More Information on Rotator Cuff Surgery.

Last updated Wednesday, January 26, 2005

Figure 12 - Consolidating split laminations of cuff

Partial thickness cuff tears

Partial defects

These partial defects are more likely to be associated with shoulder stiffness than larger full thickness defects, because the larger defects in the cuff provide the equivalent of a capsular release. Nonoperative management must emphasize stretching in internal rotation, cross-body adduction, and elevation. When a comfortable normal range of passive motion is reestablished, gentle progressive strengthening of the cuff muscles is instituted. An emphasis is always placed on gentle and comfortable progress of this rehabilitation program.

In many respects, the treatment of a partial cuff tear is analogous to the treatment of a partial Achilles tendon tear or tennis elbow. The functional deficits are likely to be related to tension on a partially torn tendon. Treatment requires first stretching and then gentle strengthening. Surgery is usually considered only if symptoms persist in spite of regaining normal passive motion and if the patient is prepared for an extended recovery period.

In planning surgical management for refractory problems from partial thickness tears, it must be determined if the patient's functional deficits are related to tension on a partially torn tendon as indicated by a positive tendon sign. In this case, completion of the detachment and reattachment, as for a full thickness tear, may be necessary. This procedure will tighten the shoulder and is not a suitable treatment for a contracted shoulder. Alternatively, the symptoms may be related to secondary subacromial abrasion from the slight superior instability resulting from the tendon defect as well as the associated thickening of the intervening bursa. Under these circumstances the abrasion sign (rotating the partially elevated arm beneath the coracoacromial arch) should reproduce the patient's symptoms. In the second instance, an anterior inferior acromioplasty and bursal resection may be of benefit as long as normal shoulder flexibility has been restored to eliminate the effect of a tight posterior capsule. Anterior acromioplasty does not treat shoulder stiffness, which must be eliminated by exercises or by surgical releases.

The decision to complete a partial thickness cuff defect may be influenced by surgical findings. The thickness of the cuff can be determined at acromioplasty by inspection for superior surface defects. For deep surface or intratendinous lesions the cuff thickness is determined by palpation, by injecting saline or dilute methylene blue solution in the joint, or by using a depth gauge or calibrated nerve hook. A tenotomy can also be performed in the most suspicious area along the line of the tendon fibers to explore the full thickness of the tissue. If, as is usually the case, the defect is near the anterior insertion of the supraspinatus, a longitudinal tenotomy and capsulotomy are performed along the anterior aspect of the supraspinatus in the rotator interval capsule. This cut is then extended at right angles posteriorly through the partially detached cuff at its insertion to the greater tuberosity, turning back the flap of cuff until tendon of full thickness is encountered. Next an attempt is made to retrieve and consolidate any split laminations of cuff which may have retracted medially (see figure 12). These are usually on the deep articular surface where the cuff lesion begins and may have retracted medially up to 1 cm. Release of the coracohumeral ligament and rotator interval capsule from the base of the coracoid will minimize tension on the repair. Then the full thickness defect is repaired in the manner previously described. The shoulder is then put through a full range of motion to verify that the acromioplasty is adequate to protect the repaired tendon from acromial abrasion.

Postoperative management is tailored by the surgeon for the patient, but often is the same as for the full thickness defects.

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