Treatment for 50% Bursal-Sided Partial-Thickness Rotator Cuff Tear with Bursitis
The recommended initial treatment for a patient with a 50% bursal-sided partial-thickness tear of the supraspinatus and infraspinatus tendons with severe tendinosis and subacromial subdeltoid bursitis should begin with conservative management including activity modification, physical therapy with eccentric strengthening exercises, and NSAIDs, with consideration of corticosteroid injections if symptoms persist.
Initial Conservative Management (0-6 weeks)
Activity Modification
- Reduce activities that exacerbate shoulder pain
- Implement relative rest without complete immobilization
- Avoid overhead activities that may cause impingement
Physical Therapy
- Focus on pain control and protected range of motion in initial phase (0-4 weeks)
- Progress to strengthening exercises and eccentric training (4-8 weeks)
- Include rotator cuff strengthening exercises specifically targeting the supraspinatus and infraspinatus
Medication
- NSAIDs for pain relief:
- Ibuprofen 1.2g daily initially, may increase to 2.4g daily if needed
- Naproxen 500mg twice daily as an alternative
- Can be combined with acetaminophen (up to 4g daily) for enhanced pain relief
Intermediate Management (6-12 weeks)
If symptoms persist after 6 weeks of conservative treatment:
Corticosteroid Injections
- Subacromial corticosteroid injection can be considered for persistent pain and inflammation
- Triamcinolone acetonide is indicated for intra-articular or soft tissue administration for rheumatic disorders 1
- Combination of intraarticular and subacromial injections may be beneficial for cases with both bursitis and partial tears 2
- Limit use to 2-3 injections with 4-6 weeks between injections
Advanced Rehabilitation
- Progress to occupation-specific training and functional exercises
- Focus on scapular stabilization and rotator cuff strengthening
- Gradually increase activity level based on symptom response
Surgical Consideration (>12 weeks)
If no improvement occurs after 3-6 months of well-managed conservative treatment:
- Arthroscopic subacromial decompression to address impingement
- Debridement or repair of the rotator cuff tear depending on:
- Extent of tear (50% thickness is a borderline indication for repair)
- Patient's age and activity level
- Duration and severity of symptoms
Imaging Considerations
- MRI is the preferred non-invasive imaging modality for evaluating rotator cuff pathology 3
- MR arthrography may be superior for evaluating partial-thickness tears but is more invasive 3
- T2-weighted imaging is necessary to differentiate tendinitis from small tears 4
- CT bursography may be considered if MRI findings are equivocal 5
Follow-up and Return to Activity
- Regular assessment at 2,6, and 12 weeks to evaluate:
- Pain levels
- Range of motion
- Functional improvement
- Return to full activity permitted when patient demonstrates:
- Complete resolution of pain
- Full range of motion
- Strength symmetry >90% compared to uninjured side
Common Pitfalls to Avoid
- Delaying treatment of subacromial bursitis, which can lead to further tendon damage
- Overuse of corticosteroid injections, which may weaken tendon tissue
- Prolonged immobilization, which can lead to stiffness and muscle atrophy
- Delayed referral for surgical evaluation when conservative measures fail
- Returning to full activity too quickly before adequate healing
The presence of a large multilocular subacromial subdeltoid bursitis with narrowed subacromial space (0.5 cm) suggests significant impingement, which may require more aggressive management if conservative treatment fails 4, 6.