The rotator cuff includes a group of muscles (the supraspinatus, infraspinatus, teres minor and subscapularis) and tendons that surround the shoulder joint to keep the humerus in place. The structure affords a significant amount of stability to the shoulder. Injuries to the rotator cuff are the most common cause of shoulder pain nationally. The keys to diagnosis are to elucidate the historical features of the patient’s shoulder pain complaints, as well as to evaluate the muscles via physical examination and imaging. Most cases of rotator cuff injury involve the supraspinatus muscle. This article will discuss management of rotator cuff injury.
If physical examination and imaging do not show clear evidence of tears to the rotator cuff (either partial or full), an alternative diagnosis should be considered, such as rotator cuff tendinopathy. Acute management for rotator cuff tendinopathy includes physical therapy, rest, ice and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Injections may also be considered, with subacromial glucocorticoid injections commonly performed in the acute to subacute period. It should be stated that the evidence for NSAIDs and subacromial steroid injections for the management of rotator cuff tendinopathy has not been shown to be consistent across multiple studies.
If examination and imaging are consistent with a tear, management can involve both nonsurgical and surgical options. The treatment of rotator cuff tears depends on several factors including the duration of symptoms, shoulder dominance, activity lifestyle, the type of tear and one’s medical comorbidities. It is important to note that to date, there are no clear research studies that demonstrate a clear long-term benefit with surgery. Aggressive physical therapy, continued surveillance via shoulder range of motion testing and repeat imaging studies can be performed every 6-12 months to assess the progression of a tear prior to considering surgery. Partial thickness tears are generally treated with non-operative management.
Although still heavily debated amongst orthopedic surgeons, the appropriate indications for surgery include failure of conservative measures such as physical therapy, home exercise programs, persistent pain despite use of medications, and worsening/non-improving shoulder function. One vital exception to this rule is an acute, full thickness traumatic tear in an otherwise healthy individual. Such injury will be treated with immediate surgery, since delay in treatment can lead to significant muscle atrophy and tendon retraction. In addition, if one has an acute or chronic rotator cuff tear resulting in sudden functional loss of shoulder flexion or abduction, urgent surgical repair would be warranted. It is important to note that older age does not preclude surgical intervention. Multiple clinical studies have showed that patients older than 65 years old were successfully treated with rotator cuff surgery when conservative treatment with physical therapy had failed.
Alternative management of other treatment modalities not yet mentioned such as ultrasound, topical agents such as lidocaine or diclofenac, glucocorticoid iontophoresis, massage, acupuncture, viscosupplementation, platelet rich plasma injections and shock-wave therapy are not yet evidenced based and require further research to define their definitive roles.
Rotator cuff injuries are the most common complaint of shoulder pain nationwide. There are both non-operative and surgical approaches to management depending on the mechanism of injury, type of injury and pre-functional activity level of the individual. In general, non-operative and maximal conservative treatment should be considered prior to surgical evaluation.
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