Emergency Department Care
Stabilization with a shoulder sling and use of an ice pack are sufficient for prehospital 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. [2] If NSAIDs alone do not provide adequate pain relief, consider adding acetaminophen to the treatment regimen. [14] Various studies indicate a heterogeneous success rate ranging from 33 to 90%. Steroid injections can reduce pain, but there is no apparent improvement in function.
A randomized, controlled trial by Ranebo et al indicated that physical therapy alone works just as well as surgical repair in the treatment of small rotator cuff supraspinatus tears. Median sagittal tear size in the study was 9.7 mm. The investigators reported that at 12-month follow-up, the median Constant-Murley score for the surgery patients was 83, compared with 78 for the physical therapy group, while the scores for the Western Ontario Rotator Cuff Index were 91% and 86%, respectively. The 2 groups did not differ with regard to the Numerical Rating Scale (for pain). [32]
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 patients with 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%. [33, 34] Findings generally suggest that early treatment precipitates a better outcome than late treatment. Studies have shown that arthroscopic repair is fully comparable to the open surgical technique. [33, 35]
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. [36, 37, 38]
In a study of 196 adult patients with full-thickness rotator cuff tears (112 underwent surgical intervention, and 84 nonoperative management), patient characteristics predictive of surgical treatment included younger age, lower body mass index (BMI), and duration of symptoms less than 1 year. Increasing age, higher BMI, and duration of symptoms longer than 1 year were predictive of nonsurgical treatment. [39]
In a study of rotator cuff tears in patients younger than 40 years (mean, 28 years; range, 16-40 years), most patients typically had a full-thickness tear with an acute traumatic etiology and responded well to both arthroscopic and open rotator cuff repair in terms of pain relief and self-reported outcomes postoperatively. These patients reported high levels of satisfaction and return to preinjury level of play. However, a subgroup of elite throwers with partial-thickness tears from chronic overuse had improved outcomes but suboptimal return to play. [40]
Navarro et al found that outpatient rotator cuff repair led to more unplanned ED and urgent care visits than other common outpatient orthopedic surgical procedures. Of 1306 outpatient rotator cuff repairs, 90 patients returned for ED or urgent care visits (6.9%). [24]
For patients with rotator cuff injury, arrange outpatient follow-up care within 1-2 days 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.
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:
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In patients younger than 60 years
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For full-thickness tear demonstrated clinically or arthrographically
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For failure to improve after 6 weeks of rehabilitation
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If the patient's employment requires shoulder use
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Rotator cuff, normal anatomy.
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Rotator cuff tear, anterior view.
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The acromioclavicular arch and the subacromial bursa.
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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.
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Rotator cuff injury.
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Normal intratendinous signal.
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Partial-thickness tear seen better on angled oblique sagittal views.
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Full-thickness tear.
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Normal plain radiograph of the shoulder in internal, external, and neutral positions.
