Review Question - QID 214084

The patient has a partial bursal sided rotator cuff tear with minimal functional deficits and has had improvement in pain with home exercises. The next best step in management would be a course of formal physical therapy for rotator cuff and periscapular muscle strengthening.

Partial-thickness rotator cuff tears are one of the most common findings noted in the elderly population. Various MRI studies have shown up to 55% of asymptomatic patients 60 yrs and older will have a rotator cuff tear. In case of smaller or chronic tears, initial management should consist of NSAIDs, corticosteroid injections, and physical therapy with a focus on rotator cuff strengthening and scapular-stabilizer strengthening over a 3-6 month treatment course. If conservative management fails, a diagnostic arthroscopy and rotator cuff debridement/repair would be indicated.

Wolff et al. reviewed the pathogenesis and treatment of partial-thickness rotator cuff tears. They note that both intrinsic and extrinsic factors play key roles in the development of these tears which are most commonly diagnosed via a combination of physical exam and MRI. The authors recommend a course of conservative management which is successful in most patients. They cite that surgery generally is considered for patients with symptoms of sufficient duration and intensity that have not improved with conservative management. Sufficient duration varies from patient to patient and can range from months to years.

Tashjian performed a review of the epidemiology, diagnosis, and treatment of rotator cuff tears. He noted that substantial full-thickness rotator cuff tears progress and enlarge with time and complaints of worsening pain usually infers tear progression. He cites smaller symptomatic full-thickness tears (< 1 cm) have been shown to have a slower rate of progression, similar to partial-thickness tears, and can be considered for initial nonoperative treatment due to the limited risk for rapid tear progression. He concluded that initial nonoperative care can be safely undertaken in older patients (>70 years old) with chronic tears; in patients with irreparable rotator cuff tears with irreversible changes, in patients of any age with small (<1 cm) full-thickness tears; or in patients without a full-thickness tear.

Figures A and B reveal normal AP and axillary lateral radiographs of the right shoulder

Incorrect Answers:
Answers 1, 2, and 4: This patient has full range of motion, has already had some improvement in pain and has yet to try any formal conservative management. The next step in management would be physical therapy.
Answer 5: A repeat MRI would only be indicated if the patient has had progressive pain and weakness unexplained by prior MRI.