I have chronic right shoulder pain and MRI shows a large full‑thickness supraspinatus tear with retraction and partial infraspinatus and subscapularis tears; what does this mean and what are my management options?

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Understanding Your MRI Results

You have a complete, full-width tear of your supraspinatus tendon with significant retraction and muscle atrophy, plus smaller partial tears in two adjacent tendons—this pattern strongly favors surgical referral over continued conservative management, especially if you are younger than 65 and remain functionally active. 1

What the MRI Shows

Your imaging reveals three distinct tendon injuries:

  • Full-thickness, full-width supraspinatus tear: The entire tendon has torn away from the bone and retracted medially to the level of your AC joint, with associated fatty streaking and muscle shrinkage—this represents a complete rupture that will not heal on its own. 1, 2

  • Partial infraspinatus tear: The front third of this tendon shows internal splitting (delamination) at its attachment, but the remainder stays intact and the muscle remains healthy. 1, 3

  • Partial subscapularis tear: The upper margin of this tendon shows progressive interstitial tearing at its insertion, though most of the tendon and all of the muscle remain normal. 1, 3

  • AC joint arthritis: Moderate degenerative changes at the top of your shoulder contribute to pain but are not the primary problem. 4

  • Subacromial bursal fluid: Fluid communicates between the bursa and joint through the torn rotator cuff—this is a hallmark MRI finding of full-thickness tears. 2, 5

Why This Matters Clinically

The combination of complete supraspinatus rupture with retraction and muscle atrophy carries a poor prognosis without surgery:

  • Conservative management alone produces excellent outcomes in only 37% of patients with symptomatic full-thickness tears, compared to 81% excellent results with successful surgical repair. 1

  • Tendon retraction to the AC joint level indicates the torn ends have pulled far from the bone, making spontaneous healing impossible and predicting worse surgical outcomes if repair is delayed. 1, 2

  • Fatty infiltration and muscle atrophy on your MRI signal chronic denervation—these changes become irreversible over time and reduce the likelihood of successful repair if you wait. 1, 6

Management Algorithm

Step 1: Determine If You Have Already Tried Conservative Treatment

  • If you have not yet completed a structured 3–6 month trial of physical therapy combined with NSAIDs, the American Academy of Orthopaedic Surgeons recommends starting there before considering surgery. 1

  • If you have already failed 3–6 months of structured physical therapy without improvement in pain or function, proceed directly to orthopedic surgical referral. 1

Step 2: Consider a Single Corticosteroid Injection

  • One subacromial corticosteroid injection with local anesthetic provides moderate evidence for short-term pain and functional improvement and can be used as an adjunct during the conservative trial. 1, 4

  • Avoid multiple injections—repeated corticosteroid injections increase the risk of tendon rupture and are not recommended. 1

  • Do not use hyaluronic acid or platelet-rich plasma injections, as the American Academy of Orthopaedic Surgeons advises against routine use due to limited supporting evidence. 1

Step 3: Refer to Orthopedic Surgery If Conservative Treatment Fails

  • The American Academy of Orthopaedic Surgeons recommends orthopedic referral for patients who show no improvement in pain or function after 3–6 months of structured physical therapy, particularly for acute traumatic tears, younger patients, and those without significant comorbidities. 1

  • Healed rotator cuff repairs demonstrate improved patient-reported and functional outcomes compared with physical therapy alone and unhealed repairs. 1

  • Your imaging shows a large full-thickness tear with retraction—the American College of Radiology emphasizes that this pattern predicts poor spontaneous healing and warrants surgical evaluation. 6

Factors That Influence Surgical Success

Favorable Prognostic Factors

  • Age younger than 65 years: Younger patients demonstrate higher tendon-healing rates (approximately 71%) compared to older cohorts (approximately 43%). 1

  • Absence of diabetes or tobacco use: These comorbidities are moderately associated with higher failure rates and poorer postoperative outcomes. 1, 6

  • Preserved infraspinatus and subscapularis muscle bulk: Your MRI shows normal signal and bulk in these muscles, which predicts better surgical outcomes. 1, 6

Unfavorable Prognostic Factors

  • Advanced age: Strongly linked to increased failure rates and poorer patient-reported outcomes after rotator cuff repair. 1

  • Workers' compensation status: Associated with poorer postoperative outcomes. 4

  • Fatty infiltration and muscle atrophy: Your supraspinatus shows both—these changes reduce surgical success and become irreversible if repair is delayed. 1, 6

What Happens If You Choose Surgery

  • Surgical goal: Reattach the torn supraspinatus tendon to bone to achieve tendon-to-bone healing, which is associated with improved clinical outcomes. 1, 4

  • Technique options: Arthroscopic, mini-open, or open repair—your surgeon will choose based on tear size, retraction, and tissue quality. 4

  • Acromioplasty is not required: The American Academy of Orthopaedic Surgeons states that acromioplasty does not improve outcomes for normal acromial bone and should not be routinely performed. 4

  • Postoperative protocol: Expect to wear a sling for 4–6 weeks followed by months of rehabilitation, with early mobilization (versus delayed mobilization up to 8 weeks) showing similar clinical and patient-reported outcomes for small- to medium-sized tears. 1, 4

Common Pitfalls to Avoid

  • Delaying surgical referral beyond 6 months of failed conservative treatment: Progressive muscle atrophy and fatty infiltration become irreversible, reducing the chance of successful repair. 1, 6

  • Expecting conservative management to heal a full-thickness tear with retraction: Your MRI shows complete tendon discontinuity with retraction to the AC joint—this will not heal without surgery. 1, 2

  • Pursuing multiple corticosteroid injections or unproven biologics: Limit corticosteroid injections to one, and avoid hyaluronic acid or PRP due to lack of evidence. 1

  • Assuming age alone disqualifies you from surgery: Chronologic age should not preclude surgical referral; decisions should prioritize functional status, patient goals, and overall health. 1

References

1
Guideline

Management of Rotator Cuff Tear

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Research

MR evaluation of subscapularis tears.

Journal of computer assisted tomography, 1999

4
Guideline

Shoulder Injury Diagnosis and Treatment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Research

Shoulder impingement syndrome: MR findings in 53 shoulders.

AJR. American journal of roentgenology, 1988

6
Guideline

Post‑Operative MRI Findings and Management at 8 Weeks After Rotator Cuff Repair

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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