The guidelines established by the New York State Workers Compensation Board are formulated to aid healthcare professionals in delivering appropriate treatment for rotator cuff tears.
Designed for medical practitioners, these Workers Compensation Board guidelines offer assistance in determining the suitable approach for individuals with rotator cuff tears.
It’s crucial to note that these guidelines do not replace clinical judgment or professional experience. The final decision on treatment for rotator cuff tears should be a collaborative one, involving the patient and their healthcare provider in consultation.
Rotator Cuff Tears Classification:
Partial or complete tears of the rotator cuff tendons, primarily the supraspinatus, may result from vascular, traumatic, degenerative factors, or a combination. Tear classification is as follows:
- Small tear: Less than one centimeter
- Medium tear: One to three centimeters
- Large tear: Three to five centimeters
- Massive tear: Greater than five centimeters, often with retraction.
History and Injury Mechanism:
Mechanism of Injury: Identified through sudden shoulder trauma or chronic overuse involving repetitive overhead motion with internal or external rotation.
History may include:
- Partial-thickness tears usually occur in age groups over 30.
- Full-thickness tears can occur in younger age groups.
- Complaints of pain along the anterior, lateral, or posterior glenohumeral joint.
Physical Findings:
Partial-Thickness Tears:
- Pain at the end of the range of motion.
- Full passive range of motion for abduction, elevation, external rotation; attainable internal rotation.
- Limited and painful active range of motion for abduction, external rotation, internal rotation, and forward flexion.
- Painful arc may be present with active elevation.
- Positive pain in resisted tests (abduction, flexion, external rotation, internal rotation, abduction/internal rotation at 90 degrees, abduction/external rotation at 45 degrees).
Full-Thickness Tears:
- Passive and resisted findings similar to partial-thickness tears.
- Severely limited active elevation with evident scapular rotation substitution.
Laboratory Tests:
General Indication:
- Generally not recommended.
Recommended in Select Patients:
- Recommended in select patients where a systemic illness or disease is suspected.
Testing Procedures:
X-ray:
- Recommended in select patients as clinically indicated.
- AP view visualizes humeral head elevation, indicating rotator cuff absence due to tear (long-standing tear).
- Lateral view or axillary view determines anterior or posterior dislocation or the presence of a Hill-Sachs lesion.
- 30 degrees caudally angulated AP view determines spur presence on the anterior/inferior surface of the acromion or the far end of the clavicle.
- Outlet view determines a downwardly tipped acromion.
Adjunctive Testing (Sonography, Arthrography or MRI):
- Recommended in select patients as clinically indicated.
- Indications: Considered when shoulder pain persists despite four to six weeks of non-operative conservative treatment, and the diagnosis is not readily identified by standard radiographic techniques.
- Sonography, arthrography, or MRI may be indicated.
- MRI should be performed sooner (e.g., one to two weeks) in cases with clinical suspicion of a full-thickness rotator cuff tear.
Non-Operative Treatment Procedures:
Indications for Medications:
- Medications, such as nonsteroidal anti-inflammatories and analgesics, would be recommended.
- Acute rotator cuff tear may suggest the need for limited use of narcotics.
Rest and Non-Operative Procedures:
- Relative rest and non-operative treatment procedures include immobilization, therapeutic exercise, alteration of occupation/workstation, thermal treatment, and therapeutic ultrasound.
- Exclusive use of passive modalities should be limited to the first two to three weeks during the acute phase of shoulder discomfort.
- Active therapies should be introduced as soon as appropriate.
Criteria for Surgical Consultation:
- If no clinically significant increase in function is observed for a partial- or full-thickness tear after adequate participation in a rehabilitation program, a surgical consultation is recommended.
- Adequate participation is defined as at least 75% attendance in an active physical therapy program with a minimum of two to three sessions per week for four weeks.
- A physical therapy program relying solely on passive modalities or lacking demonstrated compliance is deemed insufficient.
Benefits of Early Surgical Intervention:
- Early surgical intervention leads to better surgical outcomes due to healthier tissues and often results in less limitation of movement before and after surgery.
Post-Operative Procedures:
Individualized Rehabilitation Program:
- Based on communication among the physician, the surgeon, and therapist.
- Sling or Abduction Splint: Included in the program.
- Gentle Pendulum Exercise: Introduced to prevent adhesions and maintain mobilization.
- Passive Glenohumeral Range of Motion: In flexion and external rotation.
- At Six Weeks Post-Operative: Begin isometrics and activities of daily living (ADL) involvement.
- Active Assisted Range of Motion: Initiated in supine, progressing to sitting.
- At Six to Eight Weeks: Depending on tissue quality, start light resistive exercise.
- Manual Resistive Exercise: To 90 degrees, scapular mobilization exercise with glenohumeral stabilization.
- Scapular Plane Exercise: Included in the program.
- Pool Exercise: Not recommended.
Progressive Resistive Exercise:
- From three to six months, gradually returning to full activity at six to nine months.
- All active non-operative procedures listed in Section E, Therapeutic Procedures: NonOperative, should be considered.
Work Restrictions:
- Should be evaluated every four to six weeks during post-operative recovery and rehabilitation.
- Appropriate written communications to both the patient and employer.
- If progress plateaus, the provider should reevaluate the patient’s condition and make necessary adjustments to the treatment plan.
