What is the next best step for a 68-year-old man with a large full-thickness rotator cuff tear, type 2 diabetes, and stage 3 chronic kidney disease (Impaired renal function), presenting with right shoulder pain and limited internal rotation?

Management of Large Full-Thickness Rotator Cuff Tear in a 68-Year-Old Man with Type 2 Diabetes and CKD Stage 3

The next best step for this patient is to initiate conservative management with a structured rehabilitation program, pain control with NSAIDs (with caution due to CKD), and activity modification for 3 months before considering surgical referral. 1, 2

Initial Assessment and Diagnosis

The patient presents with:

• 68-year-old man with right shoulder pain
• Abrupt onset after lifting a bag two weeks ago
• Pain worsens with overhead use and at night
• Limited internal rotation and weakness in abduction/external rotation
• Positive drop arm sign (suddenly drops arm when lowering from passive elevation)
• MRI shows large full-thickness rotator cuff tear with intact tendons and atrophy of supraspinatus and infraspinatus
• Comorbidities: Type 2 diabetes and stage 3 chronic kidney disease

Treatment Algorithm

Step 1: Conservative Management (First 3 Months)

1. Pain Control

   • NSAIDs with caution due to CKD stage 3 1
   • Local thermal interventions (heat or cold) for symptomatic relief 2
   • Activity modification to avoid painful overhead movements 2

2. Structured Rehabilitation Program

   • Phase 1 (Weeks 1-4): Pain control, gentle ROM exercises, proper positioning education 2
   • Phase 2 (Weeks 5-8): Progressive ROM exercises, light strengthening for rotator cuff and periscapular muscles 2
   • Phase 3 (Weeks 9-12): Progressive resistance training, advanced scapular stabilization 2

Step 2: Follow-up and Reassessment

• Initial follow-up at 1-2 weeks to assess response to treatment 2
• Clinical reassessment at 6 weeks to evaluate progress 2
• Comprehensive evaluation at 3 months 1, 2

Step 3: Decision Point at 3 Months

• If improved: Continue rehabilitation program
• If not improved or worsened: Refer for surgical consultation 1, 2

Special Considerations for This Patient

Diabetes Management

• Diabetes increases risk of rotator cuff tears and poor outcomes after repair 3, 4, 5
• Stricter glycemic control is essential if surgical repair becomes necessary 6

Kidney Disease Considerations

• Stage 3 CKD requires caution with NSAIDs 1
• Use lowest effective dose for shortest duration
• Monitor renal function if NSAIDs are used

Surgical Considerations (if conservative management fails)

• For large tears with atrophy as in this case, debridement or partial repair may be appropriate options 2
• Diabetes is associated with poorer functional outcomes after rotator cuff repair 3

Evidence Quality and Rationale

The recommendation for initial conservative management is supported by multiple guidelines. The American Academy of Orthopaedic Surgeons recommends non-surgical care prior to consideration of surgery for rotator cuff disorders 1, 2. This is particularly important for this patient given his comorbidities of diabetes and CKD, which increase surgical risks and may compromise healing.

The structured rehabilitation approach is supported by moderate-level evidence 2, and is particularly important given the patient's recent onset of symptoms (only two weeks). The guidelines specifically recommend a trial of conservative management for 3 months before considering surgical intervention for rotator cuff tears 1.

Pitfalls and Caveats

1. Avoid rushing to surgery - Despite the MRI findings of a large full-thickness tear, guidelines recommend a trial of conservative management first 1

2. NSAIDs caution - While NSAIDs are recommended for pain control, use them cautiously in this patient with stage 3 CKD 1

3. Diabetes impact - Diabetes increases the risk of rotator cuff tears and complications after repair 3, 4, 5

4. Imaging interpretation - While MRI confirms a full-thickness tear, routine imaging is discouraged unless it will change management 1

5. Rehabilitation adherence - The success of conservative management depends on patient adherence to the rehabilitation program 2

By following this structured approach, you optimize the chance of successful non-surgical management while preserving the option for surgical intervention if conservative measures fail after an appropriate trial period.