Rotator Cuff Pathology Treatment & Management

Updated: Nov 30, 2015
  • Author: R H Bilal, MBBS, MRCS; Chief Editor: S Ashfaq Hasan, MD  more...
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Treatment

Approach Considerations

Conservative treatment of the degenerative rotator cuff involves the following:

  • Pain relief
  • Avoidance of painful motions and activities
  • Simple analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Manual physical therapy for the glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular joints and the parascapular and scapula-stabilizer muscles
  • Subacromial corticosteroid injection
  • Bupivacaine suprascapular nerve block
  • Restoration of motion and normal scapulohumeral rhythm
  • Stretching of the glenohumeral capsule and muscles
  • Manual therapy of the cervicodorsal spine (often necessary because of its close relation with the shoulder)

Patients with more advanced rotator cuff disease or a more significant injury may not respond to conservative therapies. If the patient believes that his or her quality of life is being significantly impacted by the shoulder dysfunction, then surgical intervention is a reasonable consideration. In some cases, simple debridement of a frayed or partially torn cuff tendon, along with smoothing of the undersurface of the acromion (acromioplasty) above the tendon, may be all that is needed. More significant partial tearing (>50% of tendon thickness) and complete tears require reattachment of the tendon ends back to the humeral head. [33, 34, 35]

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Conservative Therapies

Physical therapy

Physical therapy can be a useful adjunct in the conservative treatment of patients with degenerative rotator cuffs. Although numerous studies have been performed on conservative treatment and surgical approaches of the painful shoulder and, more specifically, the rotator cuff, the conclusion of a review of randomized, controlled trials of interventions for painful shoulder was that little evidence supports or refutes the efficacy of common interventions for shoulder pain. [36, 37, 38, 39]

Drawing firm conclusions about the efficacy of any of these interventions remains difficult because of, among other reasons, the lack of definition and strict diagnostic criteria for the different painful shoulder conditions, valid randomization procedures, blinding, valid scales for outcome measurement, and heterogeneous populations. In their approach to conservative patient treatment, clinicians must be critical and try to use an evidence-based medicine approach as much as possible. The clinician must also use a combination of experience and intuition to compensate for the lack of scientific evidence supporting the different therapeutic modalities.

Pharmacologic pain relief

Acetaminophen

Acetaminophen is recommended as initial treatment because of the toxicity associated with NSAIDs, the need for an analgesic rather than anti-inflammatory effect, the lower cost of a simple analgesic, and the chronicity of degenerative rotator cuff disease.

While NSAIDs are known to be effective in reducing pain and improving function and ROM, they may exert their effect through their analgesic rather than their anti-inflammatory properties. One study with poor methodologic quality showed no short-term superiority of NSAIDs over acetaminophen in the treatment of painful shoulder syndrome. Long- and short-term studies comparing the efficacy of NSAIDs with that of acetaminophen for osteoarthritis of the knee have shown similar efficacy for the two agents. Moreover, even the presence of inflammatory signs did not predict a better response to treatment with NSAIDs, suggesting that improvements are not necessarily dependent on an anti-inflammatory effect.

The analgesic effect of acetaminophen is mediated by prostaglandin inhibition.

  • Adult dose - 325-650 mg PO q4-6hr or 1000 mg tid/qid; not to exceed 4 g/day
  • Pediatric dose - For those younger than 12 years, 10-15 mg/kg PO q4-6hr prn, not to exceed 2.6 g/day; for those older than 12 years, 325-650 mg PO q4hr, not to exceed 5 doses in 24 hr
  • Contraindications - Documented hypersensitivity; known glucose-6-phosphate dehydrogenase deficiency
  • Interactions - Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
  • Pregnancy category B - Usually safe, but benefits must outweigh the risks.
  • Precautions - Hepatotoxicity possible in chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many over-the-counter products, and combined use with these products may result in cumulative doses exceeding recommended daily dose

Nonsteroidal anti-inflammatory drugs

Numerous studies on the efficacy of NSAIDs for different shoulder conditions have been published, but because most of them have poor methodologic quality, no conclusions can be drawn about the efficacy of NSAIDs.

Review articles, using strict inclusion criteria based on the quality of the methodology, concluded that the trials with the best methodology show a superior short-term efficacy (2 weeks) of NSAIDs compared with placebo; however, at 4 weeks, results did not show any statistical differences. Therefore, a short course (10-14 days) of NSAIDs is indicated as a second-line treatment. No evidence supports longer use.

In case of persistent pain, other therapeutic modalities should be sought. A comparison between different types of NSAIDs did not show evidence of the superiority of one NSAID with respect to efficacy. Therefore, an NSAID with the fewest adverse effects, such as the newer cyclooxygenase (COX)-2 selective molecules or an NSAID with a combination of prostaglandin E1 analogue (diclofenac/misoprostol), should be the drug of choice.

In an aging population taking additional medication that may interact with NSAIDs, drug interactions must be avoided. From 40-60% of drugs consumed are over-the-counter medications, most often analgesics and NSAIDs, increasing the risk of potential adverse gastrointestinal (GI) side effects. The patient should be asked whether he or she is taking any medications concomitantly, such as the following:

  • Anticoagulants (hemorrhage)
  • Corticosteroids (peptic ulcer)
  • Diuretics and antihypertensives (decreased blood pressure control)
  • Angiotensin-converting enzyme (ACE) inhibitors (acute renal failure)
  • High-dose methotrexate (increased methotrexate toxicity)
  • Lithium, digoxin, aminoglycosides (decreased renal clearance)
  • Phenytoin (decreased albumin binding)
  • Antacids (decreased NSAID levels)

NSAIDs should be avoided, if possible, in elderly patients with congestive heart failure or renal or hepatic dysfunction and who are taking other medications.

If the patient has no contraindications to the use of ibuprofen, it is usually the drug of choice for the treatment of mild-to-moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

  • Adult dose - 400 mg PO q4-6hr, 600 mg PO q6hr, or 800 mg PO q8hr while symptoms persist; not to exceed 3.2 g/day
  • Pediatric dose - For age 6 months to 12 years, 10-70 mg/kg/day PO divided tid/qid; begin at lower end of the dosing range and titrate upward; not to exceed 2.4 g/day; for older than 12 years, administer as in adults
  • Contraindications - Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
  • Interactions - Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently; monitor prothrombin time closely (instruct patients to watch for signs of bleeding)
  • Pregnancy category B - Usually safe but benefits must outweigh the risks.
  • Precautions - Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Celecoxib primarily inhibits COX-2, which is considered an inducible isoenzyme—that is, it is induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity, but at therapeutic concentrations, celecoxib does not inhibit the COX-isoenzyme; therefore, GI toxicity may be decreased. The lowest dose of celecoxib should be sought for each patient.

  • Adult dose - 200 mg/day PO qd; alternatively, 100 mg PO bid
  • Pediatric dose - Not established
  • Contraindications - Documented hypersensitivity
  • Interactions - Coadministration with fluconazole may cause an increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease plasma concentrations
  • Pregnancy category C - Safety for use during pregnancy has not been established.
  • Precautions - Use with caution in patients with compromised cardiac function, hypertension, and conditions predisposing to fluid retention, because NSAIDs may cause fluid retention and peripheral edema; use with caution in patients with severe heart failure and hyponatremia, because NSAIDs may deteriorate circulatory hemodynamics; use with caution in the presence of existing controlled infections, because NSAIDs may mask the usual signs of infection; evaluate symptoms and signs suggesting liver dysfunction, cardiac dysfunction or renal dysfunction

Ketoprofen is used for relief of mild-to-moderate pain and inflammation. Small initial dosages are indicated in small and elderly patients and in persons with renal or liver disease. Doses of more than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patients for response.

  • Adult dose - 25-50 mg PO q6-8hr prn; not to exceed 300 mg/day
  • Pediatric dose - For those aged 3 months to 14 years, 0.1-1 PO mg/kg q6-8hr; for those older than 14 years, administer as in adults
  • Contraindications - Documented hypersensitivity; GI disease
  • Interactions - Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently; monitor prothrombin time closely (instruct patients to watch for signs of bleeding)
  • Pregnancy category B - Usually safe, but benefits must outweigh the risks.
  • Precautions - Category D in third trimester of pregnancy; use with caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; use with caution in patients with anticoagulation abnormalities or during anticoagulant therapy

Ultrasound therapy

Ebenbichler showed in a randomized, doubled-blind, placebo-controlled study that the use of a pulsed ultrasound performed 5 times a week for 15 minutes (0.89 MHz frequency, 2.5 W/cm2, pulsed mode 1:4) significantly resolves calcification of the shoulder, decreases pain, and improves the short-term quality of life. [40, 41]

Long-term follow-up did not show significant differences; however, in the long term, the symptoms of calcifying tendinitis may be self-limiting and may improve independently from the resolution of the calcium deposit. This theory may explain why the use of ultrasound is only significantly effective in the short term. The short-term efficacy of ultrasound therapy has been demonstrated only in calcifying tendinitis. Its efficacy in other shoulder disorders has not been shown.

Extracorporeal shockwave therapy

Another modality that looks promising is extracorporeal shockwave therapy (ESWT). Passing a strong electric current through a flat coil induces a magnetic field and generates shock waves. Shock waves were used first for the treatment of delayed union and nonunion of fractures by stimulating osteogenesis.

In an uncontrolled study, shockwave therapy (1500 impulses of 0.28 mJ/mm2) reportedly disintegrated calcium deposits partially or completely in 62% of patients, and 75% had significant improvement in pain, power, ROM, and shoulder function. The authors of the study concluded that a larger-scale, placebo-controlled trial should be conducted to analyze the benefits of this modality.

A prospective, randomized, controlled study using a valid functional shoulder scale showed the efficacy of ESWT. At 3-6 months, significant improvement occurred in pain and function. At 6 months, calcium deposits disappeared or disintegrated in up to 77% of patients' radiographs. Comparing different regimens of shockwaves, the authors concluded that the improvement in pain and function and the radiologic disintegration of calcification were dose-dependent. [42, 43, 44, 45, 19]

ESWT appears to be a promising treatment for calcifying tendinitis. As with ultrasound therapy, its efficacy in other shoulder conditions has not been established.

Iontophoresis

Randomized, controlled studies have shown the efficacy of topical steroids, NSAIDs, and acetic acid iontophoresis, as compared with placebo, in different musculoskeletal disorders (MSDs); however, the studies were not specifically on rotator cuff disease. Moreover, a subsequent trial did not show any difference in outcomes between no treatment and treatment with acetic acid iontophoresis followed immediately by 9 sessions of ultrasound therapy in a constant mode (0.8 W/cm2 at a frequency of 1 MHz for 5 min) over a period of 3 weeks.

Some authors could not show any effect of iontophoresis on steroid migration through in vivo and in vitro studies, whereas others did. Thus, no conclusions can be made regarding the efficacy of iontophoresis in the treatment of rotator cuff disease.

Subacromial corticosteroid injection

As with NSAID therapy, many of the studies on the efficacy of corticosteroid injection for various shoulder conditions are of poor methodologic quality. Green, van Der Heijden, and Sibilia performed a systematic review of all the randomized clinical trials on corticosteroid injection. Although the trials selected were essentially the same in the three studies, their conclusions differ because of the different assessment methods. Two of these articles suggested that corticosteroid injection may be superior to placebo in the short-term treatment of rotator cuff tendinitis, whereas one suggested that no conclusive evidence was found regarding the efficacy of corticosteroid injection. [46, 47, 48, 49]

Subacromial corticosteroid and local anesthetic agent injection also appear to be more effective than an injection of a local anesthetic alone, although some authors disagree. Corticosteroid injection also appears to be significantly more effective than NSAIDs. Therefore, subacromial corticosteroid injection appears indicated when pain persists after simple analgesics and NSAIDs have been used. [50]

Because some authors have reported poorer surgical outcome in patients who have had three or more corticosteroid injections, the recommendation is that no more than two injections be given. No trials have compared the different routes of corticosteroid injection; thus, the physician should select his or her preferred route. Additionally, no trial has compared the efficacy of different corticosteroids. Triamcinolone acetonide is the agent most frequently studied.

The action mechanism is inhibition of prostaglandin formation by selective COX-2 activity. The optimal dose has not been evaluated. Recommended doses vary from 20 to 80 mg in the different trials. This author recommends 20-40 mg of triamcinolone acetonide. Adverse effects can be local or systemic. Although systemic adverse effects can occur following a subacromial injection, only local adverse effects are discussed here. Possible adverse effects include dermal atrophy, necrosis and loss of pigmentation, synovitis, septic arthritis, hemarthroses, cartilage damage and degeneration, tendon rupture, and Charcot arthropathy.

Bupivacaine suprascapular nerve block

The bupivacaine suprascapular nerve block is a relatively unknown, though effective, method to treat different painful shoulder disorders. A few randomized controlled trials have demonstrated its efficacy for painful shoulder associated with rheumatoid arthritis, for chronic rotator cuff disease, and for frozen shoulder.

Preliminary data of a study on chronic impingement syndrome conducted at the Montreal Rehabilitation Institute show its efficacy compared with placebo. At 3 months, a significant improvement in pain and function, measured by a valid functional shoulder scale, was observed. The efficacy of this procedure is supported by randomized controlled studies, and it appears to be a very promising new approach in the treatment of rotator cuff disease. [51]

The technique for nerve block is very inexpensive, simple, and safe. It consists of injecting 10 mL of bupivacaine 0.5% in the supraspinatus fossa of the scapula to produce an indirect suprascapular nerve block. In rotator cuff disease, two injections are administered 4 weeks apart.

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Surgical Intervention

Open surgery

Rotator cuff repair is most commonly accomplished by performing an open surgical procedure, which typically requires a 5- to 10-cm incision at the top of the shoulder. The deltoid muscle is split, and the undersurface of the acromion is smoothed. Strong stitches are placed in the torn ends of the rotator cuff tendons, and they are attached back to the bone of the humerus through specially created tunnels or commercially available suture anchors.

Because the entire shoulder cannot be visualized through the open approach, many surgeons perform an initial diagnostic arthroscopy of the shoulder at the time of the repair to be sure no other coexisting problems are present within the shoulder that could also be addressed at the open procedure. This technique may be performed in an inpatient setting or in an outpatient surgery facility, providing that the patient is comfortable enough to return home the same day.

Standard tendon repair techniques combined with anterior acromioplasty, postoperative limb protection, and monitored physiotherapy can produce consistent and lasting pain relief and improvement in range of motion. Open rotator cuff repair has been known to have excellent outcomes and patient satisfaction since the early 1980s. Romeo et al reported 94% patient satisfaction 4 years after open rotator cuff repair, with lasting relief of pain and improved function. [52]

In another series, Baysal reported that 96% of patients were satisfied or very satisfied with the results of their repair; 78% of patients who were working before surgery returned to work without modification by 1 year postoperatively. For the most part, patient age and size of tear did not influence postoperative range of motion or health-related quality of life. [53]

Arthroscopy

Arthroscopic surgery involves the use of a special camera attached to a long, narrow surgical telescope to visualize the inside of a joint. Working through small incisions about the size of dress-shirt buttonholes, the surgeon can use specially created instruments to repair damaged cartilage, capsule, tendon, and other tissues. The camera transmits the signal to a video monitor for improved visualization and to allow photographic and videographic documentation of the surgical findings and the procedure.

In orthopedic surgery, arthroscopy was first used to treat conditions of the knee. With new technology and refined techniques, arthroscopic surgery has become quite common for treating many knee, shoulder, elbow, wrist, hip, ankle, and foot problems. [54, 55, 56, 57, 58]

Arthroscopic treatment of rotator cuff disease initially consisted of rotator cuff inspection and debridement and arthroscopic acromioplasty. If a repairable rotator cuff tear was discovered, an open or miniopen repair of the tendon was then performed. As surgeons' skills improved and more specialized instrumentation was developed, it became possible to fix relatively small tears using arthroscopic techniques to insert anchors, pass sutures, and tie knots. In current practice, surgeons can now perform shoulder arthroscopy to repair even large rotator cuff tears using these techniques.

Arthroscopic rotator cuff repair (see the images below) is a technically challenging procedure that requires advanced arthroscopic surgical skills, careful preoperative planning, and a stepwise, systematic approach. The procedure may be performed with the patient in a "beach chair" (sitting) or a lateral decubitus (side-lying) position. Usually, the patient is under general anesthesia.

View of large tear from posterior (behind). Socket View of large tear from posterior (behind). Socket is to the right. Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.
Visualizing torn rotator cuff from within the join Visualizing torn rotator cuff from within the joint. The biceps tendon is running vertically on the left. Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.
Motorized burr removing under-surface of acromion. Motorized burr removing under-surface of acromion. Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.
View of large tear from the "50 yard line." Courte View of large tear from the "50 yard line." Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.
The side-to-side stitches begin to close the large The side-to-side stitches begin to close the large tear defect. Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.
An arthroscopic knot-tying instrument is used to p An arthroscopic knot-tying instrument is used to pass tie knots in the suture to secure the repair. Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.
Small metallic anchors (5 mm) with sutures attache Small metallic anchors (5 mm) with sutures attached are then inserted into the humerus at the site desired for tendon reattachment. The anchors are recessed below the surface, so only the suture is visible. Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.
Sutures are anchored with the metallic anchors. Co Sutures are anchored with the metallic anchors. Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.

Small (5-mm) incisions are created in the back, side, and front of the shoulder, and the arthroscope and instruments may be switched between each of these positions as necessary. A complete diagnostic arthroscopy with bursoscopy (inspection of bursa) is initially performed. Care is taken to inspect the biceps tendon within the shoulder, the fibrous ring or labrum that surrounds the glenoid, the capsule and ligaments, the cartilage surfaces of the head and glenoid, and the rotator cuff tendons. Any pathology is addressed only after a complete inspection, so as not to miss any significant findings.

Careful preoperative radiographic evaluation of the shape and size of the acromion, along with a notation of any spurs, serves as a guide for the extent of any acromioplasty (undersurface smoothing) necessary. Because the arthroscope magnifies the structures seen, irregularities in the surface of less than 1 mm can be seen and are removed. The goal is to smooth and flatten the undersurface of the acromion to provide more room for the repair and to relieve pressure from the healing tendon. An overly aggressive acromioplasty must be avoided because excessive removal of the anterior acromion can result in the humeral head sliding forward, up, and out of the socket (anterosuperior subluxation).

The rotator cuff tear is then visualized through the lateral (side) portal from the "50-yard-line view." The size and pattern of the tear are assessed. Any thin or fragmented portions are removed, and the area where the tendon will be reattached to the bone is lightly debrided to encourage new blood vessel ingrowth for healing.

The sutures are once again passed through the tendon and systematically tied. The sutures pull the tendon down to the prepared bone surface, closing the defect. This completes the repair.

At the completion of the procedure, the shoulder is injected with a long-acting local anesthetic to assist with postoperative pain management. Each portal incision is closed with a single nylon stitch and covered with a sterile bandage tape, followed by a dry, sterile dressing. A cryotherapeutic shoulder pad (Cryocuff) is applied to provide postoperative cold therapy. This assists in management of pain and swelling. Finally, a sling (Don Joy UltraSling II) is applied for immobilization and protection. The patient is then taken to the recovery room.

Arthroscopic rotator cuff repair has achieved good-to-excellent results in a large percentage of patients (95% reported in one series), with the results being independent of tear size. U-shaped tears repaired by margin convergence have been shown to have results comparable to those of crescent-shaped tears repaired directly by a tendon-to-bone technique. There is a rapid return to full overhead function after arthroscopic rotator cuff repair (average, 4 months for all tear sizes). A delay between the time of injury and the time of diagnosis, even of several years, is not a contraindication for arthroscopic rotator cuff repair.

The results from one study suggest that patients who underwent arthroscopic rotator cuff repair with or without acromioplasty experienced no difference in function or quality of life. [59]

In a prospective study of 88 patients, Castricini et al showed that augmentation of a double row surgical repair of a small to medium size tear of the rotator cuff with autologous platelet-rich fibrin matrix (PRFM) did not improve the healing. [60]

Prosthetic implants (tissue engineering)

Tissue-engineering techniques are being used to develop therapies for tendon reconstruction. Biologic and synthetic scaffolds can both repair tendon defects and improve healing by allowing for the regeneration of the tendon's natural biologic composition to restore its mechanical capacity. This process can be further enhanced through augmentation methods such as cell seeding, growth factor implantation, and gene therapy.

There are many engineered prosthetic materials being used, but there is no widely accepted treatment for massive irreparable rotator cuff tears. Allografts have been used for repair of large defects but with very little success.

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Activity

Instruct patients to limit activities to ensure rest of the affected shoulder. Refer patients to a physical therapist for conservative treatment and postoperative therapy.

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Long-Term Monitoring

Arrange outpatient follow-up care to an orthopedic surgeon and rehabilitation services to continue conservative therapy. A follow-up reassessment examination 6 weeks after beginning conservative therapy is essential to determine if treatment is successful or if further surgical treatment is needed.

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