What is the recommended management for a 72-year-old female with supraspinatus tendon tears and calcific tendinopathy in the infraspinatus and teres minor?

Management of Supraspinatus Tendon Tears and Calcific Tendinopathy

For a 72-year-old female with supraspinatus tendon tears and calcific tendinopathy in the infraspinatus and teres minor, conservative management should be the initial treatment approach, with surgery reserved only if conservative measures fail after 3-6 months.

Initial Conservative Management

Pain Management

• NSAIDs: Recommended for short-term pain relief, though they don't affect long-term outcomes 1
• Cryotherapy: Apply ice through a wet towel for 10-minute periods to reduce pain and swelling 1
• Topical NSAIDs: Consider as an alternative to oral NSAIDs to minimize gastrointestinal side effects 1

Physical Therapy

• Relative Rest: Reduce activities that aggravate symptoms while maintaining some level of activity to prevent deconditioning 1
• Eccentric Strengthening Exercises: Focus on controlled lengthening of the rotator cuff muscles to promote tendon healing 1, 2
• Range of Motion Exercises: Gradually restore shoulder mobility while respecting pain limits 1, 3
• Scapulothoracic Strengthening: Address potential muscle imbalances that may contribute to impingement 3

Additional Conservative Interventions

• Corticosteroid Injections: May provide better acute pain relief than NSAIDs but don't improve long-term outcomes 1
  • Caution: Injections directly into the tendon substance should be avoided as they may inhibit healing and reduce tensile strength 1
• Phonophoresis: Consider for calcific tendinopathy specifically, as case studies have shown resolution of calcific deposits 4
• Extracorporeal Shock Wave Therapy (ESWT): Safe and potentially effective for chronic tendinopathies, though expensive 1

Monitoring and Progression

• Evaluate response to conservative treatment over 8-12 weeks
• If improvement occurs, continue with progressive strengthening
• If minimal or no improvement after 3-6 months of proper conservative management, consider surgical referral 1

Surgical Considerations

Surgery should be considered only after failed conservative management for 3-6 months 1. For this 72-year-old patient, age is an important consideration:

• Research shows that in patients over 55 years with supraspinatus tears, operative treatment provides no significant advantage over conservative management in terms of function, pain relief, or patient satisfaction 5
• Surgical repair does not protect against glenohumeral joint degeneration or rotator cuff tear arthropathy 5

Special Considerations for Calcific Tendinopathy

Calcific tendinopathy often follows a natural course with spontaneous resorption of calcium deposits:

• Conservative management can be effective while waiting for natural resorption 3
• Cross-friction massage following phonophoresis may help with calcific deposits 4
• The stage of calcification (formative, resting, or resorptive) may influence treatment response 3

Common Pitfalls to Avoid

• Overreliance on imaging: Clinical presentation should guide treatment decisions more than imaging findings alone
• Premature surgery: In elderly patients, conservative management should be thoroughly attempted before considering surgery
• Ignoring functional goals: Treatment should focus on restoring function for activities of daily living rather than just pain relief
• Prolonged immobilization: Complete rest can lead to stiffness and muscle atrophy, worsening outcomes

Treatment Algorithm

1. First 6-8 weeks: Pain management + gentle ROM exercises + activity modification
2. Weeks 8-12: Progressive strengthening + continued pain management as needed
3. 3-6 months: Advanced strengthening + functional training
4. If no improvement after 3-6 months: Consider surgical referral, though benefits may be limited in this age group 1, 5