What is the management for a patient with chronic left shoulder pain and full thickness, partial tears of supraspinatus and infraspinatus tendons, who has had steroid injections in the past?

Management of Chronic Rotator Cuff Tears with Failed Steroid Injections

For this patient with chronic, symptomatic full-thickness tears of the supraspinatus and infraspinatus who has failed prior steroid injections, surgical rotator cuff repair should be offered as the primary treatment option. 1

Rationale for Surgical Intervention

Rotator cuff repair is an appropriate option for patients with chronic, symptomatic full-thickness tears, particularly when conservative measures have been exhausted. 1 The evidence demonstrates that surgical patients experience significantly less pain with shoulder range of motion and at night compared to those managed non-surgically, with 81% of surgical patients reporting excellent results versus only 37% with non-surgical treatment. 1

Key Factors Supporting Surgery in This Case:

• Ongoing chronic pain despite prior steroid injections indicates failure of conservative management 1
• Full-thickness tears of two tendons (supraspinatus and infraspinatus) represent significant structural pathology 2
• Multi-tendon involvement (both supraspinatus and infraspinatus) is associated with lower healing rates if left untreated and predicts poorer response to conservative therapy 2, 3

Important Considerations Before Surgery

Age-Related Healing Capacity

• Patients over 65 years have significantly lower healing rates after repair, with only 43% achieving complete tendon healing compared to higher rates in younger patients 3
• Postoperative healing rates are inconsistent in elderly patients, which should factor into surgical decision-making 1

Tear Characteristics

• Associated delamination of multiple tendons (as in this case with both supraspinatus and infraspinatus involvement) is negatively associated with tendon healing outcomes 3
• Patients with well-preserved function of the supraspinatus and infraspinatus are better candidates for conservative treatment, but this patient has already failed such management 2

If Surgery is Declined or Contraindicated

While the evidence for non-surgical management is weak and inconclusive, the following options exist:

Exercise Programs

• The evidence cannot definitively recommend for or against supervised or unsupervised exercise programs for rotator cuff tears 1
• Two level IV studies showed some improvements with both supervised and home physical therapy, though results were inconsistent 1

Additional Steroid Injections

• The evidence cannot recommend for or against additional subacromial injections in patients with rotator cuff tears 1
• One level II study found no significant difference between corticosteroid with lidocaine versus lidocaine alone at 6 weeks 1
• Clinicians should consider potential adverse effects of corticosteroid injection on rotator cuff tendon biology and healing capacity, particularly if future surgical repair is contemplated 1
• For rotator cuff disease, subacromial steroid injection demonstrated only small benefit over placebo in some trials 4

Other Modalities

• NSAIDs, activity modification, ice, heat, iontophoresis, massage, TENS, and other physical modalities lack sufficient evidence for recommendation in rotator cuff tears 1

Critical Pitfalls to Avoid

• Do not delay surgical referral indefinitely in symptomatic patients, as tear expansion over time is associated with symptom recurrence and decreased likelihood of successful conservative treatment 2
• Avoid multiple repeated corticosteroid injections without clear benefit, as this may compromise future surgical outcomes 1
• Do not assume all rotator cuff tears require immediate surgery—asymptomatic tears should not be surgically repaired 1
• Recognize that patients with high risk of tear expansion and less functional rotator cuff muscles are less likely to respond to conservative treatment and may need earlier surgical intervention 2

Practical Algorithm

1. Confirm the patient has significant ongoing pain (primary indication for surgery) 1
2. Assess patient age and functional demands—healing rates decline significantly after age 65 3
3. Refer to orthopedic surgery for evaluation given failed conservative management with prior steroid injections 1
4. If surgery is declined: Consider a trial of structured physical therapy, though evidence is weak 1
5. Avoid opioids as first-line treatment—reserve strictly for rescue analgesia 5