Rotator Cuff Injuries Treatment & Management

  • Author: Eileen C Quintana; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 1, 2012
 

Prehospital Care

Stabilization with a shoulder sling and an ice pack are sufficient for prehospital care.

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Emergency Department Care

  • Conservatively treat patients with chronic injuries that have progressed to a rotator cuff tear.
  • The goals are to reduce inflammation, relieve stress on the rotator cuff, and correct any biomechanical dysfunction.
  • Nonoperative therapy consists of rest and activity modification, shoulder sling, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and a basic shoulder-strengthening program.[1] If NSAIDs alone do not provide adequate pain relief, consider adding acetaminophen to the treatment regimen.[11]
  • Various studies indicate a heterogeneous success rate ranging from 33-90%. Steroid injections reduced pain, but no difference in improvement of function was observed.
  • Schedule follow-up treatment as soon as possible; if the patient has not improved by a 6-week assessment, consider surgical therapy.
  • Surgical therapy is indicated in patients younger than 60 years with a full-thickness tear demonstrated clinically or arthrographically, in patients who fail to improve after 6 weeks of rehabilitation, or in patients performing activity that requires shoulder use.
    • Emergent orthopedic evaluation is warranted in acute injuries or even severe extension of chronic rotator cuff injuries because they have a poor prognosis if conservative modalities are used.
    • The success rate of surgical therapy is reported to be 77-86%.[12, 13]
    • Findings generally suggest that early treatment precipitates a better outcome than late treatment. Current studies find that arthroscopic repair is fully comparable with the open surgical technique.[12, 14]
    • Functional status needs to be determined before considering any surgical intervention. Many studies have concluded that the need for surgery should consider not only age but also type of tear, duration of symptoms, and the patient's ability to comply with the rehabilitation regimen.[15, 16, 17]
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Consultations

Consider an orthopedic consultation in primarily acute injuries or even severe extension of chronic rotator cuff injuries. An orthopedic consultation for possible surgical intervention is required under the following conditions:

  • In patients younger than 60 years
  • For full-thickness tear demonstrated clinically or arthrographically
  • For failure to improve after 6 weeks of rehabilitation
  • If the patient's employment requires shoulder use
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Contributor Information and Disclosures
Author

Eileen C Quintana  MD, Assistant Professor, Departments of Pediatrics and Emergency Medicine, St Christopher's Hospital for Children; Adjunct Clinical Professor, Pediatrics and Emergency Medicine Departments, Temple University Hospital, Pediatric Emergency Dept, Philadelphia, PA

Eileen C Quintana is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO  Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph A Salomone III, MD  Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David B Levy, DO, FACEP, FAAEM  Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Dalton SE. The conservative management of rotator cuff disorders. Br J Rheumatol. Jul 1994;33(7):663-7. [Medline].

  2. Moosmayer S, Smith HJ, Tariq R, Larmo A. Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study. J Bone Joint Surg Br. Feb 2009;91(2):196-200. [Medline].

  3. Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am Acad Orthop Surg. Jun 2007;15(6):340-9. [Medline].

  4. Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam Physician. Feb 15 1998;57(4):667-74, 680-2. [Medline].

  5. Hayes K, Ginn KA, Walton JR, Szomor ZL, Murrell GA. A randomised clinical trial evaluating the efficacy of physiotherapy after rotator cuff repair. Aust J Physiother. 2004;50(2):77-83. [Medline].

  6. SooHoo NF, Rosen P. Diagnosis and treatment of rotator cuff tears in the emergency department. J Emerg Med. May-Jun 1996;14(3):309-17. [Medline].

  7. Fuchs S, Chylarecki C, Langenbrinck A. Incidence and symptoms of clinically manifest rotator cuff lesions. Int J Sports Med. Apr 1999;20(3):201-5. [Medline].

  8. Miniaci A, Salonen D. Rotator cuff evaluation: imaging and diagnosis. Orthop Clin North Am. Jan 1997;28(1):43-58. [Medline].

  9. Millstein ES, Snyder SJ. Arthroscopic evaluation and management of rotator cuff tears. Orthop Clin North Am. Oct 2003;34(4):507-20. [Medline].

  10. Hashefi M. Ultrasound in the diagnosis of noninflammatory musculoskeletal conditions. Ann N Y Acad Sci. Feb 2009;1154:171-203. [Medline].

  11. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg. Apr 2010;110(4):1170-9. [Medline].

  12. Hanusch BC, Goodchild L, Finn P, Rangan A. Large and massive tears of the rotator cuff: functional outcome and integrity of the repair after a mini-open procedure. J Bone Joint Surg Br. Feb 2009;91(2):201-205. [Medline].

  13. Zumstein MS, Jost B, Hempel J, Hodler J, Gerber C. The clinical and structural long-term results of open repair of massive tears of rotator cuff. J Bone Joint Surg Am. Nov 2008;90(11):2423-31.

  14. Morse K, Davis AD, AFra R, Kaye EK, Schepsis A, Voloshin I. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med. Sept 2008;26(9):1824-1828. [Medline].

  15. Tonino PM, Gerber C, Itoi E, Porcellini G, Sonnabend D, Walch G. Complex shoulder disorders: evaluation and treatment. J Am Acad Orthop Surg. Mar 2009;17(3):125-36. [Medline].

  16. Rudzki JR, Shaffer B. New approaches to diagnosis and arthroscopic management of partial-thickness cuff tears. Clin Sports Med. Oct 2008;27(4):691-717. [Medline].

  17. Barr KP. Rotator cuff disease. Phys Med Rehabil Clin N Am. May 2004;15(2):475-91. [Medline].

  18. Wessel J, Razmjou H, Mewa Y, Holtby R. The factor validity of the Western Ontario Rotator Cuff Index. BMC Musculoskelet Disord. May 4 2005;6:22. [Medline]. [Full Text].

  19. Quillen DM, Wuchner M, Hatch RL. Acute shoulder injuries. Am Fam Physician. Nov 15 2004;70(10):1947-54. [Medline].

  20. Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD. Long-term functional outcome of repair of large and massive chronic tears of the rotator cuff. J Bone Joint Surg Am. Jul 1999;81(7):991-7. [Medline].

  21. Soslowsky LJ, Carpenter JE, Bucchieri JS, Flatow FL. Biomechanics of the rotator cuff. Orthop Clin North Am. Jan 1997;28(1):17-30. [Medline].

  22. Kim KC, Shin HD, Lee WY. Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair. J Bone Joint Surg Am. Apr 18 2012;94(8):e481-6. [Medline].

 
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Rotator cuff, normal anatomy.
Rotator cuff tear, anterior view.
The acromioclavicular arch and the subacromial bursa.
Neer impingement test. The patient's arm is maximally elevated through forward flexion by the examiner, causing a jamming of the greater tuberosity against the anteroinferior acromion. Pain elicited with this maneuver indicates a positive test result for impingement.
Rotator cuff injury.
Normal intratendinous signal.
Partial-thickness tear seen better on angled oblique sagittal views.
Full-thickness tear.
Normal plain radiograph of the shoulder in internal, external, and neutral positions.
 
 
 
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