What is the next step in management for a 73‑year‑old woman with a painful high‑grade partial‑thickness supraspinatus tear?

Management of High-Grade Partial Supraspinatus Tear in a 73-Year-Old Woman

Begin with a 3-6 month trial of structured physical therapy combined with NSAIDs and consider a single corticosteroid injection for short-term pain relief, then refer to orthopedic surgery if no improvement occurs. 1

Initial Conservative Management (First-Line Treatment)

The American Academy of Orthopaedic Surgeons strongly recommends starting with conservative management before considering surgical intervention 1. This approach includes:

• Structured physical therapy for 3-6 months as the cornerstone of treatment, with demonstrated benefits in pain and function at 8 weeks and 3 months 2, 1
• NSAIDs for pain control and inflammation reduction 1
• Single corticosteroid injection with local anesthetic provides moderate evidence for short-term improvement in both pain and function 2, 1

Important Caveat About Corticosteroids vs. PRP

While corticosteroid injections are guideline-recommended for short-term relief, recent high-quality research from 2023 shows that intralesional PRP injection significantly reduces tear size (3.39 mm reduction in coronal plane, p=0.003) compared to subacromial corticosteroid injection (1.10 mm reduction, p=0.18 not significant), with better functional scores at 6 months 3. However, the American Academy of Orthopaedic Surgeons provides only limited evidence against routine PRP use 2, 1, creating a clinical dilemma. Given the patient's age (73 years) and the goal of avoiding progression to full-thickness tear, consider intralesional PRP as an alternative to corticosteroids if available and affordable 3.

Diagnostic Confirmation

If imaging has not yet been performed or is inadequate:

• MR arthrography is superior to standard MRI or ultrasound for detecting partial-thickness articular surface supraspinatus tears 2, 1
• MR arthrography has increased sensitivity compared to conventional MRI for this specific tear pattern 2
• Standard MRI without contrast and ultrasound have lower sensitivity for partial-thickness tears compared to MR arthrography 2

Critical Decision Point: When to Refer for Surgery

Refer to orthopedic surgery if there is no improvement in pain or function after 3-6 months of structured physical therapy 1. This is particularly important because:

• Age is a significant negative prognostic factor: Only 43% of patients over 65 years achieve complete tendon healing after surgical repair 4
• However, high-grade partial tears converted to full-thickness and repaired have significantly lower retear rates (3.6%) compared to primary full-thickness tear repairs (16.3%) 5
• Patients with surgical treatment report 81% excellent results compared to only 37% with conservative management for symptomatic tears 1

Surgical Considerations Specific to This Patient

At age 73, this patient faces specific challenges:

• Older age is strongly associated with higher failure rates and poorer patient-reported outcomes after rotator cuff repair 2
• Comorbidities are moderately associated with poorer outcomes, so assess for diabetes, smoking, and other conditions 2
• Despite age concerns, healed rotator cuff repairs demonstrate improved outcomes compared to physical therapy alone and unhealed repairs 1

Treatment Algorithm Summary

1. Months 0-3: Structured PT + NSAIDs + consider single corticosteroid injection (or PRP if available) 2, 1, 3
2. Month 3 assessment: Evaluate pain and function improvement
3. Months 3-6: Continue PT if partial improvement; refer to orthopedics if no improvement 1
4. Month 6: If conservative management fails, proceed with surgical consultation for tear completion and repair 1, 5

Common Pitfalls to Avoid

• Do not use hyaluronic acid injections or routine platelet-rich plasma without understanding the limited evidence base 2, 1
• Do not delay surgical referral beyond 6 months if conservative management clearly fails, as tear progression and muscle atrophy worsen surgical outcomes 1
• Do not assume age alone is a contraindication to surgery—functional status and patient goals matter more than chronologic age 2, 4
• Avoid multiple corticosteroid injections, as these may increase risk of tendon rupture; limit to a single injection 3