What is the treatment for a chronic infraspinatus tear?

Treatment for Chronic Infraspinatus Tear

For chronic infraspinatus tears, a progressive approach starting with conservative management is recommended, with surgical options considered for patients who fail to respond to non-surgical treatment. 1

Initial Conservative Management

Physical Therapy and Exercise

• Begin with a structured exercise program focusing on:
  • Strengthening of the deltoid anterior and teres minor muscles to help center the humeral head in the glenoid cavity 2
  • Eccentric strengthening exercises for the remaining rotator cuff muscles
  • Range of motion and stretching exercises to maintain mobility 3
  • Progressive resistance training as tolerated

Research shows that patients with irreparable rotator cuff tears can achieve significant functional improvement with a dedicated 5-month exercise program, with Oxford Shoulder Score improvements from 25.6 to 37.2 and increased range of motion in abduction by 34.4° 2.

Pain Management

• NSAIDs/COXIBs at maximum tolerated dosage for pain control 1, 3
• Ice application (cryotherapy) for short-term pain relief 3
• Consider short courses of oral corticosteroids or intra-articular glucocorticoid injections as bridging options while awaiting the effect of other treatments 1, 3
  • Caution: Avoid long-term use of corticosteroids due to potential tendon weakening 3

Evaluation of Conservative Treatment Response

• Assess treatment response at 2-4 weeks 1
• If sufficient response:
  • Continue current treatment
  • Re-evaluate at 12 weeks
  • Consider tapering or on-demand treatment if sustained improvement
• If insufficient response:
  • Consider NSAID/COXIB rotation
  • Advance to more aggressive treatment options 1

Surgical Options for Refractory Cases

When conservative management fails after 3-6 months, surgical options should be considered based on tear characteristics:

For Repairable Tears

• Arthroscopic rotator cuff repair with the goal of achieving tendon-to-bone healing 1
  • Note: Healing rates decrease with age, with only 43% of patients over 65 showing complete healing 4
  • Strength outcomes are significantly better when the tendon heals (7.3 kg vs 4.7 kg in unhealed repairs) 4

For Irreparable Tears

• Partial rotator cuff repair when complete repair cannot be achieved 1
• Arthroscopic debridement with or without release of the long head of the biceps 1
• Muscle transfers (latissimus dorsi or teres major) for irreparable tears involving both supraspinatus and infraspinatus tendons 1
  • Note: Potential complications include temporary complex regional pain syndrome and cosmetic deformity of the biceps 1

Factors Affecting Treatment Outcomes

Negative Prognostic Factors

• Advanced age (>65 years) significantly reduces healing rates 4
• Associated tears in other rotator cuff tendons (subscapularis or additional infraspinatus delamination) 4
• Workers' compensation status correlates with less favorable outcomes 1
• Fatty degeneration and muscle atrophy of the infraspinatus 5

Important Considerations

• Musculotendinous infraspinatus ruptures differ from classic rotator cuff tears:
  • Tendon attachment remains intact
  • Acute stage shows intense muscular edema
  • Eventually progresses to complete fatty infiltration within 6-12 months 5
• Early diagnosis using MRI with T2 fat-saturated sequences is crucial to identify muscular edema before permanent fatty infiltration occurs 5

Treatment Algorithm

1. Start with 3-6 months of conservative management (exercise, NSAIDs, activity modification)
2. If no improvement, obtain advanced imaging (MRI) to assess tear characteristics and muscle quality
3. For repairable tears with good muscle quality: arthroscopic repair
4. For irreparable tears or poor muscle quality: partial repair, debridement, or muscle transfers

The evidence suggests that for small, non-traumatic tears in patients over 55 years, conservative treatment may be as effective as surgical intervention over a 5-year follow-up period 6. However, younger patients with traumatic tears may benefit more from surgical repair to restore function and prevent progressive degeneration 7.