Treatment

In the acute phase, all tears should be managed conservatively:

• nonoperative management includes:
  • avoidance of activities that initiate pain
  • a range-of-motion program
  • nonsteroidal antiinflammatory medication if not contraindicated
  • occasional corticosteroid injections
  • physical modalities - initial cold treatment then graduating to heat treatment

After about three weeks, it should be possible to distinguish a partial and a complete tear. Surgery is then indicated for large tears and for acute rupture in a young patient, although reconstruction is not always successful. Surgical intervention may be undertaken arthroscopically.

If surgical treatment is not undertaken then, as the pain associated with the rotator cuff tear decreases, a graduated strengthening program is employed - this program emphasises scapular stabilising exercises and withholding deltoid strengthening until the shoulder is totally painless.

• about 50% of patients will be satisfied with nonoperative treatment - there is a significant decrease in pain and range of motion increased in these patients; however, strength remains unchanged from the initial assessment (1)

If surgical treatment is undertaken then post-operatively, the arm should be put in a sling and allowed to rest at the side of the body. Gentle pendulum motions should be started within the first week with small or medium tears, but not until the second week in the case of a large tear. Unnecessary strain should be avoided:

• when reaching for an object, flex the elbow and take a step forwards rather than using an outstretched arm
• avoid the "flying elbow" when using the shoulder - ie. the arm at 90 degrees with the humeral head impinged under the acromial arch

A well motivated patient may expect to resume normal activity by 6 months.

Notes (1):

• poor prognosis is for nonoperative treatment includes:
  • a long history of pain (6-12 months) before their initial examination
  • larger tears (>3 cm) are associated with a poorer prognosis for nonoperative treatment
  • severe weakness on initial presentation - only approximately 13% of patients with severe weakness on initial examination showed a satisfactory end result with nonoperative treatment
• pain relief is expected in approximately 50% with nonoperative management. Following surgical repair 85% of patients have relief of pain with restoration of some degree of strength
• surgical repair has shown that it can improve, if not restore, strength in patients - allthough this has not been shown for nonoperative therapy
  • surgical repair has been shown to have a higher rate of success for both pain relief and return of strength as opposed to nonoperative treatment.
• there is evidence that suggests, in an acute tear of less than 3 weeks in duration, early repair may provide a better functional result
• in older patients with limited goals and a limited lifespan then nonoperative treatment may be an effective treatment option
• management of partial rotator cuff tears is controversial (2)
  • each partial rotator cuff tear must be individually evaluated to determine if indeed the tear is actually the source of clinical symptoms
  • with the ability to grossly measure tear depth arthroscopically, the goal of restoring integrity to the rotator cuff in the younger, higher-demand patient becomes more compelling

Reference:

1. Ruotolo C, Nottage WN. Surgical and nonsurgical management of rotator cuff tears. Arthroscopy 2002;18 (5): 527-531.
2. Stetson WB et al. Arthroscopic treatment of partial rotator cuff tears. Operative Techniques in Sports Medicine 2004; 12(2):135-148.