ACC Review: Rotator cuff disorders Part 2 –
Management
Issue 14 November 2004
General points

Simple analgesics (e.g. paracetamol) may provide adequate pain relief. Use
NSAIDs with some caution

Use subacromial corticosteroid injection with caution but avoid where surgery
may be considered as a future treatment option

Supervised exercise may be beneficial but avoid therapeutic ultrasound

If there is no improvement with non-operative management, refer to a
specialist (see ACC Review Rotator Cuff Disorders Part 1 Diagnosis):


within 4-6 weeks, for those with a full thickness tear

at 6 months, for those with tendinosis/partial tears
Refer patients with massive full thickness tears to a specialist immediately
Background
The recommendations for the management of rotator cuff disorders, summarised
below, are based on the recent ACC guideline on the diagnosis and management
of soft tissue shoulder injuries.1 Diagnosis is covered in the ACC Review - Rotator
Cuff Disorders Part 1 – Diagnosis. Rotator cuff disorders include bicep tendon
disorders, which should be managed like tendinosis.
Non-operative Management
The overall evidence to support or refute common interventions for rotator cuff
disorders is unclear [1++]. The ACC guideline reviewed evidence on individual
treatments where available.
Tendinosis / partial tears

Activity modification - People with acute pain can stay active but should
avoid extremely painful movements. Activity can be increased as pain settles.

Analgesia - Simple analgesics (e.g. paracetamol) may provide adequate pain
relief. Non-steroidal anti-inflammatory drugs (NSAIDs) provide short-term
symptomatic relief [1+] but there are possible adverse effects to consider
(e.g. gastrointestinal bleeding, bronchospasm).

Subacromial corticosteroid injection - This provides short-term
symptomatic relief [1++], but should be used with caution as long term harm
has not yet been established. Potential adverse effects include facial flushing,
site infection, post-injection fl are and hyperglycaemia in patients with
diabetes. A Cochrane metaanalysis3 found that the subacromial injection may
be no more effective than NSAIDs. Refer to ACC Review Issue 6, December
2003. The benefits relative to physiotherapy are also unclear [1+]. It is
advisable to document informed consent for this injection.

Rehabilitation - There is some evidence that supervised exercise is
beneficial. There is also good evidence that ultrasound is of no additional
benefit and should not be used2 [1++]. Consider supervised active
rehabilitation for people whose symptoms have failed to settle with activity
modification and analgesics.

Referral - Refer people to an orthopaedic specialist at six months if there is a
poor response to treatment.
Full thickness tears
Non-operative management is appropriate in the acute phase of these tears.

Activity modification and analgesia - The same consideration as for
tendinosis and partial tears applies for these tears.

Subacromial corticosteroid injection - There is insufficient evidence to
determine the harm or benefit [1++]. It may be appropriate as part of longterm management where surgery is not considered as a future treatment
option [4]. Note the discussion and cautions for tendinosis/partial tears.

Rehabilitation – Supervised exercise may be of limited benefit when the
acute symptoms have settled [4].

Referral - Active and physiologically young people who have a full thickness
tear due to significant trauma should be referred to an orthopaedic specialist
within 4-6 weeks if there is a poor response to non-operative management.
Operative management for tears due largely to attrition (minimal trauma) may
not be appropriate in older sedentary people.
Massive tear
Refer people with a massive tear immediately for orthopaedic evaluation. Delay
compromises optimal outcomes for patients.
Operative Management
There is insufficient evidence regarding the benefit of surgical versus nonoperative management [1++]. However, there is consensus that early surgical
management for a massive tear has the most to offer people who are
physiologically young and active [4]. If in doubt, refer for specialist evaluation.
Summary
There is little evidence to support or refute common treatments. If pain is a
problem, use simple analgesia or NSAIDs with caution. Activity modification and
supervised exercise may be of benefit. Subacromial corticosteroid injections
provide short-term symptomatic relief but use with caution and avoid where
surgery may be undertaken. Therapeutic ultrasound is of no additional benefit
and should be avoided. The timeframe to refer to a specialist depends on the
tear. Refer massive tears immediately.
References
1. Accident Compensation Corporation, New Zealand Guidelines Group. The
Diagnosis and Management of Soft Tissue Shoulder Injuries and Related
Disorders. Wellington: ACC, 2004.
2. Kurtais Y et al. Adding ultrasound in the management of soft tissue disorders
of the shoulder: A randomised placebo-controlled trial. Phys Ther
2004;84(4):336-343.
3. Buchbinder R et al. Corticosteroid injections for shoulder pain. Cochrane Database
of Systematic Reviews, 2003 (1)
Evidence Scale
Adapted Scottish Intercollegiate Guidelines Network (SIGN)
Grading System – as used in the guideline. Evidence is graded according to the
quality of the study or studies from which it was drawn.
1++ Meta-analysis (MA)/systematic reviews (SR) of randomised controlled trials
(RCTs) with a very low risk of bias
1+ MA/SR of RCTs with a low risk of bias
1- MA/SR of RCTs with a high risk of bias
2++ SR of case-control/cohort studies with a low risk of bias/moderate
probability of causal relationship
2+ Case-control/cohort studies with a low risk of bias/moderate probability of
causal relationship
2- Case-control/cohort studies with a high risk of bias/significant risk of noncausal
relationship
3 Non-analytic studies
4 Expert opinion (from the literature or the multidisciplinary NZ Guideline
Development Team)
© ACC2004 • Printed November 2004