What is the recommended treatment for a patient with a partial infraspinatus tear?

Management of Partial Infraspinatus Tear

Conservative treatment is strongly recommended as the initial approach for patients with partial infraspinatus tears, including physical therapy with supervised exercise, NSAIDs, and activity modification for a minimum of 6 months before considering surgical options.

Initial Assessment and Diagnosis

• MRI is the preferred imaging modality for diagnosis of partial infraspinatus tears, particularly using T2 fat-saturated sequences to identify muscle edema in acute cases 1
• Plain radiographs should be obtained first to rule out structural abnormalities 1
• Assess for point tenderness, muscle spasm, range of motion limitations, and perform neurological examination to rule out radicular involvement 1

Conservative Management (First-Line Treatment)

Physical Therapy

• Supervised physical therapy is more appropriate than unsupervised home exercise for most patients 2
• Exercise programs have been shown to decrease pain and improve function in patients with rotator cuff-related symptoms 2
• Active physical therapy and supervised exercise is strongly recommended over passive physical therapy and unsupervised exercise 2
• Focus on eccentric strengthening exercises for the rotator cuff muscles 1

Medications

• NSAIDs are recommended as initial pharmacological management at maximum tolerated dosage for 2-4 weeks 1, 2
• Multivitamins and supplements may be used as patient-specific adjuncts 3

Activity Modification

• Reduce activities that cause repetitive loading of the affected muscles 1
• Avoid complete immobilization to prevent muscle atrophy 1

Monitoring and Follow-up

• Follow-up at 3 and 6 months to assess clinical improvement 3
• Consider follow-up MRI at 6 months to evaluate healing progress 3
• Use validated outcome measures such as the American Shoulder and Elbow Surgeons (ASES) score to track progress 3

Prognostic Factors

• Patients with non-dominant shoulder involvement and atraumatic onset tend to have better clinical outcomes with conservative treatment 3
• Recent research shows that 63.8% of patients with partial rotator cuff tears improve clinically with conservative treatment over 6 months 3
• 85.1% of patients show radiological improvement or stabilization of the tear with conservative management 3

When to Consider Additional Interventions

Corticosteroid Injections

• May be considered for persistent pain not responding to first-line treatments 1
• Caution: Multiple steroid injections may compromise the integrity of the rotator cuff and affect subsequent repair attempts 2

Surgical Considerations

• Consider surgical options only after failure of conservative management for at least 6 months
• For high-grade partial-thickness tears that have failed physical therapy, both débridement and repair are options, though repair may improve outcomes 2
• Early tendon repair may be considered in cases with acute musculotendinous infraspinatus ruptures to prevent progression to complete fatty infiltration 4

Special Considerations

• Acute musculotendinous infraspinatus ruptures typically undergo intense muscular edema initially, which may be replaced by fatty infiltration within 6-12 months if not properly managed 4
• In cases where MRI findings are normal despite persistent symptoms, CT bursography may be considered to identify bursal-side infraspinatus tears 5

Conservative management should be given adequate time (minimum 6 months) before considering surgical intervention, as recent evidence demonstrates good clinical outcomes with non-operative treatment for partial rotator cuff tears 3.