From the Guidelines
For a 67-year-old male with controlled diabetes and chronic right shoulder pain showing multiple full-thickness rotator cuff tears with severe muscle atrophy, surgical intervention, specifically a reverse total shoulder arthroplasty, is likely the most appropriate treatment. Given the extensive nature of the tears (supraspinatus full-thickness extending into infraspinatus and nearly complete subscapularis tear) combined with severe muscle atrophy, this approach is recommended over rotator cuff repair alone due to the chronic and irreparable nature of the damage 1.
Before proceeding with surgery, it is essential to optimize the patient's condition. This includes a trial of conservative management, such as physical therapy for 4-6 weeks to maximize shoulder function and range of motion. For pain management, initiating treatment with acetaminophen 1000mg three times daily is a reasonable first step. If necessary, and considering the patient's controlled diabetes and assuming normal kidney function, a short course of an NSAID like meloxicam 7.5mg daily could be added. However, the use of NSAIDs should be cautious and monitored due to potential renal effects in diabetic patients.
Corticosteroid injections could be considered for severe pain flares but should be limited to 1-2 injections due to potential side effects and the lack of long-term benefit in chronic conditions like this 1. The primary goal of these interventions is to improve the patient's condition pre-operatively and post-operatively, enhancing the likelihood of a successful surgical outcome.
Post-surgery rehabilitation will be crucial, involving 3-4 months of structured physical therapy. This should focus on progressive strengthening and range of motion exercises to maximize functional recovery and improve quality of life. The choice of reverse total shoulder arthroplasty is based on its ability to provide better functional outcomes in patients with severe rotator cuff tears and atrophy by altering the shoulder's biomechanics to compensate for the deficient rotator cuff. This approach prioritizes morbidity, mortality, and quality of life, considering the patient's age, comorbidities, and the extent of the rotator cuff damage.
From the Research
Treatment Options for Chronic Right Shoulder Pain
The patient's MRI shows a supraspinatus full-thickness tear extending into the superior infraspinatus, subscapularis full thickness near complete tear, severe muscle atrophy. Considering the patient's age (67 years) and controlled diabetes, the following treatment options can be explored:
- Non-steroidal anti-inflammatory drugs (NSAIDs) may not be the best option as they have a mild effect on relieving symptoms and are potentially deleterious to tissue healing 2
- Paracetamol can be considered as an analgesic of choice for most soft-tissue injury, given its similar efficacy to NSAIDs, lower cost, and lower side-effect profile 2
- Corticosteroid injections may achieve a mild to moderate reduction in pain for up to 6 weeks, but they do not promote tendon healing and should be used with caution 2, 3
- Topical glyceryl trinitrate, aprotinin injections, and prolotherapy are promising new therapeutic treatments for soft-tissue injuries, but more research is needed to confirm their effectiveness 2
Considerations for Muscle Atrophy and Tendon Tears
The patient's severe muscle atrophy and tendon tears require careful consideration:
- Early start of rehabilitation after acute strain injuries is crucial to shortening the time to return to sport, but this may not be directly applicable to the patient's chronic condition 4
- The application of ice, compression, and elevation is well tolerated by patients, but there is no evidence that these methods enhance tissue repair 4
- Surgery may be considered for muscle-tendon reinsertion and reinforcement, but this should be evaluated on a case-by-case basis 5
Palliative Care and Symptom Management
Given the patient's age and underlying health conditions, palliative care and symptom management should be prioritized: