What is the recommended treatment plan for a patient with a low-grade tear in the subscapularis and posterior two thirds of the supraspinatus tendon, moderate subacromial-subdeltoid bursitis, and an incidental finding of a probable intramuscular lipoma versus post-traumatic fatty infiltration in the infraspinatus muscle, one month post-injury?

Treatment Plan for Low-Grade Rotator Cuff Tears with Bursitis at 1 Month Post-Injury

Begin with a structured 3-6 month trial of conservative management including physical therapy focused on rotator cuff strengthening, NSAIDs for pain control, activity modification to avoid overhead movements, and consider a subacromial corticosteroid injection for the moderate bursitis. 1, 2

Initial Conservative Management (First-Line Treatment)

Physical Therapy Protocol:

• Initiate supervised physical therapy focusing specifically on strengthening the subscapularis and supraspinatus muscles, improving shoulder flexibility, and restoring functional range of motion 1, 2
• Emphasize relative rest by reducing repetitive overhead activities and loading of the damaged tendons, while avoiding complete immobilization to prevent muscular atrophy 2
• Continue therapy for a minimum of 3-6 months before considering surgical intervention 1, 2

Pharmacologic Management:

• Prescribe NSAIDs (oral or topical) primarily for analgesic effect, recognizing that chronic tendinopathy involves degeneration rather than acute inflammation 2
• Apply cryotherapy through a wet towel for 10-minute periods to reduce pain 2

Corticosteroid Injection for Bursitis:

• Consider a subacromial corticosteroid injection to address the moderate subacromial-subdeltoid bursitis, which may provide symptomatic relief 3
• One case report demonstrated successful resolution of similar pathology (infraspinatus tear with bursitis) using combined intraarticular and subacromial triamcinolone acetate (40 mg/ml) 1 ml + 1% lidocaine with adrenaline 9 ml 3
• Critical caveat: Avoid intratendinous corticosteroid injections, as they may inhibit healing and reduce tensile strength, predisposing to spontaneous rupture 2

Activity Modification

• Eliminate repetitive overhead movements and activities that aggravate the shoulder 2
• Avoid combined internal rotation with arm abduction positions that stress the rotator cuff 3
• Modify work or athletic activities to reduce repetitive loading of the damaged tendons 2

Addressing the Incidental Finding

Infraspinatus Lipoma vs. Post-Traumatic Fatty Infiltration:

• The distinction between intramuscular lipoma and post-traumatic fatty infiltration is clinically important, as fatty infiltration correlates with worse healing potential and surgical outcomes 1
• MRI is the preferred imaging modality to characterize this finding, as lipomas demonstrate pathognomonic fat signal characteristics 4, 5
• If this represents true fatty infiltration rather than lipoma, it indicates muscle quality deterioration that negatively affects both tendon healing and clinical outcomes if surgery becomes necessary 6, 1
• Subacromial lipomas are rare but can cause impingement symptoms and may require excision if symptomatic 5
• Follow-up imaging at 3-6 months can help differentiate progressive fatty infiltration from stable lipoma 4

Indications for Surgical Referral

Proceed to orthopedic surgery consultation if:

• Conservative treatment fails after 3-6 months 1, 2
• Patient develops significant functional limitations despite non-surgical treatment 1
• Progressive symptoms or inability to perform activities of daily living 1

Surgical Considerations (if needed):

• Most subscapularis and supraspinatus tears can be repaired arthroscopically 7, 8
• The primary surgical goal is achieving tendon-to-bone healing, which correlates with improved clinical outcomes 1, 2
• Do NOT perform routine acromioplasty for normal acromial bone, as studies show no significant difference in outcomes with or without acromioplasty 1, 2
• If lipoma is confirmed and causing mechanical impingement, surgical excision may be indicated 5

Follow-Up Plan

• Reassess at 6-8 weeks to evaluate response to conservative management 1
• Repeat MRI at 3-6 months if symptoms persist to assess for progression of tears or clarify the nature of the infraspinatus finding 4
• Monitor for development of muscle atrophy or increased fatty infiltration, which are negative prognostic factors 6, 1

Common Pitfalls to Avoid

• Never completely immobilize the shoulder, as this leads to muscular atrophy and deconditioning 2
• Avoid intratendinous corticosteroid injections into the rotator cuff tendons themselves 2
• Do not proceed to surgery prematurely before completing an adequate 3-6 month trial of conservative management 1, 2
• Do not ignore the fatty infiltration finding, as it has significant prognostic implications for healing and outcomes 6, 1