What is the best course of treatment for a patient in their early 70s with left shoulder pain, suspected degenerative changes, and MRI findings of mild-to-moderate supraspinatus, infraspinatus, and subscapularis tendinosis, as well as mild-to-moderate glenohumeral joint arthritis?

Treatment Approach for Degenerative Shoulder Disease with Rotator Cuff Tendinosis

For this patient in their early 70s with rotator cuff tendinosis, labral tear, and mild-to-moderate glenohumeral arthritis, initial conservative management with physical therapy, NSAIDs, and activity modification for 3-6 months is the appropriate first-line treatment, reserving surgery only if conservative measures fail. 1

Initial Conservative Management (First 3-6 Months)

Begin with a structured conservative approach that includes:

• Physical therapy focusing on rotator cuff strengthening, range of motion exercises, and scapular stabilization 1
• NSAIDs for pain control and inflammation reduction 1
• Activity modification to avoid overhead activities and positions that exacerbate pain 2
• Corticosteroid injections (ultrasound or fluoroscopy-guided) can be considered for symptom relief if initial measures provide inadequate pain control 3

The evidence strongly supports that mild cases of rotator cuff pathology and degenerative changes can be effectively treated conservatively, and the proportion of patients requiring surgery is small 1. In this age group (>70 years), rotator cuff disease is the predominant cause of shoulder pain rather than instability 3.

Key Clinical Considerations for This Patient

The MRI findings reveal multiple degenerative processes that are common in this age group:

• Rotator cuff tendinosis without full-thickness tear - The mild-to-moderate tendinosis with only trace interstitial fraying and superficial articular surface involvement suggests the cuff is still intact 3
• Labral tear - The superior-posterior labral tear is likely degenerative rather than traumatic given the patient's age and the absence of instability symptoms 3
• Mild-to-moderate glenohumeral arthritis - This contributes to pain but is not severe enough to warrant arthroplasty at this stage 2

When to Consider Surgical Intervention

Surgery should only be considered if conservative treatment fails after 3-6 months 1:

• Persistent pain despite adequate conservative management
• Functional limitation that significantly impacts quality of life
• Progressive weakness suggesting rotator cuff tear progression

Surgical options if conservative treatment fails:

• Arthroscopic subacromial decompression with debridement of partial rotator cuff tears if impingement is the primary pain generator 1
• Arthroscopic debridement of the labral tear if it is symptomatic, though in patients >70 years, labral tears are often asymptomatic and degenerative 3
• Shoulder arthroplasty (reverse total shoulder arthroplasty) is reserved for severe glenohumeral arthritis with significant pain and functional limitation, which this patient does not currently have 4, 5

Critical Pitfalls to Avoid

Do not rush to surgery in this patient population:

• The MRI findings show no full-thickness rotator cuff tear, only tendinosis with trace fraying 3
• The labral tear is likely degenerative and age-appropriate rather than a surgical lesion in a patient >70 years 3
• The glenohumeral arthritis is mild-to-moderate, not severe enough to warrant arthroplasty 2

Avoid over-interpreting MRI findings:

• Rotator cuff tendinosis and partial-thickness tears are extremely common in asymptomatic individuals over 60 years 2
• Labral tears in older patients are typically degenerative and do not require surgical treatment unless associated with instability, which is rare in this age group 3

Monitoring and Follow-Up

Reassess at 6-12 weeks:

• Evaluate pain levels, functional improvement, and range of motion
• If no improvement, consider repeat imaging only if it would change management (e.g., concern for progression to full-thickness tear) 2
• If progressive weakness develops, repeat MRI to assess for rotator cuff tear progression 3

The generally small proportion of patients with shoulder pain require surgery, and success depends on appropriate patient selection and clear structural diagnosis 1. This patient's imaging shows degenerative changes that are age-appropriate and should respond to conservative management in the majority of cases.