What is the initial management for a patient with tendinopathy in the supraspinatus and subscapularis tendons, presenting with impingement on dynamic maneuvers of the shoulder?

Initial Management of Supraspinatus and Subscapularis Tendinopathy with Impingement

Begin with relative rest combined with eccentric strengthening exercises for 3-6 months, as this conservative approach forms the cornerstone of treatment and can reverse degenerative tendon changes. 1, 2

Immediate Activity Modification

• Eliminate overhead activities and any movements that reproduce your patient's pain, particularly those involving simultaneous abduction and internal rotation of the shoulder 1, 2
• Reduce repetitive loading of the affected tendons to prevent further damage and allow healing to begin 3, 1
• Apply ice through a wet towel for 10-minute periods immediately after any pain-provoking activities for acute pain relief 2

Physical Examination Findings to Confirm

• Palpation should elicit well-localized tenderness over the supraspinatus (superior) and subscapularis (anterior) regions that matches the quality and location of activity-related pain 3, 1
• Hawkins' test (forced internal rotation with arm passively flexed to 90 degrees) will be positive—this is 92% sensitive but only 25% specific for impingement 3, 1
• Neer's test (full forward flexion between 70-120 degrees) will provoke pain—88% sensitive but only 33% specific 3, 1
• Look for deltoid or rotator cuff atrophy, which indicates chronicity 4
• Check for weakness on abduction (supraspinatus) and internal rotation (subscapularis) 4

Core Treatment Protocol

Eccentric Exercise Program (Primary Treatment)

• Initiate eccentric strengthening exercises as the foundation of treatment—these must continue for at least 3-6 months to achieve optimal results and reverse degenerative changes 1, 2
• Start conservatively to avoid worsening symptoms; inadequate exercise progression is a common pitfall 1, 2
• This active rehabilitation should remain the foundation throughout treatment 2

Pain Management

• Prescribe oral NSAIDs for short-term pain relief, though recognize they do not alter long-term outcomes 2
• Consider topical NSAIDs as an alternative with fewer systemic side effects 2
• Avoid excessive corticosteroid use—while subacromial injections may provide better acute pain relief than NSAIDs, they do not improve long-term outcomes and can weaken tendons and inhibit healing 1, 2, 5

Imaging Strategy

• Plain radiographs are appropriate initially to rule out bony abnormalities such as acromion spurs, acromioclavicular joint degeneration, or calcific deposits, though they cannot demonstrate soft tissue tendon changes 3, 1, 4
• Reserve MRI or ultrasound for unclear diagnoses or recalcitrant pain after adequate conservative management 3
• MRI is 95% sensitive and 95% specific for detecting rotator cuff tears, degeneration, and partial tears 3, 1
• Ultrasound is useful for moderate to full-thickness tears but has limited ability to detect small tears 3, 1

Intermediate Interventions (If Initial Management Insufficient)

• Extracorporeal shock wave therapy (ESWT) is safe and potentially effective for pain relief, though costly 1, 2
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1, 2
• Ultrasound-guided corticosteroid injection into the subacromial bursa can be considered for acute pain relief, but use cautiously given lack of long-term benefit 2, 5

Surgical Referral Criteria

• Refer to orthopedic surgery if pain persists despite well-managed conservative treatment for 3-6 months 1, 2
• Surgery typically involves excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 1, 2
• This is effective in carefully selected patients but should not be considered before adequate conservative trial 1, 2

Critical Pitfalls to Avoid

• Do not rely solely on Hawkins' and Neer's tests for diagnosis—they are sensitive but not specific, so clinical context is essential 1, 2
• Do not start exercises too aggressively—this commonly worsens symptoms and delays recovery 1, 2
• Do not allow premature return to overhead activities—this leads to symptom recurrence 1, 2
• Do not delay surgical referral beyond 3-6 months of failed conservative treatment 1, 2
• Do not use corticosteroids excessively—they provide only short-term relief and may compromise tendon integrity 1, 2