Shoulder Pain Management

Rotator Cuff Tears

Initial treatment for a torn rotator cuff includes heat or cold to the affected area, immobilization, physical therapy, and anti-inflammatory medications.

Figure 4: The AP view offers a clear visual showing a significant loss of space between the humeral head and the acromium, suggesting a massive rotator cuff tear.

Treatment Options
• NSAIDs and analgesics
• Cortisone injections
• Physical therapy to strengthen rotator cuff muscles
• Surgical repair for persistent pain and/or persistent weakness

Key Clinical Points
• Nonoperative treatment for a rotator cuff tear provides satisfactory symptom relief for about half of patients.¹ For patients whose chief complaint is discomfort without substantial or progressive pain, nonoperative treatment may be the appropriate initial course.
• Rotator cuff tear symptoms may resolve even without healing. They tend to either enlarge or, at best, stabilize in size. Therefore, many patients with minor rotator cuff tears will not require surgery because their symptoms will diminish over time with conservative treatment.
• Conservative treatment begins with physical therapy to strengthen the rotator cuff muscles. Strengthening the shoulder may be the most important treatment for maintaining normal shoulder function, alleviating symptoms and preventing future episodes. Patients can learn strengthening exercises from a physical therapist in a few sessions.
• Pain medications will help control the symptoms of rotator cuff tears and allow patients to perform physical therapy without intolerable pain. NSAIDs are recommended for short-term pain relief and for periodic short-term use should rotator cuff pain recur.
• Cortisone injections will enable patients to perform physical therapy by limiting inflammation at the site of the tear.
• Conservative treatment may not be successful in all circumstances. For example, conservative treatment is likely to be ineffective in young patients (<35-40 years) who have traumatic injuries. Older patients (>40 years) suffering from the onset of cuff tear arthropathy may also fail to show improvement due to the advanced state of their condition.
• Surgery may be the best initial treatment for young (<35-40 years) patients with acute rotator cuff tears or for any patient who fails to get adequate relief from an appropriate course of conservative treatment.

Patient Considerations

Intense conservative treatment may help to relieve pain and strengthen the muscles around the joint, but may not be effective in all patients. In older patients or those who have chronic injury, intense conservative therapy may be the best initial option. However, in younger patients (<35-40 years) who have an acute, traumatic injury, surgery may be considered earlier, as the likelihood that conservative treatment will help is low. Surgery is also considered in patients who have tried conservative treatment and still have difficulty with their shoulder.

Know When to Refer
• Patient not responding to conservative treatment after 4 to 6 months
• If patient's employment requires overhead use of affected arm
• Glenohumeral instability (dislocation)
• Trauma-induced, full-thickness rotator cuff tear
• Any full-thickness rotator cuff tear in a patient <50 years of age
• Acute exacerbation of a chronic rotator cuff tear with sudden loss of forward elevation (pseudoparalysis of the arm)
• Recalcitrant adhesive capsulitis treated conservatively for at least 6 months

References