Conservative care or surgery for rotator cuff tears?
Selecting the appropriate Tx for the patient’s circumstances— including age, activity level, and the size and depth of the tear—boosts the chances of a favorable outcome.
PRACTICE RECOMMENDATIONS
› Offer a trial of conservative management to patients with chronic, nontraumatic, or partial-thickness rotator cuff injury and to those who are poor surgical candidates. B
› Counsel patients that the rate of surgical complications is low and outcomes are favorable in properly selected patients for operative repair of rotator cuff tear. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
A recent meta-analysis17 found comparative evidence on treating rotator cuff tears with physical therapy to be inconclusive. At 1-year follow-up, there was no clinically significant difference between surgery and active physical therapy in either improving the Constant Shoulder Score (an assessment of function) or reducing pain caused by a rotator cuff tear. Therefore, the authors proposed, given the low risk of harm, a conservative approach should be the initial treatment modality for a tear.
A Cochrane review18 examined 60 eligible trials, in which the mean age of patients was 51 years and the mean duration of symptoms, 11 months. Overall, the review concluded that the effects of manual therapy and exercise might be similar to those of glucocorticoid injection and arthroscopic subacromial decompression. The authors noted that this conclusion is based on low-quality evidence, with only 1 study in the review that compared the combination of manual therapy and exercise to placebo.
Other conservative options. Ultrasound, topical nitroglycerin, topical lidocaine, glucocorticoid iontophoresis, transcutaneous electrical nerve stimulation, massage, acupuncture, extracorporeal shockwave therapy, hyaluronic acid, and platelet-rich plasma have been used to treat rotator cuff disease. These modalities require further study, however, to determine their effectiveness for this indication.7,19
Who is a candidate for surgical management?
Although nonoperative treatment is preferred for rotator cuff tendinitis or tendinosis and partial-thickness tears, appropriate management of full-thickness tears is debatable.20 Some surgeons advocate early operative intervention of repairable full-thickness tears to prevent further progression and reduce the risk of long-term dysfunction.
The decision to pursue operative repair depends on
- patient characteristics (age, activity level, comorbidities),
- patient function (amount of disability caused by the tear),
- characteristics of the tear (length, depth, retraction), and
- chronicity of the tear (acuity).
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