Diagnosis and Management of Partial Thickness Rotator Cuff Tears

A Comprehensive Review

Kevin D. Plancher, MD, MPH; Jaya Shanmugam, MD; Karen Briggs, MPH; Stephanie C. Petterson, MPT, PhD

J Am Acad Orthop Surg. 2021;29(24):1031-1043.

Diagnostic Injections

Selective, diagnostic injections of an anesthetic (eg, lidocaine) into either the subacromial space or glenohumeral joint may help confirm suspicion of pathology if the patient experiences persistent or recurrent symptoms. Provocative examination maneuvers are repeated after the injection to assess for alleviation of symptoms. Pain relief with a subacromial injection is suggestive of subacromial impingement with or without a RC tear. If symptom relief is achieved with a subacromial injection, we caution against proceeding to the operating room. Symptom relief after a glenohumeral injection increases suspicion of intraarticular pathologies (eg, labral tears, internal impingement, osteoarthritis, and adhesive capsulitis).

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Table 1. Ellman and Snyder Classification System for Partial Rotator Cuff Tears
Location	Ellman Classification		Snyder Classification
A Articular	1	<3 mm (<25%)	0	Normal cuff with smooth coverings of synovium and bursa
B Bursal	2	3–6 mm (25–50%)	I	Minimal superficial bursal or synovial irritation or slight capsular fraying in a small, localized area; usually <1 cm
C Intratendinous	3	>6 mm (>50%)	II	Actual fraying and failure of some RC fibers in addition to synovial, bursal, or capsular injury; usually 1–2 cm
			III	More severe RC injury, including fraying and fragmentation of tendon fibers, often involving the entire surface of a cuff tendon (most often the supraspinatus); usually 2–3 cm
			IV	Very severe partial rotator tear that usually contains a sizable flap tear in addition to fraying and fragmentation of tendon tissue and often encompasses more than a single tendon; usually >4 cm

RC = rotator cuff
Based on a normal supraspinatus tendon thickness of 12 mm.

Table 2. Summary of Studies for Treatment of Partial Thickness Rotator Cuff Tears
Author	Treatment	Number of Patients	Tear Type	Follow-up	Results
Maman et al¹⁴ (2009)	Conservative	26	7–58 mo (mean 20 mo)		MRI Tear progression - 2 (8%) Stable - 23 (89%) Decrease - 1
Lo et al²⁷ (2018)	Conservative	37	46 ± 7 mo		Notable improvement in ASES and SST MRI tear progression - 9 (24%)
Jaeger et al³³ (2016)	Débridement and acromioplasty	22	19.5–20.5 yr (mean 19.9 yr)		Successful outcomes—90.9%
Ranebo et al³⁰ (2017)	Débridement and acromioplasty	45	Articular—44 Bursal—1	21–25 yr (mean 22 yr)	Ultrasonography Retear—16 (42%) Mean relative CM—101 WORC—81%
Aydin and Karaismailoglu³⁹ (2017)	Conversion repair	29	Bursal	5 yr	CSS 38.9/87.8 (pre-op/post-op) (P < 0.001) VAS 7.9/1.31 (pre-op/post-op) (P < 0.001)
Chung et al⁴⁰ (2015)	Conversion repair	34	Articular—17 Bursal—16 Both—1	Minimum 2 yr	Retear—12 (35.3%) CTA VAS, ASES, and UCLA scores improved (P < 0.001)
Ranalletta et al³⁵ (2016)	TT	80	Articular	2 yr	ASES 44.4/76.1 (pre-op/post-op) (P < 0.001) VAS 6.3/1.3 (pre-op/post-op) (P < 0.001) 92.5% patient satisfaction
Rossi et al³⁶ (2019)	TT	62	Articular—29 Bursal—33	8–12 yr (mean 10.4 yr)	ASES 45.6/85.1 (preop/postop) (P < 0.001) VAS 6.4/1.6 (pre-op/post-op) (P < 0.001) No notable difference articular vs. bursal
Castricini et al⁴¹ (2019)	Conversion repair vs. TT	94—conversion repair 59—transtendinous	PASTA lesions	24–142 mo (mean 72.9 mo)	Overall retear rate 13.7% No notable difference in CMS, SST, satisfaction, and retear

ASES = American Shoulder and Elbow Surgeons score, CM = Constant Murley Score, CSS = Constant Shoulder Score, CTA = Computerized Tomography Arthrography, SST = Simple Shoulder Test, TT = transtendinous, UCLA = University of California Los Angeles, VAS = visual analog pain scale