What is the recommended management for a patient with a high-grade supraspinatus tendon tear, subacromial bursitis, and adhesive capsulitis?

Management of High-Grade Supraspinatus Tendon Tear with Subacromial Bursitis and Adhesive Capsulitis

Initial conservative management is recommended for this patient with a full-thickness supraspinatus tear, subacromial bursitis, and adhesive capsulitis, with surgical intervention indicated if conservative measures fail after 3-6 months. 1

Initial Assessment

• Evaluate pain level, functional limitations, and range of motion deficits
• Assess for limited external rotation (characteristic of adhesive capsulitis) and abduction limitations
• Document baseline function to track progress with treatment

Treatment Algorithm

Phase 1: Conservative Management (0-12 weeks)

1. Pain Management

   • NSAIDs for acute pain relief and anti-inflammatory effects
   • Consider short-term oral corticosteroids for significant pain and inflammation
   • Corticosteroid injections:
     • Intra-articular injection preferred for adhesive capsulitis component
     • Subacromial injection for bursitis component
     • Note: Both injection sites are effective, but subacromial injection may cause fewer fluctuations in blood glucose levels 2

2. Physical Therapy

   • Relative rest to decrease repetitive loading of the damaged supraspinatus tendon
   • Gentle range of motion exercises focusing on:
     • External rotation (critical for adhesive capsulitis)
     • Forward flexion
     • Abduction
   • Eccentric strengthening exercises for tendon healing
   • Avoid aggressive stretching that could worsen the tear

3. Adjunctive Therapies

   • Ice application through wet towel for 10-minute periods to reduce pain and inflammation
   • Consider extracorporeal shock wave therapy (ESWT) for pain relief and tendon healing

Phase 2: Advanced Conservative Management (12-24 weeks)

If inadequate improvement after initial conservative management:

1. Repeat Corticosteroid Injection

   • Consider a second injection if the first provided temporary relief
   • Combine with continued physical therapy for optimal results

2. Hydrodilatation

   • Consider for persistent adhesive capsulitis component
   • Involves distension of the joint capsule with saline and corticosteroid

3. Progressive Rehabilitation

   • Advance to more aggressive stretching and strengthening
   • Focus on rotator cuff strengthening and scapular stabilization

Phase 3: Surgical Management (if needed)

If inadequate improvement after 3-6 months of conservative management:

1. Surgical Options

   • Arthroscopic release for adhesive capsulitis
   • Rotator cuff repair for the supraspinatus tear
   • Subacromial decompression for bursitis

2. Repair Technique

   • For tears ≤3cm: Single-row fixation may be adequate
   • For tears >3cm: Double-row suture bridge fixation shows superior outcomes and lower re-tear rates 3

3. Post-surgical Rehabilitation

   • Early passive range of motion exercises
   • Progressive strengthening as healing allows
   • Return to full activities typically at 4-6 months

Special Considerations

• Diabetic Patients: Higher risk for adhesive capsulitis and may require more aggressive management
• Elderly Patients: Consider comorbidities and functional goals when deciding on surgical intervention
• Occupational Demands: Treatment may need to be accelerated for patients with overhead occupational requirements

Treatment Pitfalls to Avoid

1. Overreliance on passive modalities: While ultrasound therapy is commonly used, evidence suggests it provides little to no benefit when combined with exercise and NSAIDs 4

2. Neglecting the adhesive capsulitis component: Addressing only the rotator cuff tear without treating the frozen shoulder will lead to poor outcomes

3. Aggressive early mobilization: Can worsen the tear and inflammation; gentle, progressive rehabilitation is key

4. Delayed surgical referral: If no significant improvement is seen after 3-6 months of conservative management, surgical consultation should be pursued to prevent further functional decline 1

5. Incomplete surgical treatment: When surgery is indicated, both the capsular release and rotator cuff repair should be addressed simultaneously for optimal outcomes 3

By following this structured approach, patients with this complex shoulder condition can achieve optimal outcomes in terms of pain relief, improved function, and quality of life.