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 rotator cuff disease, but evidence of its efficacy remains dubious. in a review of 2020, the benefits and harms of shock wave therapy for rotator cuff 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 rotator cuff surgery which result in weakening of the tendon. kinesio taping was compared to sham taping and other conservative treatment for the approach of the rotator cuff 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 rotator cuff tear 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 tear and severe functional deficit from a specific event 30 to 50-year-old person with an acute rotator cuff tear 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 tears were treated arthroscopically, while larger tears would usually require an open procedure. advances in arthroscopy now allow arthroscopic repair of even the largest tears, and arthroscopic techniques are now required to mobilize many retracted tears. 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 rotator cuff tears, 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 rotator cuff, aims to relieve pressure on the rotator cuff in certain conditions and promote healing and recovery. although subacromial decompression may be beneficial in the management of partial and full-thickness tear repair, it does not repair the tear itself and arthroscopic decompression has more recently been combined with "mini-open" repair of the rotator cuff, allowing for the repair of the cuff 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 tear 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 tear 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 tears, if surgery is undertaken, tear completion (converting the partial tear to a full tear) 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 rotator cuff 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 rotator cuff tears. 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 rotator cuff tears. 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 microfractured to create a small blood clot just lateral to the repair site. rehabilitation rehabilitation after surgery consists of three stages. first, the arm is immobilized so that the muscle can heal. second, when appropriate, a therapist assists with passive exercises to regain range of motion. third, the arm is gradually exercised actively, with a goal of regaining and enhancing strength. the empty can and full can exercises are amongst the most effective at isolating and strengthening the supraspinatus. following arthroscopic rotator-cuff repair surgery, individuals need rehabilitation and physical therapy. exercise decreases shoulder pain, strengthens the joint, and improves range of motion. therapists, in conjunction with the surgeon, design exercise regimens specific to the individual and their injury. traditionally, after injury the shoulder is immobilized for six weeks before rehabilitation. however, the appropriate timing and intensity of therapy are subject to debate. most surgeons advocate using the sling for at least six weeks, though others advocate early, aggressive rehabilitation. the latter group favors the use of passive motion, which allows an individual to move the shoulder without physical effort. alternatively, some authorities argue that therapy should be started later and carried out more cautiously. theoretically, that gives tissues time to heal; though there is conflicting data regarding the benefits of early immobilization. a study of rats suggested that it improved the strength of surgical repairs, while research on rabbits produced contrary evidence. individuals with a history of rotator cuff injury, particularly those recovering from tears, are prone to reinjury. rehabbing too soon or too strenuously might increase the risk of retear or failure to heal. however, no research has proven a link between early therapy and the incidence of re-tears. in some studies, those who received earlier and more aggressive therapy reported reduced shoulder pain, less stiffness and better range of motion. other research has shown that accelerated rehab results in better shoulder function. there is consensus amongst orthopaedic surgeons and physical therapists regarding rotator cuff repair rehabilitation protocols. the timing and duration of treatments and exercises are based on biologic and biomedical factors involving the rotator cuff. for approximately two to three weeks following surgery, an individual experiences shoulder pain and swelling; no major therapeutic measures are instituted in this window other than oral pain medicine and ice. those at risk of failure should usually be more conservative with rehabilitations. that is followed by the "proliferative" and "maturation and remodeling" phases of healing, which ensues for the following six to ten weeks. the effect of active or passive motion during any of the phases is unclear, due to conflicting information and a shortage of clinical evidence. gentle physical therapy guided motion is instituted at this phase, only to prevent stiffness of the shoulder; the rotator cuff remains fragile. at three months after surgery, physical therapy intervention changes substantially to focus on scapular mobilization and stretching of the glenohumeral joint. once full passive motion is regained (at usually about four to four and a half months after surgery) strengthening exercises are the focus. the strengthening focuses on the rotator cuff and the upper back/scapular stabilizers. typically at about six months after surgery, most have made a majority of their expected gains. the objective in repairing a rotator cuff is to enable an individual to regain full function. surgeons and therapists analyze outcomes in several ways. based on examinations, they compile scores on tests; some examples are those created by the university of california at los angeles and the american shoulder and elbow surgeons. other outcome measures include the constant score; the simple shoulder test; and the disabilities of the arm, shoulder and hand score. the tests assess range of motion and the degree of shoulder function. due to the conflicting information about the relative benefits of rehab conducted early or later, an individualized approach is necessary. the timing and nature of therapeutic activities are adjusted according to age and tissue integrity of the repair. management is more complex in those who have