Non-Surgical Treatment in the absence of Full Thickness Tear
We suggest that patients who have rotator cuff-related symptoms in the absence of a full thickness tear be initially treated non-operatively using exercise and/or non-steroidal anti-inflammatory drugs.
MODERATE RECOMMENDATION Rationale
Several Level II studies 59, 60, 23 report the beneficial effects of exercise in decreasing pain and improving function in patients with rotator cuff related symptoms without a full-thickness tear. One study23 reported on 24 patients undergoing an exercise program and noted significantly improved pain scores on the VAS [visual analog scale] after 8 weeks of treatment; post hoc pairwise comparisons of the two groups in this study showed significantly more improvement in the exercise plus manual therapy group using a composite pain measure. Another study59 reported patients had significant improvements in pain at rest, pain at night and Constant-Murley scores after 3 months of a home exercise program. A third study60 randomized patients between a group undergoing exercise and a control group. The group undergoing exercise had statistically significant improvements in pain levels at rest, pain with movement and upper extremity function (DASH-Laborers subscale). No statistically significant difference was reported in patients who participated in supervised and unsupervised exercises.
Our systematic review also identified two Level II studies61, 62 that found better results with non-steroidal anti-inflammatory medications than with placebo in the treatment of rotator cuff-related symptoms in the absence of a full-thickness rotator cuff tear. The first study63 was a prospective, double-blinded placebo-controlled study in which 20 patients treated with oral diclofenac had significant improvements in pain (VAS) and shoulder function at four weeks compared to patients taking a placebo. The second study 64 reported significant improvements in shoulder function VAS scores in 10 patients treated with naproxen compared to 10 patients receiving a placebo.
Our systematic review also identified two Level II studies61, 62 that found better results with non-steroidal anti-inflammatory medications than with placebo in the treatment of rotator cuff-related symptoms in the absence of a full-thickness rotator cuff tear. The first study63 was a prospective, double-blinded placebo-controlled study in which 20 patients treated with oral diclofenac had significant improvements in pain (VAS) and shoulder function at four weeks compared to patients taking a placebo. The second study 64 reported significant improvements in shoulder function VAS scores in 10 patients treated with naproxen compared to 10 patients receiving a placebo.
- (23) Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000;30(3):126-137.
- (59) Walther M, Werner A, Stahlschmidt T, Woelfel R, Gohlke F. The subacromial impingement syndrome of the shoulder treated by conventional physiotherapy, self-training, and a shoulder brace: results of a prospective, randomized study. J Shoulder Elbow Surg 2004;13(4):417-423.
- (60) Lombardi IJr, Magri A, Fleury A, da Silva A, Natour J. Progressive resistance training in patients withshoulder impingement syndrome: a randomized controlled trial. Arthritis & Rheumatism (Arthritis Care & Research) 2008;59(5):615-622.
- (61) Adebajo AO, Nash P, Hazleman BL. A prospective double blind dummy placebo controlled study comparing triamcinolone hexacetonide injection with oral diclofenac 50 mg TDS in patients with rotator cuff tendinitis. J Rheumatol 1990;17(9):1207-1210.
- (62) England S, Farrell AJ, Coppock JS, Struthers G, Bacon PA. Low power laser therapy of shoulder tendonitis. Scand J Rheumatol 1989;18(6):427-431.