What is the recommended treatment for a 75-year-old female with a history of right shoulder dislocation, now presenting with persistent pain, subluxation of the long head of the biceps tendon, partial-thickness tears of the subscapularis and supraspinatus, and fluid in the subacromial bursa?

Treatment for Shoulder Pain with Biceps Tendon Subluxation and Rotator Cuff Tears

For this 75-year-old female with persistent shoulder pain after dislocation, subacromial corticosteroid injection combined with a structured rehabilitation program is recommended as the primary treatment approach. 1

Clinical Assessment and Findings

The patient presents with:

• Right shoulder dislocation (June 7) with reduction in ER
• Persistent pain despite initial conservative management
• Ultrasound findings (July 22):
  • Medial subluxation of long head of biceps tendon
  • Partial-thickness tear of subscapularis (12 x 4 mm)
  • Partial-thickness articular site tear of supraspinatus (10 x 8 x 3 mm)
  • Fluid in subacromial bursa
  • Positive impingement test

Treatment Algorithm

Step 1: Pain Management

• Subacromial corticosteroid injection is indicated due to documented inflammation in the subacromial bursa and positive impingement test 1
• Analgesics such as acetaminophen or NSAIDs (if no contraindications) for pain control 1

Step 2: Rehabilitation Program (Structured in Phases)

1. Initial Phase (Weeks 1-2):

   • Continue gentle stretching and mobilization techniques
   • Focus on external rotation and abduction movements
   • Avoid overhead pulley exercises (explicitly not recommended) 1
   • Proper positioning and supportive devices for the shoulder 1

2. Intermediate Phase (Weeks 3-6):

   • Progress to active-assisted range of motion exercises
   • Begin strengthening of rotator cuff muscles (especially supraspinatus and subscapularis)
   • Include scapular stabilization exercises
   • Address biceps tendon issues with specific stabilization exercises

3. Advanced Phase (Weeks 6-12):

   • Progress to active range of motion and resistance training
   • Focus on restoring normal scapulohumeral rhythm
   • Functional exercises relevant to daily activities

Specific Interventions for Key Issues

For Biceps Tendon Subluxation:

• Specific strengthening of the subscapularis muscle which helps stabilize the biceps tendon
• Avoid activities that aggravate biceps tendon pain (overhead activities, lifting)
• Consider taping techniques to provide temporary stability

For Rotator Cuff Tears:

• Progressive strengthening of intact portions of the rotator cuff
• Focus on external rotation exercises to address limitations
• Neuromuscular electrical stimulation (NMES) may be considered as an adjunctive therapy 1

For Subacromial Bursitis:

• Activity modification to reduce impingement
• Ice application for inflammation control
• Progressive exercises to improve scapular positioning

Additional Considerations

• Botulinum toxin injections could be considered if shoulder spasticity is identified during follow-up examinations 1
• Suprascapular nerve block may be considered as an adjunctive treatment if pain persists despite initial interventions 1
• Surgical options should be considered only if conservative management fails after 3-6 months

Follow-up and Progression Criteria

• Re-evaluate at 4-6 weeks to assess progress
• Progression criteria:
  • Decreased pain with movement
  • Improved range of motion, especially external rotation
  • Improved function in activities of daily living
  • Decreased signs of impingement

Pitfalls and Caveats

• Avoid aggressive passive stretching which may worsen partial-thickness tears
• Avoid overhead pulley exercises which can exacerbate impingement symptoms 1
• Monitor for signs of complete rotator cuff tear progression
• Recognize that in older patients, the healing capacity of rotator cuff tissue is reduced 1
• Be aware that biceps tendon subluxation often coexists with subscapularis tears and requires attention to both issues 2

This structured approach addresses the patient's specific pathologies while focusing on improving function and reducing pain, which will ultimately enhance her quality of life and reduce morbidity associated with persistent shoulder dysfunction.