Management of Full-Thickness Supraspinatus Tear in a 65-Year-Old Male
Initial conservative management with physical therapy, NSAIDs, and activity modification should be the first-line approach for at least 3-6 months, with surgical repair reserved for those who fail conservative treatment or have significant functional limitations. 1, 2
Initial Conservative Treatment (First-Line for 3-6 Months)
The American Academy of Family Physicians and American Academy of Orthopaedic Surgeons recommend starting with non-surgical management for all rotator cuff tears, particularly in patients over 65 years old 1, 2, 3:
- Physical therapy focusing on strengthening, flexibility, and functional restoration is the primary treatment modality 1, 2
- Relative rest by reducing repetitive overhead activities and movements that aggravate symptoms, while avoiding complete immobilization to prevent muscular atrophy and deconditioning 4, 2
- NSAIDs (topical or oral) for pain relief, though their role is primarily analgesic since chronic tendinopathy involves degeneration rather than acute inflammation 4, 2
- Cryotherapy applied through a wet towel for 10-minute periods to reduce pain 4, 2
- Activity modification to eliminate repetitive stresses and overhead movements 2
Important Caveat About Corticosteroid Injections
Avoid intratendinous corticosteroid injections as they may inhibit healing and reduce tensile strength, predisposing to spontaneous rupture 2. Peritendinous injections can provide temporary relief but should be used with caution, as their effects on tendon healing remain unclear 4.
When to Consider Surgical Repair
Proceed to surgical intervention when 1, 2:
- Conservative treatment fails after 3-6 months
- Patient has significant functional limitations despite conservative management
- Patient desires return to higher activity levels
Critical Age-Related Consideration
Patients over 65 years have significantly lower healing rates after surgical repair (only 43% complete healing vs. 71% overall), though surgery can still provide good functional outcomes and high patient satisfaction (93%) 5, 6. The evidence shows that in patients older than 55 years with small, nontraumatic supraspinatus tears, operative treatment provides no significant advantage over conservative treatment at 5+ years follow-up 3.
Surgical Approach (If Conservative Treatment Fails)
When surgery is indicated 4, 1, 2:
- Primary goal: Achieve tendon-to-bone healing, which correlates with improved clinical outcomes and better strength 4, 1, 6
- Technique options: Arthroscopic, mini-open, or open repair can all be used, as no single technique has proven superiority 4
- Do NOT perform routine acromioplasty for normal acromial bone (including type II and III morphology), as studies show no significant difference in outcomes with or without acromioplasty 1, 2
- Fixation method: Either suture anchors or bone tunnels are acceptable, as no comparative evidence supports one over the other 4
Post-Surgical Recovery Protocol
- Sling immobilization for 4-6 weeks immediately post-surgery 1, 2
- Structured rehabilitation program lasting several months is essential for optimal recovery 1
Key Clinical Pitfalls to Avoid
- Do not rush to surgery without completing an adequate trial of conservative management (minimum 3-6 months) 2, 3
- Do not perform complete immobilization during conservative treatment, as this leads to muscular atrophy and deconditioning 4, 2
- Do not inject corticosteroids into the tendon substance, only consider peritendinous injections if necessary 4, 2
- Do not routinely add acromioplasty during rotator cuff repair, as it provides no additional benefit 1, 2
Expected Outcomes
With conservative treatment, patients can achieve significant improvement in pain and function 3. If surgery is performed, complete tendon healing occurs in approximately 70% of cases overall, but only 43% in patients over 65 years 5, 6. However, even without complete healing, 93% of patients report satisfaction with surgical outcomes 5. Healed repairs demonstrate better strength (7.3 kg vs. 4.7 kg for non-healed repairs) 6.