What is the first line treatment for a patient with mild rotator cuff tendinosis?

First-Line Treatment for Mild Rotator Cuff Tendinosis

Physical therapy with supervised exercise is the first-line treatment for mild rotator cuff tendinosis, combined with NSAIDs and acetaminophen for pain control. 1

Initial Pain Management

• Start acetaminophen (paracetamol) immediately after diagnosis and continue regularly for baseline pain control 1
• Add NSAIDs or COX-2 inhibitors concurrently with acetaminophen for more effective pain management 1, 2
• Avoid opioids as first-line treatment—reserve strictly for rescue analgesia only if other methods fail 2

Physical Therapy Protocol

Strong evidence supports that patient-reported outcomes improve with physical therapy in symptomatic rotator cuff disease, making it the cornerstone of conservative management 3

Specific Exercise Prescription

• Perform loaded resistance exercises including open chain resisted band exercises and closed chain exercises 1
• Execute 3 sets of 8-12 repetitions for isotonic exercises, using loads of 8 repetition maximum 1
• Adjust resistance every 2-3 weeks with total time under tension of approximately 96 seconds per session 1
• Supervised physical therapy is more appropriate than unsupervised home exercise for optimal outcomes 1

Corticosteroid Injection Considerations

A single subacromial corticosteroid injection with local anesthetic can provide short-term improvement (4-8 weeks) in pain and function if initial conservative measures are insufficient 3, 1, 2

Critical Caveats About Steroid Injections

• Avoid multiple repeated injections—limit to a single injection as they may compromise rotator cuff integrity and affect subsequent repair attempts 1, 2
• The benefit is small and transient, with at least 5 patients needing treatment for one to achieve meaningful pain reduction 4
• Corticosteroids cannot modify the natural course of the disease and may accelerate tendon degeneration 4
• One high-quality trial found betamethasone no more effective than xylocaine alone in chronic rotator cuff tendinosis 5

Modalities with Insufficient Evidence

Do not rely on ice, heat, iontophoresis, massage, TENS, or PEMF as primary treatments due to lack of sufficient evidence 2

Treatment Algorithm Summary

1. Immediate initiation: Acetaminophen + NSAIDs for pain control 1, 2
2. Primary intervention: Supervised physical therapy with loaded resistance exercises (3 sets of 8-12 reps, adjusted every 2-3 weeks) 1
3. If inadequate response after 6 weeks: Consider single corticosteroid injection for short-term relief while continuing physical therapy 3, 1
4. If symptoms persist beyond 3-6 months: Reassess for surgical evaluation, though strong evidence shows physical therapy improves outcomes even in full-thickness tears 3

Common Pitfalls to Avoid

• Do not use multiple corticosteroid injections—they provide minimal benefit and risk tendon degeneration 1, 2, 4
• Do not prescribe opioids as first-line treatment—they should only be rescue analgesia 2
• Do not rely on passive modalities alone (ultrasound, TENS, etc.) as evidence for benefit is weak 3, 2
• Do not skip supervised physical therapy in favor of home exercises alone—supervised programs yield better outcomes 1