Management of Complex Rotator Cuff Pathology with Adhesive Capsulitis
Immediate Surgical Referral is Indicated
This patient requires urgent orthopedic surgical consultation given the severity and complexity of pathology: full-thickness tears with retraction of multiple rotator cuff tendons (supraspinatus, infraspinatus), complete rupture of the long head of biceps, muscle atrophy, and concurrent adhesive capsulitis. 1
Why Surgery Cannot Be Delayed
Multiple full-thickness tears with retraction represent irreversible structural damage that will not respond to conservative management and will continue to deteriorate, leading to progressive muscle atrophy and fatty infiltration 1, 2
The presence of teres minor atrophy indicates advanced chronicity and suggests the rotator cuff disease has progressed beyond the window where conservative therapy would be effective 2
Retracted tears have significantly lower healing rates (only 43% in patients over 65 years achieve complete healing), making early surgical intervention critical before further retraction occurs 2
The combination of infraspinatus and supraspinatus involvement (anterosuperior tears) carries a worse prognosis when diagnosis and repair are delayed 3
Surgical Approach Considerations
Primary Rotator Cuff Repair
Arthroscopic rotator cuff repair should be attempted for the supraspinatus and infraspinatus tears, as this achieves 71% complete tendon-to-bone healing in chronic full-thickness tears 2
The thin subscapularis tendon requires careful intraoperative assessment - if partial-thickness tear is present, surgical repair is indicated as subscapularis pathology portends different (worse) prognosis than isolated supraspinatus tears, especially when diagnosis is delayed 3
Biceps Tendon Management
- The ruptured long head of biceps with hematoma in the biceps fossa requires biceps tenotomy or tenodesis at the time of rotator cuff repair, though evidence does not favor one technique over the other 4
Addressing the Adhesive Capsulitis
- Capsular release should be performed arthroscopically at the time of rotator cuff repair to address the adhesive capsulitis component, as this will not resolve with the rotator cuff repair alone 5
Critical Pitfalls to Avoid
Do NOT attempt 3-6 months of conservative management - this recommendation applies to isolated, non-retracted tears in younger patients, not to this complex multi-tendon pathology with retraction and atrophy 1
The acromioclavicular osteoarthrosis may require concurrent distal clavicle excision if symptomatic impingement is present intraoperatively 5
Expect suboptimal healing rates given the complexity: associated delamination of multiple tendons significantly reduces healing rates (p=0.02), and muscle atrophy indicates chronicity 2
Postoperative Protocol
Early mobilization (within 2 weeks) versus delayed mobilization up to 8 weeks shows similar outcomes for small-to-medium tears, but this complex case may require individualized immobilization based on tissue quality and repair tension 1
Structured physical therapy is mandatory postoperatively focusing on progressive range of motion followed by rotator cuff strengthening, though formal protocols lack high-quality evidence 4, 1
Prognosis Expectations
Functional outcomes depend critically on achieving tendon-to-bone healing - healed repairs demonstrate superior patient-reported and functional outcomes compared to unhealed repairs 1
Strength recovery will be compromised: average shoulder elevation strength is 7.3 kg with healed tendons versus only 4.7 kg with unhealed tendons (p=0.001) 2
The presence of muscle atrophy is a negative prognostic factor that cannot be reversed even with successful surgical repair 2