AAOS Updates Clinical Practice Guideline for Managing Rotator Cuff Injuries

The American Academy of Orthopaedic Surgeons (AAOS) has issued an updated Clinical Practice Guideline (CPG) for the Management of Rotator Cuff Injuries, replacing previous instructions from 2019. The updated CPG zeroes in on optimizing the healing environment for patients who suffer from rotator cuff injuries, highlighting biologics and ways to improve surgical repair techniques to reduce re-tears and improve outcomes.

Shoulder disease is a major cause of musculoskeletal disability in the United States, with approximately 4.5 million patient visits annually for shoulder pain. The most common cause of shoulder pain is rotator cuff tears, which can stem from injuries or become more prevalent with age due to natural wear and tear.

“This CPG is unique because of its broad scope, from common issues like shoulder impingement and bursitis to a full spectrum of rotator cuff tears,” said David Kovacevic, M.D., CPG workgroup co-chair. “There are a significant number of updates to this CPG, which include several modifications to the 2019 recommendations and new recommendations based on quality, evidence-based research that has emerged in the past five to six years.” 

The updated CPG includes 21 recommendations (14 strong and seven moderate) and eight options (four limited and four consensus). Options are formulated with low-quality evidence, no evidence, or conflicting evidence. The CPG provides a clear framework for physicians while helping patients better understand treatment choices based on their health history.

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.

Key updated recommendations include:

• Operative Management vs. Nonoperative Management: Moderate evidence suggests that compared to nonoperative management, surgery to repair a torn rotator cuff yields improved patient-reported and functional outcomes in healed repairs. Patients report feeling better than those treated with physical therapy alone or whose repairs did not heal.
• Postoperative Mobilization Timing and Sling Use: During the postoperative healing period from arthroscopic rotator cuff repair, there is a high level of evidence to support that postoperative clinical and patient-reported outcomes are similar for small-to medium-sized full-thickness rotator cuff tears that have been managed with early mobilization (wearing a sling) or delayed mobilization (delayed up to eight weeks).
• Supervised Exercise vs. Unsupervised Exercise: A moderate recommendation states that some patients can discontinue using a sling immediately after surgery and begin moving their arm for daily activities, as prolonged sling use does not appear to hinder recovery, compared to patients who have experienced similar postoperative healing, functional outcomes, and patient-reported outcomes with prolonged sling use. Unsupervised physical therapy exercises (at home) have been shown to offer no additional benefit in pain and function over a well-taught home exercise program, following arthroscopic rotator cuff repair for small tears.
• Corticosteroid Injections for Rotator Cuff Tears: The use of a single injection of corticosteroids with local anesthetic can be considered for short-term improvement in both pain and function for patients with shoulder pain. In patients who cannot tolerate corticosteroids, injectable NSAIDs may be considered.

“In the past, multiple cortisone injections were common; however, evidence now supports using only one shot, especially for patients considering surgery to optimize healing and minimize surgical infection risk,” Dr. Kovacevic stated.

Focus on Biologics

The 2025 CPG contains a strong recommendation for bioinductive implant use during rotator cuff repair, as it may reduce the chances of re-tear and improve patient-reported outcomes. Bioinductive implants facilitate the body’s natural healing process of the tendon by inducing new tissue growth.

“Biologics are often thought of as the last frontier in rotator cuff repair,” said Aaron Chamberlain, M.D., CPG workgroup co-chair. “As surgeons, we’ve utilized different approaches to surgery (open vs. arthroscopic), different constructs (single-row vs. double-row repair), and experimented with the number of anchors and sutures. However, achieving consistent healing remains a challenge in certain cases. That’s why many in the field see biologic augmentation as a promising approach to address the underlying healing deficiencies that persist when repairs fail.”

The use of dermal allografts, a transplant of donated human tissue, was upgraded from a limited to a moderate recommendation, supporting the use of human dermal allografts, as this could lead to better patient-reported outcomes. However, this recommendation does not support the use of a porcine allograft in rotator cuff augmentation.

“Many small-to medium-sized rotator cuff tears heal well without augmentation,” Dr. Chamberlain added. “But for select cases, there’s now moderate-to high-quality evidence to guide the judicious use of these tools. More work is needed to pinpoint exactly which patients will benefit most.”

CPGs are not intended to be stand-alone documents, but rather serve as a point of reference and educational tool for orthopedic surgeons and healthcare professionals managing patients with rotator cuff injuries. CPGs recommend accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol for treatment or diagnosis. Patient care and treatment should always be based on a clinician’s independent medical judgment and the individual patient’s specific clinical circumstances. The guideline is not intended for use as a benefits determination document.
 
The full Clinical Practice Guideline for the Management of Rotator Cuff Injuries is intended for reference by orthopedic surgeons and is available through AAOS’s OrthoGuidelines website and free mobile app. 

With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. AAOS advances musculoskeletal health, providing comprehensive education to help orthopedic surgeons and allied health professionals best treat patients. AAOS is the source for information on bone and joint conditions, treatments, and related musculoskeletal healthcare issues; and it leads the healthcare discussion on advancing quality.