What is the best treatment approach for a patient with shoulder pain, a history of Polymyalgia Rheumatica (PMR), and an ultrasound showing a supraspinatus full thickness partial width tear?

Treatment of Shoulder Pain with PMR History and Supraspinatus Full-Thickness Partial-Width Tear

For this patient with a full-thickness partial-width supraspinatus tear and PMR history, initiate a trial of conservative management with physical therapy, NSAIDs/analgesics for the structural shoulder pathology, and carefully optimize glucocorticoid dosing for the underlying PMR, reserving surgical referral for cases failing 3-6 months of conservative treatment or those with significant functional impairment.

Understanding the Dual Pathology

This clinical scenario involves two distinct pain generators requiring separate consideration:

• The rotator cuff tear: A full-thickness partial-width tear represents complete disruption through the tendon thickness but not across its entire width 1, 2
• The PMR component: Active or residual inflammatory disease affecting the shoulder girdle that may amplify pain perception 1

The key challenge is distinguishing mechanical pain from the tear versus inflammatory pain from PMR, as this determines treatment priorities.

Initial Conservative Management Approach

For the Rotator Cuff Pathology

Physical therapy forms the cornerstone of initial treatment for partial-thickness and small full-thickness tears 2. The evidence strongly supports a 3-6 month trial:

• 74.5% of partial-thickness tears remain stable or improve with conservative treatment 3
• 63.8% of patients demonstrate clinical improvement even when radiological healing is incomplete 3
• Conservative treatment should include structured physical therapy focusing on rotator cuff strengthening, scapular stabilization, and range of motion exercises 2

NSAIDs and analgesics are appropriate specifically for the structural shoulder pathology, not for PMR treatment 1. This is a critical distinction—the PMR guidelines explicitly state that glucocorticoids, not NSAIDs, should treat PMR itself 1.

For the PMR Component

Ensure the patient is on appropriate glucocorticoid therapy if PMR is still active:

• If newly diagnosed or undertreated: initiate prednisone 12.5-25 mg daily, with lower doses (12.5-15 mg) preferred given the need to avoid steroid-related complications that could impair rotator cuff healing 1
• If already on maintenance therapy: verify the patient is not undertreated, as inadequate PMR control will amplify shoulder pain 1
• Consider subacromial corticosteroid injection as an adjunct for localized inflammation, though this addresses the structural pathology rather than systemic PMR 2

Monitoring and Decision Points

Clinical Predictors of Conservative Success

Patients more likely to improve with conservative treatment include those with:

• Non-dominant shoulder involvement 3
• Atraumatic onset of symptoms 3
• Smaller tear size and minimal retraction 3

When to Consider Surgical Referral

Refer to orthopedic surgery if:

• No improvement in pain or function after 3-6 months of structured physical therapy 2, 3
• Progressive weakness or inability to perform activities of daily living 2
• Patient age, activity level, and functional demands warrant more aggressive intervention 2
• Concern for tear progression on repeat imaging 3

The American Academy of Orthopaedic Surgeons indicates that surgical repair aims to achieve tendon-to-bone healing, which correlates with improved long-term outcomes 2. For full-thickness tears with retraction (as in this case with 1.4 cm retraction), surgery may ultimately provide superior results, but a conservative trial remains appropriate initially 2.

Critical Pitfalls to Avoid

Do not attribute all shoulder pain to PMR alone—this leads to overtreatment with glucocorticoids while missing the structural pathology 4. Conversely, do not undertreate active PMR while focusing solely on the rotator cuff tear.

Do not use high-dose glucocorticoids (>30 mg prednisone daily) for PMR, as this increases complications without improving outcomes and may impair tendon healing 1.

Failure to respond to appropriate treatment should prompt reassessment: Consider whether PMR is adequately controlled, whether the tear has progressed, or whether other pathology (such as adhesive capsulitis, which can coexist) is present 2, 4.

Advanced Treatment Considerations

If conservative management fails and the patient wishes to avoid or delay surgery, emerging evidence supports microfragmented adipose tissue (MFAT) with platelet-rich plasma (PRP) as a regenerative option for partial and full-thickness tears 5, 6. However, this remains investigational and should be discussed with a specialist.

Surgical repair does not require acromioplasty for normal acromial morphology, as outcomes are equivalent with or without this additional procedure 2.