What is the management for a full-thickness, retracted tear of the supraspinatus tendon at the insertion, a low-grade interstitial tear at the subscapularis tendon insertion, and tendinosis of the supraspinatus, infraspinatus, and subscapularis tendons?

From the Guidelines

The management of a full-thickness, retracted supraspinatus tendon tear with associated tendinosis and a low-grade subscapularis tear typically requires surgical intervention, specifically arthroscopic rotator cuff repair, as the full-thickness retracted tear is unlikely to heal with conservative measures alone. This recommendation is based on the most recent and highest quality study available, which suggests that early surgical repair after acute injury is an option for patients with a rotator cuff tear 1.

Pre-Surgical Management

Prior to surgery, the patient should undergo a course of physical therapy focusing on maintaining range of motion and strengthening the surrounding musculature. Pain management can include NSAIDs such as ibuprofen 400-600mg three times daily or naproxen 500mg twice daily, along with acetaminophen 1000mg three times daily as needed. However, the use of perioperative subacromial corticosteroid injections or NSAIDs is not recommended due to the lack of conclusive evidence on their effectiveness and potential negative effects on tendon healing 1.

Surgical Intervention

Arthroscopic rotator cuff repair is the recommended treatment, as it allows for minimal invasion and faster recovery times. The surgery should be performed by an experienced orthopedic surgeon, and the patient should be informed of the potential risks and benefits of the procedure.

Post-Surgical Rehabilitation

Post-surgery, the patient will require immobilization in a sling for 4-6 weeks, followed by a structured rehabilitation program lasting 3-6 months. This typically includes:

• Passive range of motion exercises initially
• Progressing to active motion at 6 weeks
• Strengthening exercises at 12 weeks The absence of muscle atrophy is a positive prognostic factor, suggesting better potential for recovery following repair 1.

Prognosis

Without surgical intervention, the tear may enlarge over time, potentially leading to irreparable damage and permanent functional limitations. Therefore, early surgical repair is crucial to prevent further damage and improve outcomes. Additionally, factors such as increasing age, workers' compensation status, and preoperative infraspinatus fatty degeneration and muscle atrophy may negatively affect outcomes and healing after rotator cuff repair 1.

Key Considerations

• The patient's overall health and medical history should be taken into account when making treatment decisions
• A thorough discussion of the potential risks and benefits of surgery should be had with the patient
• A structured rehabilitation program is crucial for optimal recovery and outcomes
• Regular follow-up appointments with the orthopedic surgeon and physical therapist are necessary to monitor progress and address any concerns or complications that may arise.

From the Research

Management of Rotator Cuff Injuries

The management of a full-thickness, retracted tear of the supraspinatus tendon at the insertion, a low-grade interstitial tear at the subscapularis tendon insertion, and tendinosis of the supraspinatus, infraspinatus, and subscapularis tendons can be approached through conservative or surgical treatment.

• Conservative management is often the initial treatment approach, especially for patients with symptomatic rotator cuff tears who are elderly or have low-grade tears 2.
• Rehabilitation plays a fundamental role in the management of rotator cuff pathology, whether the final choice is conservative or surgical treatment 3.
• Conservative management can give excellent results in cases of rotator cuff tendinopathies without rupture, partial tears less than 50% of the thickness of the tendon, chronic full-thickness tears in elderly patients, and irreparable tears 3.

Conservative Treatment Options

Conservative treatment options include:

• Physical therapy, which has been shown to demonstrate improvements in pain and strength, particularly with eccentric rehabilitation 4.
• Platelet-rich plasma (PRP) injections, which have been found to significantly improve pain and functional outcomes in patients with partial thickness rotator cuff tears 4.
• Corticosteroid injections, which have been used to treat rotator cuff tendinopathy, but with variable success rates and potential risks 5.
• Collagen injections, hyaluronic acid (HA) injections, and polydeoxyribonucleotide (PDRN) injections, which have also been studied as potential conservative treatment options for rotator cuff tears 4.

Predictors of Success

The success of conservative treatment for rotator cuff disease can depend on various factors, including:

• Activity level, American Shoulder and Elbow Surgeons (ASES) score, duration of symptoms, and status of the rotator cuff 5.
• Patient characteristics, such as age, sex, and hand dominance, which may influence treatment outcomes 5.
• The presence and size of full-thickness tears, which can affect the likelihood of successful conservative treatment 5, 6.