Review Question - QID 8861

Partial rotator cuff tears that are > 3mm depth on the bursal side and > 6mm depth on the articular side should be managed with conversion to a complete tear and subsequent repair. Tears on the bursal surface are felt to be less well-tolerated because they are on the highest tension side.

Partial RCTs represent a spectrum of disease states involving the rotator cuff. The Ellman classification organizes partial RCTs by location (A: articular, B: bursal, C: interstitial) and grade (1: < 3mm deep, 2: 3-6mm deep, 3: > 6mm deep), based on findings at the time of arthroscopy. Nonoperative management is successful in most patients and includes activity modification, anti-inflammatory medications, physical therapy and subacromial corticosteroid injections. Patients who fail non-operative management may undergo RC debridement or repair, depending on location and depth of the tear, +/- acromioplasty.

Cordasco et al. retrospectively reviewed 162 patients who underwent arthroscopic acromioplasty and debridement for shoulder impingement syndrome. Overall, patients with partial RCTs involving < 50% of the tendon (< 6mm depth, grades 1 and 2) had equivalent postoperative outcomes compared to patients without RCTs. However, patients with bursal-sided partial RCTs > 3mm in depth (grade 2B) had a significantly higher failure rate (38%), defined as a score < 70 on the L’Insalata scale, compared to articular-sided tears of the same depth (grade 2A, failure rate 5%). The authors concluded that patients with bursal-sided partial RCTs > 3mm in depth are better served with primary repair rather than debridement.

Wolff et al. reviewed the pathogenesis, diagnosis and management of partial RCTs. The articular surface of the rotator cuff has decreased vascularity and tensile strength compared to the bursal surface. Therefore, articular-sided partial RCTs are often due to degenerative tendinopathy in older patients and tensile failure in younger patients, particularly overhead throwing athletes. Bursal-sided tears are most commonly associated with extrinsic impingement of the acromion and the coracoacromial ligament.

Illustration A demonstrates an algorithm for management of partial RCTs from Wolff et al.

Incorrect Responses:
Answers 1, 2, 3 and 5: Articular-sided partial RCTs < 6mm in depth (grade 1A, 2A) and bursal-sided RCTs < 3mm in depth (grade 1B) are best managed with debridement +/- acromioplasty.