What is the recommended treatment for a patient with an undersurface tear and tendinopathy of the supraspinatus and infraspinatus tendons, advanced acromioclavicular joint osteoarthritis, and mild degenerative fraying of the posterior labrum?

Treatment of Undersurface Rotator Cuff Tears with AC Joint Osteoarthritis

Initial conservative management is recommended for patients with undersurface tears of the supraspinatus and infraspinatus tendons, advanced acromioclavicular joint osteoarthritis, and mild degenerative fraying of the posterior labrum, with surgical intervention reserved for those who fail appropriate nonsurgical treatment.

Initial Conservative Management

Pain Management

• First-line medications:
  • NSAIDs for pain control and anti-inflammatory effects 1
  • Acetaminophen as an alternative for patients with contraindications to NSAIDs
  • Note: No clinical data supports or refutes a negative effect of NSAIDs on tendon healing 2

Physical Therapy

• Focus on three primary goals:
  1. Pain reduction - particularly for motion-related pain rather than rest pain 1
  2. Improving shoulder range of motion - targeting specific soft tissues responsible for ROM limitations 1
  3. Rotator cuff strengthening - to protect the glenohumeral joint 1

Injections

• Subacromial corticosteroid injections:

  • May provide short-term pain relief for AC joint osteoarthritis 3
  • Caution: Does not alter natural disease progression 3
  • Consider diagnostic local anesthetic injection first to confirm AC joint as pain source 3, 4

• Hyaluronic acid injections:

  • Mixed evidence for efficacy 1
  • May be considered as an alternative to corticosteroids

Activity Modification

• Avoid overhead and cross-body activities that exacerbate symptoms 5
• Modify daily activities to reduce stress on the AC joint and rotator cuff 1

When to Consider Surgical Intervention

Surgical intervention should be considered after a minimum of 6 months of unsuccessful conservative treatment 3, 4. The MRI findings in this case show:

1. Undersurface tears of the supraspinatus and infraspinatus tendons with intramuscular ganglion
2. Advanced AC joint osteoarthritis with inferiorly directed osteophytes
3. Mild degenerative fraying of the posterior labrum

Surgical Options Based on Pathology:

For AC Joint Osteoarthritis:

• Distal clavicle resection (open or arthroscopic) 3, 4, 5

For Rotator Cuff Pathology:

• Arthroscopic repair of undersurface tears
• Address the intramuscular ganglion during repair

For Impingement:

• Subacromial decompression to address the inferiorly directed osteophytes that abut the supraspinatus tendon

Important Considerations

Prognostic Factors

• Muscle quality impacts outcomes:
  • Preoperative infraspinatus fatty degeneration and muscle atrophy correlate with worse outcomes and healing 2
  • Supraspinatus muscle atrophy correlates with worse outcomes and healing 2

Diagnostic Imaging

• MRI without contrast is appropriate for evaluating rotator cuff pathology 2
• Consider MR arthrography if there is concern about labral pathology 2, 6

Postoperative Considerations

• Physical therapy following surgical intervention is common practice, though high-quality studies on its effectiveness are lacking 2
• In patients with irreparable rotator cuff tears, total shoulder arthroplasty is not recommended 2

Common Pitfalls to Avoid

1. Misdiagnosis: AC joint pain can be confused with other shoulder pathologies; confirm diagnosis with local anesthetic injection 3, 4
2. Overreliance on imaging: Radiographic findings of AC joint degeneration can be seen in asymptomatic individuals 5
3. Premature surgery: Ensure adequate trial of conservative management before proceeding to surgical intervention 3, 4
4. Overlooking associated pathologies: Address all components (rotator cuff, AC joint, impingement) during surgical intervention

By following this algorithmic approach, patients with undersurface rotator cuff tears, AC joint osteoarthritis, and mild labral fraying can achieve optimal outcomes with appropriate treatment selection.