What is the best treatment approach for a patient with right shoulder tendonitis, a supraspinatus (rotator cuff) tear, and suspected ligamentous involvement?

Treatment Approach for Right Shoulder Tendonitis with Supraspinatus Tear and Suspected Ligamentous Involvement

Begin with conservative management including structured physical therapy and NSAIDs, reserving surgical intervention for cases that fail to improve after 3-6 months of appropriate non-operative treatment. 1, 2

Initial Diagnostic Confirmation

• Obtain MRI shoulder without IV contrast immediately to confirm the supraspinatus tear size, assess for full-thickness versus partial-thickness involvement, evaluate muscle atrophy and fatty infiltration, and identify any ligamentous pathology 3
• MRI is the optimal modality with 98% sensitivity for rotator cuff tears and will guide all subsequent treatment decisions 3
• The presence of suspected ligamentous involvement necessitates advanced imaging before proceeding with any treatment plan 3

Conservative Treatment Protocol (First-Line)

Patient Selection for Non-Operative Management

• Conservative treatment is particularly effective for small, non-traumatic supraspinatus tears in patients with well-preserved supraspinatus and infraspinatus function 2, 4
• A 2021 randomized controlled trial with over 5-year follow-up demonstrated no significant difference between operative and conservative treatment for small supraspinatus tears (mean 10mm) in patients older than 55 years 2

Structured Physical Therapy Program

• Implement a progressive exercise regimen focusing on scapulothoracic and glenohumeral range-of-motion exercises followed by strengthening 1, 5
• Eccentric training exercises for the rotator cuff should be incorporated as they demonstrate beneficial effects for supraspinatus tendinopathy 6
• Address any biomechanical abnormalities including scapular dyskinesis and excessive foot pronation that may contribute to shoulder pathology 1, 3

Pharmacologic Management

• Prescribe NSAIDs such as naproxen 500mg twice daily for pain control and anti-inflammatory effects 7
• For acute pain management, naproxen can be initiated at 500mg followed by 500mg every 12 hours or 250mg every 6-8 hours, with initial daily dose not exceeding 1250mg 7
• The evidence for perioperative or chronic use of NSAIDs in rotator cuff pathology is inconclusive, but they remain a reasonable option for symptom management 1

Adjunctive Modalities

• Subacromial corticosteroid injections may provide short-term pain relief (up to 6 weeks) but do not change long-term outcomes 1
• One level II study found no significant difference between corticosteroid with lidocaine versus lidocaine alone at 6 weeks in patients with rotator cuff tears 1
• Extracorporeal shock wave therapy (ESWT) appears safe and may be effective, though optimal treatment strategies require further clarification 1
• Therapeutic ultrasound, iontophoresis, and phonophoresis are widely used but lack high-quality evidence supporting their effectiveness 1

Duration of Conservative Trial

• Continue conservative management for 3-6 months before considering surgical referral 1
• Monitor for tear progression, as expansion of the tear correlates with symptom recurrence and reduced likelihood of conservative treatment success 4
• Patients with high risk of tear expansion or less functional rotator cuff muscles are less likely to respond to conservative treatment 4

Surgical Indications and Timing

When to Refer for Surgical Evaluation

• Persistent pain despite well-managed conservative treatment for 3-6 months warrants orthopedic surgical evaluation 1
• Rotator cuff repair is an option for patients with chronic, symptomatic full-thickness tears based on level III evidence 1
• One level III study demonstrated that 81% of surgical patients reported excellent results compared to 37% with non-surgical treatment, with statistically significant less pain on shoulder range of motion and at night 1

Surgical Considerations

• Routine acromioplasty is not required at the time of rotator cuff repair based on two level II studies showing no benefit in postoperative functional outcomes 1, 3
• Two randomized prospective studies found no significant differences in ASES, Constant-Murley, or DASH scores between rotator cuff repair with versus without acromioplasty 1, 3
• The evidence is inconclusive regarding optimal surgical technique (arthroscopic versus mini-open versus open repair) 1
• For irreparable tears, partial repair, debridement, or muscle transfers are treatment options that demonstrate improvement in pain and function 1

Prognostic Factors Affecting Surgical Outcomes

• Advise patients that preoperative muscle atrophy and fatty degeneration of the supraspinatus and infraspinatus negatively affect both tendon healing and clinical outcomes 1
• Workers' compensation status correlates with less favorable outcomes after rotator cuff repair based on level II and III evidence 1
• Delayed rotator cuff repair up to 4 months has not shown adverse outcomes 3

Critical Pitfalls to Avoid

• Do not proceed to orthopedic referral without obtaining MRI, as advanced imaging is essential to confirm diagnosis, characterize tear extent, assess muscle quality, and guide appropriate treatment planning 3
• Do not assume asymptomatic rotator cuff tears require surgery, as they are highly prevalent in older populations and surgery is not indicated without significant symptoms 1
• Do not use ultrasound as the primary diagnostic modality due to variable interobserver agreement for partial-thickness tears and operator-dependent limitations 3
• Do not routinely perform acromioplasty at the time of rotator cuff repair, as level II evidence demonstrates no benefit 1, 3
• Do not dismiss conservative treatment prematurely, as the 2021 randomized trial with 6.2-year follow-up showed operative treatment is no better than conservative treatment for small, non-traumatic supraspinatus tears 2

Monitoring and Follow-Up

• Reassess pain levels, functional status (using validated outcome measures like SST or ASES), and range of motion every 4-6 weeks during conservative treatment 5
• Consider repeat MRI if symptoms worsen or fail to improve, as tear progression may indicate need for surgical intervention 4
• The mean progression of glenohumeral osteoarthritis occurs regardless of treatment approach, so operative treatment does not protect against joint degeneration 2