What is the recommended treatment for a 65-year-old patient with a complete rupture of the supraspinatus tendon, complete tear of the infraspinatus tendon, subdeltoid bursitis, and limited range of motion in the left shoulder?

Treatment Recommendation for Complete Rotator Cuff Tears with Adhesive Capsulitis

This 65-year-old patient with complete full-thickness tears of both supraspinatus and infraspinatus tendons with retraction, combined with adhesive capsulitis, should be referred for urgent surgical consultation while initiating conservative management, as the presence of complete tears with retraction and significant functional limitation (only 20 degrees of abduction) indicates a high likelihood of requiring surgical repair to prevent irreversible muscle atrophy and fatty infiltration. 1, 2

Immediate Management Priorities

Surgical Referral Criteria Met

• Complete full-thickness tears with medial retraction represent a surgical indication, particularly given the patient's age and functional demands 1, 2
• The presence of two complete rotator cuff tears (supraspinatus and infraspinatus) with retraction significantly increases the risk of progressive muscle atrophy and fatty infiltration if left untreated 2, 3
• Profound weakness and inability to perform overhead activities beyond 20 degrees of abduction warrants earlier imaging and surgical consultation rather than waiting 3-6 months 1

Critical Timing Consideration

• Infraspinatus tears progress to irreversible stage 4 fatty infiltration within 6-12 months regardless of treatment approach, making early surgical intervention crucial to preserve muscle function 3
• Surgical repair shows superior outcomes compared to physical therapy alone when tears are small to medium-sized and successfully healed 2

Concurrent Conservative Management During Surgical Evaluation

Pain and Inflammation Control

• Subacromial-subdeltoid bursitis requires treatment as bursal effusion is significantly associated with shoulder pain and may be a primary factor in persistent limitation 4, 5
• Consider subacromial corticosteroid injection for bursitis, which has shown effectiveness in similar presentations with rotator cuff pathology and bursitis 5
• The combination of intraarticular and subacromial corticosteroid injections may provide better pain relief than oral NSAIDs alone 5

Addressing Adhesive Capsulitis Component

• The globally restricted movement suggesting adhesive capsulitis requires specific attention to prevent further functional decline 6
• Shoulder passive range of motion exercises should be initiated cautiously, though evidence for PROM preventing contracture is conflicting 6
• Aggressive range-of-motion exercises including shoulder, elbow, wrist and hand motion should begin early to prevent further stiffness 6

Rehabilitation Protocol (Pre-operative or If Surgery Declined)

Initial Phase: Pain Control and Gentle Mobilization

• Complete rest from all overhead activities and loaded movements is mandatory until pain subsides 1, 2
• Focus on pain-free passive range of motion within the limited 20-degree abduction tolerance 6
• Address the adhesive capsulitis component with gentle mobilization techniques 6

Progression Criteria (If Conservative Management Pursued)

Progress only when ALL criteria are met: 1, 2

• Pain-free performance of current exercises
• Full active range of motion achieved
• No increase in resting pain or night pain
• Proper scapular mechanics demonstrated during movement

Structured Rehabilitation Components

• Rotator cuff strengthening exercises targeting remaining intact structures (subscapularis, long head of biceps) 1
• Scapular stabilizer strengthening to compensate for rotator cuff deficiency 1
• Re-establishing proper shoulder and spine mechanics 1

Critical Pitfalls and Caveats

Age-Related Considerations

• At 65 years old, this patient faces higher failure rates and poorer outcomes after rotator cuff repair, requiring realistic expectations and potentially more conservative weight progression post-operatively 2
• Older patients may have pre-existing degenerative changes that complicate healing 2

Natural History Without Surgery

• Strong evidence shows that tear size, muscle atrophy, and fatty infiltration progress over 5-10 years with nonsurgical management 2
• Physical therapy improves patient-reported outcomes but does not prevent structural deterioration 2
• The infraspinatus tear will progress to complete fatty infiltration regardless of conservative treatment 3

Monitoring for Deterioration

• If symptoms persist or progress despite 3-6 months of appropriate rehabilitation, surgical consultation becomes mandatory 1, 2
• Progressive neurological symptoms require urgent evaluation to rule out nerve injury 1

Specific Treatment Algorithm

Week 1-2:

• Urgent orthopedic surgical consultation 1
• Consider subacromial corticosteroid injection for bursitis 5
• Initiate gentle passive range of motion exercises 6
• Complete rest from loaded activities 1, 2

Week 2-6 (Pre-operative or if surgery delayed):

• Continue pain-free passive range of motion 6
• Begin gentle active-assisted range of motion as tolerated 6
• Address adhesive capsulitis with mobilization techniques 6

Week 6+ (If surgery declined or delayed):

• Progress to active range of motion exercises 1
• Initiate scapular stabilization exercises 1
• Begin rotator cuff strengthening of intact structures 1
• No loaded overhead activities until all progression criteria met 1, 2

Surgical Timing Recommendation

Given the complete tears with retraction, subdeltoid bursitis, and coexisting adhesive capsulitis limiting abduction to only 20 degrees, surgical repair should be pursued within 6-12 months to prevent irreversible fatty infiltration of the infraspinatus muscle 3, 2