A<unk>  can be treated operatively or non-operatively. No benefit is seen from early rather than delayed surgery, and many with partial<unk> s and some with complete<unk> s will respond to nonoperative management. Consequently, an individual may begin with nonsurgical management. However, early surgical treatment may be considered in significant (>1 cm – 1.5 cm) acute<unk> s, or in young individuals with full-thickness<unk> s who have a significant risk for the development of irreparable<unk> <unk>  damage.<unk> -cuff surgery appears to result in similar benefits as nonoperative management. As a conservative approach has less complications and is less expensive it is recommended as initial treatment. Non-operative treatment Those with pain but reasonably maintained function are suitable for nonoperative management. This includes medications that provide pain relief such as anti-inflammatory agents, topical pain relievers such as cold packs, and if warranted, subacromial corticosteroid or local anesthetic injection. Topical glyceryl trinitrate appears effective at relieving acute symptoms however, headaches were reported as a side effect. A sling may be offered for short-term comfort, with the understanding that undesirable shoulder stiffness can develop with prolonged immobilization. Early physical therapy may afford pain relief with modalities (e.g. iontophoresis) and help to maintain motion. Ultrasound treatment is not efficacious. As pain decreases, strength deficiencies and biomechanical errors can be corrected. Shock wave therapy has seen widespread use since the 1990s to treat various musculoskeletal disorders including<unk> <unk>  disease, but evidence of its efficacy remains dubious. In a review of 2020, the benefits and harms of shock wave therapy for<unk> <unk>  disease, with or without calcificationcurrently, were investigated. They found low to moderate certainty evidence, that there were very few clinically important benefits of shock wave therapy, and uncertainty regarding its safety. A conservative physical therapy program begins with preliminary rest and restriction from engaging in activities which gave rise to symptoms. Normally, inflammation can usually be controlled within one to two weeks, using a nonsteroidal anti-inflammatory drug and subacromial steroid injections to decrease inflammation, to the point that pain has been significantly decreased to make stretching tolerable. After this short period, rapid stiffening and an increase in pain can result if sufficient stretching has not been implemented. A gentle, passive range-of-motion program should be started to help prevent stiffness and maintain range of motion during this resting period. Stiffness negatively affects the tendon-bone healing process, a critical part of recovery. Stiffness during rehabilitation is related to worse clinical outcomes, so it is important for the patient to understand the importance of a proactive regimen. Strain induced tendon remodeling, which is part of an accelerated rehabilitation protocol, has been shown to speed up the time to return to daily activities. Exercises, for the anterior, inferior, and posterior shoulder, should be part of this program. Codman exercises (giant, pudding-stirring), to "permit the patient to abduct the arm by gravity, the supraspinatus remains relaxed, and no fulcrum is required" are widely used. The use of NSAIDs, hot and cold packs, and physical therapy modalities, such as ultrasound, phonophoresis, or iontophoresis, can be instituted during this stretching period, if effective. Corticosteroid injections are recommended two to three months apart with a maximum of three injections. Multiple injections (four or more) have been shown to compromise the results of<unk> <unk>  surgery which result in weakening of the tendon. Kinesio taping was compared to sham taping and other conservative treatment for the approach of the<unk> <unk>  disease and has uncertain effects in terms of self‐reported pain, function, pain on motion and active range of motion. Rockwood coined the term orthotherapy to describe the program which is aimed at creating an exercise regimen that initially gently improves motion, then gradually improves strength in the shoulder girdle. This program involves a home therapy kit which includes elastic bands of six different colors and strengths, a pulley set, and a three-piece, one-meter-long stick. The program is individually customized. Participants are asked to use their exercise program whether at home, work, or traveling. Surgery<unk>  and surgical repair Benefits of surgery are unclear as of 2019. Several instances when surgery may be recommended include: * 20 to 30-year-old active person with an acute<unk>  and severe functional deficit from a specific event * 30 to 50-year-old person with an acute<unk>  secondary to a specific event * a highly competitive athlete who is primarily involved in overhead or throwing sports These individuals more often benefit from operative treatment because they are willing to tolerate the risks of surgery to return to their preoperative level of function, and have higher likelihood of a successful outcome. Those who do not respond to, or are unsatisfied with, conservative treatment can seek a surgical opinion. The three general surgical approaches are arthroscopic, mini open, and open-surgical repair. In the past, small<unk> s were treated arthroscopically, while larger<unk> s would usually require an open procedure. Advances in arthroscopy now allow arthroscopic repair of even the largest<unk> s, and arthroscopic techniques are now required to mobilize many retracted<unk> s. The results match open surgical techniques, while permitting a more thorough evaluation of the shoulder at time of surgery, increasing the diagnostic value of the procedure, as other conditions may simultaneously cause shoulder pain. Arthroscopic surgery also allows for shorter recovery time although differences in postoperative pain or pain medication use are not seen between arthroscopic- and open-surgery. A 2019 review found that the evidence does not support decompression surgery in those with more than 3 months of shoulder pain without a history of trauma. Even for full-thickness<unk> s, conservative care (i.e., nonsurgical treatment) outcomes are usually reasonably good. If a significant bone spur is present, any of the approaches may include an acromioplasty, a subacromial decompression, as part of the procedure. Subacromial decompression, removal of a small portion of the acromion that overlies the<unk> <unk> , aims to relieve pressure on the<unk> <unk>  in certain conditions and promote healing and recovery. Although subacromial decompression may be beneficial in the management of partial and full-thickness<unk>  repair, it does not repair the<unk>  itself and arthroscopic decompression has more recently been combined with "mini-open" repair of the<unk> <unk> , allowing for the repair of the<unk>  without disruption of the deltoid origin. The results of decompression alone tend to degrade with time, but the combination of repair and decompression appears to be more enduring. Subacromial decompression may not improve pain, function, or quality of life. Repair of a complete, full-thickness<unk>  involves tissue suture. The method currently in favor is to place an anchor in the bone at the natural attachment site, with resuture of torn tendon to the anchor. If tissue quality is poor, mesh (collagen, Artelon, or other degradable material) may be used to reinforce the repair. Repair can be performed through an open incision, again requiring detachment of a portion of the deltoid, while a mini-open technique approaches the<unk>  through a deltoid-splitting approach. The latter may cause less injury to muscle and produce better results. Contemporary techniques now use an all arthroscopic approach. Recovery can take as long as three–six months, with a sling being worn for the first one–six weeks. In the case of partial thickness<unk> s, if surgery is undertaken,<unk>  completion (converting the partial<unk>  to a full<unk>  and then repair, is associated with better early outcomes than transtendinous repairs (where the intact fibres are preserved) and no difference in failure rates. Biceps tenotomy and tenodesis are often performed concomitantly with<unk> <unk>  repair or as separate procedures, and can also cause shoulder pain. Tenodesis, which may be performed as an arthroscopic or open procedure, generally restores pain free motion it the biceps tendon, or attached portion of the labrum, but can cause pain. Tenotomy is a shorter surgery requiring less rehabilitation, that is more often performed in older patients, though after surgery there can be a cosmetic 'popeye sign' visible in thin arms. In a small minority of cases where extensive arthritis has developed, an option is shoulder joint replacement (arthroplasty). Specifically, this is a reverse shoulder replacement, a more constrained form of shoulder arthroplasty that allows the shoulder to function well even in the presence of large full thickness<unk> s. Shoulder Replacement The latest systematic reviews suggests (with low quality evidence) that total shoulder arthroplasty does not provide important benefits over hemiarthroplasty for glenohumeral osteoarthritis and<unk> s. It highlighted the current lack of high-quality evidence and need for randomized controlled trials. Biologics The main goal in biological augmentation is to enhance healing. There are a number of potential options. These include injecting an individual's own stem cells, growth factors or platelet rich plasma (PRP) into the repair site, and installing scaffolds as biological or synthetic supports to maintain tissue contour. A 2014 Cochrane review evaluated PRP and found insufficient evidence to make recommendations. Mesenchymal stem cells have no convincing evidence for their use overall, with quality human trials lacking. The greater tuberosity can also be
Rotator cuff tear
Shoulder impingement syndrome
Biceps tendon rupture
Shoulder problem
Iliotibial band syndrome
Subacromial bursitis
Retrocalcaneal bursitis
Thoracic outlet syndrome