Rotator cuff injury

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

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

active, younger patient

1st line – surgical therapy

Back

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. When surgery is undertaken before the onset of atrophy, more predictable results are ensured. One randomised 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 physiotherapy.[38]

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.

Randomised control trials, systematic reviews, and meta-analyses report similar outcomes following open, mini-open, or arthroscopic repair.[74][75][76][77] Arthroscopy may be associated with decreased short-term pain.[76]

Results from systematic reviews with meta-analyses typically indicate that double-row suture repairs facilitate improved healing rates, but not recognisable differences in outcome scores.[39][78][79][80][81][82] 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.[83]

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 recognise. 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.[84]

Plus – physiotherapy

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Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physiotherapy/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.[67] One study showed that early motion does not necessarily lead to an increased risk of re-tear compared with 6 weeks of immobilisation in double-row repairs of smaller (i.e., <3 cm) tears.[68] However, for larger tears and in the presence of poor tissue quality, delayed mobilisation is preferable.[69]

Postoperative care can safely be accelerated to 4 weeks of immobilisation in medium to large tears. One study found that 8 weeks of immobilisation offers no advantages compared with shorter periods in patients with medium-sized tears.[70]

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.[71]

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

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

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

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

In more complex surgeries, regional anaesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours.[72][73] Following this, most patients are initially placed on opioid analgesics for the first 2-4 weeks. Most patients are able to wean off opioids by their second postoperative visit.

sedentary, older patient

1st line – conservative measures

Back

1st line –

conservative measures

Non-surgical 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 non-steroidal anti-inflammatory drugs (NSAIDs) are the initial treatments. Once ROM returns (usually at about 4 weeks), toning exercises can be started while stretching continues.

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.[42] However, the limited number of studies and small size of each trial require the interpretations be done with caution.[42]

NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation). NSAIDs should be used at the lowest effective dose for the shortest effective treatment course.

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

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

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

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 non-steroidal anti-inflammatory drugs (NSAIDs).[39] It is particularly useful if significant stiffness and tendonitis symptoms limit rehabilitation exercises. Rehabilitation can typically resume after a few days of rest.[40]

A corticosteroid (e.g., methylprednisolone or triamcinolone) can be combined with local anaesthetic (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@55dba012 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.[41]

Corticosteroid injections can be repeated 3-4 times per year in a single joint if operative intervention is not warranted or desired. Patients should be informed of potential catabolic effect on tissue.

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.[59]

Primary options

triamcinolone acetonide: consult specialist for guidance on dose

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

3rd line –

surgical repair

Lack of response to at least 10-12 weeks of medical therapy and physiotherapy 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.

Plus – physiotherapy

Back

Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

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

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

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

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

acute medium/large/massive reparable tear

active, younger patient

1st line – surgical repair

Back

1st line –

surgical repair

Surgical repair is the first-line treatment for patients with good functional status, especially if functional demands are high, or if the injury is on the dominant side.

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).

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.

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

Plus – physiotherapy

Back

Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

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

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

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

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

sedentary, older patient

1st line – rehabilitation and non-steroidal anti-inflammatory drugs (NSAIDs)

Back

1st line –

rehabilitation and non-steroidal anti-inflammatory drugs (NSAIDs)

For older and sedentary patients, first-line treatment should be rehabilitation therapy with ice, stretching, exercise, and NSAIDs for pain control as required.

Rehabilitation should be managed by a physiotherapist. Focus should be on strengthening remaining cuff, deltoid, and scapular stabilisers, 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

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

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

2nd line – surgical repair

Back

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).

First-line choice should be rehabilitation therapy in sedentary, older patients.

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.

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

Plus – physiotherapy

Back

Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

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

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

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

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

acute irreparable tear

with weakness and high functional demands

1st line – superior capsule reconstruction

Back

1st line –

superior capsule reconstruction

Superior capsular reconstruction prevents superior humeral head migration, resulting in enhanced deltoid function. This procedure may be offered to patients with isolated irreparable rupture of the supraspinatus, where medical treatment has not been successful.[54] Other indications include a massive, irreparable tear of the rotator cuff or an intact or repairable subscapularies tendon (if there is intolerable pain despite conservative treatment and minimal or absent evidence of arthritis), or for patients who do not wish to undergo arthroplasty.[54][55][56] The results have been inconsistent but investigators maintain that technique success depends on graft type and thickness.[54][55]

Plus – physiotherapy

Back

Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

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

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

1st line – muscle transfer

Back

1st 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.[50][51] Lower trapezius transfer is becoming increasingly popular, because this transfer closely mimics the line of pull of the infraspinatus.[52][53]

Plus – physiotherapy

Back

Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physiotherapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed. For latissimus dorsi or lower trapezial transfers, a period of immobilisation in external rotation is usually advised in an effort to diminish tension on the repair.

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

1st line – reverse shoulder arthroplasty (RSA)

Back

1st line –

reverse shoulder arthroplasty (RSA)

RSA is an established surgical option that is used for the treatment of massive, irreparable rotator cuff tear with or without arthritis in cuff tear arthropathy settings, or in elderly patients with dislocation and cuff tear that fail non-operative management, or rotator cuff tear.[46][47] Systematic reviews and meta-analyses indicate that newer designed prostheses that offer a lateralised centre of rotation RSA may be the preferred approach.[48][49]

Plus – physiotherapy

Back

Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

The typical postoperative course normally involves a period of formal physiotherapy/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 retearing after early passive range of motion (ROM) is performed.[67] One study showed that early motion does not necessarily lead to an increased risk of retear compared with 6 weeks of immobilisation in double-row repairs of smaller (i.e., <3 cm) tears.[68] However, for larger tears and in the presence of poor tissue quality, delayed mobilisation is preferable.[69]

After arthroplasty there may be a 4- to 6-month rehabilitation programme with emphasis on regaining motion, strength, and function.

with pain and lower functional demands

1st line – debridement

Back

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. Isolated 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.[39][43][44] BMJ: subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline Opens in new window However, decompression in the presence of rotator cuff repair may, in some cases, lower recurrent tear rates.[45]

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 – physiotherapy

Back

Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

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

For subacromial debridement/tuberoplasty, physiotherapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physiotherapy modalities.

ONGOING

chronic symptomatic tear

1st line – conservative measures

Back

1st line –

conservative measures

Chronic tears should be treated initially with conservative therapies (e.g., ice and stretching, cuff strengthening, scapular stabilisation, non-steroidal anti-inflammatory drugs [NSAIDs]) before surgery is considered especially in those with low functional demand.

Involves 2-4 weeks of ice and stretch, with NSAIDs used as needed to control pain. Focus should be on strengthening remaining cuff, deltoid, and scapular stabilisers, 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.[42]

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 optimisation of rotator cuff and periscapular muscle strength and co-ordination.

Primary options

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

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

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

2nd line –

subacromial corticosteroid injection ± suprascapular nerve block

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 corticosteroids on cuff healing and infection risk.[41] Exercises can be resumed a few days after injection.

Useful if tendonitis symptoms limit rehabilitation exercises; follow with immobilisation for a few days before resuming physiotherapy.

A corticosteroid (e.g., methylprednisolone or triamcinolone) can be combined with local anaesthetic (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@69db09d2 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.[41]

Primary options

triamcinolone acetonide: consult specialist for guidance on dose

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 intervention

Back

3rd line –

surgical intervention

Surgery can be pursued if a tear is unresponsive to non-operative treatment after 10-12 weeks. Younger patients are typically treated with a more aggressive approach, with surgery considered earlier in their treatment course, especially if they complain of weakness.[32]

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; 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.[56] This technique should not be used in the presence of advanced arthropathy or irreparable subscapularis tear.

Tendon transfer may be 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.

Pain control is the primary indication for surgical intervention.

Plus – physiotherapy

Back

Plus –

physiotherapy

Treatment recommended for ALL patients in selected patient group

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

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

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

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

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Rotator cuff injury

Treatment algorithm

acute small tear

surgical therapy

physiotherapy

conservative measures

Primary options

subacromial corticosteroid injection ± suprascapular nerve block

Primary options

surgical repair

physiotherapy

acute medium/large/massive reparable tear

surgical repair

physiotherapy

rehabilitation and non-steroidal anti-inflammatory drugs (NSAIDs)

Primary options

surgical repair

physiotherapy

acute irreparable tear

superior capsule reconstruction

physiotherapy

muscle transfer

physiotherapy

reverse shoulder arthroplasty (RSA)

physiotherapy

debridement

physiotherapy

chronic symptomatic tear

conservative measures

Primary options

subacromial corticosteroid injection ± suprascapular nerve block

Primary options

surgical intervention

physiotherapy