What is the best treatment for a patient with insertional tears, labral tears, and AC joint osteoarthritis?

Treatment Approach for Insertional Rotator Cuff Tears, Labral Tears, and AC Joint Osteoarthritis

Begin with a comprehensive conservative management program including physical therapy focused on rotator cuff and periscapular strengthening, activity modification, oral NSAIDs or paracetamol, and consider intra-articular corticosteroid injections for the AC joint, reserving surgical intervention for cases that fail to respond after at least 3-6 months of non-operative treatment. 1, 2

Initial Conservative Management (First-Line Treatment)

Physical Therapy Protocol

• Rotator cuff and periscapular muscle strengthening should be the foundation of rehabilitation for both the insertional tears and labral pathology 2
• Core musculature strengthening is essential for shoulder stability 2
• Capsule flexibility exercises should be incorporated to address any restrictions 2
• Physical therapy has limited benefit for AC joint osteoarthritis itself, as therapeutic exercise plays only a minor role in this specific pathology 3

Pharmacological Management

• Start with paracetamol as the first-line analgesic, which is relatively safe and should be tried before advancing to NSAIDs 4
• Topical NSAIDs can be considered as an adjunctive treatment with lower systemic toxicity 4
• Oral NSAIDs or COX-2 inhibitors should be used at the lowest effective dose for the shortest duration, prescribed alongside a proton pump inhibitor 4
• Consider patient-specific risk factors including age, gastrointestinal, hepatic, and cardiorenal risks when selecting NSAIDs 4

Targeted Injection Therapy

• Intra-articular corticosteroid injection into the AC joint may provide short-term pain relief for moderate to severe AC joint pain, though it does not alter disease progression 4, 3
• A diagnostic local anesthetic injection into the AC joint can help confirm the AC joint as a pain source before proceeding with corticosteroid injection 3
• Avoid subacromial injections as the primary pathology involves insertional tears and labral pathology, not typical rotator cuff disease 5

Activity Modification

• Modify activities that provoke symptoms, particularly overhead activities and movements that stress the labrum 1, 2
• This conservative phase should last at least 3-6 months before considering surgical options 2, 3

Surgical Intervention (When Conservative Management Fails)

Indications for Surgery

• Failure to respond to conservative treatment after 3-6 months is the primary indication for surgical consultation 2, 3
• Persistent mechanical symptoms (locking, catching) despite conservative care 1
• Significant functional limitation affecting quality of life 4

Surgical Options by Pathology

For Labral Tears (SLAP and Posterior Inferior Labral Tears):

• Arthroscopic labral repair is the appropriate surgical treatment for symptomatic labral tears causing instability 5
• MR arthrography should be obtained preoperatively as it is the gold standard for confirming labral pathology 1, 2, 5

For Insertional Rotator Cuff Tears:

• Arthroscopic repair of partial-thickness tears if they are symptomatic and have failed conservative management 4
• The decision should be based on tear size, patient age, activity level, and functional demands 4

For AC Joint Osteoarthritis:

• Open or arthroscopic distal clavicle resection is indicated after minimum 6 months of unsuccessful conservative treatment 3
• This can be performed concurrently with labral and rotator cuff repairs during the same arthroscopic procedure 3

Post-Surgical Rehabilitation

Timeline for Return to Activity

• Minimum 6 weeks of rest from overhead activities or throwing motions after SLAP repair 2
• Additional 6 weeks of strengthening phase (total 3 months minimum before return to demanding activities) 2
• Return to sports should be based on functional testing rather than arbitrary time points 2

Critical Pitfalls to Avoid

• Do not delay imaging: Obtain standard radiographs first (AP in internal/external rotation plus axillary view), followed by MR arthrography if surgical intervention is being considered 1, 2
• Do not use rotator cuff treatment algorithms for labral pathology: These are distinct entities requiring different approaches 5
• Do not overlook associated injuries: In traumatic cases, multiple pathologies often coexist and must all be addressed 1
• Do not rush to surgery in older patients: Age should not be a barrier to treatment, but the natural history of partial rotator cuff tears in older adults may favor conservative management 4
• Do not use corticosteroid injections into the glenohumeral joint for labral tears: This does not address the structural pathology and may delay appropriate surgical intervention 5

Prognostic Considerations

• Long-term outcomes after arthroscopic labral repair show maintained improvement in most cases without significant progression of arthritis at 7-10 years follow-up 6
• Conservative management success rates vary, but surgical consultation should not be delayed beyond 6 months if symptoms persist 3, 7
• The combination of pathologies (rotator cuff, labrum, AC joint) may require staged or combined surgical approaches depending on which structure is the primary pain generator 3