What is the best treatment for old tendinopathy of the supraspinatus tendon with low-grade inflammation near the footprint?

Best Treatment for Supraspinatus Tendinopathy

Eccentric strengthening exercises combined with NSAIDs for short-term pain relief is the most effective treatment for supraspinatus tendinopathy with low-grade inflammation near the footprint. This approach addresses both pain management and tendon healing while avoiding invasive procedures with inconsistent outcomes 1, 2.

First-Line Treatment Approach

1. Exercise Therapy

   • Begin with eccentric strengthening exercises of the rotator cuff muscles
   • Start with low-load exercises that don't worsen symptoms
   • Gradually progress intensity as tolerated
   • Include hip-strengthening exercises for improved shoulder mechanics

2. Pain Management

   • Short-term NSAID use (e.g., naproxen 500mg twice daily or ibuprofen 1.2g daily)
   • Note: While NSAIDs provide short-term pain relief, their long-term effectiveness has not been demonstrated 3

Phased Rehabilitation Program

Follow this structured approach for optimal outcomes:

Phase	Focus	Duration
Initial	Pain control and protected range of motion	0-4 weeks
Intermediate	Progressive strengthening and eccentric training	4-8 weeks
Advanced	Occupation/sport-specific training and functional exercises	8-12 weeks

Second-Line Treatment Options

If first-line treatment fails after 6-8 weeks:

1. Physical Modalities

   • Evidence for ultrasound, laser therapy, and shock wave therapy is inconsistent and contradictory 1
   • May provide temporary relief but should not replace active rehabilitation

2. Injection Therapies

   • Recent evidence supports PRP and prolotherapy for chronic cases unresponsive to conventional treatment 4
   • Both PRP and prolotherapy showed improved shoulder function and pain at 6-month follow-up
   • Note: PRP group experienced more post-injection pain lasting less than two weeks

3. Percutaneous Electrolysis

   • More effective than trigger point dry needling for pain relief and improving range of motion
   • Benefits maintained at one-year follow-up 5

Important Considerations

• Avoid overreliance on passive treatments - These should support rather than replace active rehabilitation
• Education is crucial - Explain that pain doesn't necessarily correlate with damage and discuss expected recovery timeframes
• Regular assessment - Evaluate at 2,6, and 12 weeks to monitor progress
• Surgical intervention - Consider only when conservative measures fail after 3-6 months of well-managed treatment 6

Return to Activity Criteria

Return to full activity when the patient demonstrates:

• Complete resolution of pain
• Full range of motion
• Strength symmetry >90% compared to the uninjured side
• Successful completion of occupation/sport-specific functional tests

Common Pitfalls to Avoid

1. Overuse of corticosteroid injections - May provide short-term relief but can potentially weaken the tendon structure
2. Inadequate rehabilitation - Rushing through phases or skipping eccentric strengthening
3. Premature return to activity - Can lead to reinjury and chronic tendinopathy
4. Focusing only on pain relief - Addressing the underlying biomechanical issues is essential for long-term success

The evidence strongly supports starting with conservative management focusing on eccentric exercises and short-term NSAIDs before considering more invasive options 3, 1, 2.