What is the treatment for a patient with tendinosis of the rotator cuff tendons, probable calcific or chronic tendinosis of the supraspinatus tendon, fluid in the subacromial subdeltoid bursa, suspected posterior inferior labral tear, capsulitis, AC (acromioclavicular) joint arthropathy, and enthesopathy of the coracoclavicular ligament?

From the Guidelines

The treatment for a patient with multiple shoulder issues including rotator cuff tendinosis, calcific tendinopathy, subacromial bursitis, labral tear, capsulitis, AC joint arthropathy, and coracoclavicular ligament enthesopathy typically involves a comprehensive approach combining conservative and possibly surgical interventions. Initially, conservative management should include rest, activity modification, and a structured physical therapy program focusing on rotator cuff strengthening, scapular stabilization, and range of motion exercises 3-5 times weekly for 6-8 weeks, as recommended by 1. Pain management with NSAIDs such as ibuprofen 400-800mg three times daily or naproxen 500mg twice daily for 2-3 weeks can reduce inflammation. Corticosteroid injections (40mg methylprednisolone with 4-5ml lidocaine 1%) into the subacromial space or glenohumeral joint may provide temporary relief, though typically limited to 2-3 injections per year, as noted in 1. For calcific tendinopathy, ultrasound-guided needling or extracorporeal shock wave therapy might be beneficial, as suggested by 1. Some key points to consider in the treatment plan include:

• Gentle stretching and mobilization techniques to increase external rotation and abduction, as recommended by 1
• Active range of motion should be increased gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle, as recommended by 1
• Analgesics such as acetaminophen or ibuprofen can be used for pain relief, as recommended by 1
• Injections of botulinum toxin into the subscapularis and pectoralis muscles could be used to treat hemiplegic shoulder pain thought to be related to spasticity, as recommended by 1
• Subacromial corticosteroid injections can be used in patients when pain is thought to be related to injury or inflammation of the subacromial region (rotator cuff or bursa) in the hemiplegic shoulder, as recommended by 1 If conservative measures fail after 3-6 months, surgical options including arthroscopic debridement, labral repair, subacromial decompression, or rotator cuff repair should be considered. The multifaceted nature of this condition requires addressing each component while recognizing their interrelated effects on shoulder biomechanics and function. Some of the key considerations for surgical intervention include:
• Excision of abnormal tendon tissue and performance of longitudinal tenotomies to release areas of scarring and fibrosis, as noted in 1
• Surgical techniques vary by tendinopathy location, as noted in 1
• Referral to an orthopedic surgeon for surgical evaluation may be warranted if pain persists despite a well-managed conservative treatment trial, as suggested by 1

From the Research

Tendinosis of the Rotator Cuff Tendons

• Tendinosis of the rotator cuff tendons without evidence of rotator cuff tear by MRI, and probable calcific or chronic tendinosis of the supraspinatus tendon, can be treated with conservative management, including physical therapy and oral analgesics or anti-inflammatories 2.
• Treatment options may also include corticosteroid injections, although the judicious administration of such injections remains controversial 2.

Fluid in the Subacromial Subdeltoid Bursa

• The presence of fluid in the subacromial subdeltoid bursa may indicate bursitis, which can be treated with conservative management, including physical therapy and oral analgesics or anti-inflammatories 2.
• Corticosteroid injections may also be considered for treatment of bursitis 2.

Suspected Posterior Inferior Labral Tear

• A suspected posterior inferior labral tear can be confirmed with MR arthrography 3, 4.
• Treatment options for labral tears include conservative management with relative rest and non-steroid anti-inflammatory agents, as well as physical therapy, although the effectiveness of physical therapy is controversial 5.
• Surgical treatment, including arthroscopic debridement of labral tears and surgical repair of associated structural problems, may also be necessary 5.

Capsulitis and AC Joint Arthropathy

• Capsulitis and AC joint arthropathy can be treated with conservative management, including physical therapy and oral analgesics or anti-inflammatories 2.
• Treatment options for AC joint arthropathy may also include corticosteroid injections, although the judicious administration of such injections remains controversial 2.
• Surgical options, including open or arthroscopic distal clavicle resection, may be considered for AC joint arthropathy after a minimum of 6 months of unsuccessful conservative treatment 2.

Enthesopathy of the Coracoclavicular Ligament

• Enthesopathy of the coracoclavicular ligament can be treated with conservative management, including physical therapy and oral analgesics or anti-inflammatories 2.
• Treatment options may also include corticosteroid injections, although the judicious administration of such injections remains controversial 2.

Comprehensive Treatment Plan

• A comprehensive treatment plan for a patient with tendinosis of the rotator cuff tendons, probable calcific or chronic tendinosis of the supraspinatus tendon, fluid in the subacromial subdeltoid bursa, suspected posterior inferior labral tear, capsulitis, AC joint arthropathy, and enthesopathy of the coracoclavicular ligament may include a combination of conservative management, physical therapy, and surgical treatment, as necessary 2, 3, 4, 5, 6.