What is the recommended treatment for a middle‑aged adult with shoulder pain, limited active forward elevation, and imaging showing subacromial space narrowing with irregularities of the greater tuberosity?

Treatment of Subacromial Space Narrowing with Greater Tuberosity Irregularities

Initial treatment should be conservative with physical therapy focused on rotator cuff strengthening and range of motion exercises, as surgical intervention (arthroscopic subacromial decompression) should only be considered after adequate non-operative treatment has failed. 1

Diagnostic Significance of Imaging Findings

• Greater tuberosity irregularities are highly predictive of rotator cuff pathology, with 75% of shoulders showing irregular greater tuberosities having rotator cuff tears on imaging, and 90% of shoulders with confirmed rotator cuff tears demonstrating tuberosity irregularities. 2

• Subacromial space narrowing combined with greater tuberosity irregularities suggests chronic rotator cuff disease with mechanical impingement, though imaging findings alone do not confirm symptomatic impingement and may be present in asymptomatic individuals. 3

• The combination of these findings in a middle-aged adult with limited active forward elevation strongly suggests rotator cuff tendinopathy or partial/full-thickness tear requiring further evaluation. 4, 2

Initial Conservative Management (First-Line Treatment)

• Non-operative care should be the primary treatment approach, including structured physical therapy with specific focus on:

  • Rotator cuff strengthening exercises targeting supraspinatus, infraspinatus, and subscapularis 4, 5
  • Range of motion exercises emphasizing external rotation and abduction 6
  • Scapular stabilization exercises to address dysfunctional scapulothoracic movement patterns 5

• Avoid overhead pulley exercises as they encourage uncontrolled abduction and may worsen impingement symptoms. 6

• Proper positioning and activity modification to reduce mechanical stress on the subacromial space 1

• Consider adjunctive treatments such as NSAIDs for pain control and anti-inflammatory effect 4

Duration of Conservative Treatment

• A defined period of adequate non-operative treatment must be attempted before considering surgery, though specific duration is not universally established in guidelines. 1

• Most clinical practice guidelines recommend 3-6 months of structured conservative therapy before surgical consultation for persistent symptoms. 1

Advanced Imaging Considerations

• MRI without contrast or ultrasound should be obtained if not already performed to definitively characterize rotator cuff integrity, as plain radiographs showing subacromial narrowing and tuberosity irregularities are highly suggestive but not diagnostic of rotator cuff tears. 1, 6, 2

• MRI is particularly useful for assessing tendon retraction, muscle atrophy, and fatty infiltration—findings that influence surgical decision-making and prognosis. 1

• For patients over 35 years, standard MRI without contrast is typically sufficient as shoulder pain is predominantly related to rotator cuff disease in this age group. 1, 6

Surgical Considerations (Second-Line Treatment)

• Surgery should only be considered after failure of adequate conservative treatment, as high-quality evidence shows that arthroscopic subacromial decompression outcomes are comparable to exercise-based rehabilitation or sham surgery. 1

• National guidelines acknowledge that arthroscopic subacromial decompression can be used for pure subacromial impingement when symptoms fail to resolve with adequate non-operative treatment, despite evidence of limited effectiveness. 1

• Displaced greater tuberosity fractures (>3-5mm superior displacement) are an exception requiring surgical consideration, as this degree of displacement adversely affects rotator cuff biomechanics and causes subacromial impingement in active patients. 7

Critical Pitfalls to Avoid

• Do not assume all improvement from surgery is due to the surgical intervention itself—some benefit may result from natural history, regression to the mean, or non-surgical co-interventions. 1

• Avoid rushing to surgery based solely on imaging findings, as subacromial space narrowing and tuberosity irregularities may be present in asymptomatic individuals. 3

• Do not perform aggressive passive range-of-motion exercises improperly, as this can cause more harm than good in the complex shoulder joint. 1

• Recognize that imaging reveals predisposing factors but no pathognomonic indicators of symptomatic impingement—clinical correlation is essential. 3

When to Refer to Orthopedic Surgery

• Failure of 3-6 months of structured conservative therapy with persistent functional limitation 1

• Presence of massive rotator cuff tears that may require expedited repair for optimal outcomes 6

• Significantly displaced greater tuberosity fractures (>3-5mm) in active patients 7

• Progressive weakness suggesting complete rotator cuff tear with risk of muscle atrophy and fatty infiltration 1