What is the recommended management approach for a patient with a Hill-Sachs lesion, rotator cuff tendon tear, and mild to moderate osteoarthrosis, who has a history of asbestos exposure and pleural calcifications, but no fracture, dislocation, or osseous lesion?

Management of Hill-Sachs Lesion with Rotator Cuff Tear and Osteoarthrosis

Primary Treatment Recommendation

Begin with supervised physical therapy as the initial treatment for the rotator cuff tear, combined with NSAIDs and acetaminophen for pain control, while monitoring the Hill-Sachs lesion for engagement symptoms. 1, 2

Initial Conservative Management Algorithm

Pain Management (First-Line)

• Start acetaminophen (paracetamol) immediately and continue regularly as baseline analgesia 3
• Add NSAIDs or COX-2 specific inhibitors concurrently with acetaminophen for enhanced pain control 3
• Consider a single corticosteroid injection with local anesthetic for short-term pain relief (2-6 weeks), but avoid multiple injections as they compromise rotator cuff integrity and affect subsequent repair attempts 4, 1, 2
• Reserve opioids only for rescue analgesia when other methods fail 3

Physical Therapy Protocol

• Initiate supervised physical therapy rather than unsupervised home exercises for optimal outcomes 1, 2
• Strong evidence supports that patient-reported outcomes improve with physical therapy in symptomatic full-thickness rotator cuff tears 2
• Use loaded resistance exercises including open chain resisted band exercises and closed chain exercises, performing 3 sets of 8-12 repetitions at 8 repetition maximum, adjusted every 2-3 weeks 1

Hill-Sachs Lesion Assessment

Critical Evaluation Points

• The Hill-Sachs lesion requires assessment for "engagement" with the glenoid rim during shoulder motion, as engaging lesions are associated with recurrent instability 5, 6
• Only 7% of Hill-Sachs lesions are "engaging" lesions that extend medially over the glenoid track and require specific treatment 6
• Key clinical finding: Assess for subjective and objective signs of shoulder instability during desired activities, not just the presence of the lesion itself 5
• All engaging Hill-Sachs lesions are associated with concomitant glenoid bone loss, making this a bipolar injury that must be identified 5, 6

Non-Engaging Lesions (Most Common)

• Small bony defects and non-engaging lesions in which the glenohumeral joint remains stable during activities can be managed non-surgically with focused rehabilitation 5
• The Hill-Sachs lesion identified on your imaging is likely non-engaging given the absence of dislocation history and can be observed 5

Monitoring During Conservative Treatment

Important Prognostic Factors

• Age consideration: Older age is associated with higher failure rates and poorer patient-reported outcomes after rotator cuff repair 4, 1, 2
• Rotator cuff tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonsurgical management 2
• Comorbidities are associated with poorer patient-reported outcomes 4

Red Flags Requiring Surgical Consideration

• Persistent symptoms after 3-6 months of appropriate conservative treatment 1
• Development of shoulder instability symptoms (recurrent subluxation or dislocation) indicating an engaging Hill-Sachs lesion 5
• Progressive weakness or functional decline despite physical therapy 2

Surgical Indications

For Rotator Cuff Tear

• Strong evidence shows that healed rotator cuff repairs (particularly small to medium tears) demonstrate improved patient-reported and functional outcomes compared with physical therapy and unhealed repairs 1, 2
• Surgical repair is indicated for chronic, symptomatic full-thickness tears when conservative treatment fails after an appropriate trial period 1
• No specific technique (arthroscopic, mini-open, or open repair) can be recommended over another based on current evidence 4
• Routine acromioplasty should NOT be performed concomitantly with rotator cuff repair for small to medium-sized tears 4

For Hill-Sachs Lesion

• Surgical treatment (arthroscopic or open techniques) is indicated only if the lesion is engaging and causing recurrent instability despite rehabilitation 5
• Identification of concomitant glenoid bone loss is essential before surgical planning, as this represents a bipolar injury 5, 6

Asbestos Exposure Considerations

Clinical Implications

• The pleural calcifications indicate previous asbestos exposure but do not directly affect orthopedic management 7, 8
• Monitor for respiratory symptoms, as asbestos-related pleural disease can affect lung volumes and flows 8
• Consider pulmonary consultation if respiratory symptoms develop, given the 20-40 year latency period for asbestos-related complications 7

Osteoarthrosis Management

Conservative Approach

• The mild to moderate acromioclavicular and glenohumeral osteoarthrosis should be managed conservatively alongside the rotator cuff tear 1
• NSAIDs provide dual benefit for both rotator cuff pain and osteoarthrosis symptoms 3, 1

Surgical Consideration for Advanced Disease

• If massive, unrepairable rotator cuff tear develops with glenohumeral joint arthritis and conservative treatment fails, reverse shoulder arthroplasty can improve patient-reported outcomes 2

Common Pitfalls to Avoid

• Do not perform multiple corticosteroid injections, as they compromise rotator cuff integrity and affect subsequent repair attempts 1, 2
• Do not rely solely on unsupervised home exercises without proper instruction and supervision 2
• Do not surgically address the Hill-Sachs lesion unless it is engaging and causing instability symptoms 5
• Do not routinely perform acromioplasty with rotator cuff repair for small to medium tears 4
• Do not use non-cross-linked porcine small intestine submucosal xenograft patches for rotator cuff repair due to 20-30% complication rates 4