What is the recommended management plan for a male patient with a painful left shoulder, restricted movements, and ultrasound findings of a full thickness tear of the supraspinatus tendon, rupture of the long head of the biceps tendon, mild subscapularis tendinopathy, and degenerative changes of the acromioclavicular (AC) joint?

Management of Full-Thickness Supraspinatus Tear with Multiple Shoulder Pathologies

This patient requires urgent orthopedic surgery referral for rotator cuff repair given the full-thickness supraspinatus tear (19mm x 16mm), complete long head biceps rupture, and evidence of muscle atrophy in the teres minor, which collectively indicate significant structural damage that will not resolve with conservative management alone. 1

Immediate Surgical Referral Indications

This case demonstrates multiple features that mandate surgical evaluation rather than prolonged conservative management:

• Full-thickness rotator cuff tear measuring 19mm x 16mm - This exceeds the threshold for conservative management, which is typically reserved for tendinosis and partial tears <50% 1
• Complete rupture of the long head of biceps tendon - This represents significant structural failure and is associated with rotator cuff pathology 2
• Teres minor atrophy - Muscle atrophy is a critical prognostic indicator that suggests chronicity and predicts poorer outcomes if repair is delayed 3
• Subscapularis tendinopathy with calcifications - The presence of echogenic foci with shadowing (5-6mm) in the subscapularis insertion represents calcific tendinopathy, which combined with supraspinatus tearing creates an anterosuperior rotator cuff injury pattern 4, 2

Why Conservative Management Is Inappropriate Here

The guideline recommendation for 3-6 months of conservative treatment applies specifically to tendinosis and partial-thickness tears <50%, not full-thickness tears 1. In this patient:

• Tendon retraction, muscle atrophy, and fatty infiltration are critical findings that influence surgical decision-making regarding the type of operative repair (open, mini-open, or arthroscopic) and provide prognostic information 5
• Asymmetric muscle atrophy following tendon tear occurs rapidly, with the fascial portion atrophying by 43% while the scapular portion undergoes fatty infiltration 3
• Delayed diagnosis and treatment of subscapularis tears portend worse prognosis, especially when combined with supraspinatus pathology 4

Pre-Surgical Optimization (While Awaiting Surgery)

While surgical consultation is arranged, implement targeted symptom management:

• NSAIDs for short-term pain relief, preferably topical formulations to minimize systemic effects 1
• Relative rest - reduce aggravating activities but maintain gentle range of motion to prevent further stiffness 1
• Ice therapy after activity to reduce pain and inflammation 1
• Avoid aggressive passive range-of-motion exercises as these could cause additional harm to the compromised rotator cuff 5
• Avoid overhead pulley exercises which can worsen rotator cuff pathology 5

Additional Pathology Requiring Attention

AC joint degenerative changes with synovitis and focal tenderness - This may require concurrent treatment at the time of rotator cuff surgery or separate intervention if symptoms persist post-operatively 5. The AC joint pathology could be addressed with corticosteroid injection or distal clavicle excision if conservative measures fail.

Subacromial-subdeltoid bursal thickening and effusion - This moderate bursitis will likely improve following rotator cuff repair, but the surgeon should evaluate for the need for bursectomy during the procedure 5.

Equivocal 11mm anechoic focus in suprascapular notch - While this may represent a ganglion cyst, it requires surgical visualization as suprascapular notch cysts can cause nerve compression and contribute to muscle atrophy 5.

Critical Pitfalls to Avoid

• Do not delay surgical referral - The presence of teres minor atrophy indicates this is not an acute injury and further delay will worsen the prognosis for successful repair 3
• Do not perform routine acromioplasty unless the surgeon documents type II or III acromion morphology causing impingement 1
• Do not assume the biceps rupture is incidental - It is part of the rotator interval pathology pattern and may require surgical attention to reconstruct the pulley system 2
• Do not overlook the subscapularis pathology - The calcifications and tendinopathy represent "hidden lesions" of the rotator interval that must be addressed during surgery 2

Surgical Planning Considerations

The surgeon will need to determine:

• Type of repair (open, mini-open, or arthroscopic) based on tear size, retraction, and tissue quality 5
• Management of the ruptured biceps tendon - Options include tenotomy, tenodesis, or reconstruction of the biceps pulley system 2
• Subscapularis repair if intraoperative findings reveal more extensive tearing than appreciated on ultrasound 4, 2
• Need for subacromial decompression based on acromion morphology 1