AAOS Guideline on Optimizing the Management of Rotator Cuff Problems
Summary of Recommendations
The following is a summary of the recommendations in the AAOS' clinical practice guideline, Optimizing the Management of Rotator Cuff Problems. This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient and physician.
Full Thickness Tears and Asymptomatic Patients
1. In the absence of reliable evidence, it is the opinion of the work group that surgery not be performed for asymptomatic, full thickness rotator cuff tears.
Strength of Recommendation: Consensus
Full Thickness Tears and Symptomatic Patients
2. Rotator cuff repair is an option for patients with chronic, symptomatic full thickness tears.
Strength of Recommendation: Weak
Rotator Cuff Tears and Exercise
3. a. We cannot recommend for or against exercise programs (supervised or unsupervised) for patients with rotator cuff tears.
Strength of Recommendation: Inconclusive
Rotator Cuff Tears and Corticosteroid Injections
3. b. We cannot recommend for or against subacromial injections for patients with rotator cuff tears.
Strength of Recommendation: Inconclusive
Rotator Cuff Tears and NSAIDS, Activity Modification, Ice, Heat, Iontophoresis, Massage, T.E.N.S., PEMF, and Phonophoresis
3. c. We cannot recommend for or against the use of NSAIDS, activity modification, ice, heat, iontophoresis, massage, Transcutaneous Electrical Nerve Stimulation (TENS), Pulsed Electromagnetic Field (PEMF), or phonophoresis (ultrasound) for nonoperative management of rotator cuff tears.
Strength of Recommendation: Inconclusive
Rotator Cuff Related Symptoms and Exercise or Nonsteroidal Anti-Inflammatory Medication
4. a. 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.
Strength of Recommendation: Moderate
Rotator Cuff Related Symptoms and Corticosteroid Injections or PEMF
4. b. We cannot recommend for or against subacromial corticosteroid injection or Pulsed Electromagnetic Field (PEMF) in the treatment of rotator cuff-related symptoms in the absence of a full thickness tear.
Strength of Recommendation: Inconclusive
Rotator Cuff Related Symptoms and Iontophoresis, Phonophoresis, Transcutaneous electrical nerve stimulation (TENS), ice, heat, massage or activity modification
4. c. We cannot recommend for or against the use of iontophoresis, phonophoresis, transcutaneous Electrical Nerve Stimulation (TENS), ice, heat, massage, or activity modification for patients who have rotator cuff related symptoms in the absence of a full thickness tear.
Strength of Recommendation: Inconclusive
Acute Traumatic Rotator Cuff Tears and Surgery
5. Early surgical repair after acute injury is an option for patients with a rotator cuff tear.
Strength of Recommendation: Weak
Perioperative Interventions –Corticosteroid Injections/NSAIDS
6. We cannot recommend for or against the use of perioperative subacromial corticosteroid injections or non-steroidal anti-inflammatory medications in patients undergoing rotator cuff surgery.
Strength of Recommendation: Inconclusive
Confounding factors – Age, Atrophy/Fatty Degeneration and Worker's Compensation Status
7. a. It is an option for physicians to advise patients that the following factors correlate with less favorable outcomes after rotator cuff surgery:
Strength of Recommendation:
Increasing Age: Weak
MRI Tear Characteristics: Weak
Worker's Compensation Status: Moderate
Confounding Factors - Diabetes, Co-morbidities, Smoking, Infection, and Cervical Disease
7. b. We cannot recommend for or against advising patients in regard to the following factors related to rotator cuff surgery:
Diabetes
Comorbidities
Smoking
Prior Shoulder Infection
Cervical Disease
Surgery - Acromioplasty
8. We suggest that routine acromioplasty is not required at the time of rotator cuff repair.
Strength of Recommendation: Moderate
Surgery – Partial Rotator Cuff Repair, Debridement, or muscle transfers for patients with irreparable rotator cuff tears when surgery is indicated.
9. It is an option to perform partial rotator cuff repair, debridement, or muscle transfers for patients with irreparable rotator cuff tears when surgery is indicated.
Strength of recommendation: Weak
Surgery – Tendon to Bone Healing
10. a. It is an option for surgeons to attempt to achieve tendon to bone healing of the cuff in all patients undergoing rotator cuff repair.
Strength of Recommendation: Weak
Surgery - Suture Anchors and Bone Tunnels
10. b. We cannot recommend for or against the preferential use of suture anchors versus bone tunnels for repair of full thickness rotator cuff tears.
Strength of Recommendation: Inconclusive
Surgery – Arthroscopic, Open, Mini-Open
10. c. We cannot recommend for or against a specific technique (arthroscopic, mini-open or open repair) when surgery is indicated for full thickness rotator cuff tears.
Strength of Recommendation: Inconclusive
Surgery - Non-Crosslinked, Porcine Small Intestine Submucosal Xenografts
11. a. We suggest surgeons not use a non-crosslinked, porcine small intestine submucosal xenograft patch to treat patients with rotator cuff tears.
Strength of Recommendation: Moderate
Surgery - Allografts and Xenografts
11. b. We cannot recommend for or against the use of soft tissue allografts or other xenografts to treat patients with rotator cuff tears.
Strength of Recommendation: Inconclusive
Post-Operative Treatment - Cold Therapy
12. In the absence of reliable evidence, it is the opinion of the work group that local cold therapy is beneficial to relieve pain after rotator cuff surgery.
Strength of Recommendation: Consensus
Post-Operative – sling, shoulder immobilizer, abduction pillow, or abduction brace
13. a. We cannot recommend for or against the preferential use of an abduction pillow versus a standard sling after rotator cuff repair.
Strength of Recommendation: Inconclusive
Post-Operative Rehabilitation – Range of Motion Exercises
13. b. We cannot recommend for or against a specific time frame of shoulder immobilization without range of motion exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive
Postoperative Rehabilitation – Active Resistance Exercises
13. c. We cannot recommend for or against a specific time interval prior to initiation of active resistance exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive
Post-Operative Rehabilitation – Home Based Exercise and Facility Based Rehabilitation
13. d. We cannot recommend for or against home-based exercise programs versus facility-based rehabilitation after rotator cuff surgery.
Strength of Recommendation: Inconclusive
Post-Operative - Infusion Catheters
14. We cannot recommend for or against the use of an indwelling subacromial infusion catheter for pain management after rotator cuff repair.
Strength of Recommendation: Inconclusive