and liftoff test results, suggestive of rotator cuff tendinopathy or tear?

Management of Rotator Cuff Tear with Positive Empty Can and Liftoff Tests

Begin with a structured 3-6 month trial of physical therapy combined with NSAIDs, reserving surgical referral for patients who fail to improve in pain or function after this period. 1, 2

Initial Diagnostic Confirmation

Obtain advanced imaging to characterize the tear before finalizing treatment decisions:

• MRI without contrast, MR arthrography, or ultrasound are equally appropriate for confirming full-thickness tears (94% sensitivity, 93% specificity for MRI; 92% sensitivity, 93% specificity for ultrasound) 2
• Plain radiographs should be obtained first to exclude other pathology, including Grashey projection and axillary lateral or scapular Y view 2
• MR arthrography is superior if partial-thickness tear is suspected, particularly for articular surface tears 2

Conservative Management Protocol (First-Line Treatment)

Physical therapy is the cornerstone of initial treatment and demonstrates strong evidence for improving patient-reported outcomes in symptomatic rotator cuff tears: 1

• Prescribe an active and task-oriented rehabilitation program focusing on exercises and patient education 3
• Exercise programs improve pain and function in rotator cuff pathology, with benefits demonstrated at 8 weeks and 3 months 1
• Continue structured physical therapy for 3-6 months before considering surgical referral 2

Adjunctive pain management options:

• Single corticosteroid injection with local anesthetic provides moderate evidence for short-term improvement in both pain and function 1
• NSAIDs and acetaminophen may reduce pain in the short term 3
• Avoid routine use of hyaluronic acid injections (limited evidence) 1
• Do not use platelet-rich plasma for rotator cuff tendinopathy or partial tears (limited evidence does not support routine use) 1

Critical Decision Point: When to Refer for Surgery

Refer to orthopedic surgery if no improvement in pain or function after 3-6 months of structured physical therapy: 2

Factors Favoring Early Surgical Consideration:

• Acute traumatic tears may benefit from early repair (within 3 weeks shows better results than delayed repair) 1
• Younger patients (older age correlates with higher failure rates and poorer outcomes after repair) 1
• Absence of significant comorbidities (comorbidities correlate with poorer outcomes) 1

Evidence Supporting Surgical Intervention:

• Healed rotator cuff repairs demonstrate improved patient-reported and functional outcomes compared with physical therapy alone and unhealed repairs 1
• Patients with surgical treatment report 81% excellent results compared to only 37% with conservative management for symptomatic full-thickness tears 1, 4

Critical Pitfalls to Avoid

Time-sensitive deterioration occurs with delayed treatment:

• Rotator cuff tear size, muscle atrophy, and fatty infiltration progress over 5-10 years with nonsurgical management alone 1
• Progressive muscle atrophy and fatty degeneration correlate with worse outcomes and diminished healing potential if surgical repair is eventually pursued 4
• Conservative treatment failure after 3-6 months indicates need for surgical intervention before irreversible changes occur 4
• MRI tear characteristics that worsen over time (tear size, retraction, fatty infiltration) directly correlate with poorer surgical outcomes if repair is delayed 4

Do not perform routine acromioplasty:

• Moderate evidence does not support routine acromioplasty as concomitant treatment with arthroscopic repair for small- to medium-sized full-thickness tears 1

Postoperative Considerations (If Surgery Pursued)

• Early mobilization versus delayed mobilization up to 8 weeks show similar clinical and patient-reported outcomes for small- to medium-sized tears 1
• Biological augmentation with platelet-derived products does not improve patient-reported outcomes, though limited evidence suggests liquid PRP may decrease retear rates 1