What is the treatment for severe supraspinatus tendinosis?

Treatment for Severe Supraspinatus Tendinosis

The treatment for severe supraspinatus tendinosis should begin with conservative management including NSAIDs, eccentric exercises, and physical therapy for at least 3-6 months before considering surgical options. 1, 2

Initial Conservative Management

First-line Treatments

• NSAIDs: Recommended as first-line medication for pain and inflammation
• Relative rest and activity modification: Reduce activities that exacerbate pain
• Physical therapy: Focus on eccentric exercises, which have shown beneficial effects
• Manual therapy: Joint and soft tissue mobilization combined with exercise has demonstrated improved outcomes 3

Exercise Protocol

• Eccentric training (high frequency, low intensity)
• Range of motion exercises, particularly for external rotation
• Graded activity to increase functional use of the affected shoulder
• Proper technique modification for athletes and manual laborers to minimize repetitive stress 1

Physical Modalities

Evidence-Based Options

• Extracorporeal Shock Wave Therapy (ESWT): Safe and effective for tendon healing, though optimal treatment strategies need further research 1, 4
• Ultrasound therapy: May increase collagen synthesis and potentially decrease pain, though evidence for consistent benefit is weak 1
• Percutaneous Electrolysis (PE): Recent evidence shows superior outcomes compared to trigger point dry needling at one-year follow-up for pain relief and improving range of motion 5

Injection Therapies

• Corticosteroid injections: Should be used with caution as they may inhibit healing and reduce tensile strength
• Platelet-Rich Plasma (PRP): One-shot injection has shown non-inferiority to ESWT at 6-month follow-up 4

Treatment Progression and Monitoring

• Reassess pain and function every 4-6 weeks
• Adjust treatment plan if no improvement after 8-12 weeks
• Complete resolution typically requires 3-6 months of appropriate conservative management

Surgical Consideration

Surgical consultation should be considered if:

• Pain persists despite 3-6 months of well-managed conservative treatment 1
• Functional limitations significantly impact quality of life
• Progressive joint degeneration is evident on follow-up imaging

Surgical techniques typically include:

• Excision of abnormal tendon tissue
• Longitudinal tenotomies to release areas of scarring and fibrosis 1

Important Considerations and Pitfalls

• Avoid strict immobilization: This can lead to further stiffness and functional limitations 2
• Beware of overdiagnosis: There is no indication for surgical treatment of asymptomatic rotator cuff tears 2
• Diagnostic imaging timing: Useful after 6 weeks of symptoms, with ultrasound recommended to exclude rotator cuff rupture 2
• Tendinosis vs. tendinitis: Treatment should address degenerative nature of tendinosis rather than focusing solely on inflammation
• Technique modification: Essential for athletes and manual laborers to prevent recurrence 1

Evidence-Based Treatment Algorithm

1. Weeks 0-6: NSAIDs + relative rest + initiation of eccentric exercises
2. Weeks 6-12: Add manual therapy + progress exercise intensity if tolerated
3. Weeks 12-24: Consider ESWT, PRP, or PE if inadequate improvement
4. After 24 weeks: Surgical consultation if conservative measures fail