With MRI showing full‑thickness partial‑width tears of the anterior supraspinatus and posterior infraspinatus, low‑grade subscapularis tear, intra‑articular long‑head biceps tendinosis, superior labral tear, inferior humeral head cartilage loss, and a small intramuscular lipoma in the teres minor, what is the recommended next step in management?

Management of Complex Rotator Cuff Pathology with Multiple Tears

Refer immediately to an orthopedic shoulder surgeon for surgical evaluation given the presence of full-thickness tears involving multiple tendons (supraspinatus, infraspinatus, subscapularis), superior labral tear, and advanced glenohumeral cartilage loss—this constellation of findings indicates structural failure requiring operative assessment rather than prolonged conservative management. 1

Why Immediate Surgical Referral is Indicated

Your MRI demonstrates several features that shift management away from the standard 3-6 month conservative trial:

• Multiple full-thickness tears: You have complete disruption through the anterior supraspinatus and posterior infraspinatus tendons, not just isolated pathology 1
• Subscapularis involvement: The low-grade interstitial tear in the subscapularis is significant because this tendon retracts faster than other rotator cuff muscles and becomes difficult to mobilize if repair is delayed 2, 3
• Superior labral tear: This intra-articular pathology compounds the rotator cuff injury and typically requires arthroscopic treatment 4
• Advanced cartilage loss: Full-thickness cartilage loss of the inferior humeral head indicates degenerative joint disease that may influence surgical approach and prognosis 5

Critical Prognostic Factors to Discuss with Your Surgeon

The MRI report contains findings that directly impact surgical decision-making and outcomes:

• Minimal muscle atrophy: This is favorable—advanced atrophy and fatty infiltration predict irreparability and poor surgical outcomes 1, 6
• Tendon retraction status: The report does not specify retraction distance, which your surgeon will assess to determine repairability 6, 5
• Tear geometry: Full-thickness partial-width tears (complete through thickness but not entire width) may be repairable with margin convergence techniques 5

The Teres Minor Mass Requires Separate Attention

• Likely intramuscular lipoma: The 2.2 x 5.6 x 3.1 cm fat-signal mass without thick septations, nodular components, or abnormal enhancement has benign imaging characteristics 4
• No urgent intervention needed: This finding does not require immediate treatment but should be documented and monitored 4
• Does not affect rotator cuff surgery: The lipoma location in the teres minor (which is intact) should not preclude rotator cuff repair 4

What the Surgeon Will Evaluate

Your orthopedic consultation will focus on:

• Symptom severity and functional limitation: Pain level, inability to perform activities of daily living, and nighttime symptoms 1
• Age and activity level: While advanced age is associated with higher failure rates, chronologic age alone should not preclude surgery if you are otherwise healthy and functional 1
• Comorbidities: Diabetes and tobacco use are moderately associated with poorer outcomes and should be optimized preoperatively 1
• Surgical goals: Whether complete anatomic repair is achievable or whether partial repair, tendon transfer, or arthroplasty is more appropriate given the cartilage loss 5

Why Not Start with Physical Therapy

The standard AAOS recommendation for 3-6 months of structured physical therapy before surgical referral applies primarily to:

• Isolated partial-thickness tears 1
• Single full-thickness tears without retraction 1
• Tendinopathy without structural tear 1

Your case involves multiple full-thickness tears with associated labral pathology and advanced cartilage loss—a pattern that indicates structural failure requiring surgical assessment rather than prolonged conservative management 1, 6.

Common Pitfall to Avoid

Do not delay surgical consultation while attempting prolonged conservative management—the subscapularis tear in particular has a tendency to retract rapidly, and delayed repair makes mobilization and successful healing more difficult 2, 3. Early surgical evaluation allows the surgeon to determine optimal timing and approach, even if surgery is not performed immediately 1.

The Biceps Pathology

• Long head biceps tendinosis with fraying: This is commonly associated with anterosuperior rotator cuff tears and superior labral tears 2, 3
• Will be addressed during surgery: The surgeon will likely perform either biceps tenotomy (cutting the tendon) or tenodesis (reattaching it to bone) as part of the rotator cuff repair 2

Expected Surgical Outcomes

• Healed repairs demonstrate superior outcomes: Successful tendon-to-bone healing correlates with improved patient-reported and functional outcomes compared to physical therapy alone or failed repairs 1
• Success rates with surgery: Patients with symptomatic full-thickness tears report 81% excellent results with surgical treatment versus only 37% with conservative management 1