What are the treatment options for an adult or elderly patient with an MRI showing full thickness tears of the subscapularis and supraspinatus tendons, medial retraction, volume loss, marked tendinopathy at the biceps, severe Acromioclavicular (AC) joint arthrosis, and a superior labral tear?

Treatment Approach for Multi-Tendon Rotator Cuff Tears with Severe Degenerative Changes

This patient requires urgent orthopedic surgical consultation for consideration of rotator cuff repair, given the presence of full-thickness tears of both subscapularis and supraspinatus tendons with medial retraction and volume loss, which portend poor outcomes if left untreated. 1, 2

Immediate Management

Orthopedic Referral is Critical

• Acute and traumatic full-thickness tears with retraction should be repaired surgically due to the tendency of these tendons to retract medially and develop progressive muscle atrophy 2
• The presence of both subscapularis and supraspinatus tears significantly worsens prognosis, with subscapularis tears portending a different and often worse prognosis than isolated supraspinatus tears, especially when diagnosis is delayed 3
• Volume loss indicates chronicity and muscle atrophy, which correlates with larger tear size, higher Goutallier grades (fatty infiltration), and worse surgical outcomes 4, 5

Why Surgery is Strongly Indicated

The combination of findings makes this a surgical case:

• Full-thickness tears of two major rotator cuff tendons with retraction indicate complete disruption requiring anatomic repair 1, 2
• Medial retraction prevents spontaneous healing and leads to progressive muscle atrophy if not addressed 2
• Marked biceps tendinopathy is invariably present with subscapularis tears and must be addressed surgically (tenotomy or tenodesis) 2
• Superior labral tear adds to the complexity and typically requires arthroscopic repair 6
• The goal of surgery is to achieve tendon-to-bone healing, which correlates with improved long-term outcomes 1

Surgical Considerations

Repair Approach

• Arthroscopic repair is the preferred technique for most subscapularis and supraspinatus tears, using a laterally-based single row repair 2
• For subscapularis tears: one anchor for tears ≤50% of tendon length, two anchors for tears ≥50% 2
• Tendon mobilization is critical for larger tears to achieve adequate repair without excessive tension 7, 2
• Acromioplasty is not required for normal acromial morphology and does not improve outcomes 1

Addressing Associated Pathology

• Biceps pathology must be addressed through tenotomy or tenodesis given the marked tendinopathy 2
• Superior labral tear should be repaired arthroscopically during the same procedure 6
• Severe AC joint arthrosis may require distal clavicle excision if symptomatic, though this can be staged 6

If Surgery is Delayed or Contraindicated

Conservative Management (Suboptimal for This Case)

• Physical therapy focusing on rotator cuff strengthening and scapular stabilization can be attempted, though outcomes are poor with full-thickness tears and retraction 8, 1
• Subacromial corticosteroid injection may provide temporary pain relief but does not address the structural pathology 8
• Activity modification and anti-inflammatory medications as adjuncts 1

Critical Monitoring Points

• Reassess at 3-6 months if conservative management is attempted, though this delay allows further muscle atrophy and worsens surgical outcomes 8, 1
• Progressive weakness, inability to perform overhead activities, or worsening pain indicate failure of conservative treatment 1

Critical Pitfalls to Avoid

Timing is Everything

• Delayed diagnosis and treatment of subscapularis tears leads to worse outcomes compared to acute repair 3, 2
• Progressive muscle atrophy and fatty infiltration occur with delayed treatment, making repair more difficult and less successful 4, 5
• The presence of volume loss already indicates chronicity, making urgent referral even more critical 4

Associated Pathology Cannot Be Ignored

• Biceps pathology is invariably present with subscapularis tears and must be addressed surgically 2
• Concomitant rotator cuff tears (both subscapularis and supraspinatus in this case) are associated with larger tear sizes, higher Goutallier grades, and increased muscle volume loss 4
• Superior labral tears require arthroscopic repair and will not heal with conservative management 6

Age and Chronicity Considerations

• Patients ≥55 years with subscapularis tears have larger tear sizes (35mm vs 19mm), higher Goutallier grades (2.7 vs 0.8), and greater muscle volume loss (25% vs 5%) compared to younger patients 4
• Chronic tears with significant degeneration may not be repairable and could require salvage procedures like tendon transfers or reverse total shoulder arthroplasty 7