**5. Injections**

be beneficial because it allows patients to return to their activities of daily living (ADLs) earlier, which could impact aspects such as reducing time away from work and the risk of depression, and improving quality of life (which are associated with poor outcome). Future studies should further investigate this exercise program. Kuhn et al. [55] conducted a multi-centre prospective cohort study of 381 patients who underwent physiotherapy over a 12-week period with a 2-year follow-up. The patients' compliance diaries showed a variation in programs from no therapy to supervision and home, home only, and supervision only. If after 6 weeks the patients were no longer in pain and/or the pain was not affecting their ADLs, then conservative management was successful. Only 9% of patients had surgery after 6 weeks, and a total of 15% of patients had surgery in the first 12 months. After this time, it is deemed that the patient is unlikely to have surgery for RCT. This study was performed only on atraumatic patients only; thus, it is not a reflection of acute traumatic tears. The treatment strategies for these patients were primarily focused on exercise therapy, manual therapy, and heat and cold therapy. However, there were no comparison intervention groups to establish which treatment modality was superior to another, and the therapist could tailor the therapy to the patient's individual presentation, making it difficult to form a conclusion on the most effective aspect of the therapy program. Edwards et al. [56] conducted a review of the current treatment strategies during rehabilitation and concluded the use of anterior deltoid training allows adequate shoulder elevation without upward migration of the humeral head. In this review, the authors also noted the role of the teres minor during external rotation with infraspinatus tears as part of allowing the greater tuberosity of the humerus to clear the acromion during shoulder elevation. Studies that have been researched currently show a general trend of 10–15 repetitions twice a day; however, further research to justify using the prescription recommended for this specific

It appears that the nature of the studies that have been reviewed do not always focus on complete RCTs, which is due to the lack of available evidence on the management of complete RCTs. Therefore, the conclusions in this review are limited. More studies focusing on the surgical and conservative management of complete RCTs need to be completed to delve further

It is unclear if there is a true inflammatory element to rotator cuff tendinopathy and whether non-steroidal anti-inflammatory drugs (NSAIDs) will address this pathophysiology [57]. Currently, no trial or study has been conducted for evaluating NSAIDs as an oral preparation or topically, or other analgesics specifically, for efficacy in the treatment of complete RCTs. Only investigations for shoulder pain in general have been conducted [43]. One metaanalysis of 12 studies concludes that oral NSAIDs can lead to a reduction in pain in individuals with rotator cuff tendinopathy, but there are gastrointestinal or cardiovascular-associated

type of training is warranted.

24 Advances in Shoulder Surgery

**4. Systemic medications**

risks [58].

into the optimal management of this pathology.

The concept of using injections for the treatment of RCTs is not new to the field of orthopaedic surgery, as the practice of using injections such as corticosteroids (CS) and sodium hyaluronate (HA) is common in many practices. CS and HA are both injectable pharmaceutical agents that can be used to decrease pain and stiffness, and they have demonstrated significant impact on improving quality of life for patients with RCTs.

A 2015 in vitro study found that CS injections decreased cell proliferation in rotator cuff tendons, and the resulting strength of these tendons decreased as compared to the strength after HA injections [59]. The same study also conducted an experiment on the effects of CS and HA injections in rats. Like the in vitro study, the animal study found apoptosis in rotator cuff tendons, inhibition of cell proliferation, a delay in tendon healing, and decreased biomechanical strength in CS subjects [59].

Clinical application of these agents is highlighted by a study conducted in 2001, in which 40% of a group with RCTs that received HA injections were satisfied with the durable effects produced at 24-weeks follow-up [60]. In addition, 35% of the group that received CS injections expressed satisfaction over a 5-week period with the injections [60]. Moreover, another study found statistically significant pain relief in groups with HA injections as compared to the control group [61]. In another study, a combination of HA injections and rehabilitation programs led to an improvement of mobility in elderly patients [62]. When using CS injections, no difference was found in groups with different frequencies of injections [63].
