Review Question - QID 218087

This patient's findings on exam and imaging are consistent with supraspinatus tear which is most commonly located 15 mm posterior to the biceps tendon near the supraspinatus/infraspinatus junction.

Rotator cuff tears are a common source of shoulder pain that may be a result of traumatic injuries or, more commonly, degenerative pathology in elderly patients. The primary function of the rotator cuff is to provide dynamic stability by balancing the force couples around the glenohumeral joint. Supraspinatus tears are most commonly found 15 mm posterior to the biceps tendon. Treatment considerations include age, activity level, mechanism of injury (traumatic vs. degenerative), characteristics of tear, and tissue quality among other factors. Nonoperative treatment is generally the first line of treatment for most tears with therapy focused on strengthening surrounding rotator cuff and periscapular muscles. Options for surgical treatment are extensive including debridement alone, repair, tendon transfer, superior capsular reconstruction, subacromial balloon spacer, and arthroplasty. Retear rates after surgical repair are highly variable ranging from 10-90%. Poor prognostic factors following surgical repair include age, large tear (>5 cm), muscle atrophy, significant tendon retraction, diabetes, and smoking. Postoperative protocols vary by surgeon and include early and late motion protocols with no clinically significant difference in motion or retear rates at one year.

Mall et al prospectively followed 195 subjects with an asymptomatic rotator cuff tear to monitor for the development of pain to identify characteristics of those who developed pain versus those who remained asymptomatic. They compared 44 patients who developed pain to 55 patients who remained asymptomatic over two years. Patients who developed pain were more likely to demonstrate progression of tear size with 18% of the full-thickness tears showing an increase of >5 mm, and 40% of the partial-thickness tears had progressed to a full-thickness tear. They also found that larger tears were more likely to develop pain than smaller tears.

Jarrett et al provided a review of the current concepts on rotator cuff tears with an emphasis on surgical management. They note that partial tears with greater than 50% of tendon involvement should be repaired. Articular-sided partial tears with less than 50% of the footprint involved can be treated with debridement, while bursal-sided tears require a more aggressive approach. While biomechanical studies have shown superior results with double-row repair compared with single-row, there is no clear advantage in terms of clinical outcomes.

Kim et al performed an ultrasound of 360 shoulders with either a full-thickness (n=272) or a partial-thickness rotator cuff tear (n=88) and measured the dimensions of the tear and the distance from the biceps tendon to the anterior margin of the tear as a reference point to identify the most common location of degenerative rotator cuff tears. They found that tears most commonly near the junction of the supraspinatus and infraspinatus, starting most commonly 13 to 17 mm posterior to the biceps tendon.

Figures A and B are coronal and axial views of PD fat-saturated MRI sequences demonstrating a full-thickness supraspinatus tear, respectively.

Incorrect Answers:
Answer 1: Retear rates are highly variable ranging from 10-90%.
Answer 2: Age is a risk factor for retear after surgical repair.
Answer 4: Biceps tendon subluxation is associated with subscapularis tendon tears, not supraspinatus tears.
Answer 5: Early-guided motion (<6 weeks post-op) does not result in improvement of short-term PROs and some studies have shown higher pain scores at short-term follow-up with early motion.