Management of rotator cuff tears
- Scott David Martin, MD
Scott David Martin, MD
- Associate Professor of Orthopedic Surgery
- Harvard Medical School
- Tamara L Martin, MD
Tamara L Martin, MD
- Assistant Professor of Orthopedic Surgery
- Harvard Medical School
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
The glenohumeral joint allows for tremendous mobility but is highly susceptible to injury. What is commonly described as the rotator cuff (RC) is a composite of muscles arising from the scapula and inserting onto the humerus. The rotator cuff is crucial to the function and stability of the glenohumeral joint [1-3].
Records of rotator cuff problems extend to the third century BC, when Hippocrates described the relationship of the tendons around the shoulder and noted the injuries associated with these tendons and the variability in their healing . Rotator cuff disease remains a common cause of shoulder pain, accounting for over 4.5 million physician visits per year in the United States alone . While the radiographic imaging, physical therapy, and surgical techniques used to diagnose and manage rotator cuff tears have improved, the indications for surgery remain controversial .
The management of rotator cuff tears will be reviewed here. The diagnosis of rotator cuff tears, diagnosis and management of rotator cuff tendinopathy, and the diagnostic approach to shoulder pain are discussed elsewhere. (See "Presentation and diagnosis of rotator cuff tears" and "Rotator cuff tendinopathy" and "Evaluation of the patient with shoulder complaints".)
TREATMENT OPTIONS AND EVIDENCE
The treatment of rotator cuff tears depends upon several factors, including the duration of symptoms, shoulder dominance, the type of tear (partial versus full thickness), and patient factors such as age, comorbidities, and activity level [5,7-11]. Treatment options include surgical repair and nonoperative management. To date, few randomized trials have been performed that directly compare surgical and nonsurgical management of rotator cuff tears [5,7]. Available trials have not demonstrated a clear benefit to surgery [12-14]. Well-controlled, prospective trials are needed to determine the relative risks and benefits of, and appropriate patients for, each approach.
Two systematic reviews of studies evaluating common interventions for the treatment of rotator cuff tears, including studies comparing different surgical approaches and others comparing surgery with physical therapy, found there was insufficient evidence to support one intervention over another and found the quality of many studies to be poor [7,15]. Therefore, our approach to the management of rotator cuff tears, summarized in the accompanying algorithm, is necessarily based upon observational data, animal studies, evidence extrapolated from successful treatment of non-rotator cuff tendon tears, and our clinical experience (algorithm 1) [8,16-20].
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- TREATMENT OPTIONS AND EVIDENCE
- SURGICAL INDICATIONS FOR ROTATOR CUFF TEARS
- NONOPERATIVE MANAGEMENT
- Physical therapy
- Glucocorticoid injection
- Other nonsurgical treatments
- PARTIAL THICKNESS ROTATOR CUFF TEARS
- ACUTE ROTATOR CUFF TEARS
- CHRONIC, SYMPTOMATIC ROTATOR CUFF TEARS
- SURGICAL MANAGEMENT
- Surgical approaches
- Adjuncts to surgery
- POSTOPERATIVE CARE AND RETURN TO WORK OR SPORTS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS