What is the recommended treatment for bilateral shoulder ultrasound findings showing subscapularis tendinosis, supraspinatus tendinosis, partial-thickness tear, subacromial bursitis, acromioclavicular osteoarthrosis, and adhesive capsulitis?

Management of Bilateral Shoulder Pathology with Adhesive Capsulitis

The recommended treatment for bilateral shoulder pathology with adhesive capsulitis, tendinosis, partial-thickness tear, subacromial bursitis, and acromioclavicular osteoarthrosis should begin with conservative management including physical therapy focusing on rotator cuff and scapular stabilization exercises, proper positioning, and pain management, followed by more invasive interventions if symptoms persist. 1

Initial Assessment and Management

• Clinical Assessment:

  • Evaluate the severity of adhesive capsulitis (thickened inferior glenohumeral ligament)
  • Assess rotator cuff pathology (subscapularis and supraspinatus tendinosis, partial-thickness tear)
  • Evaluate subacromial bursitis and impingement
  • Assess acromioclavicular osteoarthrosis
  • Test for regional sensory changes 2

• Initial Positioning and Support:

  • Proper positioning with joints positioned higher than proximal joints
  • Consider supportive devices and slings to stabilize the subluxed shoulders
  • Avoid overhead pulley exercises as they may worsen the condition 2, 1

Treatment Algorithm

First-Line Treatment:

1. Physical Therapy:

   • Rotator cuff and scapular stabilization exercises
   • Range of motion exercises (avoiding aggressive passive movements)
   • Manual therapy techniques 1, 3

2. Pain Management:

   • NSAIDs or acetaminophen for pain control 4
   • Consider taping of the affected shoulders to reduce pain 1

3. Patient Education:

   • Proper positioning and handling of the affected arms
   • Home exercise program
   • Activity modification 2, 1

Second-Line Treatment (if inadequate response after 4-6 weeks):

1. Injection Therapy:

   • Ultrasound-guided corticosteroid injections:
     • For subacromial bursitis: Subacromial-subdeltoid bursa injection 5
     • For adhesive capsulitis: Glenohumeral joint injection 4
     • For calcific tendinopathy (noted in left supraspinatus): Consider ultrasound-guided lavage and aspiration 5, 6

2. Advanced Physical Therapy:

   • Consider neuromuscular electrical stimulation (NMES) for pain management 2
   • Joint mobilization techniques specific for adhesive capsulitis 3

Third-Line Treatment (if inadequate response after 3-6 months):

1. Suprascapular Nerve Block:

   • Consider for chronic shoulder pain not responsive to conventional treatments 2, 5

2. Consider Surgical Consultation:

   • If significant functional limitations persist despite therapy
   • Options include manipulation under anesthesia and arthroscopic capsular release 4
   • For partial-thickness rotator cuff tears that fail conservative management 1

Special Considerations

• Adhesive Capsulitis Management:

  • This condition is often self-limited but can persist for years
  • Bilateral involvement suggests potential systemic factors that should be evaluated
  • Patients over 60 years have higher prevalence of rotator cuff tears with adhesive capsulitis 7

• Calcific Tendinopathy (Left Shoulder):

  • Ultrasound therapy has shown effectiveness for calcific tendinitis
  • Consider ultrasound-guided lavage if symptoms persist 6

• Monitoring Progress:

  • Use dynamic ultrasound to monitor progress and response to treatment 1
  • Regular reassessment of pain, range of motion, and function

Treatment Efficacy and Expectations

• Physical therapy interventions have shown benefit for rotator cuff disease, with exercise demonstrating short-term recovery (RR 7.74) and longer-term functional benefit (RR 2.45) 3
• Combining mobilization with exercise provides additional benefit compared to exercise alone for rotator cuff disease 3
• Adhesive capsulitis may resolve spontaneously but often takes 1-3 years; treatment accelerates recovery and improves outcomes 4
• Ultrasound therapy has shown effectiveness for calcific tendinitis but not for non-calcific rotator cuff tendinitis 6, 3

Pitfalls to Avoid

• Avoid aggressive passive range-of-motion exercises, especially overhead pulley exercises, as they may exacerbate symptoms 2
• Don't rely solely on corticosteroid injections without addressing underlying biomechanical issues through physical therapy 3
• Avoid neglecting the bilateral nature of the condition, which may indicate systemic factors requiring additional evaluation
• Don't delay treatment of adhesive capsulitis, as earlier intervention typically leads to better outcomes 4

This comprehensive approach addresses the multiple pathologies identified in the bilateral shoulder ultrasound findings while prioritizing interventions that will improve morbidity, mortality, and quality of life outcomes.