What is the recommended treatment for a patient with supraspinatus (rotator cuff muscle)/infraspinatus (rotator cuff muscle) tendinosis after surgical repair?

Treatment of Supraspinatus/Infraspinatus Tendinosis Post-Repair

After surgical repair of supraspinatus/infraspinatus tendons, treatment centers on multimodal pain management, strict protection of the healing repair through immobilization and gradual rehabilitation progression over 6 months, with eccentric strengthening as the cornerstone of intermediate-phase recovery. 1

Immediate Postoperative Pain Management (First 48-72 Hours)

Multimodal analgesia is the foundation of postoperative pain control:

• Start paracetamol combined with NSAIDs or COX-2 inhibitors pre-operatively or intra-operatively and continue postoperatively unless contraindicated 1
• Use continuous interscalene block rather than single-shot techniques, as rebound pain typically occurs at 6-8 hours and continuous blocks provide superior pain control beyond this window 1
• Administer intravenous dexamethasone to prolong interscalene block duration and reduce supplemental analgesic requirements 2, 1
• Reserve opioids strictly as rescue medication, not as primary analgesics, given the effectiveness of the multimodal approach 1

Immobilization Phase (First 4-6 Weeks)

The primary biological goal is achieving tendon-to-bone healing, which takes absolute precedence over early mobilization:

• Immobilize the shoulder in a sling or abduction brace immediately after surgery 1
• Enforce relative rest by avoiding all overhead activities and any movements that reproduce pain 1
• Early motion protocols (starting at postoperative day 2-3) show no pain advantage over delayed protocols (starting at day 28), so timing should be surgeon-directed based on repair tension and tear characteristics 2, 1
• Passive range of motion exercises may begin under physical therapy guidance, but timing depends critically on tear size and repair quality 1

Critical pitfall to avoid: Do not progress rehabilitation aggressively during this phase—gradual loading is essential to prevent repair failure 1

Intermediate Recovery Phase (6 Weeks to 6 Months)

Eccentric strengthening becomes the rehabilitation cornerstone:

• Begin active-assisted range of motion exercises around 6 weeks postoperatively 1
• Implement eccentric strengthening exercises as the primary intervention and continue for at least 3-6 months 1, 3
• Progress loading gradually to avoid symptom exacerbation and protect the healing tendon 1
• Customize the rehabilitation program based on individual tear and repair characteristics, advancing according to patient progress with ongoing therapist-surgeon communication 4

The rehabilitation progresses through 4 distinct stages over 24 weeks, balancing tendon repair healing against the risk of postoperative stiffness 4

Factors Affecting Recovery Outcomes

Preoperative muscle quality is a critical prognostic indicator:

• Preoperative muscle atrophy and fatty degeneration of the supraspinatus and infraspinatus correlate with worse healing and inferior clinical outcomes 1
• Workers' compensation status correlates with less favorable outcomes and potentially longer recovery trajectories 1

Important caveat: Musculotendinous infraspinatus ruptures (distinct from classic rotator cuff tears) progress to stage 4 complete fatty infiltration regardless of treatment, and this progression cannot be reversed even with surgery 5

Critical Pitfalls to Avoid

• Never use perioperative corticosteroid injections—evidence regarding their effect on tendon healing is inconclusive and they may actively inhibit healing 1
• Do not expect full recovery before 6 months—tendon healing is a biological process that cannot be rushed, and patients must understand this timeline 1
• Avoid aggressive early rehabilitation—protection of the repair is paramount, and overly aggressive mobilization risks repair failure 1, 6
• Do not use a one-size-fits-all protocol—patients at risk for stiffness may benefit from early closed-chain overhead stretches (table slides), while others should delay overhead stretches until 6 weeks 6

Additional Treatment Modalities

Physical modalities such as laser, ultrasound, and shock-wave therapy have little and contradictory evidence for supraspinatus tendinopathy and should not be prioritized 3. Transcutaneous electrical nerve stimulation (TENS) may provide lower pain scores at 12 hours and postoperative day 7 with reduced opioid consumption 2.