What is the treatment for supraspinatus and infraspinatus tendinosis with a focal low-grade partial-thickness intrasubstance tear of the supraspinatus tendon?

Management of Supraspinatus and Infraspinatus Tendinosis with Partial-Thickness Tear

Conservative management is the first-line treatment for supraspinatus and infraspinatus tendinosis with a small (3x3 mm) focal low-grade partial-thickness intrasubstance tear of the supraspinatus tendon. 1

Diagnosis and Imaging

• MRI and ultrasound are equally appropriate (rating 9/9) for evaluating rotator cuff pathology 1
• MRI findings in tendinosis include:
  • Tendinous enlargement
  • Heterogeneous signal pattern
  • Diffuse increased signal intensity on T1-weighted images
  • Slight increase in signal intensity on T2-weighted images 1
• Partial-thickness tears can occur at the articular surface, bursal surface, or within the tendon substance (intrasubstance) 1

Treatment Algorithm

Phase 1: Conservative Management (0-6 weeks)

1. Pain Management:

   • NSAIDs are strongly recommended as first-line treatment 2
   • Ibuprofen 1.2g daily (can be increased to 2.4g if needed)
   • Can be combined with acetaminophen (up to 4g daily) for inadequate relief 2

2. Physical Therapy:

   • Eccentric strengthening exercises for the rotator cuff 3
   • Range of motion exercises to prevent stiffness
   • Scapular stabilization exercises

3. Physical Modalities (optional):

   • Application of local heat for symptomatic relief 2
   • Note: Laser, ultrasound, and shock-wave therapy have limited and contradictory evidence 3

Phase 2: Intermediate Management (6-12 weeks)

If symptoms persist despite initial conservative management:

1. Progressive Rehabilitation:

   • Advance to more challenging strengthening exercises
   • Sport-specific or occupation-specific training 2

2. Consider Injection Therapy:

   • Corticosteroid injections may provide short-term relief but do not change long-term outcomes 1
   • Limit to 2-3 injections with 4-6 weeks between injections 2

Phase 3: Advanced Management (>12 weeks)

For persistent symptoms despite 3-6 months of well-managed conservative treatment:

1. Surgical Consultation:
   • Consider surgical referral if pain persists and significantly impacts quality of life 2
   • Surgical options may include:
     • Arthroscopic debridement
     • Partial repair
     • Transtendon repair techniques 4

Surgical Considerations

• Small partial-thickness tears (like the 3x3 mm described) typically do not require surgical intervention unless conservative management fails 1
• If surgery is needed, options include:
  • Debridement alone
  • Partial repair
  • Transtendon repair techniques that preserve intact tendon fibers 4

Factors Affecting Prognosis

• Age: Patients over 65 years have significantly lower rates of healing after rotator cuff repair 5
• Associated tears: Delamination of the subscapularis or infraspinatus tendons negatively affects healing 5
• Mechanical interaction: The supraspinatus and infraspinatus tendons interact mechanically, so pathology in one can affect the other 6

Return to Activity Criteria

Return to full activity is permitted when the patient demonstrates:

• Complete resolution of pain during and after activity
• Full range of motion compared to uninjured side
• Strength symmetry >90% compared to uninjured side
• Successful completion of sport-specific functional tests 2

Key Considerations

• Small (3x3 mm) partial-thickness tears often respond well to conservative management
• The natural history of partial articular supraspinatus tendon avulsion is not clearly defined 7
• Mechanical interaction between supraspinatus and infraspinatus tendons means that both should be addressed in rehabilitation 6
• Regular follow-up at 2,6, and 12 weeks is recommended to assess healing and function 2