What is the initial treatment approach for a patient with a tear in the supraspinatus tendon?

Initial Treatment of Supraspinatus Tears

Begin with a structured 3-6 month trial of conservative management including physical therapy, NSAIDs for pain control, activity modification, and consider subacromial corticosteroid injection. 1

Conservative Management Protocol

Physical Therapy (Primary Treatment)

• Initiate a structured physical therapy program focused on rotator cuff strengthening, particularly the supraspinatus and subscapularis muscles, with emphasis on eccentric exercises and restoring functional range of motion. 1
• Eccentric exercise has proven beneficial for tendinopathy and should be incorporated into the rehabilitation program. 2
• Tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers, making controlled loading essential. 2
• Avoid complete immobilization, as this leads to muscular atrophy and deconditioning. 1

Activity Modification

• Eliminate repetitive overhead movements and activities that aggravate the shoulder. 1
• Reduce activity to decrease repetitive loading of the damaged tendon (relative rest). 2
• Allow continuation of activities that do not worsen pain, as complete rest is counterproductive. 2

Pharmacologic Management

• Prescribe NSAIDs primarily for analgesic effect rather than anti-inflammatory properties, as chronic tendinopathy involves degeneration rather than acute inflammation. 1
• Topical NSAIDs reduce tendon pain and eliminate the increased risk of gastrointestinal hemorrhage associated with systemic NSAIDs. 2

Corticosteroid Injections

• Consider a subacromial (peritendinous) corticosteroid injection for pain relief, particularly when moderate bursitis is present. 1
• Critical caveat: Avoid intratendinous injections directly into the rotator cuff tendon substance, as these may have deleterious effects on the tendon. 1
• Injected corticosteroids may be more effective than oral NSAIDs for acute phase pain relief, but they do not alter long-term outcomes. 2
• The evidence for perioperative corticosteroid use is inconclusive regarding effects on tendon healing. 2

Adjunctive Therapies

• Apply ice through a wet towel for 10-minute periods for short-term pain relief and to reduce swelling. 2
• Stretching exercises are widely accepted and generally thought to be helpful. 2

Follow-Up and Monitoring

Reassessment Timeline

• Reassess at 6-8 weeks to evaluate response to conservative management. 1
• Monitor for development of muscle atrophy or increased fatty infiltration, which are negative prognostic factors. 1

Prognostic Factors to Monitor

• Fatty infiltration and muscle atrophy of the supraspinatus and infraspinatus correlate with worse healing potential and surgical outcomes if surgery becomes necessary. 2, 1
• Preoperative infraspinatus fatty degeneration and muscle atrophy correlate with worse outcomes and healing. 2
• Workers' compensation status correlates with less favorable outcomes. 2

Surgical Referral Indications

Refer to orthopedic surgery if conservative treatment fails after 3-6 months or if the patient develops significant functional limitations despite non-surgical treatment. 1, 3

Evidence Supporting Conservative Management

• For small, nontraumatic supraspinatus tears in patients older than 55 years, operative treatment is no better than conservative treatment at mid-term follow-up (mean 6.2 years). 4
• Conservative treatment of partial-thickness rotator cuff tears leads to clinical improvement in 63.8% of patients and radiologic improvement in 85.1% at 6 months. 5
• Patients with atraumatic onset and non-dominant shoulder involvement are more likely to improve clinically with conservative treatment. 5

Surgical Outcomes Context

• When surgery is performed, arthroscopic repair achieves complete tendon healing in 71% of cases, with healing rates significantly lower in patients over 65 years (43%). 6
• The absence of healing after surgical repair is associated with inferior strength. 6

Critical Pitfalls to Avoid

• Do not perform complete immobilization—this causes muscular atrophy and deconditioning. 1
• Do not inject corticosteroids directly into the tendon substance—only peritendinous/subacromial injections should be considered. 1
• Do not proceed to premature surgery before completing an adequate 3-6 month trial of conservative management. 1
• Do not ignore fatty infiltration findings on imaging, as they have significant prognostic implications for healing and outcomes. 1