What is the recommended treatment for a patient with left shoulder pain and ultrasound findings of multiple tears and tendinopathy in the rotator cuff?

Management of Multiple Full-Thickness Rotator Cuff Tears with Tendinopathy

Given the presence of multiple full-thickness tears (subscapularis 37x32mm, supraspinatus 24x20mm with 16mm retraction), moderate biceps tendinosis, and associated degenerative changes, this patient should proceed with MRI for surgical planning while simultaneously initiating conservative management, as the extent of pathology suggests surgical intervention will likely be necessary but conservative treatment remains the appropriate first-line approach. 1, 2

Immediate Next Steps

Confirm Diagnosis with MRI

• MRI without contrast is rated as "usually appropriate" (rating 9) by the American College of Radiology for evaluating rotator cuff tears and is equivalent to MR arthrography and ultrasound depending on local expertise. 1
• MRI will provide critical prognostic information including degree of tendon retraction, muscle atrophy, and fatty infiltration—factors that directly influence surgical candidacy, operative approach, and postoperative outcomes. 1
• The American Academy of Orthopaedic Surgeons emphasizes that tendon retraction, muscle atrophy, and fatty infiltration are essential findings for decisions regarding conservative versus operative repair and for providing postoperative prognosis. 1

Initiate Conservative Management Immediately

• Begin with relative rest by reducing activities that aggravate symptoms while maintaining some movement to prevent complete immobilization and muscle atrophy. 2
• Apply ice therapy to reduce pain and inflammation, particularly after activity or when pain flares. 2
• Start short-term NSAIDs for pain relief, with consideration of topical NSAIDs to minimize systemic side effects. 2

Conservative Treatment Protocol (3-6 Month Trial)

Physical Therapy Components

• Initiate physical therapy focusing on gentle range of motion exercises progressing to strengthening exercises with emphasis on eccentric training. 2
• Focus rotator cuff strengthening on the remaining intact infraspinatus to compensate for the torn supraspinatus and subscapularis. 2
• Teach modified movement patterns for daily activities to reduce impingement and pain. 2
• The American Academy of Family Physicians recommends eccentric strengthening exercises as they have proven beneficial in tendinopathies and may help reverse degenerative changes. 2

Corticosteroid Injection Consideration

• The American Academy of Orthopaedic Surgeons provides moderate evidence supporting a single corticosteroid injection with local anesthetic for short-term improvement in both pain and function. 1
• This may be particularly beneficial for the biceps tenosynovitis and impingement components. 2
• Critical pitfall: Limit to a single injection—overuse of corticosteroid injections should be avoided. 3

Additional Conservative Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is limited. 2
• Orthotics or braces may help support the shoulder during healing, though evidence for effectiveness is limited but they are safe. 2

Surgical Considerations

Indications for Surgery

• Surgery should be considered if conservative management fails after 3-6 months of appropriate treatment. 2
• The American Academy of Orthopaedic Surgeons reports that one study showed 81% of surgical patients reported excellent results compared with 37% with nonsurgical treatment. 3
• However, a 2017 meta-analysis found no clinically significant difference between surgery and active physiotherapy at 1-year follow-up, with differences below the minimal clinically important difference. 4

Surgical Options

• Arthroscopic options would include subscapularis repair, supraspinatus repair, subacromial decompression for impingement, and biceps tenotomy or tenodesis for biceps tenosynovitis. 2
• The American Academy of Orthopaedic Surgeons provides strong evidence that for small to medium-sized full-thickness tears, early mobilization and delayed mobilization up to 8 weeks show similar postoperative outcomes. 1

Prognostic Factors

• The American Academy of Orthopaedic Surgeons provides strong evidence that older age is associated with higher failure rates and poorer patient-reported outcomes after rotator cuff repair. 1, 3
• The presence of comorbidities is associated with poorer outcomes according to moderate evidence. 1
• Assess for medical conditions that may affect treatment choices, particularly regarding NSAIDs and surgical candidacy. 2

Biological Augmentation (Not Recommended)

• The American Academy of Orthopaedic Surgeons provides strong evidence that does not support biological augmentation of rotator cuff repair with platelet-derived products for improving patient-reported outcomes. 1
• Limited evidence supports liquid platelet-rich plasma only in the context of decreasing retear rates, not for improving functional outcomes. 1
• The American Academy of Orthopaedic Surgeons provides limited evidence that does not support routine use of PRP for treatment of rotator cuff tendinopathy or partial tears. 1

Treatment Algorithm

Weeks 0-6

• Begin conservative management with rest modification, ice, NSAIDs, and gentle exercises. 2
• Obtain MRI to assess tear characteristics, retraction, muscle quality, and fatty infiltration. 1

Weeks 6-12

• Add structured physical therapy with eccentric strengthening if minimal improvement is seen. 2
• Consider single corticosteroid injection if pain limits participation in therapy. 1, 2

Months 3-6

• Continue conservative management for at least 3 months before considering surgical options. 2
• Reassess pain levels and functional ability every 2-4 weeks during treatment. 2

After 3-6 Months

• Surgical consultation is warranted if symptoms remain debilitating after 3-6 months of appropriate conservative care. 2
• The decision should weigh the extent of tears (both subscapularis and supraspinatus are significant), degree of retraction (16mm from biceps tendon), presence of calcification, and patient age/comorbidities. 1, 2

Critical Pitfalls to Avoid

• Do not proceed directly to surgery without a trial of conservative management—even with full-thickness tears, conservative treatment should be attempted first as many patients improve without surgery. 4
• Do not use multiple corticosteroid injections—limit to single injection for short-term relief only. 3
• Do not ignore the calcification in the supraspinatus—this may require specific attention with ultrasound-guided needle aspiration and lavage if symptomatic. 5
• Monitor for progression—reassess every 2-4 weeks for worsening symptoms that might indicate further tearing. 2
• Over 90% of patients with suspected rotator cuff pathology who undergo premature MRI do not proceed to surgery, representing unnecessary economic burden. 6