Shoulder and Elbow

Evaluation and Management of Partial Thickness Rotator Cuff Tears

The Problem

Partial thickness tears of the rotator cuff have the potential to cause significant pain and functional limitations in affected patients. Partial thickness tears can be on the articular side of the tendon, on the bursal side of the tendon or intra-tendinous. The extreme variability in etiology, size and location of partial-thickness tears of the rotator cuff coupled with limited data regarding their management have caused these injuries to represent a complex clinical problem.

In the older patient population, partial thickness tears more commonly affect the articular side of the supraspinatus tendon near its insertion onto the footprint of the greater tuberosity. These articular-sided supraspinatus tears occur due to poor vascularity in this region coupled with a significantly reduced tensile strength compared to the bursal side, which is composed of rupture-resistant elastic tendon bundles. In the younger, overhead throwing athlete, partial thickness tears are seen more posteriorly at the supraspinatus-infraspinatus interval.

The main etiological factors differ for each subtype of partial thickness tear. Bursal-sided tears tend to be primarily caused by subacromial impingement. Articular-sided tears usually result from trauma to a degenerated tendon. Intratendinous tears result from differential shear stress within the supraspinatus tendon.

Biomechanical studies have demonstrated that in the presence of a partial thickness tear, the strain patterns within the remaining intact rotator cuff are impacted. This coupled with the limited potential for spontaneous healing predisposes the tissue to tear progression.

While conservative treatment is often effective in reducing pain and improving range of motion and function, persistent symptoms and disability may be present warranting surgical intervention. A variety of approaches to the surgical management of partial thickness rotator cuff tears have been described with varying results in the literature.

Clinical Presentation

Partial-thickness tears are often asymptomatic, but can present with pain and limited shoulder function. Patients will often report pain and stiffness of the affected shoulder with partial-thickness tears often presenting with more pain than full-thickness tears. Night pain in addition to pain exacerbated by active, overhead activity are typical presenting complaints. Bursal-sided tears are notably more painful than intratendinous or articular-sided partial-thickness tears. Overhead athletes usually have a different presentation than their older counterparts, with their primary complaints being deep, posterior shoulder pain and decreased throwing velocity.

Diagnostic Workup

Physical Examination

The physical signs and symptoms of disease of the rotator cuff are often non-specific and can be classified into two groups: those that are caused by inflammation of the subacromial bursa and rotator cuff tendon, which result in a painful arc of motion, impingement signs and contractures and those that result from tendon tears, which may present with a drop arm sign, muscle weakness and atrophy.

Inspection - Look for signs of suprapinatus and/or infraspinatus atrophy, taking arm dominance into account.

Palpation - Patients with rotator cuff pathology may be tender to palpation over the anterolateral aspect of the shoulder in the region of the supraspinatus insertion on the greater tuberosity.

Range of Motion - Active (AROM) and passive range of motion (PROM) needs to be assessed for both the affected and the contralateral shoulder. Passive forward flexion less than 110 degrees, external rotation less than 25 degrees, and internal rotation below the second sacral vertebral level suggest shoulder stiffness raising concerns for associated adhesive capsulitis. Patients with differences in AROM and PROM increase suspicion for rotator cuff pathology. Commonly, patients with partial thickness rotator cuff tears have normal active ROM but report a painful arc present with forward flexion and abduction between 80 and 120 degrees.

Rotator Cuff Strength Testing/Provocative Tests - Each portion of the rotator cuff should be tested for strength and whether or not resistive testing elicits pain. Specific provocative shoulder exam tests include:

The Jobe Test -- Indicates the integrity of the supraspinatus tendon and for subacromial impingement. Tests patients’ ability to resist downward pressure on the arm held at 90 degrees in the scapular plane and 45 degrees internal rotation. Weakness is better than pain as a criterion for a positive test.

Neer Impingement Sign/Test -- Indicates impingement of the greater tuberosity against the acromion during range of motion. The examiner should stabilize the scapula with one hand while using the other to elevate the arm in the scapular plane. A positive sign is pain in the 70-110 degree range in a shoulder with full range of motion. A positive test is relief of pain from the above maneuver following administration of a subacromial lidocaine injection.

Hawkins Test -- Indicates impingement of the greater tuberosity on the coracoacromial ligament. Flex shoulder and elbow to 90 degrees, then forcibly internally rotate the shoulder. Pain with this maneuver indicates a positive test.

Radiographic Workup

The initial evaluation of patients with shoulder pain often includes a plain X-ray series including a Grashey view, scapular Y view and an axillary view. While patients with partial thickness rotator cuff tears rarely have findings on plain radiographs, X-rays can identify the presence of glenohumeral degenerative changes and allow for an assessment of acromial morphology. For patients presenting with a history and physical examination consistent with rotator cuff pathology, MRI and ultrasound have become the imaging modalities of choice.

MRI -- Provides the most complete evaluation of the anatomy and structural integrity of the shoulder. Reported to pick up rotator cuff pathology with a sensitivity of 84% and specificity of 96%. The MRI diagnosis of a partial thickness rotator is based on the presence of increased signal and disruption of the normal insertion onto the greater tuberosity. Abnormal morphology on T1 images with corresponding increased signal in the area on T2 images is consistent with rotator cuff injury. Increased joint or subacromial bursal fluid may also be demonstrated in the setting of partial-thickness tears.

Ultrasound -- Cost-effective, but usability is highly operator dependent. Partial-thickness tears will show focal tendon contour defect or a linear band of either mixed hypohyperechoic or purely anechoic appearance. More accurate for full-thickness than partial-thickness tears since it is difficult to distinguish partial-thickness tears from scarring within the tendon or a small full-thickness lesion.

Non–Operative Management

A trial of non-operative management for patients presenting with a partial thickness rotator cuff tear is the usual approach with improvements in pain, motion and strength often seen. Non-operative management includes activity modification with avoidance of provocative activities, anti-inflammatory medications, subacromial corticosteroid injections and supervised physical therapy to maintain or regain range of motion, perform capsular stretching and improve rotator cuff and periscapular muscle strength once inflammation and pain have subsided. While there is limited data supporting the use of subacromial corticosteroid injections in the setting of partial thickness rotator cuff tears, many patients get significant relief following this portion of their non-operative treatment regimen. Many patients improve with conservative measures over the course of 3-6 months. There is some data to support the fact that bursal-sided tears respond poorly to non-operative treatment and early surgical intervention is recommended.

Indications for Surgery

Patients with persistent symptoms of pain and disability after an adequate trial of non-operative treatment should be considered for surgery. Patients with high grade articular sided lesions (> 50% of the tendon insertion) and those with bursal sided tears should be observed closely for their response to non-operative management with consideration given to early surgical intervention.

Surgical Technique

Intraoperative Assessment/Diagnostic Arthroscopy

As part of the standard diagnostic shoulder arthroscopy, the insertion of the rotator cuff on the greater tuberosity is assessed via the posterior viewing portal. Frayed tendon fibers are debrided using the arthroscopic shaver back to normal appearing tendon. Once the debridement is complete, articular sided partial thickness rotator cuff tears can be classified according the Ellman Classification. This system is based on anatomic studies which found that the mean thickness of the insertion of the supraspinatus on the greater tuberosity footprint.

Ellman's classification is based on size of the tear and whether it is on the articular sided (A) or bursal side (B). Grade 1à less than 3 mm in depth. Grade 2à 3-6mm. Grade 3à greater than 6mm, representing over 50% of tendon thickness.

The site of the articular sided lesion can be tagged with a PDS suture to allow for assessment of the bursal side of the rotator cuff when the arthroscope is redirected into the subacromial space.

Recommended treatment includes debridement with or without acromioplasty for Grade 1 bursal-sided tears and Grades 1 and 2 articular-sided tears. Acromioplasty should be considered when an extrinsic etiology is suspected, represented by impingement of the cuff on the underside of the acromion, a bursal-side tear, and/or fraying of the underside of the coracoacromial ligament. For Grade 3 articular-sided tears and Grade 2 or 3 bursal-sided tears, repair of the tendon should be performed, the technique of which is based on surgeon preference and patient goals. Options include transtendinous repair, takedown and repair and transosseous repair.

Debridement of a Partial–Thickness Rotator Cuff Tear With or Without Acromioplasty

Debridement may relieve mechanical irritation in the subacromial space and the glenohumeral joint. It may also remove inflammatory cells and inflammatory mediators.

  1. Place patient in the beach-chair or lateral position under general anesthesia or interscalene nerve block.

  2. Perform a comprehensive diagnostic shoulder arthroscopy of the glenohumeral joint through a standard posterior portal.

  3. The site of the partial thickness tear is debrided with an arthroscopic shaver back to normal appearing tendon.

  4. Following the debridement, assess the supraspinatus footprint using an arthroscopic probe to determine depth of the partial-thickness tear allowing for characterization of the tear according to the Ellman classification.

  5. After intra-articular debridement, the site of the partial thickness tear is tagged with a PDS suture allowing for assessment of the bursal surface of the rotator cuff in the subacromial space.

  6. The undersurface of the acromion is debrided of soft tissue with a radiofrequency probe.

  7. Using an arthroscopic burr or bone cutting shaver an acromioplasty is performed removing any undersurface spurs creating adequate space for the underlying rotator cuff.

Transtendinous Repair

Transtendinous repair has the theoretical advantage of retaining the lateral portion of the original footprint of the cuff insertion and minimizing the length-tension mismatch of the repaired rotator cuff.

  1. Place patient in the beach-chair or lateral position under general anesthesia or interscalene nerve block.

  2. Perform a comprehensive diagnostic shoulder arthroscopy of the glenohumeral joint through a standard posterior portal.

  3. For articular sided tears, the site of the partial thickness tear is debrided with an arthroscopic shaver back to normal appearing tendon.

  4. Following the debridement, assess the supraspinatus footprint using an arthroscopic probe to determine depth of the partial-thickness tear allowing for characterization of the tear according to the Ellman classification.

  5. Percutaneously a suture anchor is inserted into the footprint on the greater tuberosity.

  6. Sutures from the anchor are shuttled through the edges of the partial thickness tear and then tied in the subacromial space. Shuttling can be performed with a spinal needle or suture passing device and a passing PDS suture.

  7. For articular-sided tears <1.5 cm in the anterior-posterior direction, only one suture anchor is used.

  8. For articular-sided tears >1.5 cm in the anterior-to-posterior direction, two bioabsorbable suture anchors double-loaded with #2 nonabsorbable polyester are used.

Full Takedown and Repair

This is the author's preferred approach for Ellman 3 injuries as it provides the most reliable and reproducible approach to partial thickness rotator cuff tears - both articular sided and bursal sided.

  1. Place patient in the beach-chair or lateral position under general anesthesia or interscalene nerve block.

  2. Perform a comprehensive diagnostic shoulder arthroscopy of the glenohumeral joint through a standard posterior portal.

  3. The site of the partial thickness tear is debrided with an arthroscopic shaver back to normal appearing tendon.

  4. Following the debridement, assess the supraspinatus footprint using an arthroscopic probe to determine depth of the partial-thickness tear allowing for characterization of the tear according to the Ellman classification.

  5. For articular sided tears, tag the lesion site with a PDS suture using a spinal needle for localization in the subacromial space.

  6. In the subacromical space an acromioplasty should be performed if an impingement lesion is visualized (either before or after the rotator cuff repair).

  7. Once the defect is localized, the tear is completed using a shaver and the tear edges are debrided back to normal appearing tendon.

  8. The footprint is cleared of soft tissue and decorticated.

  9. Depending on the size of the tear in the anterior-posterior dimension 1-2 suture anchors are inserted at the junction of the greater tuberosity and articular surface.

  10. Sequential suture passage is performed through the tendon edge using the surgeon's choice of passing devices (lassos, self-retrieving passer, etc).

  11. Arthroscopic knot tying is performed.

  12. Depending on surgeon preference two lateral row anchors can be inserted for a double row repair construct.

Transosseous Repair

  1. Place patient in the beach-chair or lateral position under general anesthesia or interscalene nerve block.

  2. Perform a comprehensive diagnostic shoulder arthroscopy of the glenohumeral joint through a standard posterior portal.

  3. The site of the partial thickness tear is debrided with an arthroscopic shaver back to normal appearing tendon.

  4. Following the debridement, assess the supraspinatus footprint using an arthroscopic probe to determine depth of the partial-thickness tear allowing for characterization of the tear according to the Ellman classification.

  5. The anteroposterior extension of the lesion should measure at least 9mm to perform this transosseous technique.

  6. Before tendon repair, the arthroscope is switched into the subacromial space through a standard lateral portal and bursectomy is performed using a full radius 5.5mm shaver to better assess the bursal side of the rotator cuff.

  7. A specialized device is used to pass sutures through the supraspinatus tendon at the site of the partial thickness tear, directly at the border between the intact and debrided tendon tissue.

  8. The sutures are then passed out of the lateral cortex 1.5cm distal to the top of the greater tuberosity and tied in this position.

  9. To place the two transosseous tunnels next to each other, a minimum bone bridge of 3mm in between should be preserved.

Pearls and Pitfalls of Techniques

Pearls

Understand the various options and approaches in the management of partial thickness tears.

Adequately debride the site of the partial thickness tear to better understand its extent and be able to classify the tear appropriately.

Viewing the tear site from the lateral portal may improve visualization and aid in suture passage.

Pitfalls

Inadequate debridement may lead to mis-classification of the injury and an incorrect treatment decision.

Potential Complications

Debridement with or without acromioplasty does not prevent the progression to a full-thickness tear.

Those who underwent takedown and repair have a small risk (10%) of re-tearing their tendon, with higher risk to older patients.

Significantly higher risk of treatment failure with bursal lesions (20%) than articular.

Aside from tear progression, other complications are rare including stiffness and infection.

Post–operative Rehabilitation

Debridement with or without acromioplasty

Sling for comfort until post-operative pain has subsided.

Patients should perform active and passive shoulder motion as tolerated in the immediate post-operative period.

Takedown and Repair

- Standard rotator cuff post-op protocol

Patient placed in an abduction shoulder immobilizer for 4-6 weeks, coming out of the sling for passive range of motion exercises.

Active motion initiated at 4 weeks and resistive exercises initiated at 12.

Return to normal activities at 6 months.

Transtendon repair

Slightly accelerated therapy program, taking patients out of the abduction shoulder immobilizer for active range of motion at 3 weeks, with strengthening started at 10 weeks post-operatively.

Continuous passive motion machines were used in the rehab protocol of Ide et al after transtendon repair.

Transosseous repair

Arm immobilized in a sling for 6 weeks, coming out for passive range of motion exercises.

After 6 weeks, active assisted range of motion exercises in all planes begin including isometric and dynamic exercises.

Overhead and internal rotation stretches are commenced on regaining full range of motion between a period of 2-4 months.

In terms of sling immobilization, placing the shoulder in a neutral rotation position as opposed to traditional sling immobilization in internal rotation may reduce the risk of repair failure.

At final follow-up, most patients report no significant difference in post-operative range of motion compared with the contralateral side.

Outcomes/Evidence in the Literature

Comparing outcomes for debridement with or without acromioplasty for partial thickness rotator cuff tears (Strauss et al). See Table I.

Table I.

Comparing outcomes for debridement with or without acromioplasty for partial thickness rotator cuff tears (Strauss et al).

Comparing clinical outcomes for transtendon repair, full takedown and repair, and transosseous repair of partial-thickness rotator cuff tears (Strauss et al). See Table II.

Table II.

Comparing clinical outcomes for transtendon repair, takedown and repair, and transosseous repair of partial-thickness rotator cuff tears (Strauss et al).

Strauss, EJ, Salata, MJ, Kercher, J, Barker, JU, McGill, K, Bach, BR, Romeo, AA, Verma, NN. "The Arthroscopic Management of Partial Thickness Rotator Cuff Tears: A Systematic Review of the Literature". Arthroscopy. vol. 27. 2011. pp. 568-580.

(Systematic review of the management of partial thickness rotator cuff tears with assessment of outcomes reported in the literature.)

Finnan, RP, Crosby, LA. "Partial Thickness Rotator Cuff Tears". JSES. vol. 19. 2010. pp. 609-616.

(Review article on the evaluation and management of partial thickness rotator cuff tears.)

Ellman, H. "Diagnosis and Treatment of Incomplete Rotator Cuff Tears". CORR. 1990. pp. 64-74.

(Review article on the evaluation and management of partial thickness rotator cuff tears.)

Gonzalez-Lomas, G, Kippe, MA, Brown, GD. "In Situ Transtendon Repair Outperforms Tear Completion and Repair for Partial Articular Sided Supraspinatus Tendon Tears". JSES. vol. 17. 2008. pp. 722-728.

(Biomechanical study comparing two repair techniques for high-grade, partial, articular-sided supraspinatus tendon tears of the rotator cuff: transtendon in situ repair and tear completion with repair. The in situ transtendon repair had statistically significant less gapping (P = .0001) and higher mean ultimate failure strength (P = .0011) than the double-row repair leading the authors to conclude that in situ transtendon repair was biomechanically superior to tear completion for partial, articular-sided supraspinatus tears.)

Wolff, AB, Sethi, P, Sutton, KM, Covey, AS, Magit, DP, Medvecky, M. "Partial Thickness Rotator Cuff Tears". JAAOS. vol. 14. 2006. pp. 715-725.

(Review article on the evaluation and management of partial thickness rotator cuff tears.)

Ide, J, Maeda, S, Takagi, K. "Arthroscopic Transtendon Repair of Partial Thickness Articular Side Tears of the Rotator Cuff: Anatomical and Clinical Study". AJSM. vol. 33. 2005. pp. 1672-1679.

(In 43 cadaveric shoulders the authors measured the width of the supraspinatus insertion (medial-to-lateral direction) and the distance between the articular cartilage edge and the tendon insertion. The mean width of the supraspinatus insertion was 9.6 mm and the mean distance between the articular cartilage edge and the tendon insertion was 0.3 mm. A clinical study group of 17 patients (mean age, 42 years; range, 17-51 years) was observed for a mean follow-up of 39 months - the mean University of California at Los Angeles and Japanese Orthopaedic Association scores significantly improved from 17.3 and 68.4 points to 32.9 and 94.8 points, respectively. Rated on the Japanese Orthopaedic Association scale, results were excellent in 14, good in 2, and fair in 1 patient; there were no poor results. Of 6 overhead-throwing athletes, 2 returned to their previous sports at the same level, 3 returned at a lower level, and 1 was unable to return.)

Park, JY, Yoo, MJ, Kim, MH. "Comparison of Surgical Outcomes Between Bursal and Articular Partial Thickness Rotator Cuff Tears". Orthopaedics. vol. 26. 2003. pp. 387-390.

(Twenty-four articular and 13 bursal partial thickness rotator cuff tears were evaluated for pain relief and functional recovery. At 6 months post-operatively, the average pain score decreased from 6.2 to 1.7 in patients with articular tears and from 7.1 to 0.9 in patients with bursal tears. Although pain relief and functional recovery were excellent in both groups, the results were better in patients with bursal partial thickness rotator cuff tears at 6 months post-operatively.)

Porat, S, Nottage, WM, Fouse, MN. "Repair of Partial Thickness Rotator Cuff Tears: A Retrospective Review with Minimum Two Year Follow Up". JSES. vol. 17. 2008. pp. 729-731.

(Take down and repair resulted in improvement of mean UCLA score from 17.25 to 31.45 with good to excellent results reported in 83.3% of patients. Authors concluded that completion of high grade partial thickness rotator cuff tears followed by repair results in clinical improvement.)

Tauber, M, Koller, H, Resch, H. "Transosseous Arthroscopic Repair of Partial Articular Surface Supraspinatus Tendon Tears". Knee Surg Sports Traumatol Arthrosc. vol. 16. 2008. pp. 608-613.

(Authors describe a transtendon arthroscopic technique of transosseous refixation of articular-sided partial tears leaving the bursal layer of the supraspinatus tendon intact. A curved hollow needle is used to perform an all arthroscopic transosseous mattress suture restoring anatomic tendon-to-bone contact of the rotator cuff to the footprint. Preliminary clinical results of 16 patients are convincing with significant pain relief and functional improvement - UCLA score improved from 15.8 to 32.8 and VAS reduced from 7.9 to 1.2.)

Waibl, B, Buess, E. "Partial Thickness Articular Surface Supraspinatus Tears: A New Transtendon Suture Technique". Arthroscopy. vol. 21. 2005. pp. 376-381.

(Authors describe a transtendon suture technique that is able to preserve the intact tendon fibers and to achieve firm attachment of the tendon to the humeral footprint using 1 double-loaded suture anchor. The clinical results of the first 22 consecutive patients are reported, showing an increase in the UCLA score from 17.1 to 31.2 points and a patient satisfaction rate of 91%.)

Summary

Partial thickness rotator cuff tears can be a significant source of shoulder pain and functional limitation. When non-operative management fails, surgical intervention is warranted. There is currently no high-level evidence to support a specific treatment algorithm for partial thickness rotator cuff pathology. What is supported by the data available is that in general, tears that involve less than 50% of the tendon insertion can be treated with good results by debridement with or without a formal acromioplasty. When the tear is greater than 50%, surgical repair is necessary with a number of options available to the surgeon. Understanding the nature of partial thickness rotator pathology and the available treatment approaches allows for successful outcomes in the majority of patients.

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