What is the best management approach for a patient with rotator cuff tendinopathy, supraspinatus tendinopathy with chronic partial thickness tears, involving the adjacent anterior infraspinatus tendon, long head of the biceps (LHB) tendinopathy, acromio-clavicular (AC) joint pain, subacromial/subdeltoid bursitis, and mild inferior glenohumeral ligament (IGHL) thickening suggestive of adhesive capsulitis?

Management of Complex Rotator Cuff Pathology with Adhesive Capsulitis

Begin with a structured 3-month trial of NSAIDs combined with physical therapy targeting both rotator cuff strengthening and capsular stretching, reserving a single subacromial corticosteroid injection for persistent symptoms, followed by orthopedic surgical consultation if conservative management fails given the chronic partial-thickness tears involving the anterior rotator cuff cable region. 1

Initial Conservative Management (First 3 Months)

Pharmacologic Treatment

• Start NSAIDs or COX-2 inhibitors as first-line medication for pain control and inflammation management 2
• Add paracetamol concurrently with NSAIDs for more effective pain control 2
• Avoid opioids except as rescue analgesia only when other methods fail—never as first-line treatment 2

Physical Therapy Program

• Implement a home exercise program focusing on both rotator cuff strengthening and capsular stretching exercises, which has demonstrated significant improvements in pain at rest, nighttime pain, and functional scores after 3 months 2
• The dual pathology of tendinopathy and adhesive capsulitis requires addressing both strength deficits and range of motion limitations 1
• Physical therapy should emphasize scapular stabilization and biomechanical correction to address the underlying dysfunction contributing to subacromial impingement 3

Second-Line Intervention (If Conservative Management Fails)

Corticosteroid Injection

• Administer a single subacromial corticosteroid injection with local anesthetic for short-term improvement in pain and function 2, 1
• Critically important: Limit to a single injection—avoid multiple repeated corticosteroid injections as they are not supported by evidence 2
• This provides temporary relief while continuing physical therapy 1

Surgical Consultation Criteria

When to Refer to Orthopedic Surgery

Your imaging findings warrant early surgical evaluation for several critical reasons:

• Anterior cable involvement is biomechanically significant: The chronic partial-thickness tears involving the adjacent anterior infraspinatus tendon likely affect the rotator cuff cable insertion, which is the primary load-bearing structure within the supraspinatus 4
• Anterior cable tears demonstrate significantly greater tear gapping (median 5.2 mm vs 1.3 mm for crescent tears) and altered biomechanics, making them more clinically relevant than posterior tears 4
• Partial tears involving greater than 50% of tendon thickness should be repaired surgically 5
• Even partial tears less than 50% thickness on the bursal side warrant a more aggressive surgical approach compared to articular-sided tears 5

Surgical Options to Discuss

Rotator Cuff Repair:

• The American Academy of Orthopaedic Surgeons recommends rotator cuff repair involving reattachment of torn tendon to bone, performed arthroscopically, mini-open, or open 1
• Acromioplasty is not required for normal acromial morphology (including type II and III) when performing rotator cuff repair 1
• Surgical intervention provides better long-term outcomes for achieving tendon-to-bone healing, which is associated with improved clinical outcomes 1

LHB Tendon Management:

• The LHB tendinopathy commonly occurs with rotator cuff tears and can be a significant pain source 6
• Biceps tenotomy or tenodesis combined with rotator cuff repair provides substantial pain relief 6
• Even when rotator cuff repair is not possible, isolated tenotomy or tenodesis of the LHB tendon can provide substantial pain relief 6
• The choice between tenotomy and tenodesis depends on age, activity level, and willingness to comply with postoperative rehabilitation 6

AC Joint Pathology:

• If moderate AC joint degeneration is causing significant pain at the top of the shoulder, distal clavicular excision can be performed concurrently 1

Critical Pitfalls to Avoid

• Do not delay surgical consultation indefinitely: Anterior cable tears are biomechanically more significant and may need early surgical intervention to prevent progression 4
• Do not use multiple corticosteroid injections: This is not evidence-based and should be strictly limited to a single injection 2
• Do not ignore the adhesive capsulitis component: The mild IGHL thickening requires aggressive capsular stretching in physical therapy to prevent progression to true frozen shoulder 1
• Do not treat LHB tendinopathy in isolation: It commonly coexists with rotator cuff pathology and inflammation of one structure leads to inflammation of the other 6

Expected Recovery Timeline

• Post-surgical recovery typically requires wearing a sling for 4-6 weeks followed by months of rehabilitation 1
• Tear size is the most important determinant of outcome regarding active motion, strength, and patient satisfaction 7
• Standard tendon repair techniques combined with anterior acromioplasty and monitored physiotherapy produce consistent and lasting pain relief and improvement in range of motion 7