Review Question - QID 214107

This patient has a partial-thickness articular-sided rotator cuff tear which has failed conservative management. Of the options listed, a rotator cuff repair or debridement would be the most appropriate next step.

Initially, partial-thickness rotator cuff tears are most commonly managed by conservative means. A combination of formal physical therapy, NSAIDs, and corticosteroid injections are common treatment modalities for partial-thickness rotator cuff tears. However, if conservative management of the partial thickness tear fails, surgical intervention is typically recommended. This patient's MRI demonstrates a partial thickness articular-sided rotator cuff tear. Despite extensive conservative management, he continues to remain symptomatic. Without significant glenohumeral arthritis, rotator cuff repair or debridement would be reasonable treatment options for this patient. Rotator cuff tendon debridement is often utilized for articular-sided tears measuring less than <50% of the supraspinatus footprint, whereas rotator cuff repair is indicated in tears >50% of the footprint.

Pedowitz et al. reviewed treatment recommendations for rotator cuff tears. The authors upheld four moderate-grade recommendations, including: (1) exercise and NSAIDs be used to initially manage rotator cuff symptoms in the absence of a full-thickness tear, (2) routine acromioplasty is not required at the time of rotator cuff repair, (3) non-cross-linked, porcine small intestine submucosal xenograft patches should not be used to manage rotator cuff tears, and (4) surgeons may advise patients that workers' compensation status correlates with less favorable outcomes after rotator cuff surgery.

Keener et al. reviewed the treatment of patients with painful rotator cuff tears and evaluated risk factors for tear enlargement, progression of muscle degeneration, and decline in the function over time. They report that factors that influence tendon healing include age, tear size, and severity of degenerative muscle changes, and discussed that an understanding of these variables can be used to refine appropriate surgical indications. The authors conclude that although conservative treatment can be successful for many of these tears, some tears may benefit from early surgical intervention.

Figures A-C are the MRI images demonstrating a partial thickness articular-sided rotator cuff tear.

Incorrect Answers:
Answer 1: This patient has failed conservative management and received no significant improvement in the past with a cortisone injection. Therefore, a repeat injection is not indicated at this time.
Answer 2: This patient has failed an 12-week course of formal physical therapy and continued therapy is unlikely to provide significant relief.
Answer 3: There is no clinical evidence that this patient has adhesive capsulitis, given his full symmetric passive range of motion, and thus an arthroscopic capsular release is not indicated.
Answer 4: Rotator interval release may be indicated in patients with adhesive capsulitis or in an attempt to help mobilize a retracted subscapularis tendon for repair. However, similar to the previous answer, there is no evidence of adhesive capsulitis or a retracted subscapularis tear in this patient and thus this would not be indicated.