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 Recommendations for Rotator Cuff Tears with AC Joint Osteoarthritis

For a patient with undersurface tears and tendinopathy of the supraspinatus and infraspinatus tendons, advanced acromioclavicular joint osteoarthritis, and mild degenerative labral fraying, initial conservative management is recommended, with progression to surgical intervention if conservative measures fail after 6 months. 1, 2

Initial Conservative Management

First-Line Approach

• NSAIDs: The American Academy of Orthopaedic Surgeons notes that NSAIDs can be used for pain control and anti-inflammatory effects without negative impact on tendon healing 1
• Activity modification: Particularly important to avoid overhead and cross-body movements that exacerbate AC joint pain 3
• Physical therapy: Focus on:
  • Rotator cuff strengthening exercises to protect the glenohumeral joint
  • Improving scapular motion and posture
  • Gentle range of motion exercises that don't aggravate symptoms 4

Second-Line Interventions

• Corticosteroid injections: Consider for short-term pain relief if diagnostic local anesthetic injection provides relief
  • Note: These do not alter disease progression and should be used judiciously 2
• Oral supplements: Vitamin C and D supplementation may help slow cartilage degeneration 4

Diagnostic Considerations

• MRI without contrast (as already performed) is appropriate for evaluating rotator cuff pathology 1
• The presence of an intramuscular ganglion (4.8 × 0.9 × 0.7 cm) in the infraspinatus muscle warrants special attention as it indicates intrasubstance extension of the tear

Surgical Intervention

• Consider if conservative management fails after 6 months of appropriate treatment 2, 3
• Surgical options include:
  • For AC joint osteoarthritis: Open or arthroscopic distal clavicle resection 2, 5
  • For rotator cuff tears: Arthroscopic repair, considering the quality of the infraspinatus muscle
  • The American Academy of Orthopaedic Surgeons cautions that infraspinatus fatty degeneration and muscle atrophy correlate with worse surgical outcomes 1

Important Considerations

Prognostic Factors

• The presence of supraspinatus and infraspinatus muscle atrophy may predict worse outcomes with surgical intervention 1
• The intramuscular ganglion indicates more significant pathology that may influence treatment decisions

Common Pitfalls

1. Overlooking AC joint pathology: AC joint osteoarthritis is often neglected despite being a common source of shoulder pain 2, 3
2. Relying solely on imaging: Radiographic findings of AC joint degeneration can be seen in asymptomatic individuals 5
3. Inadequate conservative management: Physical therapy alone has limited benefit for AC joint osteoarthritis but is important for rotator cuff pathology 2
4. Inappropriate surgical timing: Rushing to surgery before adequate conservative management (minimum 6 months) 3

Post-Surgical Considerations

• Physical therapy following surgical intervention is common practice, though high-quality studies on its effectiveness are limited 1
• The American Academy of Orthopaedic Surgeons recommends against total shoulder arthroplasty in patients with irreparable rotator cuff tears 1