Nonoperative treatment of rotator cuff tears should include anti-inflammatory medication together with subacromial injection of local anesthetics and steroids no more than twice. This treatment should be supported by physical therapy. Physical therapy should aim for maintenance or restoration of free active and passive range of motion and strengthening of the shoulder girdle.

Only a few studies have reported on the outcome of nonoperative treatment of rotator cuff tears. Additionally, most of these suffer a selection bias, as the study population was asymptomatic at the time of decision-making or undesirable for operative treatment. However, Bokor et al. reported on 53 patients treated nonoperatively with rotator cuff tears [20]. After 7 years, 74 % of patients had minor or no pain and 86 % rated their result as satisfactory. Two-thirds of the patients complaining of pain less than 3 months stayed asymptomatic until follow-up. Only 56 % of patients with symptoms for longer than 6 months remained asymptomatic. Patients with moderate symptoms can be managed nonoperatively over several years without significant progression of degenerative structural joint. But there is a risk of progression from a reparable to an irreparable tear within 4 years [21].

Christian Gerber once stated that the ideal tendon repair should have high initial fixation strength, allow minimal gap formation and maintain mechanical stability until solid healing has occurred [22]. Today, several fixation techniques meet these requirements. However, depending on the shape and size of the cuff tear or stage of tendon degeneration, tears reoccur in 11–94 % [3].

Fortunately, even after a re-rupture, the majority of patients experience significant increase of the shoulder scores, predominantly as a result of a reduction in pain.

Several studies demonstrate that clinical outcome and number of re-ruptures are comparable after arthroscopic or mini-open procedures for reconstruction of supraspinatus and subscapularis tears [23–25]. Therefore, the choice of the operative procedure should depend on the surgeon’s skills. Further, there is no evidence for superiority of performing subacromial decompression at the time of rotator cuff reconstruction [26]. An evolution of fixation techniques can be seen in arthroscopic cuff repair. Single-row repair was followed by the development of double-row repair and double-row suture bridge repair techniques. In biomechanical testing, the primary stability of the double-row suture bridge technique seems to be superior in comparison to single-row fixation. They provide a higher load to failure, self-reinforcing characteristics (stronger under load), and better resistance to shear and rotational forces. In clinical studies, the double-row suture bridge repair tends to have higher outcome in shoulder scores and lower re-tear rates compared with single-row reconstruction in small and moderate tears [27–29]. However, in massive rotator-cuff tears, double-row fixation of the tendon provides significantly superior clinical and radiologic outcome [30].