What is the best treatment approach for a patient in their late 70s with uncontrolled pain, a full-thickness/near full-thickness tear of the supraspinatus tendon, underlying supraspinatus tendinosis, partial-thickness tear of the subscapularis tendon, and mild to moderate acromioclavicular arthrosis?

Treatment of Full-Thickness Rotator Cuff Tear in a Late 70s Patient with Uncontrolled Pain

For a patient in their late 70s with uncontrolled pain and full-thickness supraspinatus tear, initial management should prioritize aggressive non-operative treatment including corticosteroid injections, structured physical therapy, and pain management, with surgical referral reserved for failure of conservative treatment after 3 months or if there is acute massive tear requiring expedited repair. 1, 2

Initial Conservative Management Approach

Pain Control as Primary Objective

• Subacromial or glenohumeral corticosteroid injection (triamcinolone) should be administered early for patients with inflammation and uncontrolled pain, as this provides significant short-term pain reduction and allows participation in rehabilitation 3, 1
• NSAIDs should be used for acute pain management in conjunction with injection therapy 1
• Consider suprascapular nerve block as an adjunctive treatment option, which has shown superiority to placebo in reducing shoulder pain for up to 12 weeks 3

Structured Physical Therapy Protocol

• Complete rest from aggravating activities initially until pain becomes manageable 1
• Aggressive stretching and mobilization focusing on external rotation and abduction to prevent development of adhesive capsulitis, which is common in this age group 1
• Avoid overhead pulley exercises, as these encourage uncontrolled abduction and can worsen rotator cuff pathology 1
• Progress to rotator cuff and scapular stabilizer strengthening only after achieving pain-free motion 1
• Exercise therapy should be low intensity, high frequency, combining eccentric training with attention to posture 2

Multidisciplinary Pain Management

• For patients with clinical signs of neuropathic pain (sensory changes, allodynia, hyperpathia), trial neuromodulating pain medications 3
• Consider occupational therapy interventions, particularly if symptoms persist beyond 6 weeks 2
• Functional electrical stimulation may improve shoulder lateral rotation and reduce pain 1

Surgical Referral Indications

Urgent Referral Criteria

• Massive rotator cuff tear requiring expedited repair for optimal outcomes should be referred urgently 4
• Acute complete tears benefit from earlier surgical intervention 4

Elective Referral After Failed Conservative Treatment

• Patients who fail appropriate 3-month course of non-surgical treatment should be referred to orthopedic surgery 5, 2
• There is no convincing evidence that surgical treatment for subacromial pain syndrome is more effective than conservative management in general, making the trial of conservative therapy essential 2
• In patients over 35-40 years, rotator cuff disease and degenerative changes are the predominant pathology, and many can be successfully managed non-operatively 4, 5

Age-Specific Considerations for This Patient

• Patients in their late 70s are more likely to have rotator cuff tears associated with shoulder pathology compared to younger patients 3
• The multiple pathologies identified (subscapularis partial tear, biceps tendinosis, AC arthrosis, labral tear) are typical degenerative findings in this age group 4
• Quality of life and functional goals should guide treatment intensity, as surgical outcomes may be less predictable in elderly patients with multiple comorbidities 3

Critical Pitfalls to Avoid

• Do not assume surgical intervention is necessary based solely on MRI findings, as there is no indication for surgical treatment of asymptomatic rotator cuff tears 2
• Do not immobilize the shoulder strictly, as this increases risk of adhesive capsulitis 2
• Do not delay corticosteroid injection in patients with uncontrolled pain, as pain control is essential for participation in rehabilitation 3, 1
• Failing to assess for scapular dyskinesis is a critical error, as poor scapular mechanics both contribute to and result from rotator cuff pathology 4

Treatment Timeline and Monitoring

• Diagnostic imaging with ultrasound is useful after 6 weeks of symptoms to monitor healing 2
• Rehabilitation in a specialized unit can be considered for chronic, treatment-resistant cases with pain-perpetuating behavior 2
• Return to activities may be allowed after completing a functional, progressive program over 1-3 months without symptoms 1
• If pain remains uncontrolled or function does not improve after 3 months of appropriate conservative treatment, proceed with orthopedic surgical consultation 5, 2