Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute small tear

1st line – surgical therapy

Back
ACUTE
|
acute small tear
|
active, younger patient
1st line – 

surgical therapy

Acute tears are those identified within 6 weeks of significant known trauma. Small tears usually involve a modest loss of range of motion and strength.

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. Surgeons generally should perform the technique that provides the best and most reliable results in their hands.

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]

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]​ 

Plus – physical therapy

Back
ACUTE
|
acute small tear
|
active, younger patient
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physical therapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed.

Tear size may be an influential factor in the rate of re-tearing after early passive range of motion (ROM) is performed.[69]​ One study showed that early motion does not necessarily lead to an increased risk of re-tear compared with 6 weeks of immobilization in double-row repairs of smaller (i.e., <3 cm) tears.[70] However, for larger tears and in the presence of poor tissue quality, delayed mobilization is preferable.[71]

Postoperative care can safely be accelerated to 4 weeks of immobilization in medium to large tears. One study found that 8 weeks of immobilization offers no advantages compared with shorter periods in patients with medium-sized tears.​[72]

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but was likely to result in improper tendon healing in shoulders with large-sized tears.[73]

For subacromial debridement/tuberoplasty, physical therapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physical therapy modalities. After a rotator cuff repair the schedule may involve 6-12 months of rehabilitation (e.g., motion, strength, other physical therapy modalities) with slower progression to allow adequate healing of the repair. After arthroplasty there may be a 4- to 6-month program with emphasis on regaining motion, strength, and function.

Superior capsule reconstruction requires 6 weeks of immobilization followed by active assisted ROM for an additional 6 weeks.

Subsequent to balloon spacer insertion, patients are required to engage in early rehab focusing on deltoid and scapular strengthening.

Following tendon or muscle transfer procedures there might typically follow an extensive 12-month rehabilitation program with the goal of retraining muscles to provide shoulder function.

In more complex surgeries, regional anesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours. Following this, most patients are initially placed on narcotic medications for the first 2-4 weeks. Most patients are able to wean off narcotic pain medications by their second postoperative visit.

1st line – conservative measures

Back
ACUTE
|
acute small tear
|
sedentary, older patient
1st line – 

conservative measures

Two to 4 weeks of ice and stretch, with nonsteroidal anti-inflammatory drugs (NSAIDs) used as needed to control pain. Focus should be on strengthening remaining cuff, deltoid, and scapular stabilizers, as well as posterior capsular stretching.

Meta-analysis suggests that NSAIDs are less effective than corticosteroid injection at achieving remission in patients with shoulder pain at 4-6 weeks after treatment.[40]​ However, the limited number of studies and small size of each trial require the interpretations be done with caution.[40]

Activity should be modified to reduce overhead lifting. When range of motion returns (usually around 4 weeks), toning should be added while stretching is continued.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally initially, followed by 250 mg every 6-8 hours when required, maximum 1250 mg/day

2nd line – subacromial corticosteroid injection ± suprascapular nerve block

Back
ACUTE
|
acute small tear
|
sedentary, older patient
2nd line – 

subacromial corticosteroid injection ± suprascapular nerve block

A single subacromial corticosteroid injection can be performed if the patient fails to respond to rehabilitation therapy and nonsteroidal anti-inflammatory drugs (NSAIDs).[37]​ It is particularly useful if significant stiffness and tendonitis symptoms limit rehabilitation exercises. Rehabilitation can typically resume after a few days of rest.[38]

A corticosteroid (e.g., methylprednisolone or triamcinolone) can be combined with local anesthetic (e.g., lidocaine and/or bupivacaine), allowing a larger volume (8-9 mL) to flood the rotator cuff surface.[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@3c49abd9 Regimens vary from institution to institution.

Contraindications include septic arthritis, previous adverse reaction, or systemic infection. In addition, if surgery is anticipated, no more than one injection shoulder be administered and there should be a several week interval between the injection and surgery.[39]

Corticosteroid injections can be repeated 3-4 times per year in a single joint if operative intervention is not warranted or desired.

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]

Primary options

triamcinolone acetonide: consult specialist for guidance on dose

or

methylprednisolone acetate: consult specialist for guidance on dose

-- AND --

lidocaine: consult specialist for guidance on dose

and/or

bupivacaine: consult specialist for guidance on dose

3rd line – surgical repair

Back
ACUTE
|
acute small tear
|
sedentary, older patient
3rd line – 

surgical repair

Lack of response to at least 10-12 weeks of medical and physical therapy should prompt consideration of open, mini-open, or arthroscopic repair. Surgeons generally should perform the technique that provides the best and most reliable results in their hands.

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]

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]

Plus – physical therapy

Back
ACUTE
|
acute small tear
|
sedentary, older patient
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physical therapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed.

Tear size may be an influential factor in the rate of re-tearing after early passive range of motion (ROM) is performed.[69]​ One study showed that early motion does not necessarily lead to an increased risk of re-tear compared with 6 weeks of immobilization in double-row repairs of smaller (i.e., <3 cm) tears.[70] However, for larger tears and in the presence of poor tissue quality, delayed mobilization is preferable.[71]

Postoperative care can safely be accelerated to 4 weeks of immobilization in medium to large tears. One study found that 8 weeks of immobilization offers no advantages compared with shorter periods in patients with medium-sized tears.​[72]

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but was likely to result in improper tendon healing in shoulders with large-sized tears.[73]

For subacromial debridement/tuberoplasty, physical therapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physical therapy modalities. After a rotator cuff repair the schedule may involve 6-12 months of rehabilitation (e.g., motion, strength, other physical therapy modalities) with slower progression to allow adequate healing of the repair. After arthroplasty there may be a 4- to 6-month program with emphasis on regaining motion, strength, and function.

Superior capsule reconstruction requires 6 weeks of immobilization followed by active assisted ROM for an additional 6 weeks.

Subsequent to balloon spacer insertion, patients are required to engage in early rehab focusing on deltoid and scapular strengthening.

Following tendon or muscle transfer procedures there might typically follow an extensive 12-month rehabilitation program with the goal of retraining muscles to provide shoulder function.

In more complex surgeries, regional anesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours. Following this, most patients are initially placed on narcotic medications for the first 2-4 weeks. Most patients are able to wean off narcotic pain medications by their second postoperative visit.

acute medium/large/massive reparable tear

1st line – surgical repair

Back
ACUTE
|
acute medium/large/massive reparable tear
|
active, younger patient
1st line – 

surgical repair

Acute tears are those identified within 6 weeks of significant known trauma. Medium, large, and massive tears typically reduce abduction strength greatly and significantly limit ability to raise arm over shoulder (although function through the deltoid or other muscles may be preserved early on). If injury is on the dominant side or functional demands are high, consider surgery.

Options include arthroscopic, mini-open, and open repair. Surgeons generally should perform the technique that provides the best and most reliable results in their hands. However, a massive tear or one affecting the subscapularis may be approached best with an open exposure, unless the surgeon is an expert arthroscopist.

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]

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]

Surgical outcomes are best within 6 weeks of injury; therefore, early intervention is warranted.

Plus – physical therapy

Back
ACUTE
|
acute medium/large/massive reparable tear
|
active, younger patient
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physical therapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed.

Tear size may be an influential factor in the rate of re-tearing after early passive range of motion (ROM) is performed.[69]​ One study showed that early motion does not necessarily lead to an increased risk of re-tear compared with 6 weeks of immobilization in double-row repairs of smaller (i.e., <3 cm) tears.[70] However, for larger tears and in the presence of poor tissue quality, delayed mobilization is preferable.[71]

Postoperative care can safely be accelerated to 4 weeks of immobilization in medium to large tears. One study found that 8 weeks of immobilization offers no advantages compared with shorter periods in patients with medium-sized tears.​[72]

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but was likely to result in improper tendon healing in shoulders with large-sized tears.[73]

For subacromial debridement/tuberoplasty, physical therapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physical therapy modalities. After a rotator cuff repair the schedule may involve 6-12 months of rehabilitation (e.g., motion, strength, other physical therapy modalities) with slower progression to allow adequate healing of the repair. After arthroplasty there may be a 4- to 6-month program with emphasis on regaining motion, strength, and function.

Superior capsule reconstruction requires 6 weeks of immobilization followed by active assisted ROM for an additional 6 weeks.

Subsequent to balloon spacer insertion, patients are required to engage in early rehab focusing on deltoid and scapular strengthening.

Following tendon or muscle transfer procedures there might typically follow an extensive 12-month rehabilitation program with the goal of retraining muscles to provide shoulder function.

In more complex surgeries, regional anesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours. Following this, most patients are initially placed on narcotic medications for the first 2-4 weeks. Most patients are able to wean off narcotic pain medications by their second postoperative visit.

1st line – rehabilitation and NSAIDs

Back
ACUTE
|
acute medium/large/massive reparable tear
|
sedentary, older patient
1st line – 

rehabilitation and NSAIDs

First-line choice should be rehabilitation therapy in sedentary, older patients, with ice, stretching, exercise, and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control as required. Rehabilitation should be managed by a physical therapist. Focus should be on strengthening remaining cuff, deltoid, and scapular stabilizers, as well as posterior capsular stretching.

If injury is on the dominant side or functional demands are high, surgery can be considered subsequently.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally initially, followed by 250 mg every 6-8 hours when required, maximum 1250 mg/day

2nd line – surgical repair

Back
ACUTE
|
acute medium/large/massive reparable tear
|
sedentary, older patient
2nd line – 

surgical repair

Medium, large, and massive tears typically reduce abduction strength greatly and significantly limit ability to raise arm over shoulder (although function through the deltoid or other muscles may be preserved early on).

If injury is on the dominant side or functional demands are high, surgery can be considered subsequently. Options include arthroscopic, mini-open, and open repair. Surgeons generally should perform the technique that provides the best and most reliable results in their hands.

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]

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]

A massive tear or one affecting the subscapularis may be approached best with an open exposure, unless the surgeon is an expert arthroscopist.

Plus – physical therapy

Back
ACUTE
|
acute medium/large/massive reparable tear
|
sedentary, older patient
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physical therapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed.

Tear size may be an influential factor in the rate of re-tearing after early passive range of motion (ROM) is performed.[69]​ One study showed that early motion does not necessarily lead to an increased risk of re-tear compared with 6 weeks of immobilization in double-row repairs of smaller (i.e., <3 cm) tears.[70] However, for larger tears and in the presence of poor tissue quality, delayed mobilization is preferable.[71]

Postoperative care can safely be accelerated to 4 weeks of immobilization in medium to large tears. One study found that 8 weeks of immobilization offers no advantages compared with shorter periods in patients with medium-sized tears.​[72]

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but was likely to result in improper tendon healing in shoulders with large-sized tears.[73]

For subacromial debridement/tuberoplasty, physical therapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physical therapy modalities. After a rotator cuff repair the schedule may involve 6-12 months of rehabilitation (e.g., motion, strength, other physical therapy modalities) with slower progression to allow adequate healing of the repair. After arthroplasty there may be a 4- to 6-month program with emphasis on regaining motion, strength, and function.

Superior capsule reconstruction requires 6 weeks of immobilization followed by active assisted ROM for an additional 6 weeks.

Subsequent to balloon spacer insertion, patients are required to engage in early rehab focusing on deltoid and scapular strengthening.

Following tendon or muscle transfer procedures there might typically follow an extensive 12-month rehabilitation program with the goal of retraining muscles to provide shoulder function.

In more complex surgeries, regional anesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours. Following this, most patients are initially placed on narcotic medications for the first 2-4 weeks. Most patients are able to wean off narcotic pain medications by their second postoperative visit.

acute irreparable tear

1st line – superior capsule reconstruction

Back
ACUTE
|
acute irreparable tear
|
with weakness and high functional demands
1st line – 

superior capsule reconstruction

Patients who have irreparable cuff tears and are too young for arthroplasty may be candidates for superior capsule reconstruction. The procedure employs a graft to reconstruct the superior capsule and may inhibit proximal humeral migration.[52]

Plus – physical therapy

Back
ACUTE
|
acute irreparable tear
|
with weakness and high functional demands
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physical therapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed.

Tear size may be an influential factor in the rate of re-tearing after early passive range of motion (ROM) is performed.[69]​ One study showed that early motion does not necessarily lead to an increased risk of re-tear compared with 6 weeks of immobilization in double-row repairs of smaller (i.e., <3 cm) tears.[70] However, for larger tears and in the presence of poor tissue quality, delayed mobilization is preferable.[71]

Postoperative care can safely be accelerated to 4 weeks of immobilization in medium to large tears. One study found that 8 weeks of immobilization offers no advantages compared with shorter periods in patients with medium-sized tears.​[72]

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but was likely to result in improper tendon healing in shoulders with large-sized tears.[73]

For subacromial debridement/tuberoplasty, physical therapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physical therapy modalities. After a rotator cuff repair the schedule may involve 6-12 months of rehabilitation (e.g., motion, strength, other physical therapy modalities) with slower progression to allow adequate healing of the repair. After arthroplasty there may be a 4- to 6-month program with emphasis on regaining motion, strength, and function.

Superior capsule reconstruction requires 6 weeks of immobilization followed by active assisted ROM for an additional 6 weeks.

Subsequent to balloon spacer insertion, patients are required to engage in early rehab focusing on deltoid and scapular strengthening.

Following tendon or muscle transfer procedures there might typically follow an extensive 12-month rehabilitation program with the goal of retraining muscles to provide shoulder function.

In more complex surgeries, regional anesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours. Following this, most patients are initially placed on narcotic medications for the first 2-4 weeks. Most patients are able to wean off narcotic pain medications by their second postoperative visit.

2nd line – muscle transfer

Back
ACUTE
|
acute irreparable tear
|
with weakness and high functional demands
2nd line – 

muscle transfer

The ideal tendon transfer patient has high physical demands for shoulder strength. Weakness is the primary symptom.

Treatment requires ability 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]

Plus – physical therapy

Back
ACUTE
|
acute irreparable tear
|
with weakness and high functional demands
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physical therapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed.

Tear size may be an influential factor in the rate of re-tearing after early passive range of motion (ROM) is performed.[69]​ One study showed that early motion does not necessarily lead to an increased risk of re-tear compared with 6 weeks of immobilization in double-row repairs of smaller (i.e., <3 cm) tears.[70] However, for larger tears and in the presence of poor tissue quality, delayed mobilization is preferable.[71]

Postoperative care can safely be accelerated to 4 weeks of immobilization in medium to large tears. One study found that 8 weeks of immobilization offers no advantages compared with shorter periods in patients with medium-sized tears.​[72]

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but was likely to result in improper tendon healing in shoulders with large-sized tears.[73]

For subacromial debridement/tuberoplasty, physical therapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physical therapy modalities. After a rotator cuff repair the schedule may involve 6-12 months of rehabilitation (e.g., motion, strength, other physical therapy modalities) with slower progression to allow adequate healing of the repair. After arthroplasty there may be a 4- to 6-month program with emphasis on regaining motion, strength, and function.

Superior capsule reconstruction requires 6 weeks of immobilization followed by active assisted ROM for an additional 6 weeks.

Subsequent to balloon spacer insertion, patients are required to engage in early rehab focusing on deltoid and scapular strengthening.

Following tendon or muscle transfer procedures there might typically follow an extensive 12-month rehabilitation program with the goal of retraining muscles to provide shoulder function.

In more complex surgeries, regional anesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours. Following this, most patients are initially placed on narcotic medications for the first 2-4 weeks. Most patients are able to wean off narcotic pain medications by their second postoperative visit.

1st line – debridement

Back
ACUTE
|
acute irreparable tear
|
with pain and lower functional demands
1st line – 

debridement

May benefit patients who have lower functional demands for overhead lifting and whose greatest functional limitation is pain.

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​

Care must be taken to preserve the coracoacromial ligament, because the coracoacromial arch has been shown to be important to preserve in the setting of massive irreparable tears.

Plus – physical therapy

Back
ACUTE
|
acute irreparable tear
|
with pain and lower functional demands
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physical therapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed.

Tear size may be an influential factor in the rate of re-tearing after early passive range of motion (ROM) is performed.[69]​ One study showed that early motion does not necessarily lead to an increased risk of re-tear compared with 6 weeks of immobilization in double-row repairs of smaller (i.e., <3 cm) tears.[70] However, for larger tears and in the presence of poor tissue quality, delayed mobilization is preferable.[71]

Postoperative care can safely be accelerated to 4 weeks of immobilization in medium to large tears. One study found that 8 weeks of immobilization offers no advantages compared with shorter periods in patients with medium-sized tears.​[72]

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but was likely to result in improper tendon healing in shoulders with large-sized tears.[73]

For subacromial debridement/tuberoplasty, physical therapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physical therapy modalities. After a rotator cuff repair the schedule may involve 6-12 months of rehabilitation (e.g., motion, strength, other physical therapy modalities) with slower progression to allow adequate healing of the repair. After arthroplasty there may be a 4- to 6-month program with emphasis on regaining motion, strength, and function.

Superior capsule reconstruction requires 6 weeks of immobilization followed by active assisted ROM for an additional 6 weeks.

Subsequent to balloon spacer insertion, patients are required to engage in early rehab focusing on deltoid and scapular strengthening.

Following tendon or muscle transfer procedures there might typically follow an extensive 12-month rehabilitation program with the goal of retraining muscles to provide shoulder function.

In more complex surgeries, regional anesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours. Following this, most patients are initially placed on narcotic medications for the first 2-4 weeks. Most patients are able to wean off narcotic pain medications by their second postoperative visit.

ONGOING

chronic symptomatic tear

1st line – conservative measures

Back
ONGOING
|
chronic symptomatic tear
1st line – 

conservative measures

A trial of rehabilitation should be considered before surgery, especially in those with low functional demands.

Involves 2-4 weeks of ice and stretch, with nonsteroidal anti-inflammatory drugs (NSAIDs) used as needed to control pain. Focus should be on strengthening remaining cuff, deltoid, and scapular stabilizers, as well as posterior capsular stretching.

Meta-analysis suggests that NSAIDs are less effective than corticosteroid injection at achieving remission in patients with shoulder pain at 4-6 weeks after treatment. However, the limited number of studies and small size of each trial require the interpretations be done with caution.[40]

Activity should be modified to reduce any overhead lifting. When range of motion returns (usually around 4 weeks), toning should be added while stretching is continued.

Goal is to relieve pain and restore a functional arc of motion, including optimization of rotator cuff and periscapular muscle strength and coordination.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally initially, followed by 250 mg every 6-8 hours when required, maximum 1250 mg/day

2nd line – subacromial corticosteroid injection ± suprascapular nerve block

Back
ONGOING
|
chronic symptomatic tear
2nd line – 

subacromial corticosteroid injection ± suprascapular nerve block

Can be performed if patient does not respond to rehabilitation therapy and nonsteroidal anti-inflammatory drugs (NSAIDs).

Useful if tendonitis symptoms limit rehabilitation exercises; follow with immobilization for a few days before resuming physical therapy.

A corticosteroid (e.g., methylprednisolone or triamcinolone) can be combined with local anesthetic (e.g., lidocaine and/or bupivacaine), allowing a larger volume (8-9 mL) to flood the rotator cuff surface. [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@4f6cf1e0 Regimens vary from institution to institution.

Contraindications include septic arthritis, previous adverse reaction, or systemic infection. In addition, if surgery is anticipated, no more than one injection shoulder be administered.[39]

Corticosteroid injections can be repeated 3-4 times per year in a single joint if operative intervention is not warranted or desired.

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]

Primary options

triamcinolone acetonide: consult specialist for guidance on dose

or

methylprednisolone acetate: consult specialist for guidance on dose

-- AND --

lidocaine

and/or

bupivacaine

3rd line – surgical intervention

Back
ONGOING
|
chronic symptomatic tear
3rd line – 

surgical intervention

Usually considered in cases that remain refractory to nonoperative physical and medical treatments after 10-12 weeks.

First-line surgical options include arthroscopic, mini-open, or open repair. However, even with reparable tears, muscle atrophy and migration of the humeral head portend poor surgical outcomes and likely re-tear postoperatively.

Second-line surgical options include debridement, which may result in pain relief for irreparable tears; superior capsule reconstruction, for massive retracted tears that are deemed irreparable; or a balloon spacer, for irreparable cuff tears in patients who not candidates for arthroplasty.

Arthroplasty or glenohumeral arthrodesis are third-line surgical options. Hemiarthroplasty, reverse total shoulder arthroplasty, and rotator cuff tear arthroplasty are salvage procedures for patients who have longstanding tears and develop cuff tear arthropathy. These procedures may provide pain relief for irreparable tears, but may fail to restore strength and motion. Good flexion results and abduction have been described (up to 140°), although external rotation strength remains limited. Glenohumeral arthrodesis is a salvage procedure for irreparable tears that is intended for pain reduction at the expense of permanently reduced range of movement.

Patients who have irreparable cuff tears and are too young for arthroplasty may be candidates for superior capsule reconstruction. The procedure employs a graft to reconstruct the superior capsule and may inhibit proximal humeral migration.[52]

Pain control is the primary indication for surgical intervention.

Plus – physical therapy

Back
ONGOING
|
chronic symptomatic tear
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physical therapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed.

Tear size may be an influential factor in the rate of re-tearing after early passive range of motion (ROM) is performed.[69]​ One study showed that early motion does not necessarily lead to an increased risk of re-tear compared with 6 weeks of immobilization in double-row repairs of smaller (i.e., <3 cm) tears.[70] However, for larger tears and in the presence of poor tissue quality, delayed mobilization is preferable.[71]

Postoperative care can safely be accelerated to 4 weeks of immobilization in medium to large tears. One study found that 8 weeks of immobilization offers no advantages compared with shorter periods in patients with medium-sized tears.​[72]

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but was likely to result in improper tendon healing in shoulders with large-sized tears.[73]

For subacromial debridement/tuberoplasty, physical therapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physical therapy modalities. After a rotator cuff repair the schedule may involve 6-12 months of rehabilitation (e.g., motion, strength, other physical therapy modalities) with slower progression to allow adequate healing of the repair. After arthroplasty there may be a 4- to 6-month program with emphasis on regaining motion, strength, and function.

Superior capsule reconstruction requires 6 weeks of immobilization followed by active assisted ROM for an additional 6 weeks.

Subsequent to balloon spacer insertion, patients are required to engage in early rehab focusing on deltoid and scapular strengthening.

Following tendon or muscle transfer procedures there might typically follow an extensive 12-month rehabilitation program with the goal of retraining muscles to provide shoulder function.

In more complex surgeries, regional anesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours. Following this, most patients are initially placed on narcotic medications for the first 2-4 weeks. Most patients are able to wean off narcotic pain medications by their second postoperative visit.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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