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American Academy of Orthopaedic SurgeonsOrthopaedic Surgery2025advanced

Management of Rotator Cuff Injuries

Published by American Academy of Orthopaedic Surgeons · GRADE Evidence to Decision Framework (EtDF)

21Recommendations
591References
2Tables
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Summary

AI-generated

Shoulder disease is a major cause of musculoskeletal disability in the United States, affecting approximately 8% of all American adults. Rotator cuff pathology is the leading cause of shoulder-related disability seen by orthopaedic surgeons, with surgical volume and associated costs on the rise.

rotator cuff injuryAAOSorthopaedic surgeryguidelinesrecommendationsphysical therapyarthroscopic repairacromioplasty

Key Takeaways

  • 1
    Both physical therapy and operative treatment result in significant improvement for small to medium full-thickness rotator cuff tears.
  • 2
    Physical therapy improves patient-reported outcomes, but tear size and muscle atrophy may progress over 5 to 10 years with non-operative management.
  • 3
    Healed rotator cuff repairs show improved patient-reported and functional outcomes compared to physical therapy.
  • 4
    Routine acromioplasty is not suggested for therapeutic benefit as a concomitant treatment with arthroscopic repair.
  • 5
    Early or delayed mobilization (up to 8 weeks) yield similar post-operative outcomes.

Key Recommendations

MANAGEMENT OF SMALL TO MEDIUM TEARS

  • 1

    Both physical therapy and operative treatment result in significant improvement in patient-reported outcomes for patients with symptomatic small to medium full-thickness rotator cuff tears.

    StrongEvidence: HighTreatment

LONG TERM NON-OPERATIVE MANAGEMENT

  • 2

    Patient-reported outcomes (PROs) improve with physical therapy in symptomatic patients with full-thickness rotator cuff tears. However, the rotator cuff tear size, muscle atrophy, and fatty infiltration may progress over 5 to 10 years with non-operative management.

    StrongEvidence: HighManagement

OPERATIVE MANAGEMENT VS NON-OPERATIVE MANAGEMENT

  • 3

    Healed rotator cuff repairs show improved patient-reported and functional outcomes compared to physical therapy and unhealed rotator cuff repairs.

    ModerateEvidence: ModerateTreatment

ACROMIOPLASTY & ROTATOR CUFF REPAIR

  • 4

    The routine use of acromioplasty as a concomitant treatment is not suggested for therapeutic benefit as compared to arthroscopic repair alone for patients with small to medium sized full-thickness rotator cuff tears.

    ModerateEvidence: ModerateSurgical Technique

DIAGNOSIS (CLINICAL EXAMINATION)

  • 5

    Clinical examination can be useful to diagnose or stratify patients with rotator cuff tears; however, a combination of tests will increase diagnostic accuracy compared to any single clinical examination test.

    StrongEvidence: HighDiagnosis

DIAGNOSIS (IMAGING)

  • 6

    MRI, MRA, CT and ultrasound are useful adjuncts to a clinical exam and radiographs for identifying rotator cuff tears.

    StrongEvidence: HighDiagnosis

POST-OP MOBILIZATION TIMING

  • 7

    Postoperative clinical and patient-reported outcomes are similar for small to medium-sized full-thickness rotator cuff tears managed with early mobilization or delayed mobilization (delayed up to 8 weeks) for patients who have undergone arthroscopic rotator cuff repair.

    StrongEvidence: HighRehabilitation

POST-OP SLING USE

  • 8

    Following arthroscopic rotator cuff repair, in certain patient populations, outcomes are not adversely affected with immediate weaning of sling use to allow active ROM for ADLs compared to prolonged sling use because similar post-operative healing, functional outcomes, and patient-reported outcomes are achieved.

    ModerateEvidence: ModerateRehabilitation

SUPERVISED EXERCISE VS UNSUPERVISED EXERCISE

  • 9

    Visits of physical therapy for supervision of exercises that are performed independently at home do not provide greater improvements in pain and function outcomes (at 3 months, up to 1 year) compared to a single session of physical therapist instruction followed by an independent home program in patients following arthroscopic rotator cuff repair for small tears.

    ModerateEvidence: ModerateRehabilitation

CORTICOSTEROID INJECTIONS FOR ROTATOR CUFF TEARS

  • 10

    The use of a single injection of corticosteroids with local anesthetic can be considered for short-term improvement in both pain and function for patients with shoulder pain. In patients who cannot tolerate corticosteroids, injectable NSAIDs may be considered.

    ModerateEvidence: HighTreatment

PROLOTHERAPY

  • 11

    Prolotherapy is not recommended for use in patients with full-thickness rotator cuff tears.

    StrongEvidence: HighTreatment

HIGH-GRADE PARTIAL-THICKNESS ROTATOR CUFF TEARS

  • 12

    Conversion to full-thickness or transtendinous/in-situ repair can be performed in patients that failed conservative management with high-grade partial-thickness rotator cuff tears.

    StrongEvidence: HighSurgical Technique

PARTIAL ROTATOR CUFF TEAR

  • 13

    Debridement or repair of high-grade partial-thickness cuff tears that have failed physical therapy can be performed; however, repair of high-grade partial tears can improve outcomes.

    StrongEvidence: HighSurgical Technique

BIOLOGICAL AUGMENTATION WITH PLATELET DERIVED PRODUCTS

  • 14

    Biological augmentation of rotator cuff repair with platelet-derived products is not recommended for improving patient-reported outcomes; however, limited evidence supports the use of liquid platelet rich plasma (PRP) in the context of decreasing retear rates.

    StrongEvidence: HighTreatment

SINGLE-ROW VS DOUBLE ROW REPAIR – PATIENT REPORTED OUTCOMES

  • 15

    Double row rotator cuff repair constructs are not recommended for improving patient-reported outcomes compared to single row repair constructs.

    StrongEvidence: HighSurgical Technique

SINGLE-ROW VS DOUBLE ROW REPAIR - RETEARS

  • 16

    Double row repairs can result in lower overall retear rates after primary repair and improved patient-reported outcomes in large (>3cm) repairs. However, when evaluating for only full-thickness retears, double row repairs are not significantly favored.

    StrongEvidence: HighSurgical Technique

MARROW STIMULATION

  • 17

    Marrow stimulation at the time of rotator cuff repair does not improve patient-reported outcomes; however, this technique may decrease retear rates in patients with larger tear sizes.

    StrongEvidence: HighSurgical Technique

DERMAL ALLOGRAFTS

  • 18

    The use of human dermal allografts to augment rotator cuff repair can lead to lower retear rates and better patient-reported outcomes, but porcine allograft is not suggested for use in rotator cuff augmentation.

    ModerateEvidence: ModerateSurgical Technique

BIOINDUCTIVE IMPLANTS

  • 19

    The use of bioinductive tendon implants to augment rotator cuff repair or as an alternative to non-augmented repair can lead to lower retear rates and better patient-reported outcomes.

    StrongEvidence: HighSurgical Technique

OPEN VS ARTHROSCOPIC REPAIRS

  • 20

    Evidence shows no difference in long-term (> 1 year) patient-reported outcomes or cuff healing rates between open and arthroscopic repairs; however, arthroscopic-only technique is associated with better short-term improvement in post operative recovery of motion and decreased visual analog scale (VAS) scores.

    StrongEvidence: HighSurgical Technique

POSTOPERATIVE PAIN MANAGEMENT

  • 21

    Multimodal analgesia programs or non-opioid individual modalities can be considered to provide added benefit for postoperative pain management following rotator cuff repair.

    ModerateEvidence: ModerateTreatment

HYALURONIC ACID INJECTIONS FOR ROTATOR CUFF PATHOLOGY

  • 22

    The use of hyaluronic acid injections may be considered in the non-operative management of rotator cuff pathology with no tears.

    LimitedEvidence: HighTreatment

PLATELET RICH PLASMA (PRP) INJECTION IN PARTIAL-THICKNESS TEARS

  • 23

    The routine use of platelet rich plasma is not supported for the treatment of rotator cuff tendinopathy or partial tears.

    LimitedEvidence: HighTreatment

MULTIPLE STEROID INJECTIONS FOR ROTATOR CUFF TEARS

  • 24

    Multiple steroid injections may compromise the integrity of the rotator cuff, which may affect attempts at subsequent repair.

    LimitedEvidence: HighTreatment

PLATELET RICH PLASMA (PRP) INJECTION IN FULL-THICKNESS TEARS

  • 25

    Evidence suggests that the routine use of PRP in the non-operative management of full-thickness rotator cuff tears may not be indicated.

    LimitedEvidence: ModerateTreatment

UNREPAIRABLE TEARS WITHOUT ARTHROPATHY (NON-REVERSE ARTHROPLASTY)

  • 26

    In the absence of reliable evidence, it is the opinion of the workgroup that physical therapy, biceps tenotomy/tenodesis, partial repair, tendon transfer, superior capsular reconstruction, arthroscopic debridement, balloon spacers, graft interposition, or graft augmentation (non-porcine) can improve patient-reported outcomes.

    ConsensusEvidence: Moderate/LowTreatment

MASSIVE UNREPAIRABLE ROTATOR CUFF TEAR WITHOUT ARTHROPATHY (REVERSE ARTHROPLASTY)

  • 27

    In the absence of reliable evidence, it is the opinion of the workgroup that in patients with massive, unrepairable tears and significant functional loss who have failed other treatments, reverse arthroplasty can improve patient-reported outcomes.

    ConsensusEvidence: LowSurgical Technique

MASSIVE UNREPAIRABLE TEARS WITH ARTHROPATHY (REVERSE ARTHROPLASTY)

  • 28

    In the absence of reliable evidence, it is the opinion of the workgroup that after failure of conservative treatment, reverse shoulder arthroplasty for massive unrepairable tears with glenohumeral joint arthritis can improve patient-reported outcomes.

    ConsensusEvidence: LowSurgical Technique

SURGICAL TREATMENT VS. PHYSICAL THERAPY FOR LOW- OR INTERMEDIATE-GRADE PARTIAL-THICKNESS TEARS

  • 29

    In the absence of reliable evidence, it is the opinion of the workgroup that physical therapy can improve outcomes in patients with low-grade or intermediate-grade partial-thickness rotator cuff tears. In patients with persistent pain and functional impairment after appropriate non-operative treatment, surgery can improve outcomes.

    ConsensusEvidence: ConsensusTreatment

Scope & Objectives

Clinical Topic

Management of Rotator Cuff Injuries

Objectives

To help improve treatment based on the current best evidence for the management of rotator cuff injuries.

Target Patient Population

Adults with rotator cuff injuries

Diagnostic Criteria

Clinical examination (utilizing tests such as Bear Hug, Belly Press, Empty Can, etc.) combined with imaging adjuncts (MRI, MRA, CT, ultrasound) are useful to diagnose and identify rotator cuff tears.

Target Providers

Orthopaedic surgeonsPrimary care physiciansGeriatriciansHospital based adult medicine specialistsPhysical therapistsOccupational therapistsNurse practitionersPhysician assistantsEmergency physicians

Patient Criteria & Setting

Therapeutic Area

Musculoskeletal Disease

Guideline Scope

TreatmentDiagnosisManagement

Inclusion Criteria

  • Adults
  • Rotator cuff injuries

Exclusion Criteria

  • Pediatric patients

Care Settings

Various practice settings

Evidence Grading

System: GRADE Evidence to Decision Framework (EtDF)

Evidence Levels

LowEvidence from two or more 'Low' quality studies or evidence from a single 'Moderate' quality study.
HighEvidence from two or more 'High' quality studies.
ModerateEvidence from two or more 'Moderate' quality studies, or evidence from a single 'High' quality study.
Very Low / ConsensusEvidence from one 'Low' quality study or no supporting evidence.

Recommendation Strength

StrongEvidence from two or more 'High' quality studies with consistent findings recommending for or against the intervention. Or Rec is upgraded using the EtD framework.
LimitedEvidence from two or more 'Low' quality studies with consistent findings or evidence from a single 'Moderate' quality study recommending for or against the intervention. Or Rec is downgraded using the EtD framework.
ModerateEvidence from two or more 'Moderate' quality studies with consistent findings or evidence from a single 'High' quality study recommending for or against the intervention. Or Rec is upgraded or downgraded using the EtD framework.
ConsensusEvidence from one 'Low' quality study, no supporting evidence, or Rec is downgraded using the EtD framework. In the absence of sufficient evidence, the guideline workgroup is making a statement based on their clinical opinion.

Safety & Contraindications

Contraindications

  • Prolotherapy for patients with full-thickness rotator cuff tears
  • Porcine allograft for use in rotator cuff augmentation

Monitoring Guidance

Surveillance with serial clinical evaluation and imaging for patients treated non-operatively following a rotator cuff tear may be considered if surgical repair remains a viable option.

Authors & Contributors

American Physical Therapy AssociationAmerican Orthopaedic Society for Sports MedicineAmerican Society of Shoulder and Elbow TherapistsArthroscopy Association of North AmericaAmerican College of Sports Medicine

Guideline Features

Flowcharts includedBased on systematic reviewMultidisciplinary

Learning Context

Difficulty

advanced

Exam Relevance

Bear Hug TestBelly Press TestEmpty Can TestExternal Rotator Lag SignHawkins TestJobe TestLift Off TestNeer TestYocum Test

Learning Paths

Rotator Cuff InjuriesShoulder SurgeryPhysical TherapyArthroscopic RepairSports Medicine