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Rotator cuff injury

The right clinical information, right where it's needed

Last updated: Apr 05, 2018


Table of Contents
Summary 3

Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 4

Prevention 5
Secondary prevention 5

Diagnosis 6
Case history 6
Step-by-step diagnostic approach 6
Risk factors 8
History & examination factors 9
Diagnostic tests 10
Differential diagnosis 12
Diagnostic criteria 13

Treatment 15
Step-by-step treatment approach 15
Treatment details overview 18
Treatment options 20
Emerging 33

Follow up 34
Recommendations 34
Complications 34
Prognosis 35

Guidelines 37
Diagnostic guidelines 37
Treatment guidelines 37

Online resources 38

Evidence scores 39

References 40

Images 46

Disclaimer 53
Summary

◊ Common shoulder condition, especially in older and active people. Tears can be symptomatic or
asymptomatic.

◊ Cause of tear can be traumatic or attritional.

◊ Treatment typically based on degree of dysfunction, pain, and quality of tendons and muscles of the
rotator cuff, as well as patient goals and activity level.

◊ In patients with lower functional demands, rehabilitation therapy, including ROM and strengthening
exercises, is critical to return patients to better function. A subacromial injection can alleviate pain.

◊ If higher activity level is desired or the tear is acute, surgical intervention has a better functional result
than non-operative treatment.
Rotator cuff injury Basics

Definition
The spectrum of rotator cuff pathology is one of the most common groups of conditions affecting the adult
shoulder. Tears can occur with trauma (such as with shoulder dislocation in patients >40 years of age) or
BASICS

be attritional (such as with repetitive overhead activity or chronic degeneration). Shoulder impingement,
subacromial bursitis, rotator cuff syndrome, and rotator cuff tendonitis all overlap and can be a continuum of
terminology representing similar pathology.

Epidemiology
Multiple studies have illustrated the direct correlation between incidence of tears and increasing age. In one
study, MRIs performed in 96 asymptomatic patients found a 34% overall prevalence of rotator cuff tears (28%
in patients ≤60 years old and 54% in patients >60 years old).[1] Another study found similar results using
ultrasound in 411 asymptomatic volunteers: 23.4% overall prevalence and 38% prevalence for patients older
than 60 years.[2] No other significant differences or trends in epidemiology are known.

Aetiology
Rotator cuff tears can result from an acute traumatic event, repetitive or vigorous overhead activity (such
as throwing a baseball or painting), or chronic degeneration. They can be considered the final stage of a
continuum of pathology and clinical symptoms referred to as subacromial impingement syndrome. The space
between the undersurface of the acromion and the superior aspect of the humeral head (the impingement
interval) is maximally narrowed in a normal patient with abduction of the shoulder. Impingement can result
from any condition that further narrows this space. Anatomically, this space is affected by the morphology of
the undersurface of the acromion: type I (flat), type II (curved), and type III (curved with an anterior hook).[3]
Extrinsic compression or loss of rotator cuff competency can lead to impingement. For example, cadaveric
studies have described an increased incidence of rotator cuff tears in patients with a type II or III acromion.[3]

Pathophysiology
Tears associated with chronic impingement syndrome start on the bursal surface or within the tendon
substance. A common factor leading to impingement is diminished tendon blood supply due to ageing.
Because of the poor blood supply in the area along the rotator cuff insertion and the critical stresses
placed on this area, attritional and intrinsic tears commonly begin in this location along the supra- and
infraspinatus.[4]

Intrinsic degeneration due to repetitive or vigorous overhead motion preferentially occurs on the articular
side of the cuff due to fibre pattern and blood supply. Instability can result in both macro- and microtrauma
or internal impingement. Accordingly, there is an increased association between rotator cuff tears and labral
disorders, especially superior labrum anterior posterior (SLAP) tears.

It has been suggested that with modern imaging techniques and arthroscopy it may be possible to replace
the non-specific diagnosis of 'impingement' with specific diagnoses of rotator cuff tendinosis, partial tear, and
complete tear, and that these definitions and diagnoses better reflect the pathophysiology of damage to the
rotator cuff.[5]

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Rotator cuff injury Prevention

Secondary prevention
Patients who smoke should be advised to quit, as smoking has been implicated as a factor in failure of
rotator cuff repairs.[81]

PREVENTION

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Rotator cuff injury Diagnosis

Case history
Case history #1
A right-handed 65-year-old man presents after painting a room in his house. He complains of pain in his
right shoulder, which worsens with overhead lifting, and some night pain since the onset of symptoms.
He has no past history of shoulder problems and no other medical conditions. He has no neurological
symptoms and does not complain of weakness.

Case history #2
A 57-year-old woman who is typically sedentary presents complaining of shoulder pain after a trip and
fall onto her outstretched hand. She has no prior history of shoulder injuries. She has pain on the lateral
aspect of her shoulder and weakness with external rotation and forward elevation.

Other presentations
Not all patients present with symptoms related to activity or injury; the onset of symptoms can be
insidious.

Step-by-step diagnostic approach


Definitive diagnosis of rotator cuff tear is made with advanced imaging, although history and examination can
provide a reliable presumptive diagnosis for most tears.

History
The patient's history should include a discussion of any inciting injury, symptom-limiting and pain-eliciting
DIAGNOSIS

activities, vocational requirements, and treatment goals. Shoulder pain is the most common presenting
symptom of rotator cuff tear. Pain is typically aggravated by overhead activities. Patients may also
complain of functional weakness, loss of motion, night pain, and deltoid pain. Acute pain and weakness
may be seen following traumatic rotator cuff rupture.

Physical examination
Examination should document strength of the rotator cuff, signs of impingement, and ROM, especially
elevation and internal and external rotation. Loss of active motion but retention of passive motion is highly
suggestive of a full-thickness rotator cuff tear. A classic and most convincing sign of a full-thickness tear is
weakness with resisted external rotation with the arm at the side and elbow flexed to 90°.

A combination of 4 tests can be used to assess the strength of the rotator cuff.

• The empty-can test evaluates the supraspinatus. The patient raises both arms slightly forward from
the coronal plane of the trunk with thumbs pointing to the floor (as if emptying a can). The examiner
applies pressure to the top of the arms, which the patient attempts to resist. Weakness indicates a
supraspinatus tear.
[Fig-1]

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Rotator cuff injury Diagnosis
• The external rotation test isolates the infraspinatus. With the arm at his or her side and the elbow
flexed to 90°, the patient attempts to externally rotate against resistance supplied by the examiner.
Infraspinatus tears result in pain and weakness.
[Fig-2]
• The lift-off test evaluates the patient's ability to lift the hand away from the small of the back as the
examiner applies resistance. The examiner must ensure that the patient uses the shoulder and arm
rather than wrist and fingers to perform this task. Weakness suggests a subscapularis tear.
[Fig-3]
• For the belly-press test, the patient presses the hand against the umbilicus with the elbow forward
from the trunk. The examiner applies resistance by placing his or her hand between the patient's
hand and abdomen. Inability to maintain elbow anterior to the coronal plane of the trunk suggests a
subscapularis tear.
[Fig-4]
The patient should be actively pushing against the examiner's hand in all these tests. Muscle strength can
be graded on a 0 to 5 scale. Weakness (0/5 to 3/5) suggests a rotator cuff tear. Provocative impingement
tests (Neer and Hawkins) are typically positive with rotator cuff tears. The Neer impingement test can be
performed with the patient seated or standing. The examiner keeps one hand on the patient's scapula to
prevent rotation. As the patient's arm is elevated by the examiner, reproduction of pain is a positive test for
impingement. With the Hawkins test, the patient's arm is positioned in 90° of elevation and the elbow is
bent to 90°. The examiner places an internal rotation force on the patient's arm. Reproduction of pain is a
positive test for impingement.

The presence of pain and limited active motion, or signs of impingement, warrant a diagnostic
subacromial injection with local anaesthetic followed by re-examination. If the rotator cuff is intact,
strength should improve after the pain-relieving injection.

Experts differ on the importance of history and physical examination in diagnosing rotator cuff tear.[8] One
study of 103 patients with tears reported that the characteristics of the pain, the site of tenderness, and
weakness to resisted abduction did not correlate with the presence or severity of the tear, although the
extent of tear did relate to the limitation of shoulder abduction.[9]

DIAGNOSIS
In contradistinction, a retrospective review of 42 patients found a favourable correlation between pre-
operative diagnostic examination and operative findings.[10]

• The size of tear was correctly predicted pre-operatively in 24 patients (57%).


• The clinical assessment of the presence of tear had a sensitivity of 91% and specificity of 75%,
which compares favourably with rates for more invasive diagnostic measures.
A systematic literature search has evaluated sensitivity and specificity of 5 clinical tests. The Hawkins-
Kennedy test, Neer’s sign, and the empty can test proved to be better for ruling out subacromial
impingement (when the examination was normal) rather than ruling it in. The drop arm test and the lift-off
test were more useful at ruling in impingement if the test was positive.[11]
[Fig-5]

[Fig-6]

[Fig-7]

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Rotator cuff injury Diagnosis
Imaging
X-rays are typically used during the initial evaluation to rule out fractures after trauma and to evaluate
other pathology, such as acromioclavicular joint and glenohumeral arthritis. Advanced imaging is
recommended if surgery is being contemplated or if a patient continues to have pain and decreased
motion after 6 weeks of therapy.

MRI is usually the advanced modality of choice, as ultrasound is highly demanding and requires an
experienced ultrasonographer and radiologist for appropriate interpretation. CT scan and CT arthrography
are less commonly used, as further pathology can be more difficult to identify with those imaging
modalities. However, they may be used if other imaging is not available. Sensitivity and specificity of MRI
utilised to detect full-thickness rotator cuff tears are 91% and 97%, respectively.[12]

MRI and ultrasound provide the surgeon with important information to permit better pre-operative planning
and establish realistic treatment expectations. The amount of retraction and atrophy, tear size, number
of tendons involved, and presence of fatty infiltration are all important considerations. In particular, the
sagittal oblique images provide excellent information regarding muscle quality and infiltrate. If available,
magnetic resonance arthrography has been found to be more sensitive and specific than MRI and
ultrasound (which are equivalent) in the diagnosis of rotator cuff tears.[13]

Risk factors
Strong
age >60 years
• Using MRI, one study found a 54% prevalence of tears in asymptomatic patients >60 years of age.[1]
• In another study, ultrasound performed in symptomatic and asymptomatic patients found that the
presence of bilateral tears was highly correlated with age: <48 years old - no tear; 48 to 68 years old
- unilateral tear; >68 years old - bilateral tear.[6] Logistic regression showed a 50% chance of bilateral
tear after age 66 years.
DIAGNOSIS

Weak
hx of repetitive overhead movement
• Repetitive overhead activity, especially in throwing sports, can have long-term effects on the avascular
portion of the rotator cuff. Biomechanics of the thrower's shoulder predispose this area of the cuff to
undergo significant strain with each throw, leading to eventual articular-sided rotator cuff tears and,
occasionally, full-thickness tears.
• An episode of vigorous overhead activity, such as painting and overhead lifting, may incite subacromial
bursitis or impingement symptoms, which can be prodromes to tearing and failure of the rotator cuff.

hx of superior labral tears


• There is an increased association between rotator cuff tears and labral disorders, especially in
superior labrum anterior posterior (SLAP) region.[7]
• This is more common with repetitive overhead arm use, such as weightlifting or throwing.

shoulder injury
• Not all patients will present with an acute or subacute injury; the onset of symptoms can be insidious.

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Rotator cuff injury Diagnosis

History & examination factors


Key diagnostic factors
presence of risk factors (common)
• Key risk factors include age >60 years.

shoulder pain (common)


• Most common presenting complaint for rotator cuff impingement or rotator cuff tear. Pain is typically
aggravated by overhead activities.

shoulder weakness (common)


• Common finding with rotator cuff tears, especially if associated with resisted external rotation or
abduction and elevation.

loss of active ROM (common)


• Highly suggestive of rotator cuff tear.

pain and weakness on external rotation test (common)


• With the arm at his or her side and the elbow flexed to 90°, the patient attempts to externally rotate
against resistance supplied by the examiner. Infraspinatus tears result in pain and weakness.
[Fig-2]

pain and weakness on empty-can test (common)


• The patient raises both arms slightly forward from the coronal plane of the trunk with thumbs pointing
to the floor (as if emptying a can). The examiner applies pressure to the top of the arms, which the
patient attempts to resist. Weakness indicates a supraspinatus tear.
[Fig-1]

Other diagnostic factors

DIAGNOSIS
deltoid pain (common)
• Because the deltoid cannot compensate for a deficient rotator cuff, patients often present with deltoid
fatigue or night-time deltoid pain. The pain often radiates down the arm and into the proximal forearm,
especially at night.

night pain (common)


• Can be related to overuse of the deltoid or can occur as the patient rolls onto the inflamed, irritated
shoulder.

pain and weakness on lift-off test (common)


• Evaluates the patient's ability to lift the hand away from the small of the back as the examiner applies
resistance. The examiner must ensure that the patient uses the shoulder and arm rather than wrist and
fingers to perform this task. Weakness suggests a subscapularis tear.
[Fig-3]

pain and weakness on belly-press test (common)

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Rotator cuff injury Diagnosis
• The patient presses the hand against the umbilicus with the elbow forward from the trunk.
The examiner applies resistance by placing his or her hand between the patient's hand and
abdomen.[14]Inability to maintain elbow anterior to the coronal plane of the trunk suggests a
subscapularis tear.
[Fig-4]

pain on Neer impingement test (common)


• The Neer impingement test can be performed with the patient seated or standing. The examiner keeps
one hand on the patient's scapula to prevent rotation. As the patient's arm is elevated by the examiner,
reproduction of pain is a positive test for impingement.
[Fig-5]

pain on Hawkins impingement test (common)


• The patient's arm is positioned in 90° of elevation and the elbow is bent to 90°. The examiner places
an internal rotation force on the patient's arm. Reproduction of pain is a positive test for impingement.
[Fig-6]

adhesive capsulitis (uncommon)


• Adhesive capsulitis ('frozen shoulder') is defined as the symmetrical loss of both passive and active
motion due to soft-tissue contracture. Loss of passive shoulder motion is uncommon in the presence
of large or massive rotator cuff tear. Stiffness can occur with massive chronic tears as a result of injury
or failure to move the shoulder (prolonged immobilisation).

Diagnostic tests
1st test to order

Test Result
DIAGNOSIS

x-rays usually normal; may


show opacities if
• X-rays are typically normal in an acute, non-traumatic rotator cuff
calcific tendonitis
injury.
present; may show
• In a post-traumatic shoulder, the surgeon must exclude emergent
superior migration of the
or urgent shoulder pathology early. Other trauma from high-energy
mechanisms can include glenoid fracture, greater tuberosity humerus humeral head relative
to the glenoid (large or
fracture, and glenohumeral dislocation.
massive tears); may show
• A standard x-ray series consisting of a true anteroposterior, axillary
pseudosubluxation of
lateral, and outlet/scapular Y views is key to excluding these
the humeral head inferior
associated pathologies.
to the glenoid (acute
massive tears)

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Rotator cuff injury Diagnosis

Other tests to consider

Test Result
diagnostic injection weakness despite pain
relief
• To distinguish true weakness from weakness caused by pain, a pain-
relieving injection of 1% lidocaine into the subacromial bursa should
be followed by retesting of rotator cuff strength.
[Fig-7]
• If strength does not improve, the test suggests rotator cuff tear.
MRI full-/partial-thickness
tears, intrasubstance
• Advanced imaging is recommended if surgery is being contemplated
signal change, fat ty
or if patient continues to have pain and decreased motion after 6
infiltration, retraction,
weeks of therapy.
fluid within subacromial
• MRI is often the modality of choice, as ultrasound is highly operator
bursa, effusion
dependent.
• MRI has 100% sensitivity and 95% specificity in the diagnosis of
complete tears, and consistently predicts the size of tear.[15] Sagittal
oblique images provide excellent information regarding muscle quality
and infiltrate.
• This imaging modality cannot be used if the patient has an implanted
pacemaker or defibrillator.
ultrasound full-/partial-thickness
tears, intrasubstance
• Advanced imaging is recommended if surgery is being contemplated
signal change, fat ty
or if patient continues to have pain and decreased motion after 6
infiltration, retraction,
weeks of therapy.
• Ultrasound is a better modality than MRI if there is prior metal fluid within subacromial
bursa, effusion
hardware, such as suture anchors, present in the humeral head or
glenoid. It also allows a dynamic evaluation of the shoulder, whereas
other imaging modalities are static. However, the diagnostic accuracy
of ultrasound is tremendously operator dependent.
• A study of 100 consecutive cases found ultrasound to have 100%
sensitivity, 85% specificity, and 96% overall accuracy in detecting
full-thickness tears.[16] A subsequent meta-analysis found 95%

DIAGNOSIS
sensitivity and 96% specificity for full-thickness rotator cuff tears, and
72% sensitivity and 93% specificity for partial-thickness tears.[17]
magnetic resonance arthrography full-/partial-thickness
tears, intrasubstance
• Advanced imaging is recommended if surgery is being contemplated
signal change, fat ty
or if patient continues to have pain and decreased motion after 6
infiltration, retraction,
weeks of therapy.
fluid within subacromial
• In a meta-analysis, magnetic resonance arthrography was found to
bursa, effusion
be more sensitive and specific than MRI and ultrasound (which are
equivalent) in the diagnosis of rotator cuff tears.[13]
CT arthrography in full-thickness tears,
fluid within subacromial
• Rarely used. Soft tissue detail is superior with MRI and ultrasound.
bursa connecting to fluid
within the glenohumeral
joint

CT scan in full-thickness tears,


fat ty infiltration,
• Rarely used. Soft tissue detail is superior with MRI and ultrasound. It
retraction, fluid within
can show healing of cuff tears after rotator cuff repair and is good to
subacromial bursa
evaluate muscle quality.

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Rotator cuff injury Diagnosis

Differential diagnosis

Condition Differentiating signs / Differentiating tests


symptoms
Rotator cuff impingement • May have weakness due to • Advanced imaging will not
pain. show rotator cuff tear; may
show inflammation within
tendons or bursa. MRI would
also show some increased
fluid in the subacromial
space and the subdeltoid
bursa, as well as increased
signal.
• If the rotator cuff is intact,
strength should improve after
pain-relieving injection of
anaesthetic.

Rotator cuff tendonitis • May have weakness due to • Advanced imaging will not
pain. show rotator cuff tear; may
show inflammation within
tendons.
• If the rotator cuff is intact,
strength should improve after
pain-relieving injection of
anaesthetic.

Subacromial bursitis • May have weakness due to • Advanced imaging will not
pain. show rotator cuff tear; may
show inflammation within
bursa.
• If the rotator cuff is intact,
strength should improve after
pain-relieving injection of
DIAGNOSIS

anaesthetic.
[Fig-7]

Greater tuberosity • Identical presentation to • X-ray findings of fracture.


humerus fracture acute tear.

Biceps tendonitis • Tenderness at bicipital • Advanced imaging reveals


groove. inflammation surrounding
biceps tendon and
occasionally intrasubstance
signal change.
• Pain in the anterior region of
the shoulder with Speed test
(resisted forward arm flexion
with the elbow extended)
or Yergason test (resisted
forward supination).

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Rotator cuff injury Diagnosis

Condition Differentiating signs / Differentiating tests


symptoms
Glenohumeral • Can co-exist with an acute • X-rays demonstrate typical
osteoarthritis rotator cuff tear, but the changes of osteoarthritis
symptoms for each diagnosis (decreased joint space,
differ. Osteoarthritis results subchondral sclerosis,
in painful glenohumeral subchondral cysts, and
stiffness and limitation of osteophyte formation).
active and passive motion.
In contrast, loss of passive
motion in rotator cuff tear is
uncommon. Degenerative
changes can occur following
untreated chronic massive
rotator cuff, but such
changes are relatively
uncommon immediately
following an acute tear.

Superior labral tear • Weakness is not a • MRI finding of a superior


presenting symptom. labral tear.
• Pain during active
compression test (resisted
arm elevation with the arm
15° adducted, forward flexed
parallel with the floor and
maximal pronation).

Acromioclavicular • Pain over superior aspect • X-rays and MRI demonstrate


arthritis of shoulder, especially at arthritic changes or
acromioclavicular joint. inflammation at the
• Overhead and cross-body acromioclavicular joint.
activities exacerbate pain. • Pain localised to the
acromioclavicular joint during
cross-body test (the patient's

DIAGNOSIS
shoulder is forward flexed
to 90° and adducted across
body).

Diagnostic criteria
Classification of rotator cuff tears can be based on several factors:
• Size of tear (area involved = length x width): tears are considered small if <1 cm^2, medium if 1 to 2
cm^2, large if 2 to 3 cm^2, and massive if >3 cm^2. This is usually based on the anterior to posterior
length of the tear; >5 cm anterior to posterior is considered massive.
• Tendons involved: small and medium-sized tears can be defined as involving 1 tendon, and large
and massive tears as involving ≥2 tendons. Supraspinatus involvement is most common, followed
by infraspinatus, then subscapularis, and least frequently teres minor. Massive tears involving
supraspinatus and infraspinatus together, or supraspinatus and subscapularis together, are not
uncommon.
• Thickness of tear: can be partial thickness (commonly articular-sided but also bursal-sided) or full
thickness.

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Rotator cuff injury Diagnosis
• Acute or chronic: tears are generally considered acute if they are identified within 6 weeks of a
significant known trauma with alteration in shoulder function and associated pain.
DIAGNOSIS

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Rotator cuff injury Treatment

Step-by-step treatment approach


The decision to treat a rotator cuff tear surgically or non-surgically should be based on several factors,
including size of tear, patient age, expected activity level, degree of tendon retraction, and presence of
rotator cuff muscle atrophy and fatty replacement. Earlier surgical intervention may be needed when there is
weakness and substantial functional disability, or if pain continues despite several months of physiotherapy
and medical therapy.[18] [19] [20]

The time since injury is also an important consideration, as the function and appearance of a torn rotator
cuff deteriorate with time. With chronic tears, muscle tissue atrophies and is replaced with fatty tissue,
often termed fatty degeneration. A direct correlation has been described between the extent of the fatty
degeneration of the rotator cuff muscle and the time from injury.[21] Researchers found improved outcomes
and a reduced re-tear rate when repair was performed when fatty degeneration was minimal. In patients over
60 years of age, a favourable outcome can still be expected after repair.[22]

Acute tears (identified within 6 weeks of a significant known


trauma)
Treatment options for acute tears are determined in large part by the size of tear and how symptomatic
the patient is at the time of presentation. Involvement of a physiotherapist is often helpful.

For small tears

• Surgical repair is the first-line treatment for patients with good functional status, especially if
functional demands are high. Options include arthroscopic, mini-open, and open repair. The
primary goal is to provide a pain-free joint with good function. The results of single- versus
double-row repairs are controversial. One meta-analysis found no significant difference in clinical
outcomes.[23] However, another meta-analysis found that double-row repairs have a lower re-
tear rate, a higher American Shoulder and Elbow Surgeons (ASES) score, and a greater range of
motion (internal rotation) compared with single-row repairs, especially in tears >3 cm.[24] A final
meta-analysis found that single-row repairs result in significantly higher re-tear rates compared with
double-row repairs, especially with regard to partial-thickness re-tears. No detectable differences in
outcomes were found.[25] These 3 studies suggest that double-row repairs lead to better healing
rates, but no short-term difference in outcome scores.
• Non-surgical options should be considered first for older and sedentary patients with small
tears with mild loss of ROM and strength, and for patients with low functional demands. Ice,
stretching, and non-steroidal anti-inflammatory drugs (NSAIDs) are the initial treatments. Once
ROM returns (usually at about 4 weeks), toning exercises can be started while stretching continues.
A subacromial corticosteroid injection can be used to control inflammation and reduce pain if
rehabilitation therapy and NSAIDs are ineffective. Meta-analysis suggests that NSAIDs are less
effective than corticosteroid injection at achieving remission in patients with shoulder pain at 4
to 6 weeks after treatment. However, the limited number of studies and small size of each trial
require the interpretations be done with caution.[26]Rehabilitation can resume a few days after the
injection.[27] Surgery should be considered if patient does not respond to medical and rehabilitation
TREATMENT

therapy after 4 to 6 weeks.


[Fig-7]
For medium, large, or massive reparable tears

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Rotator cuff injury Treatment

• Surgical repair is the first-line treatment for patients with good functional status, especially if
functional demands are high. Options include arthroscopic, mini-open, and open repair. The
primary goal is to provide a pain-free joint with good function.
• If patient is older and sedentary, rehabilitation therapy with NSAIDs, ice, stretching, and
exercise1[C]Evidence should be considered before surgery.
For irreparable tears

• Debridement is appropriate for patients with pain as their predominant symptom and lower
demands for shoulder strength. The ideal debridement patient has good deltoid function and an
intact coracoacromial arch. Debridement can be performed with subacromial decompression if
necessary, taking care to preserve the coracoacromial ligament.
• Muscle transfer is appropriate for patients with high demands for shoulder strength. Patients
must be able and willing to perform extensive post-operative rehabilitation. Muscle transfers have
been effective for anterosuperior tears involving the subscapularis and supraspinatus, and for
posterosuperior tears involving the supraspinatus and infraspinatus. Effective donors are the
pectoralis major for anterosuperior tears and the latissimus dorsi for posterosuperior tear.[30] [31]
• Reverse total shoulder arthroplasty is indicated for advanced glenohumeral degenerative changes
secondary to a longstanding rotator cuff tear (cuff tear arthropathy).[32] A standard total shoulder
arthroplasty should not be used in patients with glenohumeral arthritis who have an irreparable
rotator cuff tear.[33]

Chronic tears
Chronic tears should be treated initially with conservative therapies (e.g., ice and stretching, anti-
inflammatory medications, and subacromial injections). Involvement of a physiotherapist is often helpful.
Surgery can be pursued if a tear is intractable to non-operative treatment.

In an older patient with a large chronic tear, the quality of the tissue is often less than optimal for healing.
These patients and others with low functional demands are frequently less interested in powerful
overhead actions and more interested in pain relief with a functional arc of motion. A well-designed, non-
operative rehabilitation programme consisting of stretching and strengthening can attain these goals.[34]
The focus of this rehabilitation is pain control, restoration of full passive motion, and optimisation of rotator
cuff and periscapular muscle strength and co-ordination.

Subacromial corticosteroid injection can be used if symptoms limit rehabilitation exercises. Exercises can
be resumed a few days after injections.

A meta-analysis found that suprascapular nerve block had similar efficacy compared with intra-articular
corticosteroid injection for shoulder pain, and may be used as an adjunct therapy if corticosteroid injection
alone does not provide sustained pain relief.[35]

For patients still in considerable pain after 6 to 12 weeks of therapy, the following surgical options should
be considered on a case-by-case basis:[32] [36]
TREATMENT

• Arthroscopic, mini-open, or open surgical repair: typically considered for patients with both pain and
functional limitations who are anticipating return to an active lifestyle.
• Debridement and subacromial decompression: typically used for patients with minimal functional
limitations but pain as a primary complaint, and for patients with limited functional goals and
expectations.

16 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment
• Hemiarthroplasty, reverse total shoulder arthroplasty, or rotator cuff tear arthroplasty: salvage
procedures for patients who have long-standing tears and develop cuff tear arthropathy.[33]
• Glenohumeral arthrodesis: can be considered as a last resort for intolerable pain but will eliminate
all glenohumeral motion. Rarely used in younger patients but may be considered in those who have
failed reverse total shoulder arthroplasty.
Younger patients are typically treated with a more aggressive approach, with surgery considered earlier in
their treatment course, especially if they complain of weakness.[36]
[Fig-7]

Techniques for surgical repair


In open rotator cuff repairs, the surgeon is constrained to the area visualised within the incision to perform
the repair. Arthroscopy, however, allows the surgeon to approach and assess the tear from multiple
angles to better define the tear and repair it anatomically. The ability to address glenohumeral pathology
at the time of rotator cuff repair is a major benefit. Labral tears, specifically superior labrum anterior
posterior (SLAP) tears, and biceps tendon pathology frequently accompany rotator cuff tears. Concurrent
treatment of these lesions could potentially contribute to an improved post-operative result.

Despite these advantages, open, mini-open, and arthroscopic repair have been found to have similar
outcomes and satisfaction rates.

• Classically described open rotator cuff repair affords a satisfaction rate ranging between 70% and
95%.[37]
• For all-arthroscopic repair, one study reported an 84% satisfaction rate at 2.5 years post-
operation.[38] Another found a 95% satisfaction rate at 3.5 years post-operation, with no significant
differences for outcomes following repair of small or medium tears versus large or massive
tears.[39]
• Newer repair techniques including double-row anchor repairs and trans-osseous equivalent repairs
may have improved healing compared with traditional single row arthroscopic repairs.[40] [41] [42]
[43] However, this higher rate of tendon healing with a double-row repair may not translate into an
improvement in shoulder function, patient satisfaction, or return to work.[44]
• Studies reflect that a subacromial decompression is not necessary in conjunction with rotator cuff
repair to obtain a successful result.[45] [46]
• Platelet-rich plasma (PRP) has been used with favourable but inconsistent results to augment
rotator cuff repair.[47] [48] When the initial tear size was greater than 3 cm in anterior to posterior
length, arthroscopic double row repair plus PRP exhibited decreased re-tear rates compared with
the group without PRP.[49]However, for enlarged tears, even with double row repair, the beneficial
effects of PRP alone are insufficient to compensate for the progressed tissue damage.[50] PRP
may promote healing of small- and medium-sized tears to reduce re-tear rates.[50] However, meta-
analysis does not support the use of platelet rich plasma in the arthroscopic repair of full-thickness
rotator cuff tears over repairs without platelet rich plasma.[51] [52] There is no difference in re-tear
rate between triple-loaded single-row repair, or a suture-bridging double-row repair, when both are
augmented with PRP at 12 months post-surgery.[53]
TREATMENT

• A head-to-head comparison of mini-open versus all-arthroscopic repair reported no significant


difference in outcomes and satisfaction rates (93% mini-open, 91% all-arthroscopic).[54] However,
the early post-operative motion was considerably better for all-arthroscopic repair but motion was
equal at final visit. Thus, patients may be able to perform post-operative rehabilitation sooner after
all-arthroscopic repair than after mini-open repair. Several subsequent studies similarly reported no

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
17
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment
significant difference in outcome between mini-open and all-arthroscopic repairs.[55] [56] [57] [58]
[59] [60]
Subscapularis tears may occur in younger patients, especially as a result of a traumatic injury. Excellent
healing rates (with restoration of function) can be expected after surgery.[61] They may be repaired by
either open or arthroscopic techniques; however, arthroscopic techniques should only be approached
by those with considerable experience of performing arthroscopy. Partial subscapularis tears, usually of
the upper half of the subscapularis, may be easier to repair by arthroscopic means. Surgeons generally
should use whichever approach provides the best and most reliable results in their hands.

Treatment details overview


Consult your local pharmaceutical database for comprehensive drug information including contraindications,
drug interactions, and alternative dosing. ( see Disclaimer )

Acute ( summary )
acute small tear

active, younger patient 1st surgical therapy

plus physiotherapy

sedentary, older patient 1st conservative measures

2nd subacromial corticosteroid injection ±


suprascapular nerve block

3rd surgical repair

plus physiotherapy

acute medium/large/massive
reparable tear

active, younger patient 1st surgical repair

plus physiotherapy

sedentary, older patient 1st rehabilitation and NSAIDs

2nd surgical repair

plus physiotherapy

acute irreparable tear

with weakness and high 1st muscle transfer


functional demands
TREATMENT

plus physiotherapy

with pain and lower 1st debridement


functional demands

plus physiotherapy

18 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Ongoing ( summary )
chronic symptomatic tear

1st conservative measures

2nd subacromial corticosteroid injection ±


suprascapular nerve block

3rd surgical intervention

plus physiotherapy

TREATMENT

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
19
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Treatment options

Acute
acute small tear

active, younger patient 1st surgical therapy

» Acute tears are those identified within 6 weeks


of significant known trauma. Small tears usually
involve a modest loss of ROM and strength.

» Surgical repair is the first-line treatment for


patients with good functional status, especially if
functional demands are high.

» The results of single- versus double-row


repairs are controversial. One meta-analysis
found no significant difference in clinical
outcomes.[23] However, another meta-analysis
found that double-row repairs have a lower
re-tear rate, a higher American Shoulder and
Elbow Surgeons (ASES) score, and a greater
range of motion (internal rotation) compared
with single-row repairs, especially in tears >3
cm.[24] A final meta-analysis found that single-
row repairs result in significantly higher re-
tear rates compared with double-row repairs,
especially with regard to partial-thickness re-
tears. No detectable differences in outcomes
were found.[25] These 3 studies suggest that
double-row repairs lead to better healing rates,
but no short-term difference in outcome scores.

» Options include arthroscopic, mini-open, and


open repair. Surgeons generally should perform
the technique that provides the best and most
reliable results in their hands.

» Subscapularis tears may be repaired by


either open or arthroscopic techniques;
however, arthroscopic approaches should only
be approached by those with considerable
experience in arthroscopy. Partial subscapularis
tears, usually of the upper half of the
subscapularis, may be easier to repair with
arthroscopic means. Excellent healing rates
(with restoration of function) can be expected
after surgery.[61]
plus physiotherapy
TREATMENT

» The typical post-operative course normally


involves a period of formal physiotherapy/
rehabilitation. The length and type of
rehabilitation varies based on the type of
intervention performed.

20 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Acute
» Tear size may be an influential factor in the
rate of re-tearing after early passive ROM is
performed.[62]

» Early motion does not lead to an increased


risk of re-tear compared with 6 weeks of
immobilisation in double-row repairs of smaller
(i.e., <3 cm) tears.[63] Early ROM exercise
accelerated recovery from post-operative
stiffness for patients after arthroscopic rotator
cuff repair, but was likely to result in improper
tendon healing in shoulders with large-sized
tears.[64]

» For subacromial decompression/debridement


this typically involves 6-12 weeks of passive/
active motion, rotator cuff strengthening, and
other physiotherapy modalities. After a rotator
cuff repair the schedule may involve 6-12
months of rehabilitation (e.g., motion, strength,
other physiotherapy modalities) with slower
progression to allow adequate healing of the
repair. After arthroplasty there may be a 4- to 6-
month programme with emphasis on regaining
motion, strength, and function. Following
tendon or muscle transfer procedures there
might typically follow an extensive 12-month
rehabilitation programme with the goal of re-
training muscles to provide shoulder function.

» In more complex surgeries, regional


anaesthesia with an intrascalene block provides
good immediate pain control for the first 12-24
hours. Following this, most patients are initially
placed on narcotic medications for the first
2-4 weeks. Most patients are able to wean off
narcotic pain medications by their second post-
operative visit.
sedentary, older patient 1st conservative measures
Primary options

» diclofenac potassium: 50 mg orally


(immediate-release) three times daily when
required

OR

» ibuprofen: 200-400 mg orally every 4-6


hours when required, maximum 2400 mg/day
TREATMENT

OR

» naproxen: 500 mg orally initially, followed


by 250 mg every 6-8 hours when required,
maximum 1250 mg/day

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
21
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Acute
» Two to 4 weeks of ice and stretch, with non-
steroidal anti-inflammatory drugs (NSAIDs) used
as needed to control pain.

» Meta-analysis suggests that NSAIDs are


less effective than corticosteroid injection at
achieving remission in patients with shoulder
pain at 4 to 6 weeks after treatment. However,
the limited number of studies and small size of
each trial require the interpretations be done with
caution.[26]

» Activity should be modified to reduce overhead


lifting. When ROM returns (usually around 4
weeks), toning should be added while stretching
is continued.
2nd subacromial corticosteroid injection ±
suprascapular nerve block
Primary options

» triamcinolone acetonide: consult specialist


for guidance on dose
-or-
» methylprednisolone acetate: consult
specialist for guidance on dose
--AND--
» lidocaine: consult specialist for guidance on
dose
-and/or-
» bupivacaine: consult specialist for guidance
on dose

» Subacromial corticosteroid injection can


be performed if the patient fails to respond
to rehabilitation therapy and NSAIDs. It is
particularly useful if significant stiffness
and tendonitis symptoms limit rehabilitation
exercises. Rehabilitation can typically resume
after a few days of rest.

» A corticosteroid (e.g., methylprednisolone


or triamcinolone) can be combined with local
anaesthetic (e.g., lidocaine and/or bupivacaine),
allowing a larger volume (8 to 9 mL) to flood the
rotator cuff surface.
[Fig-7]

Regimens vary from institution to institution.

» Contraindications include septic arthritis,


TREATMENT

previous adverse reaction, or systemic infection.

» Corticosteroid injections can be repeated 3


to 4 times per year in a single joint if operative
intervention is not warranted or desired.

22 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Acute
» A meta-analysis found that suprascapular
nerve block had similar efficacy compared with
intra-articular corticosteroid injection for shoulder
pain, and may be used as an adjunct therapy if
corticosteroid injection alone does not provide
sustained pain relief.[35]
3rd surgical repair

» Lack of response to 4-6 weeks of medical


therapy and physiotherapy should prompt
consideration of open, mini-open, or
arthroscopic repair. Surgeons generally should
perform the technique that provides the best and
most reliable results in their hands.

» The results of single- versus double-row


repairs are controversial. One meta-analysis
found no significant difference in clinical
outcomes.[23] However, another meta-analysis
found that double-row repairs have a lower
re-tear rate, a higher American Shoulder and
Elbow Surgeons (ASES) score, and a greater
range of motion (internal rotation) compared
with single-row repairs, especially in tears >3
cm.[24] A final meta-analysis found that single-
row repairs result in significantly higher re-
tear rates compared with double-row repairs,
especially with regard to partial-thickness re-
tears. No detectable differences in outcomes
were found.[25] These three studies suggest that
double-row repairs lead to better healing rates,
but no short-term difference in outcome scores.

» Subscapularis tears may be repaired by


either open or arthroscopic techniques;
however, arthroscopic approaches should only
be approached by those with considerable
experience in arthroscopy. Partial subscapularis
tears, usually of the upper half of the
subscapularis, may be easier to repair with
arthroscopic means. Excellent healing rates
(with restoration of function) can be expected
after surgery.[61]
plus physiotherapy

» The typical post-operative course normally


involves a period of formal physiotherapy/
rehabilitation. The length and type of
rehabilitation varies based on the type of
intervention performed.
TREATMENT

» Tear size may be an influential factor in the


rate of re-tearing after early passive ROM is
performed.[62]

» Early motion does not lead to an increased


risk of re-tear compared with 6 weeks of

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
23
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Acute
immobilisation in double-row repairs of smaller
(i.e., <3 cm) tears.[63] Early ROM exercise
accelerated recovery from post-operative
stiffness for patients after arthroscopic rotator
cuff repair, but was likely to result in improper
tendon healing in shoulders with large-sized
tears.[64]

» For subacromial decompression/debridement


this typically involves 6-12 weeks of passive/
active motion, rotator cuff strengthening, and
other physiotherapy modalities. After a rotator
cuff repair the schedule may involve 6-12
months of rehabilitation (e.g., motion, strength,
other physiotherapy modalities) with slower
progression to allow adequate healing of the
repair. After arthroplasty there may be a 4- to 6-
month programme with emphasis on regaining
motion, strength, and function. Following
tendon or muscle transfer procedures there
might typically follow an extensive 12-month
rehabilitation programme with the goal of re-
training muscles to provide shoulder function.

» In more complex surgeries, regional


anaesthesia with an intrascalene block provides
good immediate pain control for the first 12-24
hours. Following this, most patients are initially
placed on narcotic medications for the first
2-4 weeks. Most patients are able to wean off
narcotic pain medications by their second post-
operative visit.
acute medium/large/massive
reparable tear

active, younger patient 1st surgical repair

» Acute tears are those identified within 6 weeks


of significant known trauma. Medium, large, and
massive tears typically reduce strength by about
half and significantly limit ability to raise arm over
shoulder (although function through the deltoid
or other muscles may be preserved early on).
If injury is on the dominant side or functional
demands are high, consider surgery.

» Options include arthroscopic, mini-open,


and open repair. Surgeons generally should
perform the technique that provides the best and
most reliable results in their hands. However, a
TREATMENT

massive tear or one affecting the subscapularis


may be approached best with an open exposure,
unless the surgeon is an expert arthroscopist.

24 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Acute
» Surgical outcomes are best within 6 weeks
of injury; therefore, early consideration is
warranted.
plus physiotherapy

» The typical post-operative course normally


involves a period of formal physiotherapy/
rehabilitation. The length and type of
rehabilitation varies based on the type of
intervention performed.

» Tear size may be an influential factor in the


rate of re-tearing after early passive ROM is
performed.[62]

» Post-operative care can safely be accelerated


to 4 weeks of immobilisation in medium to
large tears. One study found that 8 weeks of
immobilisation offers no advantages compared
with shorter periods.[65] Early ROM exercise
accelerated recovery from post-operative
stiffness for patients after arthroscopic rotator
cuff repair, but was likely to result in improper
tendon healing in shoulders with large-sized
tears.[64]

» For subacromial decompression/debridement


this typically involves 6-12 weeks of passive/
active motion, rotator cuff strengthening, and
other physiotherapy modalities. After a rotator
cuff repair the schedule may involve 6-12
months of rehabilitation (e.g., motion, strength,
other physiotherapy modalities) with slower
progression to allow adequate healing of the
repair. After arthroplasty there may be a 4- to 6-
month programme with emphasis on regaining
motion, strength, and function. Following
tendon or muscle transfer procedures there
might typically follow an extensive 12-month
rehabilitation programme with the goal of re-
training muscles to provide shoulder function.

» In more complex surgeries, regional


anaesthesia with an intrascalene block provides
good immediate pain control for the first 12-24
hours. Following this, most patients are initially
placed on narcotic medications for the first
2-4 weeks. Most patients are able to wean off
narcotic pain medications by their second post-
operative visit.
sedentary, older patient 1st rehabilitation and NSAIDs
TREATMENT

Primary options

» diclofenac potassium: 50 mg orally


(immediate-release) three times daily when
required

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
25
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Acute
OR

» ibuprofen: 200-400 mg orally every 4-6


hours when required, maximum 2400 mg/day

OR

» naproxen: 500 mg orally initially, followed


by 250 mg every 6-8 hours when required,
maximum 1250 mg/day

» First-line choice should be rehabilitation


therapy in sedentary, older patients with NSAIDs
for pain control as required. Rehabilitation should
be managed by a physiotherapist. If injury is on
the dominant side or functional demands are
high, surgery can be considered subsequently.
2nd surgical repair

» Medium, large, and massive tears typically


reduce strength by about half and significantly
limit ability to raise arm over shoulder (although
function through the deltoid or other muscles
may be preserved early on).

» First-line choice should be rehabilitation


therapy in sedentary, older patients.

» If injury is on the dominant side or functional


demands are high, surgery can be considered
subsequently. Options include arthroscopic,
mini-open, and open repair. Surgeons generally
should perform the technique that provides the
best and most reliable results in their hands.
However, a massive tear or one affecting the
subscapularis may be approached best with an
open exposure, unless the surgeon is an expert
arthroscopist.
plus physiotherapy

» The post-operative course normally involves a


period of formal physiotherapy/rehabilitation. The
length and type of rehabilitation varies based on
the type of intervention performed.

» Tear size may be an influential factor in the


rate of re-tearing after early passive ROM is
performed.[62]

» Post-operative care can safely be accelerated


TREATMENT

to 4 weeks of immobilisation in medium to


large tears. One study found that 8 weeks of
immobilisation offers no advantages compared
with shorter periods.[65] Early ROM exercise
accelerated recovery from post-operative
stiffness for patients after arthroscopic rotator

26 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Acute
cuff repair, but was likely to result in improper
tendon healing in shoulders with large-sized
tears.[64]

» For subacromial decompression/debridement


this typically involves 6-12 weeks of passive/
active motion, rotator cuff strengthening, and
other physiotherapy modalities. After a rotator
cuff repair the schedule may involve 6-12
months of rehabilitation (e.g., motion, strength,
other physiotherapy modalities) with slower
progression to allow adequate healing of the
repair. After arthroplasty there may be a 4- to 6-
month programme with emphasis on regaining
motion, strength, and function. Following
tendon or muscle transfer procedures there
might typically follow an extensive 12-month
rehabilitation programme with the goal of re-
training muscles to provide shoulder function.

» In more complex surgeries, regional


anaesthesia with an intrascalene block provides
good immediate pain control for the first 12-24
hours. Following this, most patients are initially
placed on narcotic medications for the first
2-4 weeks. Most patients are able to wean off
narcotic pain medications by their second post-
operative visit.
acute irreparable tear

with weakness and high 1st muscle transfer


functional demands
» The ideal muscle transfer patient has high
physical demands for shoulder strength.
Weakness is the primary symptom.

» Treatment requires ability to perform extensive


post-operative rehabilitation.
plus physiotherapy

» The post-operative course normally involves a


period of formal physiotherapy/rehabilitation. The
length and type of rehabilitation varies based on
the type of intervention performed.

» Tear size may be an influential factor in the


rate of re-tearing after early passive ROM is
performed.[62]

» For subacromial decompression/debridement


TREATMENT

this typically involves 6-12 weeks of passive/


active motion, rotator cuff strengthening, and
other physiotherapy modalities. After a rotator
cuff repair the schedule may involve 6-12
months of rehabilitation (e.g., motion, strength,
other physiotherapy modalities) with slower

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
27
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Acute
progression to allow adequate healing of the
repair. After arthroplasty there may be a 4- to 6-
month programme with emphasis on regaining
motion, strength, and function. Following
tendon or muscle transfer procedures there
might typically follow an extensive 12-month
rehabilitation programme with the goal of re-
training muscles to provide shoulder function.

» In more complex surgeries, regional


anaesthesia with an intrascalene block provides
good immediate pain control for the first 12-24
hours. Following this, most patients are initially
placed on narcotic medications for the first
2-4 weeks. Most patients are able to wean off
narcotic pain medications by their second post-
operative visit.
with pain and lower 1st debridement
functional demands
» May benefit patients who have lower functional
demands for overhead lifting and whose greatest
functional limitation is pain.

» Ideal debridement candidates have adequate


deltoid function and an intact coracoacromial
arch.

» Subacromial decompression can be added


when there is evidence of an impingement lesion
on the coracoacromial ligament or there is a
spur on the acromion. Care must be taken to
preserve the coracoacromial ligament, because
the coracoacromial arch has been shown to be
important to preserve in the setting of massive
irreparable tears.
plus physiotherapy

» The post-operative course normally involves a


period of formal physiotherapy/rehabilitation. The
length and type of rehabilitation varies based on
the type of intervention performed.

» Tear size may be an influential factor in the


rate of re-tearing after early passive ROM is
performed.[62]

» For subacromial decompression/debridement


this typically involves 6-12 weeks of passive/
active motion, rotator cuff strengthening, and
other physiotherapy modalities. After a rotator
cuff repair the schedule may involve 6-12
TREATMENT

months of rehabilitation (e.g., motion, strength,


other physiotherapy modalities) with slower
progression to allow adequate healing of the
repair. After arthroplasty there may be a 4- to 6-
month programme with emphasis on regaining
motion, strength, and function. Following

28 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury Treatment

Acute
tendon or muscle transfer procedures there
might typically follow an extensive 12-month
rehabilitation programme with the goal of re-
training muscles to provide shoulder function.

» In more complex surgeries, regional


anaesthesia with an intrascalene block provides
good immediate pain control for the first 12-24
hours. Following this, most patients are initially
placed on narcotic medications for the first
2-4 weeks. Most patients are able to wean off
narcotic pain medications by their second post-
operative visit.

Ongoing
chronic symptomatic tear

1st conservative measures


Primary options

» diclofenac potassium: 50 mg orally


(immediate-release) three times daily when
required

OR

» ibuprofen: 200-400 mg orally every 4-6


hours when required, maximum 2400 mg/day

OR

» naproxen: 500 mg orally initially, followed


by 250 mg every 6-8 hours when required,
maximum 1250 mg/day

» A trial of rehabilitation should be considered


before surgery, especially in those with low
functional demands.

» Involves 2 to 4 weeks of ice and stretch, with


NSAIDs used as needed to control pain.

» Meta-analysis suggests that NSAIDs are


less effective than corticosteroid injection at
achieving remission in patients with shoulder
pain at 4 to 6 weeks after treatment. However,
the limited number of studies and small size of
each trial require the interpretations be done with
caution.[26]
TREATMENT

» Activity should be modified to reduce any


overhead lifting. When ROM returns (usually
around 4 weeks), toning should be added while
stretching is continued.

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Rotator cuff injury Treatment

Ongoing
» Goal is to relieve pain and restore a functional
arc of motion, including optimisation of rotator
cuff and periscapular muscle strength and co-
ordination.
2nd subacromial corticosteroid injection ±
suprascapular nerve block
Primary options

» triamcinolone acetonide: consult specialist


for guidance on dose
-or-
» methylprednisolone acetate: consult
specialist for guidance on dose
--AND--
» lidocaine
-and/or-
» bupivacaine

» Can be performed if patient does not respond


to rehabilitation therapy and NSAIDs.

» Useful if tendonitis symptoms limit


rehabilitation exercises; follow with
immobilisation for a few days before resuming
physiotherapy.

» A corticosteroid (e.g., methylprednisolone


or triamcinolone) can be combined with local
anaesthetic (e.g., lidocaine and/or bupivacaine),
allowing a larger volume (8 to 9 mL) to flood the
rotator cuff surface.
[Fig-7]

Regimens vary from institution to institution.

» Contraindications include septic arthritis,


previous adverse reaction, or systemic infection.

» Corticosteroid injections can be repeated 3


to 4 times per year in a single joint if operative
intervention is not warranted or desired.

» A meta-analysis found that suprascapular


nerve block had similar efficacy compared with
intra-articular corticosteroid injection for shoulder
pain, and may be used as an adjunct therapy if
corticosteroid injection alone does not provide
sustained pain relief.[35]
3rd surgical intervention
Primary options
TREATMENT

» arthroscopic, mini-open or open repair:


even with reparable tears, muscle atrophy
and migration of the humeral head portend

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Rotator cuff injury Treatment

Ongoing
poor surgical outcomes and likely re-tear
post-operatively

Secondary options

» debridement and subacromial


decompression: may result in pain relief for
irreparable tears

Tertiary options

» arthroplasty: hemiarthroplasty, reverse


total shoulder arthroplasty, and rotator cuff
tear arthroplasty are salvage procedures for
patients who have long-standing tears and
develop cuff tear arthropathy
May provide pain relief for irreparable tears,
but may fail to restore strength and motion;
good flexion results and abduction have been
described (up to 140°), although external
rotation strength remains limited.

OR

» glenohumeral arthrodesis: a salvage


procedure for irreparable tears, intended for
pain reduction at the expense of permanently
reduced ROM

» Usually considered in cases that remain


refractory to non-operative physical and medical
treatments after 6 to 12 weeks. Pain control is
the primary indication for surgical intervention.
plus physiotherapy

» The typical post-operative course normally


involves a period of formal physiotherapy/
rehabilitation. The length and type of
rehabilitation varies based on the type of
intervention performed.

» Tear size may be an influential factor in the


rate of re-tearing after early passive ROM is
performed.[62]

» For subacromial decompression/debridement


this typically involves 6-12 weeks of passive/
active motion, rotator cuff strengthening, and
other physiotherapy modalities. After a rotator
cuff repair the schedule may involve 6-12
months of rehabilitation (e.g., motion, strength,
TREATMENT

other physiotherapy modalities) with slower


progression to allow adequate healing of the
repair. After arthroplasty there may be a 4- to 6-
month programme with emphasis on regaining
motion, strength, and function. Following
tendon or muscle transfer procedures there

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Rotator cuff injury Treatment

Ongoing
might typically follow an extensive 12-month
rehabilitation programme with the goal of re-
training muscles to provide shoulder function.

» In more complex surgeries, regional


anaesthesia with an intrascalene block provides
good immediate pain control for the first 12-24
hours. Following this, most patients are initially
placed on narcotic medications for the first
2-4 weeks. Most patients are able to wean off
narcotic pain medications by their second post-
operative visit.
TREATMENT

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Rotator cuff injury Treatment

Emerging
Dermal allografts
Augmentation of large to massive rotator cuff repairs with human dermal allografts has been associated with
superior functional and structural outcome compared with conventional repair. Further research is needed
before this approach can be recommended.[66]

Ultrasonophoresis
Ultrasonophoresis (with diclofenac) has been shown to improve ROM, and decrease pain reported by
patients with impingement syndrome, compared with iontophoresis when combined with a suitable exercise
programme.[67]

High-energy extracorporeal shock wave therapy and ultrasound-


guided needling
Minimally invasive treatment options that have been studied for use when first-line conservative treatment
fails in patients with chronic calcific rotator cuff tendinopathy. These therapies have shown excellent clinical
outcomes with no long-term complications or severe adverse effects reported.[68]

Botulinum toxin
Adults with shoulder pain have reported improved pain scores and ROM when treated with botulinum toxin
compared with conventional treatment (e.g., corticosteroid injection).[69]

Reverse shoulder arthroplasty with lateralisation of the center of


rotation
Reverse shoulder arthroplasty (RSA) is an established surgical option that is used for the treatment of cuff
tear arthropathy. One study found that lateralised RSA resulted in significantly improved external rotation in
patients with an intact teres minor muscle compared with non-lateralised RSA.[70]

TREATMENT

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Rotator cuff injury Follow up

Recommendations
Monitoring
FOLLOW UP

• With non-operative management, reasonable follow-up is every 3 months for 1 year, then annually.
• With operative intervention, follow-up typically starts at 1 to 2 weeks with work on passive ROM.
This is usually under the supervision of a physiotherapist. At 6 weeks, work on active ROM can
be started. General strengthening can be initiated at 12 weeks, and sport- or activity-specific
strengthening can be started at 16 to 20 weeks. However, post-operative regimens vary and some
surgeons prefer not to start any motion until 3 to 4 weeks.
• One study showed that providing advice and instructions on a shoulder muscle strengthening
programme to be undertaken at home was no more effective in improving disability and quality of
life after rotator cuff repair than usual post-operative instruction.[80]

Patient instructions
If surgery has been undertaken, advice on which motions are safe, depending on the location of the
rotator cuff repair and the quality of the rotator cuff tendons, is recommended.

Regular follow-up appointments and an exercise programmes can be given to help recover strength and
motion in the shoulder. [American Academy of Orthopaedic Surgeons: rotator cuff tears] Also, advice
should be given on when the patient can return to sports, work, and other activities that involve overhead
arm motions. Return to full activity including work and sports will vary with individual patient factors and
surgical procedures performed. It can be as short as 3 months for patients undergoing subacromial
decompression, or as long as 1 year in patients undergoing massive rotator cuff repair, arthroplasty,
or tendon transfers. The physiotherapist serves as an important advisor in determining suitability for
full activity. The patient should have full passive and active motion and full strength comparable to the
uninjured side prior to reinitiating full activity.

Complications

Complications Timeframe Likelihood


rotator cuff tear arthropathy long term medium

Loss of the normal humeral head depressing function and force-couple of the rotator cuff results in
superior migration of the humeral head with eccentric superior loading of the glenoid cartilage and
progressive arthritis of the glenohumeral joint.

non-steroidal anti-inflammatory drug (NSAID)-related long term low


GI events

NSAIDs cause an increased risk of serious GI adverse events, including bleeding, ulceration, and
perforation of the stomach or intestines, which may be fatal.

Risk increases with longer use, concomitant use with corticosteroids or anticoagulants, smoking, use of
alcohol, older age, and decline in general health status.

Use extreme caution in patients with a prior history of GI bleeding or ulceration, and monitor for adverse
effects.

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Rotator cuff injury Follow up

Complications Timeframe Likelihood


re-rupture of rotator cuff variable high

FOLLOW UP
This is the most common complication associated with repair of the rotator cuff. The re-tear rate has been
found to range between 11.4% and 94%.[79] However, failure of tendon healing does not necessarily
correlate with bad outcome. In one study, repair without evidence of re-tear resulted in an 85% pain-free
rate; however, the presence of a full-thickness re-tear still resulted in a 70% pain-free rate.[73]

post-operative septic arthritis variable low

Risk after arthroscopic repair 0.1% to 0.5%. Risk after open repair 0.5% to 2%.

adhesive capsulitis variable low

Also known as frozen shoulder, this involves loss of both passive and active motion due to soft tissue
contracture that results in mechanical block. It can occur with massive chronic tears as a result of injury
or failure to move the shoulder (prolonged immobilisation) post-injury or post-surgery. Early aggressive
mobilisation is effective in reducing adhesions and preventing adhesive capsulitis. Initial management
consists of physiotherapy for joint mobilisation and capsular stretching. Treatment often requires surgery:
manipulation under anaesthesia, arthroscopic capsular release, or open capsular release. Aggressive
post-operative therapy is required to prevent reformation of adhesions.

Prognosis

Multiple studies have found that surgical repair provides a good functional result and high level of patient
satisfaction. For patients with low functional demands, however, non-surgical rehabilitation is often preferable
and can provide a good outcome as well.

Surgical repair
The primary goal of surgery is to provide a pain-free joint with good function. Arthroscopic, mini-open, and
open surgery all have good patient satisfaction with regard to this goal.[32] [38] [39] [54] [60] Patients can
anticipate a return to normal function by 26 to 52 weeks, depending on extent of tear, associated pathology,
and activity level.

Failure of rotator cuff healing does not typically translate to poor patient satisfaction. Failure rates of healing
up to 94% have been shown after rotator cuff repair, yet excellent and good patient satisfaction across
multiple studies and techniques exceeds 85%.[71] [72] [73] [74] However, one review suggests that some
important differences in clinical outcome are likely to exist between patients with healed and non-healed
rotator cuff repairs. Further study is needed to conclusively define these differences and prognostically
determine clinical outcomes.[75]

Nevertheless, older physiological age, chronicity and retraction of the tear, atrophy, and fatty degeneration of
the cuff muscle have all been implicated with worse results, regardless of the surgical approach. Additionally,
younger, high-demand patients may be faced with limited ability to return to sports and less post-operative
satisfaction.

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Rotator cuff injury Follow up

Non-operative rehabilitation
For patients with low functional demands, a well-designed, non-operative rehabilitation programme
consisting of stretching and strengthening can provide pain relief with a functional arc of motion. Researchers
FOLLOW UP

have reported a 68% excellent/good result using a home-based rehabilitation programme.[34] One
study found that results from a home-based therapy programme compare favourably to those of a formal
occupational therapy programme, with two-thirds of patients in each group having significant improvement
after a 2-month programme.[76]

In patients with subacrominal impingement, home versus supervised exercises were similarly effective
with no significant differences in pain and disability. Supervision of more than the first session of a 6-week
exercise regimen failed to result in significant differences in pain and disability.[77] [78]

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Rotator cuff injury Guidelines

Diagnostic guidelines

North America

Optimizing the management of rotator cuff problems


Published by: American Academy of Orthopaedic Surgeons Last published: 2010

Treatment guidelines

North America

Optimizing the management of rotator cuff problems


Published by: American Academy of Orthopaedic Surgeons Last published: 2010

GUIDELINES
Opioids in the management of chronic non-cancer pain: an update of ASIPP
guidelines
Published by: American Society of Interventional Pain Physicians Last published: 2008

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Rotator cuff injury Online resources

Online resources
1. American Academy of Orthopaedic Surgeons: rotator cuff tears (external link)
ONLINE RESOURCES

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Rotator cuff injury Evidence scores

Evidence scores
1. Improvement assessed by improvement in 1 or more of shoulder impairment, shoulder disability,
pain, patient-perceived effect/benefit, impact on quality of life: there is poor-quality evidence from
observational studies that supports the use of exercise in the management of full-thickness rotator cuff
tears.[28] [29]
Evidence level C: Poor quality observational (cohort) studies or methodologically flawed randomized
controlled trials (RCTs) of <200 participants.

EVIDENCE SCORES

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Rotator cuff injury References

Key articles
• Yamaguchi K, Tetro Am, Blam O, et al. Natural history of asymptomatic rotator cuff tears: a longitudinal
REFERENCES

analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg. 2001;10:199-203.


Abstract

• Beaudreuil J, Dhénain M, Coudane H, Mlika-Cabanne N. Clinical practice guidelines for the surgical
management of rotator cuff tears in adults. Orthop Traumatol Surg Res. 2010;96:175-179. Abstract

• Williams GR Jr, Rockwood CA Jr, Bigliani LU, et al. Rotator cuff tears: why do we repair them? J Bone
Joint Surg. 2004;86:2764-2776. Abstract

• Nho SJ, Shindle MK, Sherman SL, et al. Systematic review of arthroscopic rotator cuff repair and mini-
open rotator cuff repair. J Bone Joint Surg Am. 2007;89(suppl 3):127-136. Abstract

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of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
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of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
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injections for management of tendinopathy: a systematic review of randomised controlled trials.
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evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009;18:138-160. Abstract

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32. Beaudreuil J, Dhénain M, Coudane H, Mlika-Cabanne N. Clinical practice guidelines for the surgical
management of rotator cuff tears in adults. Orthop Traumatol Surg Res. 2010;96:175-179. Abstract

33. Izquierdo R, Voloshin I, Edwards S, et al; American Academy of Orthopedic Surgeons. Treatment of
glenohumeral osteoarthritis. J Am Acad Orthop Surg. 2010;18:375-382. Abstract

34. Williams GR Jr, Rockwood CA Jr, Bigliani LU, et al. Rotator cuff tears: why do we repair them? J Bone
Joint Surg. 2004;86:2764-2776. Abstract

35. Chang KV, Hung CY, Wu WT, et al. Comparison of the effectiveness of suprascapular nerve block
with physical therapy, placebo, and intra-articular injection in management of chronic shoulder pain: a
meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2016;97:1366-1380. Abstract

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42 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
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of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
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structural healing? A systematic review. Am J Sports Med. 2010;38:835-841. Abstract

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full-thickness rotator cuff tears. Arthroscopy. 2011;27:978-985. Abstract

45. Chahal J, Mall N, MacDonald PB, et al. The role of subacromial decompression in patients undergoing
arthroscopic repair of full-thickness tears of the rotator cuff: a systematic review and meta-analysis.
Arthroscopy. 2012;28:720-727. Abstract

46. Pedowitz RA, Yamaguchi K, Ahmad CS, et al. Optimizing the management of rotator cuff problems. J
Am Acad Orthop Surg. 2011;19:368-379. Abstract

47. Longo UG, Loppini M, Berton A, et al. Platelet-rich plasma augmentation in rotator cuff surgery: state
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48. Moraes VY, Lenza M, Tamaoki MJ, et al. Platelet-rich therapies for musculoskeletal soft tissue injuries.
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49. Warth RJ, Dornan GJ, James EW, et al. Clinical and structural outcomes after arthroscopic repair of
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and meta-regression. Arthroscopy. 2015;31:306-320. Abstract

50. Vavken P, Sadoghi P, Palmer M, et al. Platelet-rich plasma reduces retear rates after arthroscopic
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2015;43:3071-3076. Abstract

51. Zhao JG, Zhao L, Jiang YX, et al. Platelet-rich plasma in arthroscopic rotator cuff repair: a meta-
analysis of randomized controlled trials. Arthroscopy. 2015;31:125-135. Abstract

52. Cai YZ, Zhang C, Lin XJ. Efficacy of platelet-rich plasma in arthroscopic repair of full-thickness rotator
cuff tears: a meta-analysis. J Shoulder Elbow Surg. 2015;24:1852-1859. Abstract

53. Barber FA. Triple-loaded single-row versus suture-bridge double-row rotator cuff tendon repair with
platelet-rich plasma fibrin membrane: a randomized controlled trial. Arthroscopy. 2016;32:753-761.
Abstract

54. Severud EL, Ruotolo C, Abbott DD, et al. All-arthroscopic versus mini-open rotator cuff repair: a long-
term retrospective outcome comparison. Arthroscopy. 2003;19:234-238. Abstract

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Rotator cuff injury References
55. Sauerbrey AM, Getz CL, Piancastelli M, et al. Arthroscopic versus mini-open rotator cuff repair: a
comparison of clinical outcome. Arthroscopy. 2005;21:1415-1420. Abstract
REFERENCES

56. Verma NN, Dunn W, Adler RS, et al. All-arthroscopic versus mini-open rotator cuff repair: a
retrospective review with minimum 2 year follow-up. Arthroscopy. 2006;22:587-594. Abstract

57. Coghlan JA, Buchbinder R, Green S, et al. Surgery for rotator cuff disease. Cochrane Database Syst
Rev. 2008;(1):CD005619. Abstract

58. Morse K, Davis AD, Afra R, et al. Arthroscopic versus mini-open rotator cuff repair: a comprehensive
review and meta-analysis. Am J Sports Med. 2008;36:1824-1828. Abstract

59. Nho SJ, Shindle MK, Sherman SL, et al. Systematic review of arthroscopic rotator cuff repair and mini-
open rotator cuff repair. J Bone Joint Surg Am. 2007;89(suppl 3):127-136. Abstract

60. Wang YJ, Song YC, Fang R, et al. Comparison of therapeutic effect of arthroscope versus mini-open
in treating rotator cuff impairment: a meta-analysis. Chin J Evid Based Med. 2010;10:1222-1227.

61. Mall NA, Chahal J, Heard WM, et al. Outcomes of arthroscopic and open surgical repair of isolated
subscapularis tendon tears. Arthroscopy. 2012;28:1306-1314. Abstract

62. Kluczynski MA, Nayyar S, Marzo JM, et al. Early versus delayed passive range of motion after rotator
cuff repair: a systematic review and meta-analysis. Am J Sports Med. 2015;43:2057-2063. Abstract

63. Keener JD, Galatz LM, Stobbs-Cucchi G, et al. Rehabilitation following arthroscopic rotator cuff repair:
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64. Chang KV, Hung CY, Han DS, et al. Early versus delayed passive range of motion exercise for
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65. Koh KH, Lim TK, Shon MS, et al. Effect of immobilization without passive exercise after rotator cuff
repair: randomized clinical trial comparing four and eight weeks of immobilization. J Bone Joint Surg
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66. Ferguson DP, Lewington MR, Smith TD, et al. Graft utilization in the augmentation of large-to-massive
rotator cuff repairs: a systematic review. Am J Sports Med. 2016 Feb 4 [Epub ahead of print]. Abstract

67. García I, Lobo C, López E, et al. Comparative effectiveness of ultrasonophoresis and iontophoresis
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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
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Rotator cuff injury Images

Images
IMAGES

Figure 1: Empty-can test


From the collection of Daniel J. Solomon, MD; used with permission

46 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
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Rotator cuff injury Images

IMAGES
Figure 2: External rotation test
From the collection of Daniel J. Solomon, MD; used with permission

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
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IMAGES Rotator cuff injury Images

Figure 3: Lift-off test


From the collection of Daniel J. Solomon, MD; used with permission

48 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
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Rotator cuff injury Images

IMAGES
Figure 4: Belly-press test
From the collection of Daniel J. Solomon, MD; used with permission

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
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IMAGES Rotator cuff injury Images

Figure 5: Neer impingement test


From the collection of Daniel J. Solomon, MD; used with permission

50 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
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Rotator cuff injury Images

IMAGES
Figure 6: Hawkins impingement test
From the collection of Daniel J. Solomon, MD; used with permission

This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
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IMAGES Rotator cuff injury Images

Figure 7: Subacromial injection. Insert needle just inferior to posterior edge of acromion (x), aiming parallel to
the undersurface of the acromion
From the collection of Daniel J. Solomon, MD; used with permission

52 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 05, 2018.
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Contributors:

// Authors:

Robert J. Gionfriddo, DO
Assistant Director
Department of Medicine, Hartford Hospital, Hartford, CT
DISCLOSURES: RJG declares that he has no competing interests.

Jason Jacob, MD
Assistant Director
Department of Medicine, Hartford Hospital, Hartford, CT
DISCLOSURES: JJ declares that he has no competing interests.

// Acknowledgements:
Dr Robert J. Gionfriddo and Dr Jason Jacob would like to gratefully acknowledge Dr Daniel J. Solomon and
Dr Michael G. Clarke, previous contributors to this monograph. DJS serves as a speaker/course instructor
for Arthrex Inc. and Pacific Medical Inc. and has received honoraria from both companies. MGC declares
that he has no competing interests.

// Peer Reviewers:

Mat thew T. Provencher, MD


Assistant Director
Orthopaedic Shoulder and Sports Surgery, Naval Medical Center San Diego, San Diego, CA
DISCLOSURES: MTP declares that he has no competing interests.

Radhakant Pandey, FRCS, McH(orth)


Consultant in Trauma and Orthopaedics
Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Leicester, UK
DISCLOSURES: RP declares that he has no competing interests.