Would surgery be considered for a patient with shoulder tendinosis and a less than 50% bursal tear?

Surgery for Shoulder Tendinosis and <50% Bursal Tear

Surgery is typically not indicated for shoulder tendinosis with a <50% bursal-sided partial-thickness rotator cuff tear; conservative management should be pursued for at least 3-6 months before considering surgical intervention. 1, 2

Initial Conservative Management (First-Line Treatment)

Conservative treatment should be the primary approach for this pathology, as soft tissue injuries including partial rotator cuff tears typically undergo a period of conservative management before considering surgery. 3

Key conservative interventions include:

• Relative rest to reduce activities that aggravate symptoms while maintaining some movement to prevent muscle atrophy 1
• NSAIDs for short-term pain relief (topical formulations may be preferable to minimize systemic effects) 1
• Physical therapy focusing on gentle range of motion exercises progressing to eccentric strengthening exercises, which have proven beneficial in tendinopathies and may help reverse degenerative changes 1
• Ice therapy to reduce pain and inflammation, particularly after activity 1

Duration of Conservative Treatment

Conservative management should continue for at least 3-6 months before considering surgical options. 1 This timeline allows adequate opportunity for symptom resolution and functional improvement with non-operative measures.

Predictors of Conservative Treatment Failure

While pursuing conservative management, be aware that certain factors predict higher failure rates:

• Bursal-sided tears have significantly higher failure rates compared to articular-sided tears 2
• Tears involving >50% of tendon depth are associated with conservative treatment failure 2
• Dominant arm involvement predicts higher failure rates 2

However, since your patient has a <50% bursal tear, they fall into a category where conservative treatment has demonstrated good success rates. 4

When Surgery May Be Considered

Surgical intervention should only be considered if:

• Symptoms remain debilitating after 3-6 months of appropriate conservative care 1
• Pain significantly limits participation in physical therapy despite corticosteroid injection 1
• There is progressive functional decline or evidence of tear progression 1

Surgical Options (If Conservative Treatment Fails)

If surgery becomes necessary after failed conservative management, the approach would include:

• Arthroscopic debridement with selective acromioplasty (for type II or III acromions only) has shown good outcomes for partial-thickness tears <50% 4
• Both bursal-sided and articular-sided tears <50% demonstrate significant improvement in pain and function scores at 2 years post-debridement 4
• Full-layer repair preserving intact tendon fibers may be considered for tears approaching 50% depth 5

Clinical Pitfalls to Avoid

• Do not rush to surgery for partial-thickness tears <50%, as these respond well to conservative management in the majority of cases 2, 4
• Do not perform routine acromioplasty unless there is documented type II or III acromion morphology causing impingement 6, 4
• Do not assume all bursal tears require surgery despite their association with higher failure rates—the <50% depth threshold is critical 2, 4

Monitoring During Conservative Treatment

Reassess the patient every 2-4 weeks during conservative treatment to monitor:

• Pain levels and functional ability 1
• Response to physical therapy and ability to participate in exercises 1
• Any signs of tear progression or worsening symptoms that might indicate need for earlier surgical consultation 1