What is the recommended treatment for a patient with rotator cuff tears, tendinopathy, and acromioclavicular joint osteoarthritis?

Treatment of Rotator Cuff Tears with Acromioclavicular Joint Osteoarthritis

Initial treatment should be conservative management with physical therapy, NSAIDs, and activity modification before considering surgical intervention for patients with rotator cuff tears, tendinopathy, and acromioclavicular joint osteoarthritis.

Initial Conservative Management

Physical Therapy

• Supervised physical therapy is preferred over unsupervised home exercise programs for patients with rotator cuff pathology 1
• Focus on:
  • Rotator cuff strengthening exercises
  • Scapular stabilization
  • Range of motion exercises
  • Posterior capsule stretching

Medications and Injections

• NSAIDs for pain management and inflammation reduction
• Subacromial corticosteroid injections may provide short-term relief, but evidence is inconclusive 1
• Caution: Multiple steroid injections may compromise rotator cuff integrity and affect subsequent repair attempts 1
• Consider diagnostic local anesthetic injection into the acromioclavicular joint to confirm it as a pain source 2

Activity Modification

• Avoid overhead activities and positions that exacerbate symptoms
• Modify daily activities to reduce strain on the shoulder

When to Consider Surgical Management

Surgery should be considered after failure of 3-6 months of conservative management, with the specific approach determined by:

For Partial-Thickness Rotator Cuff Tears

• Débridement versus repair depends on tear characteristics
• High-grade partial tears (>50% thickness) that have failed physical therapy may benefit from repair 1

For Full-Thickness Rotator Cuff Tears

• Rotator cuff repair is an option for chronic, symptomatic full-thickness tears 1
• Early surgical repair may be beneficial after acute injury 1

For Acromioclavicular Joint Osteoarthritis

• Distal clavicle resection (DCR) should be carefully considered when performing rotator cuff repair 3, 4
• Research shows no significant difference in clinical outcomes between combined DCR with rotator cuff repair versus isolated rotator cuff repair 4

For Advanced Disease with Irreparable Tears

• In patients with massive, irreparable rotator cuff tears and pseudoparalysis who have failed other treatments, reverse shoulder arthroplasty can improve outcomes 1
• Total shoulder arthroplasty should not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear 1

Important Clinical Considerations

• The presence of inferiorly directed osteophytes at the acromioclavicular joint (as noted in the MRI) can contribute to impingement symptoms
• The intramuscular ganglion (4.8 x 0.9 x 0.7 cm) in the infraspinatus muscle may require additional consideration during treatment planning
• Type II acromion, as identified in the MRI, is associated with impingement syndrome

Postoperative Considerations (If Surgery Is Performed)

• Multimodal pain management programs are recommended after rotator cuff repair 1
• The benefit of formal physical therapy after shoulder surgery remains unclear in the literature, though it is commonly recommended 1

Common Pitfalls to Avoid

1. Failing to identify acromioclavicular joint arthritis as a potential pain source separate from rotator cuff pathology
2. Overuse of corticosteroid injections, which may compromise rotator cuff integrity
3. Premature surgical intervention before adequate trial of conservative management
4. Performing total shoulder arthroplasty in patients with irreparable rotator cuff tears
5. Neglecting to address both the rotator cuff pathology and acromioclavicular joint disease when both are symptomatic

The treatment approach should progress from conservative to surgical options based on patient response, with careful consideration of the specific pathology identified on imaging and clinical examination.