Approach

The decision to treat a rotator cuff tear surgically or nonsurgically should be based on several factors, including size of tear, patient age, expected activity level, degree of tendon retraction, and presence of rotator cuff muscle atrophy and fatty replacement.

Earlier surgical intervention may be needed when there is weakness and substantial functional disability, or if pain continues despite several months of physical and medical therapy.​[30][31][32]​ In addition, if the patient requires a strong arm for vocational or recreational needs, then repair should be considered.

The time since injury is also an important consideration, as the function and appearance of a torn rotator cuff generally deteriorate with time. With chronic tears, muscle tissue may atrophy in time and is replaced with fatty tissue, often termed fatty degeneration. Risk factors for re-tear after arthroscopic (minimally invasive) rotator cuff repair include fatty infiltration (subscapularis and infraspinatus) and symptom duration.[33]​ A direct correlation has been described between the extent of the fatty degeneration of the rotator cuff muscle and the time from injury.[34] Researchers found improved outcomes and a reduced re-tear rate when repair was performed when fatty degeneration was minimal. In patients over 60 years of age, a favorable outcome can still be expected after repair, provided tissue quality remains sufficient.[35]

Acute tears (identified within 6 weeks of a significant known trauma)

Treatment options for acute tears are determined in large part by the size of tear and how symptomatic the patient is at the time of presentation. Involvement of a physical therapist is often helpful. If there is external rotation weakness, then infraspinatus involvement is present and surgery is more likely to be necessary.

Surgical repair of acute small tears

Surgical repair is the first-line treatment for patients with good functional status, especially if functional demands are high. When surgery is undertaken before the onset of atrophy, more predictable results are ensured. One randomized controlled trial of people with rotator cuff tear not exceeding 3 cm found that primary tendon repair improved pain, motion, and strength at 10 years compared with physical therapy.[36]

​Surgical options include arthroscopic, mini-open, and open repair. The primary goal is to provide a pain-free joint with good function.

Conservative measures for small acute tears

​Nonsurgical options should be considered first for older and sedentary patients with small tears with mild loss of range of motion (ROM) and strength, and for patients with low functional demands. Ice, stretching, and nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial treatments. Once ROM returns (usually at about 4 weeks), toning exercises can be started while stretching continues. A single subacromial corticosteroid injection can be used to control inflammation and reduce pain if rehabilitation therapy and NSAIDs are ineffective.[37]​ ​Rehabilitation can resume a few days after the injection.[38] Repeated injections are to be avoided, as healing of a potential surgical repair may be compromised.[39]

One systematic review and meta-analysis suggested that NSAIDs are less effective than corticosteroid injection at achieving remission in patients with shoulder pain at 4-6 weeks after treatment.[40] However, as this review included a limited number of small studies, the results should be interpreted with caution.[40]

Surgery should be considered if the patient does not respond to medical and rehabilitation therapy after several weeks, with most investigators recommending at least 3 months of nonoperative treatment for smaller or partial tears.

[Figure caption and citation for the preceding image starts]: Subacromial injection. Insert needle just inferior to posterior edge of acromion (x), aiming parallel to the undersurface of the acromionFrom the collection of Daniel J. Solomon, MD; used with permission [Citation ends].com.bmj.content.model.Caption@106e4604

Management of acute medium, large, or massive reparable tears

Surgical repair is the first-line treatment for patients with good functional status, especially if functional demands are high. Options include arthroscopic, mini-open, and open repair. The primary goal is to provide a pain-free joint with good function.

If the patient is older and sedentary, rehabilitation therapy with NSAIDs, ice, stretching, and exercise should be considered before surgery. Focus should be on strengthening remaining cuff, deltoid, and scapular stabilizers, as well as posterior capsular stretching.

Irreparable tears

Debridement may be appropriate for patients with pain as their predominant symptom and lower demands for shoulder strength. The ideal debridement patient has good deltoid function and an intact coracoacromial arch.

Arthroscopic debridement can include bursectomy, acromioclavicular joint resection, and smoothing of the greater tuberosity. Subacromial decompression for the treatment of symptomatic rotator cuff disease presenting with impingement features and without full‐thickness rotator cuff tears does not provide clinically important benefits compared with placebo surgery with respect to pain, function, or quality of life, and is no longer routinely recommended.[37][41][42] BMJ: subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline Opens in new window

​Tendon transfer is appropriate for patients with high demands for shoulder strength. Patients must be able and willing to perform extensive postoperative rehabilitation. Muscle transfers have been effective for anterosuperior tears involving the subscapularis and supraspinatus, and for posterosuperior tears involving the supraspinatus and infraspinatus. Effective donors are the pectoralis major for anterosuperior tears and the latissimus dorsi for posterosuperior tear.[43][44]​ Lower trapezius transfer is becoming increasingly popular, because this transfer closely mimics the line of pull of the infraspinatus.[45][46]​​​ 

Reverse total shoulder arthroplasty is indicated for advanced glenohumeral degenerative changes secondary to a longstanding rotator cuff tear (cuff tear arthropathy).[47] A standard total shoulder arthroplasty should not be used in patients with glenohumeral arthritis who have an irreparable rotator cuff tear, as abduction will predictably be limited.[48]

Chronic tears

In general, chronic tears should be treated initially with conservative therapies (e.g., ice and stretching, anti-inflammatory medications, and subacromial injections). Involvement of a physical therapist is often helpful.

Surgery can be pursued if a tear is unresponsive to nonoperative treatment. Younger patients are typically treated with a more aggressive approach, with surgery considered earlier in their treatment course, especially if they complain of weakness.[30]​ Patient belief in the success of rehabilitation is a strong predictor of nonoperative outcome, more so than tear size.[49]

​In an older patient with a large chronic tear, the quality of the tissue is often less than optimal for healing. These patients and others with low functional demands are frequently less interested in powerful overhead actions and more interested in pain relief with a functional arc of motion. A well-designed, nonoperative rehabilitation program, consisting of stretching and strengthening, can attain these goals.​[49][50]​​ The focus of this rehabilitation is pain control, restoration of full passive motion, and optimization of rotator cuff and periscapular muscle strength and coordination.

Subacromial corticosteroid injection can be used if symptoms limit rehabilitation exercises, but should be used with caution if surgery is a reasonable possibility due to the adverse effects of steroids on cuff healing.[39]​ Exercises can be resumed a few days after injection. 

One meta-analysis found that suprascapular nerve block had similar efficacy compared with intra-articular corticosteroid injection for shoulder pain, and may be used as an adjunct therapy if corticosteroid injection alone does not provide sustained pain relief.[51]

For patients with considerable pain after 10-12 weeks of therapy, the following surgical options should be considered on a case-by-case basis.[30]​​[43][44][45][46][47]​​​​[48]​​[52][53]​​​​​​​​

  • Arthroscopic, mini-open, or open surgical repair: typically considered for patients with both pain and functional limitations who are anticipating return to an active lifestyle.

  • Debridement: typically used for patients with minimal functional limitations but pain as a primary complaint, and for patients with limited functional goals and expectations. Tuberoplasty can be performed when there is a prominent greater tuberosity, which may abut the acromion on abduction.

  • Hemiarthroplasty and reverse total shoulder arthroplasty: salvage procedures for patients who have longstanding tears and develop cuff tear arthropathy.

  • Superior capsule reconstruction: typically used for younger active patients with irreparable tears. The procedure employs a graft to reconstruct the superior capsule and may inhibit proximal humeral migration. This technique should not be used in the presence of advanced arthropathy.

  • Balloon spacer: indicated for irreparable tears. An inflatable biodegradable balloon is inserted under the acromion to act as a physical barrier to reduce subacromial friction. This device may help enhance deltoid rehabilitation.

  • Tendon transfer: appropriate for patients with high demands for shoulder strength and considered when muscle belly tissue is poor and may not function, even in the presence of a successful tendon repair.

  • Glenohumeral arthrodesis: can be considered as a last resort for intolerable pain but will eliminate all glenohumeral motion. Rarely used in younger patients but may be considered in those who have failed reverse total shoulder arthroplasty, especially in the presence of persistent infection.

[Figure caption and citation for the preceding image starts]: Subacromial injection. Insert needle just inferior to posterior edge of acromion (x), aiming parallel to the undersurface of the acromionFrom the collection of Daniel J. Solomon, MD; used with permission [Citation ends].com.bmj.content.model.Caption@52167b6f

Techniques for surgical repair

Surgical options include arthroscopic, mini-open, and open repair. The primary goal is to provide a pain-free joint with good function.

In open rotator cuff repairs, the surgeon is constrained to the area visualized within the incision to perform the repair. Arthroscopy, a minimally invasive technique, allows the surgeon to approach and assess the tear from multiple angles to better define the tear and repair it anatomically. The ability to address glenohumeral pathology at the time of rotator cuff repair, in conjunction with enhanced visualization, is a major benefit.

Randomized control trials, systematic reviews, and meta-analyses report similar outcomes following open, mini-open, or arthroscopic repair.[54][55][56][57]​​​​​​​ Arthroscopy may be associated with decreased short-term pain.[56]​ 

Results from systematic reviews with meta-analyses typically indicate that double-row suture repairs facilitate improved healing rates, but not recognizable differences in outcome scores.[37][58][59][60][61][62]​​​​​​​​​​​​ Double-row suture repair is a more demanding technique than single-row repair. Single-row repair augmented with microfracture may offer some benefit in enhancing the biology of healing by microfracture or abrasion of the greater tuberosity.[63]​ 

Associated pathology and biologic augmentation

Superior labrum anterior posterior (SLAP) tears and biceps tendon pathology frequently accompany rotator cuff tears. Subscapularis tears may also be present and are often difficult to recognize. The subscapularis is the largest cuff muscle and tears may be associated with significant pain and dysfunction. Recognition and concurrent treatment of these lesions may contribute to improved postoperative function.[64]

Platelet-rich plasma (PRP) has been used to augment rotator cuff repair of full-thickness tears with inconsistent results.[65][66][67][68]​​​​​​​ Practice guidelines conclude that the use of PRP in patients undergoing rotator cuff repair does not improve patient reported outcomes.[37]​ Long-term re-tear rates may be reduced in patients who receive PRP.[67]​ 

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