AAOS Board of Directors approves Clinical Practice Guideline for Management of Rotator Cuff Injuries

During their August meeting, the AAOS Board of Directors approved the Evidence-Based Clinical Practice Guideline (CPG) for the Management of Rotator Cuff Injuries. This update to the 2019 guideline evaluates the management of rotator cuff injuries and patient-reported outcomes (PROs).

The guideline excluded all prognostic factor recommendations, as they do not fit the criteria for forming actionable guideline recommendations. Instead, a Prognostic Summary of Evidence was created. This summary does not recommend for or against any specific interventions but offers an overview of the existing evidence.

The evidence led to the development of 14 strong recommendations, which address:

• Management of small to medium tears, high-grade partial-thickness tears, and partial tears
• Use of prolotherapy and biological augmentation
• Bioinductive implants
• Timing of postoperative immobilization
• Marrow stimulation
• Diagnostic approaches through clinical evaluation and imaging
• PROs for long-term nonoperative care
• Outcomes for open versus arthroscopic repair and single-row versus double-row repair

The guideline also presents seven moderate-strength recommendations, which cover:

• Comparisons between operative and nonoperative treatment
• Use of acromioplasty during rotator cuff repair for small to medium full-thickness tears
• Sling use following surgery
• Supervised versus unsupervised physical therapy
• Use of corticosteroid injections
• Dermal allografts
• Strategies for postoperative pain management.

In addition to the 21 recommendations, the guideline includes four limited-strength and four consensus-based “options” to address areas with limited, conflicting, or insufficient evidence. The limited-strength options in this guideline noted that hyaluronic acid injections may be considered as a nonoperative treatment for patients with rotator cuff issues without actual tears. They also advised against the routine use of platelet-rich plasma injections for rotator cuff tendinopathy and partial tears, as well as nonoperative management of full-thickness tears. The options also advise against administering multiple steroid injections for rotator cuff tears.

In the absence of reliable evidence, the work group developed the following consensus options:

• Reverse shoulder arthroplasty may improve PROs in individuals with massive, unrepairable rotator cuff tears, including those with coexisting glenohumeral joint osteoarthritis
• The opinion on surgical treatment versus physical therapy for low- or intermediate-grade partial-thickness tears
• PROs on unrepairable tears without arthropathy

The guideline was developed in collaboration with representatives from the American Shoulder and Elbow Surgeons, the American Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North America, the American Society of Shoulder and Elbow Surgeons, and the American Physical Therapy Association. This CPG and accompanying documentation are available at orthoguidelines.org.