Rotator Cuff Tear - Treatment - Non-operative Treatment

Non-operative Treatment

Patients with pain and maintenance of reasonable function are generally treated for pain relief at first. Non-operative treatment of shoulder pain thought to be related to the rotator cuff, or a tear of the rotator cuff, includes oral medications that provide pain relief such as anti-inflammatory medications, topical pain relievers such as cold packs and if warranted a subacromial cortisone/local anesthetic injection to block the pain and start direct instillation of anti-inflammatory treatment. An alternative to needle injection is iontophoresis, a battery powered patch which phoresis the medication to the target tissue. A sling may be offered for comfort for a day or two, with the awareness that the shoulder can become stiff with prolonged immobilization, which is to be avoided. Early physical therapy may afford pain relief with modalities (ex. iontophoresis) and help to maintain motion. Ultrasound treatment is not efficacious. As pain decreases, strength deficiencies and biomechanical errors can be corrected.

A non-operative or conservative physical therapy treatment program begins with preliminary rest and restriction from engaging in the event which caused the injury itself. Frequently the duration of rest is too short. Under normal situations, inflammation can usually be controlled within 1 to 2 weeks, using NSAIDs and subacromial steroid injections to decrease inflammation, to the point that pain has been significantly decreased to make stretching tolerable. After this short period of 1 to 2 weeks rapid stiffening and an increase in pain can result if sufficient stretching has not been implemented.

A gentle, passive range-of-motion program should be started to help prevent stiffness and maintain range of motion during this resting period. Exercises, for the anterior, inferior, and posterior shoulder, should be performed by the patient as a part of the motion program. Codman exercises are renowned sources of motion using the pendulum to "permit the patient to abduct the arm by gravity, the supraspinatus remains relaxed, and no fulcrum is required," which is widely practiced in clinics. The use of NSAIDs; hot and cold packs; and physical therapy modalities, such as ultrasound, phonophoresis, or iontophoresis, can be instituted during this stretching period, if effective. Injections are recommended 2 to 3 months apart with a maximum of three injections. Multiple steroid injections (four or more) have been shown to compromise the results of rotator cuff surgery which result in weakening the tendon in . Before any rotator cuff strengthening can be started, the shoulder must have a full range of motion.

After a full, painless range of motion is achieved, the patient may advance to a gentle strengthening program. Rockwood coined the term orthotherapy to describe this program. The program is aimed at creating an exercise regimen that initially gently improves motion, then gradually improves strength in the shoulder girdle. Each patient is given a home therapy kit, which includes elastic bands of six different colors and strengths; a pulley set; and a three-piece, 1-m-long stick. The program is customized to each individual patient, fitting the needs of the patient and altering when necessary. Patients are asked to do all their home exercise program on their own whether that be at home, at work, or when traveling.

There are several instances in which nonoperative treatment would not be suggested. The first is the 20- to 30-year-old active patient with an acute tear and severe functional deficit from a specific event. The second is the 30- to 50-year-old patient with an acute rotator cuff tear secondary to a specific event. The third instance is the highly competitive athlete who is primarily involved in overhead or throwing sports. These patients need to be treated operatively because rotator cuff repair is necessary for restoration of the normal strength required to return these athletes to the same competitive preoperative level of function. Patients who do not respond or are unsatisfied with conservative treatment should seek operative management.