What is the current management for supraspinatus tears in adults?

Management of Supraspinatus Tears in Adults

For complete supraspinatus tears, initiate conservative management with eccentric strengthening exercises for 3-6 months, and refer for surgical repair if symptoms persist or significant functional limitations exist, as surgery achieves 71% complete healing rates and superior strength outcomes. 1, 2, 3

Initial Assessment and Diagnosis

Distinguish between tendinopathy and complete tears through clinical examination and imaging:

• Physical examination findings: Palpation provokes well-localized tenderness at the supraspinatus insertion; the Hawkins test (forced internal rotation at 90° flexion) is 92% sensitive but only 25% specific, while the Neer test (forward flexion 70-120°) is 88% sensitive but 33% specific 1

• Imaging selection: MRI is the gold standard with 95% sensitivity and 95% specificity for detecting full-thickness tears, degeneration, and partial tears; ultrasound detects moderate-to-complete tears but misses small tears; plain radiographs only identify bony abnormalities 1

• Red flag: Multiple symptomatic tendons should prompt evaluation for rheumatic disease 1

Conservative Management Protocol (First-Line for All Tears)

Implement this structured approach for at least 3-6 months before considering surgery:

• Activity modification: Relative rest by avoiding overhead activities and movements that reproduce pain; this is crucial to prevent further damage 1, 2

• Cryotherapy: Apply ice through a wet towel for 10-minute periods immediately after pain-provoking activities 2

• Eccentric strengthening exercises: These constitute the cornerstone of treatment and can reverse degenerative tendon changes; continue for minimum 3-6 months with gradual progressive loading to avoid symptom exacerbation 1, 2, 4

• NSAIDs: Use oral or topical NSAIDs for short-term pain relief only; they provide no long-term benefit 2

• Extracorporeal shock wave therapy (ESWT): Safe and potentially effective for pain relief, though expensive 1, 2

Critical Corticosteroid Warning

Use corticosteroid injections with extreme caution or avoid entirely:

• Corticosteroids may provide acute pain relief but do not improve long-term outcomes, may inhibit healing, and reduce tendon strength predisposing to rupture 2

• Never inject into the tendon substance itself; only peritendinous injection may be considered, and even this should be used cautiously 2

Surgical Referral Criteria

Refer to orthopedic surgery when:

• Pain persists despite 3-6 months of well-managed conservative treatment 1, 2

• Significant functional limitations persist despite conservative measures 2

• Do not delay surgical referral beyond 6 months: Chronic tears develop muscle atrophy and fatty degeneration that worsen surgical outcomes 2

Surgical Approach and Outcomes

Arthroscopic repair using tension-band suture techniques is the standard surgical approach:

• Surgery involves excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 1, 2

• Healing rates: Arthroscopic repair achieves complete tendon healing in 71% of patients, with average Constant scores improving from 51.6 to 83.8 points postoperatively 3

• Strength outcomes: Average shoulder elevation strength is significantly better when the tendon heals (7.3 kg) versus when it does not heal (4.7 kg) 3

Prognostic Factors Affecting Surgical Outcomes

Consider these factors when counseling patients:

• Age: Only 43% of patients over 65 years achieve complete tendon healing compared to higher rates in younger patients 3

• Muscle quality: Infraspinatus fatty degeneration, muscle atrophy, and supraspinatus muscle atrophy correlate with worse healing and clinical outcomes 2

• Associated tears: Delamination of subscapularis or infraspinatus tendons significantly reduces healing rates 3

• Workers' compensation status: Correlates with less favorable outcomes 2

Special Consideration for Partial-Thickness Tears

High-grade partial tears (≥50% tendon thickness) have two surgical options:

• Completion of the partial tear to full-thickness tear followed by repair results in significantly lower retear rates (3.6%) compared to full-thickness tear repair alone (16.3%), with equivalent functional outcomes 5

• This allows surgeons to choose the procedure based on comfort and experience level 5

Common Pitfalls to Avoid

• Starting with aggressive exercises: Progression must be gradual in the conservative pathway to prevent symptom worsening 2

• Premature return to activities: Before adequate healing leads to symptom recurrence 1

• Relying on physical examination alone: The Hawkins and Neer tests are sensitive but not specific; confirm diagnosis with MRI 1

• Excessive corticosteroid use: Remember they weaken tendons and do not improve long-term outcomes 1, 2

• Delaying surgical referral: Beyond 6 months of failed conservative treatment allows irreversible muscle changes 2