Ortho Dx: The treatment dilemma with partial rotator cuff tears

Slideshow

  • Anteroposterior radiograph of a 49-year-old woman with a 4-month history of left shoulder pain shows no abnormalities.

    Slide

    Anteroposterior radiograph of a 49-year-old woman with a 4-month history of left shoulder pain shows no abnormalities.

  • An outlet radiograph of the patient also shows no abnormalities.

    Slide

    An outlet radiograph of the patient also shows no abnormalities.

  • Magnetic resonance imaging of the patient shows a partial thickness articular-sided rotator cuff tear of the left shoulder.

    Slide

    Magnetic resonance imaging of the patient shows a partial thickness articular-sided rotator cuff tear of the left shoulder.

A 49-year-old woman presents with a 4-month history of left shoulder pain. She enjoys going to the gym and cross training, but her shoulder has been bothering her with overhead activities. She received a subacromial injection 2 months earlier and underwent several weeks of physical therapy with minimal relief. Anteroposterior and outlet radiographs show no abnormalities. Magnetic resonance imaging shows a partial thickness articular-sided rotator cuff tear of the left shoulder. Left shoulder arthroscopy is performed and reveals a partial tear through 60% of the depth of the supraspinatus tendon.

This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.

Partial thickness tears of the rotator cuff present a treatment dilemma. These patients often have tried conservative treatment including rest, nonsteroidal anti-inflammatory drugs, subacromial injections, and physical therapy with no relief before electing to undergo surgery. Partial thickness tears have...

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Partial thickness tears of the rotator cuff present a treatment dilemma. These patients often have tried conservative treatment including rest, nonsteroidal anti-inflammatory drugs, subacromial injections, and physical therapy with no relief before electing to undergo surgery. Partial thickness tears have limited healing potential and will likely progress over time.

Despite this, most patients will continue to improve with conservative treatment up to 18 months. However, it is reasonable to consider surgery when conservative treatment has been ineffective for a period of 3 to 6 months. Many partial tears that are treated with arthroscopy, rotator cuff debridement, and acromioplasty have good to excellent results at 2 to 5 years. Findings during shoulder arthroscopy, including location of the partial rotator cuff tear, size of the tear, and other pathology seen during arthroscopy determine the best course of treatment. Arthroscopic debridement of partial tears is essential in determining the true depth of the tear and may stimulate healing and remove inflammatory cells.

Partial thickness tears can occur on the articular side, intratendinous, on the bursal side, or in a combination of these sites. Articular-sided supraspinatus tendon tears are the most common in older patients, and bursal-sided tears are typically more symptomatic. Bursal-sided tears are more likely to progress to symptomatic full thickness tears than are articular-sided tears.

Partial tears >50% of the tendon depth usually do poorly with conservative treatment. The thickness of a rotator cuff measures approximately 11 mm to 12 mm. A tear >6 mm in depth on the articular side and >3 mm in depth on the bursal side will do poorly with observation and should be treated with rotator cuff repair. When the partial tear is >50% of the tendon depth, the tear is often completed and then repaired back down to the humerus with suture anchors.

Younger athletes with partial rotator cuff tears are the exception to these rules, and nonsurgical treatment should be the mainstay of treatment. These athletes often are unable to return to the same level of activity after rotator cuff surgery, particularly repair. Adequate rehabilitation, rest, the administration of nonsteroidal anti-inflammatory drugs, and possible steroid injections can resolve symptoms in this population effectively.1,2

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

References

  1. Wolff AB, Sethi P, Sutton KM, Covey AS, Magit DP, Medvecky M. Partial-thickness rotator cuff tears. J Am Acad Orthop Surg. 2006;14:715-725.  
  2. Shaffer B, Huttman D. Rotator cuff tears in the throwing athlete. Sports Med Arthrosc. 2014;22:101-109. 
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