What is the recommended treatment approach for a patient with supraspinatus tendinosis?

Treatment of Supraspinatus Tendinosis

Begin with eccentric strengthening exercises continued for at least 3-6 months combined with relative rest from overhead activities, as this is the cornerstone of treatment that can reverse degenerative tendon changes. 1, 2

Initial Conservative Management (First-Line Treatment)

Activity Modification and Pain Control

• Reduce repetitive overhead activities and movements that reproduce pain to prevent further tendon damage and allow healing 1, 2
• Apply ice through a wet towel for 10-minute periods immediately after pain-provoking activities for acute pain relief 1
• Use oral NSAIDs for short-term pain relief (topical NSAIDs offer similar benefit with fewer systemic side effects), though neither alters long-term outcomes 1

Exercise Therapy (Most Critical Component)

• Eccentric strengthening exercises must be the foundation of your treatment plan and should continue for a minimum of 3-6 months to achieve optimal results 1, 2
• Start with gentle progression—beginning too aggressively will worsen symptoms 1, 2
• These exercises can reverse degenerative changes in tendon structure 1

Intermediate Interventions (If Initial Management Insufficient After 6-12 Weeks)

Adjunctive Therapies

• Extracorporeal shock wave therapy (ESWT) is safe and potentially effective for pain relief, though costly 1, 2
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1, 2
• Platelet-rich plasma (PRP) single injection showed non-inferiority to ESWT at 6-month follow-up in reducing pain and improving function 3
• Percutaneous electrolysis demonstrated superior pain relief compared to trigger point dry needling at one-year follow-up 4

Corticosteroid Injections (Use With Extreme Caution)

• Corticosteroid injections may provide better acute pain relief than NSAIDs but do not improve long-term outcomes 1
• They may inhibit healing and reduce tendon strength, potentially predisposing to rupture 1, 5
• Never inject into the tendon substance itself—only peritendinous injection may be considered 5

Surgical Management (After 3-6 Months of Failed Conservative Treatment)

Indications for Surgical Referral

• Refer to orthopedic surgery if pain persists despite well-managed conservative treatment for 3-6 months 1, 2, 5
• Significant functional limitations persist despite conservative measures 5

Surgical Approach

• Surgery typically involves excision of abnormal tendinous tissue and longitudinal tenotomies to release scarring and fibrosis 1, 2, 5
• Arthroscopic repair using tension-band suture techniques is the standard surgical approach 5
• Surgery is effective in carefully selected patients 1, 2

Critical Pitfalls to Avoid

Diagnostic Errors

• Hawkins' test (92% sensitive, 25% specific) and Neer's test (88% sensitive, 33% specific) are sensitive but not specific for supraspinatus impingement—ensure proper diagnosis 1, 2
• Palpation should provoke well-localized tenderness similar to activity-related pain 2

Treatment Errors

• Do not start with aggressive exercises—inadequate progression worsens symptoms 1, 2, 5
• Do not allow premature return to activities before adequate healing, as this leads to symptom recurrence 1, 2
• Do not delay surgical referral beyond 6 months of failed conservative treatment, as chronic tears develop muscle atrophy and fatty degeneration that worsen surgical outcomes 2, 5
• Do not rely on corticosteroids for long-term management—they provide no lasting benefit and may weaken the tendon 1, 5

Key Clinical Nuances

• Workers' compensation status correlates with less favorable outcomes and should be discussed during surgical counseling 5
• Preoperative infraspinatus fatty degeneration and muscle atrophy correlate with worse healing and clinical outcomes 5
• If multiple symptomatic tendons are present, evaluate for rheumatic disease 2