What is the recommended treatment for a patient with a supraspinatus tear?

Treatment of Supraspinatus Tear

Conservative management with complete rest followed by structured rehabilitation is the recommended initial treatment for supraspinatus tears, particularly for small, nontraumatic tears in patients over 55 years, as operative treatment shows no superior outcomes compared to physiotherapy alone. 1, 2

Initial Conservative Management

All patients with supraspinatus tears should begin with conservative treatment regardless of tear size or age. 1, 2

Immediate Phase

• Complete rest from all aggravating activities is mandatory until the patient becomes completely asymptomatic, particularly critical for overhead athletes and workers performing repetitive shoulder movements 1
• Implement pain control measures and activity modification immediately upon diagnosis 1
• Continue complete rest until pain-free at rest and with basic activities of daily living 1

Structured Rehabilitation Protocol (1-3 months)

The rehabilitation program should follow this systematic progression 1:

• Restore full passive and active range of motion without pain 1
• Address scapular dyskinesis, as poor coordination of scapular upward rotation and posterior tilting contributes to rotator cuff injury 1
• Perform rotator cuff strengthening targeting the supraspinatus, external rotators, and other cuff muscles 1
• Strengthen scapular stabilizers to restore proper scapulohumeral rhythm 1
• Correct muscular imbalances, particularly weakened posterior shoulder musculature combined with overdeveloped anterior musculature 1
• Re-establish proper mechanics of the shoulder and spine before return to activity 1

Evidence Supporting Conservative Treatment

A high-quality randomized controlled trial with over 5-year follow-up demonstrated no significant differences between physiotherapy alone, acromioplasty with physiotherapy, and rotator cuff repair with acromioplasty in patients over 55 years with small, nontraumatic supraspinatus tears. 2

• Mean improvement in Constant score was 18.5 for physiotherapy alone, 17.9 for acromioplasty with physiotherapy, and 20.0 for rotator cuff repair (P = 0.84) 2
• No significant differences in pain scores (P = 0.74) or patient satisfaction (P = 0.83) 2
• Operative treatment did not protect against glenohumeral osteoarthritis or rotator cuff tear arthropathy progression 2

Patients with well-preserved function of the supraspinatus and infraspinatus are the best candidates for conservative treatment. 3

When to Consider Surgical Referral

Surgery should be considered only after failed conservative management or in specific high-risk populations. 3

Indications for surgical consideration:

• Failure to improve clinically within the expected 1-3 month timeframe 1
• Progression to fatty degeneration on repeat imaging 1
• High risk of tear expansion 3
• Less functional rotator cuff muscles at baseline 3
• Recurrence of symptoms related to tear expansion after initially successful conservative treatment 3

Critical Pitfalls to Avoid

Do not allow premature return to activity - athletes and workers must complete the full rehabilitation protocol and demonstrate pain-free motion and full strength before resuming throwing or overhead activities 1

Recognize that secondary impingement from rotator cuff weakness is the primary mechanism in younger patients, not primary structural impingement 1

Monitor for progression to fatty degeneration - if patients fail to improve within 1-3 months, obtain repeat imaging to assess for muscle quality deterioration 1

Underlying Pathophysiology Context

The supraspinatus tendon is vulnerable due to 4:

• Repeated impingement involving subacromial impingement and superior migration of the humeral head, affecting approximately 1 in 50 adults 4
• Inherently poor blood supply in the region proximal to the tendon insertion 4
• Minimal anatomical clearance between the tendon and coracoacromial arch during normal shoulder abduction 4