What is the best treatment approach for a patient with mild subscapularis tendinopathy, slight enthesopathic changes, and a history of osteopenia?

Treatment of Mild Subscapularis Tendinopathy with Enthesopathic Changes and Osteopenia

Begin with relative rest, eccentric strengthening exercises, and NSAIDs for pain control, while simultaneously addressing the osteopenia with DXA screening and appropriate bone health management. 1, 2

Immediate Conservative Management

The foundation of treatment is relative rest combined with eccentric strengthening exercises, which have proven beneficial in reversing degenerative changes and reducing symptoms in tendinopathies. 1, 2, 3

Pain Control

• Apply ice through a wet towel for 10-minute periods to provide short-term pain relief. 1, 2
• Prescribe topical NSAIDs as first-line pharmacologic treatment since they provide similar pain relief to oral NSAIDs with fewer systemic side effects—particularly important given the osteopenia. 2, 3
• Oral NSAIDs can be used for short-term pain relief, but recognize they provide only symptomatic relief without altering long-term outcomes or the degenerative process. 1, 2
• Paracetamol up to 4g/day is an acceptable oral analgesic first choice due to its favorable safety profile. 2

Activity Modification

• Reduce activities causing repetitive loading of the subscapularis tendon, but avoid complete immobilization which accelerates muscle atrophy and deconditioning. 1, 2, 3
• For athletes or manual laborers, modify technique to minimize repetitive stresses on the tendon. 1, 2

Rehabilitation Protocol

Initiate eccentric strengthening exercises immediately as they have proven beneficial in reversing degenerative changes, reducing symptoms, and increasing strength in tendinosis. 1, 2, 4

• Implement deep transverse friction massage to reduce pain. 1, 2, 3
• The eccentric training program should last 8-12 weeks with multiple daily repetitions and weekly monitoring. 4

Addressing the Osteopenia

Given the history of osteopenia, screening and management of bone health is critical, particularly because enthesopathic changes suggest chronic tendon stress at bone insertion sites. 1

• Perform DXA scanning of both spine and hips to assess current bone density status, as osteopenia can progress and affect tendon healing capacity. 1
• Consider that the age, physical activity level, and presence of enthesopathic changes should guide the frequency of follow-up DXA scans. 1
• Address fall risk through evaluation and counseling, as patients with osteopenia and tendon pathology have increased fracture risk. 1

Advanced Interventions (If Conservative Treatment Fails After 3-6 Months)

Corticosteroid injections provide better acute pain relief than oral NSAIDs but should be used with caution as they do not alter long-term outcomes and may inhibit healing and reduce tensile strength—particularly concerning given the osteopenia and enthesopathic changes. 1, 2, 5

• Extracorporeal shock wave therapy (ESWT) is a safe, noninvasive option for chronic tendinopathies that appears effective, though further research is needed to clarify optimal treatment strategies. 1, 2, 5
• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak. 1

Surgical Considerations

Surgery should only be considered if pain persists despite 3-6 months of well-managed conservative treatment. 1, 2, 3, 5

• Surgical techniques for subscapularis tendinopathy typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 1
• Arthroscopic debridement and side-to-side repair has shown excellent outcomes (97% satisfaction) in non-insertional subscapularis tendinopathy with significant improvements in pain and function. 6

Critical Pitfalls to Avoid

• Never completely immobilize the shoulder, as this accelerates muscular atrophy and deconditioning. 2, 3, 5
• The presence of joint effusions is uncommon with tendinopathy and should raise suspicion for intra-articular pathology requiring different management. 2
• Do not ignore the osteopenia, as poor bone health can impair tendon healing at entheseal sites and increase fracture risk. 1
• Avoid using corticosteroid injections as first-line treatment given the osteopenia and potential for further weakening of the tendon-bone interface. 1, 2

Expected Outcomes

Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment. 2, 3, 5

• Expect well-localized tenderness on palpation that reproduces the patient's activity-related pain. 2
• Monitor pain levels, functional improvement, and range of motion during the treatment course. 5, 7
• If symptoms persist beyond 6 months despite appropriate conservative management, surgical consultation is warranted. 1, 2