What are the treatment options for a 50-year-old patient with a near-complete rupture of the supraspinatus and infraspinatus tendons, severe acromioclavicular joint osteoarthritis, and mild fatty atrophy of the infraspinatus?

Treatment Options for Near-Massive Rotator Cuff Tear in a 50-Year-Old Patient

This 50-year-old patient with a near-massive rotator cuff tear (2.1 x 1.9 cm full-thickness component) and mild fatty atrophy should be offered surgical rotator cuff repair as the primary treatment option, given the patient's relatively young age, the severity of the tear, and the presence of early muscle degeneration that will worsen without intervention.

Surgical Management: Primary Recommendation

For this patient, surgical intervention is strongly indicated because:

• The tear involves near-complete rupture of both supraspinatus and infraspinatus tendons with a 2.1 x 1.9 cm full-thickness component, which qualifies as a near-massive tear 1
• At age 50, this patient is significantly younger than the population studied in conservative management trials (which focused on patients >55 years) 2
• Mild fatty atrophy is already present in the infraspinatus, indicating early irreversible muscle degeneration that will progress without repair 2
• The severe AC joint osteoarthritis can be addressed simultaneously with arthroscopic distal clavicle resection during the same surgical procedure 3, 4

Surgical Approach

The recommended surgical procedure should include:

• Arthroscopic rotator cuff repair of the supraspinatus and infraspinatus tendons with excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring 1
• Concurrent arthroscopic distal clavicle resection (typically 5-10mm) to address the severe AC joint osteoarthritis, which offers rapid rehabilitation with excellent functional results 5
• Biceps tenosynovitis management through either tenotomy or tenodesis, given the moderate tenosynovitis noted on MRI 1
• Subacromial decompression if indicated intraoperatively, though this remains somewhat controversial 2

Conservative Management: When Appropriate

Conservative treatment would only be reasonable if:

• The patient refuses surgery after informed consent about progression risks 2
• Significant medical comorbidities make surgical risk prohibitive 1
• The patient has minimal functional demands and acceptable pain levels 2

Conservative Protocol (If Surgery Declined)

If conservative management is chosen despite the unfavorable tear characteristics:

• Physical therapy focusing on rotator cuff strengthening and scapular stabilization exercises, though evidence shows this provides inferior outcomes compared to surgery in tears of this size 2
• NSAIDs or acetaminophen for pain management, with NSAIDs being more effective than acetaminophen for acute shoulder pain 1
• Corticosteroid injection into the subacromial space may provide temporary relief (3-6 months), though it does not alter disease progression 1
• Activity modification to minimize repetitive overhead stresses and impingement 1

Critical caveat: A 2021 randomized controlled trial found no significant difference between operative and conservative treatment at 6.2-year follow-up, BUT this study only included small tears (mean 10mm) in patients older than 55 years 2. This patient's tear is more than twice that size (21mm) and the patient is younger, making these findings not directly applicable.

Management of Severe AC Joint Osteoarthritis

The severe AC joint osteoarthritis requires specific attention:

• Initial conservative treatment includes NSAIDs, activity modification avoiding cross-body adduction, and potentially corticosteroid injection into the AC joint for short-term relief (though this does not alter disease progression) 3, 4
• Surgical distal clavicle excision is indicated after 6 months of unsuccessful conservative treatment, but should be performed concurrently with rotator cuff repair in this patient to avoid two separate surgeries 3, 4, 5
• Arthroscopic approach is preferred over open technique as it preserves the deltotrapezial fascia, allows rapid rehabilitation, and produces excellent functional results 5

Postoperative Rehabilitation Protocol

Following surgical repair, implement a structured rehabilitation program:

• Immediate postoperative phase (0-6 weeks): Sling immobilization with early passive range-of-motion exercises to prevent stiffness while protecting the repair 1
• Early strengthening phase (6-12 weeks): Progress to active-assisted and then active range of motion, followed by gentle rotator cuff strengthening 1
• Advanced strengthening (3-6 months): Progressive resistance exercises focusing on rotator cuff and scapular stabilizers 1
• Return to full activity (6-12 months): Gradual return to overhead activities and heavy lifting as tolerated 1

Critical Pitfalls to Avoid

Common errors in management include:

• Delaying surgery in younger patients with large tears: Fatty infiltration progresses rapidly and becomes irreversible, making delayed repairs less successful 2
• Treating only the rotator cuff while ignoring AC joint pathology: The severe AC joint arthritis will continue causing pain even after successful rotator cuff repair 3, 4
• Overly aggressive early rehabilitation: This can lead to repair failure; respect tissue healing timelines 1
• Assuming conservative management is equivalent: The evidence for conservative treatment applies only to small tears (<10mm) in older patients (>55 years), not this clinical scenario 2

Additional Considerations

Address the biceps tenosynovitis and glenohumeral changes:

• The moderate biceps tenosynovitis should be addressed surgically during rotator cuff repair, as it contributes to anterior shoulder pain 1
• The high-grade cartilage thinning on the superior humeral head indicates early degenerative changes that may progress to rotator cuff tear arthropathy, making timely repair even more critical 2
• The small glenohumeral effusion likely represents reactive inflammation from the chronic tear and should resolve after repair 1