Management of Rotator Cuff Injuries
Publication Date: March 23, 2020
Last Updated: March 14, 2022
RECOMMENDATIONS
MANAGEMENT OF SMALL TO MEDIUM TEARS
Strong evidence supports that both physical therapy and operative treatment result in significant improvement in patient-reported outcomes for patients with symptomatic small to medium full-thickness rotator cuff tears. (S)
312070
LONG TERM NON-OPERATIVE MANAGEMENT
Strong evidence supports that patient reported outcomes (PRO) improve with physical therapy in symptomatic patients with full thickness rotator cuff tears. However, the rotator cuff tear size, muscle atrophy, and fatty infiltration may progress over 5 to 10 years with non operative management. (S)
312070
OPERATIVE MANAGEMENT
Moderate evidence supports that healed rotator cuff repairs show improved patient reported and functional outcomes compared to physical therapy and unhealed rotator cuff repairs. (M)
312070
ACROMIOPLASTY & ROTATOR CUFF REPAIR
Moderate strength evidence does not support the routine use of acromioplasty as a concomitant treatment as compared to arthroscopic repair alone for patients with small to medium sized full-thickness rotator cuff tears. (M)
312070
DISTAL CLAVICLE RESECTION
Moderate strength evidence supports the use of distal clavicle resection as a concomitant treatment to arthroscopic repair for patients with full-thickness rotator cuff tears and symptomatic acromioclavicular joints. (M)
312070
DIAGNOSIS (CLINICAL EXAMINATION)
Strong evidence supports that clinical examination can be useful to diagnose or stratify patients with rotator cuff tears; however, a combination of tests will increase diagnostic accuracy. (S)
312070
DIAGNOSIS (IMAGING)
Strong evidence supports that MRI, MRA, and ultrasound are useful adjuncts to a clinical exam for identifying rotator cuff tears. (S)
312070
POST-OP MOBILIZATION TIMING
Strong evidence suggests similar postoperative clinical and patient-reported outcomes for small to medium sized full-thickness rotator cuff tears between early mobilization and delayed mobilization up to 8 weeks for patients who have undergone arthroscopic rotator cuff repair. (S)
312070
CORTICOSTEROID INJECTIONS FOR ROTATOR CUFF TEARS
Moderate evidence supports the use of a single injection of corticosteroids with local anesthetic for short-term improvement in both pain and function for patients with shoulder pain. (M)
312070
HYALURONIC ACID INJECTIONS FOR ROTATOR CUFF TEARS
Limited evidence supports the use of hyaluronic acid injections in the non-operative management of patients with rotator cuff pathology. (L)
312070
PLATELET RICH PLASMA (PRP) INJECTION IN PARTIAL-THICKNESS TEARS
Limited evidence does not support the routine use of platelet rich plasma for the treatment of rotator cuff tendinopathy or partial tears. (L)
312070
HIGH-GRADE PARTIAL THICKNESS ROTATOR CUFF TEARS
Strong evidence supports the use of either conversion to full-thickness or transtendinous/in-situ repair in patients that failed conservative management with high-grade partial thickness rotator cuff tears. (S)
312070
PROGNOSTIC FACTORS (AGE)
Strong evidence supports that older age is associated with higher failure rates and poorer patient reported outcomes after rotator cuff repair. (S)
312070
PROGNOSTIC FACTORS (HIGHER BMI)
Moderate evidence supports that higher BMI is correlated with higher re-tear rates after rotator cuff repair surgery; however, strong evidence supports that there is no correlation between higher BMI and worse patient-reported outcomes following rotator cuff repair. (M)
312070
PROGNOSTIC FACTORS (WORKER’S COMPENSATION)
Strong evidence supports the presence of a worker’s compensation claim is associated with poorer patient reported outcomes after rotator cuff repair. (S)
312070
PROGNOSTIC FACTORS (COMORBIDITES)
Moderate evidence supports the association of poorer patient reported outcomes in patient with more comorbidities. (M)
312070
PROGNOSTIC FACTORS (DIABETES)
Moderate evidence suggests that patients with diabetes will have higher re-tear rates and poorer quality of life and patient reported outcome scores after rotator cuff repair. (M)
312070
PROGNOSTIC FACTORS (PATIENT EXPECTATIONS)
Moderate evidence correlates higher preoperative patient expectations for surgery with higher patient reported outcomes after rotator cuff repair. (M)
312070
BIOLOGICAL AUGMENTATION WITH PLATELET DERIVED PRODUCTS
Strong evidence does not support biological augmentation of rotator cuff repair with platelet-derived products on improving patient reported outcomes; however, limited evidence supports the use of liquid platelet rich plasma in the context of decreasing re-tear rates. (S)
312070
SINGLE-ROW VS DOUBLE-ROW REPAIR
Strong evidence does not support double row rotator cuff repair constructs on improving patient-reported outcomes compared to single row vertical mattress repair constructs. (S)
312070
SINGLE-ROW VS DOUBLE-ROW REPAIR RE-TEARS
Strong evidence supports lower re-tear rates after double row repair compared to single row vertical mattress repair when evaluating for both partial and full thickness retears after primary repair; however, when evaluating the data for only full thickness retears, limited evidence does not support lower re-tear rates after double row primary repair. (S)
312070
MARROW STIMULATION
Limited evidence suggests that marrow stimulation at the time of rotator cuff repair does not improve patient-reported outcomes. However, this technique may decrease re-tear rates in patients with larger tear sizes. (L)
312070
DERMAL ALLOGRAFTS
Limited evidence supports the use of dermal allografts to augment the repair of large and massive rotator cuff tears to improve patient reported outcomes. (L)
312070
XENOGRAFTS
Limited evidence does not support the use of xenografts to augment the repair of large and massive rotator cuff tears. (L)
312070
OPEN VS ARTHROSCOPIC REPAIR
Strong evidence supports no difference in long-term (> 1 year) patient-reported outcomes or cuff healing rates between open and arthroscopic repairs; however, arthroscopic-only technique is associated with better short-term improvement in post operative recovery of motion and decreased visual analog score (VAS) scores. (S)
312070
POSTOPERATIVE PAIN MANAGEMENT
Moderate strength evidence supports the use of multimodal programs or non-opioid individual modalities to provide added benefit for postoperative pain management following rotator cuff repair. (M)
312070
CONSENSUS STATEMENTS
SUPERVISED EXERCISE VS UNSUPERVISED EXERCISE
In the absence of reliable evidence, it is the opinion of the work group that supervised physical therapy is more appropriate than unsupervised home exercise for some patients following rotator cuff repair. (C)
312070
MULTIPLE STEROID INJECTIONS FOR ROTATOR CUFF TEARS
In the absence of reliable evidence, it is the opinion of the work group that multiple steroid injections may compromise the integrity of the rotator cuff, which may affect attempts at subsequent repair. (C)
312070
PLATELET RICH PLASMA (PRP) INJECTION IN FULL-THICKNESS TEARS
In the absence of reliable evidence, it is the consensus of the work group that we do not recommend the routine use of platelet rich plasma in the non-operative management of full-thickness rotator cuff tears. (C)
312070
PARTIAL ROTATOR CUFF TEAR
In the absence of reliable evidence, the work group is unable to define a preference for the choice of debridement versus repair of high-grade partial-thickness cuff tears that have failed physical therapy, however repair of high grade partial tears could improve outcomes. (C)
312070
UNREPAIRABLE TEARS WITHOUT ARTHROPATHY (BIOLOGIC PROCEDURES)
In the absence of reliable evidence, it is the opinion of the work group that physical therapy, biceps tenotomy/tenodesis, partial repair, tendon transfer, superior capsular reconstruction, arthroscopic debridement, or allograft augmentation (nonporcine) can improve patient reported outcomes. (C)
312070
MASSIVE, UNREPAIRABLE ROTATOR CUFF TEAR (REVERSE ARTHROPLASTY)
In the absence of reliable evidence, it is the opinion of the work group that in patients with massive, unrepairable rotator cuff tears and pseudoparalysis who have failed other treatments, reverse arthroplasty can improve patient reported outcomes. (C)
312070
UNREPAIRABLE TEARS WITH ARTHROPATHY
In the absence of reliable evidence, it is the opinion of the workgroup that after failure of conservative treatment, reverse shoulder arthroplasty for unrepairable tears with glenohumeral joint arthritis can improve patient reported outcomes. (C)
312070
Title
Management of Rotator Cuff Injuries
Authoring Organization
American Academy of Orthopaedic Surgeons
Endorsing Organization
American Physical Therapy Association
Publication Month/Year
March 23, 2020
Last Updated Month/Year
February 5, 2024
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Home health, Hospital, Operating and recovery room, Outpatient
Intended Users
Physical therapist, occupational therapist, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Rehabilitation, Management, Treatment
Diseases/Conditions (MeSH)
D017006 - Rotator Cuff, D000070636 - Rotator Cuff Injuries, D000070656 - Rotator Cuff Tear Arthropathy
Keywords
rotator cuff injury, rotator cuff tear
Source Citation
American Academy of Orthopaedic Surgeons. Treatment of Pediatric Diaphyseal Femur Fractures Evidence-Based Clinical Practice Guideline. www.aaos.org/rccpg. Published March 23, 2020.
Methodology
Number of Source Documents
218
Literature Search Start Date
February 1, 2017
Literature Search End Date
August 1, 2018