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Operative Versus Non-Operative Treatment Of Partial Thickness Rotator Cuff Tears

Al Ahmad W*

*Clinical fellow in Orthopaedics, Leicester General Hospital, UK

Address for Correspondence:  

Clinical fellow in Orthopaedics
Leicester General Hospital, UK
Telephone: 00447766202871
Address: 3 Coronation Road
Earl Shilton, Leicester  LE9 7HL



A literature search of partial thickness rotator cuff tears (1) produced five articles. Three articles were selected. Three types of Partial tears were identified: Superficial or Bursal, Interstitial or intratendinous. 38 shoulders were treated surgically with good results (2). Deep tears were associated with trauma. A sub classification system was produced looking at location, degree and area of defect (3). A prospective study was undertaken between 1979 and 1985. It included six cases diagnosed using bursography. All six patients were treated surgically after a failed conservative treatment and had good post operative results. Diagnostic methods used were Arthrography, Bursography and arthroscopic assessment which can prove valuable in intratendinous tears.

J.Orthopaedics 2008;5(4)e13


Operative; non-operative; Rotator Cuff; partial tear; review.


The rotator cuff bursa is the largest bursal surface in the human body, with various muscles and tendon working on the shoulder joint to produce stability, movement and function. The anatomical complexity can lead to different problems and different symptoms arising from and around the shoulder joint. In contrast to the abundance of literature on complete rotator cuff tears, little have been reported on incomplete thickness tears. This highlights the fact that the clinical significance of partial tears has been underestimated. The diagnosis and treatment of incomplete tears can be problematic. Patients present with symptoms ranging from pain and loss of function to restricted movement and muscle wasting.  A problem such as a partial or complete tear can affect the delicate balance of the shoulder girdle leading to further issues disturbing its function. Treatment can be conservative using pain relief, rest, physiotherapy and injections. While surgical repair can be done through open approach or using arthroscopic approach. This article will try to shine a light at different diagnostic methods and treatment modalities used in cases of partial thickness tear of the rotator cuff.

Material and Methods :

Few search principles had to be established to get a better understanding of the process of literature search. To commence with, A Bibliographic databases was used, which allowed the search to be expanded and to include articles from numerous journals and from different dates. Secondly, the main keywords were identified resulting in a good search strategy. Thirdly, keywords were combined by either narrowing the search using “and” or broadening it using “or”. Finally, a valid exclusion criterion was introduced, which helped in narrowing the search results. (1) was used to search for the keywords. The main keywords were identified and arranged in order of its significance to this search. The significant keywords were: Rotator cuff, partial and incomplete. The less significant ones were: Surgical, operative, non operative and conservative.

Only English and full text journals from Ovid were included. The significant keywords were applied to title search only, while the lesser significant keywords were applied to keyword search.

 “Or” was utilized to establish the relation between “partial” and “incomplete”, and then between “Surgical”, “operative”, “non operative” and “conservative”.

The resulting search was then combined using “and” with the search from “rotator cuff”.

Table 1 summarises the technique used and displays the number articles found during the literature search. Table 2 presents five articles as the final results obtained from the literature search engine.

Two articles were excluded from this paper and the search results were narrowed down to only three papers. The first excluded article (4) looked at the usage of MRI and MRA in the diagnosis of rotator cuff tears, which obviously was far from the subject search performed in this paper. The second article not to be included (5) was aimed at treating a small and specific group of patient (Overhead athletes), which might not apply to the rest of the shoulder injuries. Furthermore the full text wasn’t available for those two articles. The remaining three articles were analysed and criticised in order to create a clearer image that can aid in future research.

Table .1.  Explaining the search criteria: rotator cuff “and” partial “or” incomplete “and” surgical “or” operative “or” non operative ”or” conservative (1)





rotator cuff.m_title.









2 or 3


5 [mp=title, abstract, full text, caption text]


6 [mp=title, abstract, full text, caption text]



non [mp=title, abstract, full text, caption text]


8 [mp=title, abstract, full text, caption text]



5 or 6 or 7 or 8



1 and 4 and 9



10 and "Clinical Orthopaedics & Related Research" [Journals]



Table .2.  Showing the result of the search (1)

1.       Nuccion, S 1; Hame, S L. 1; Chuan, J 1; Seeger, L 1 THE ACCURACY OF MRI AND MRA IN DIAGNOSIS OF PARTIAL TEARS OF THE ROTATOR CUFF. Medicine & Science in Sports & Exercise. 33(5) Supplement 1:S275, May 2001.

2.       Selvanetti, A. *; Giombini, A. [degrees]; Caruso, I. * NONOPERATIVE TREATMENT OF PARTIAL-THICKNESS ROTATOR CUFF TEARS IN OVERHEAD ATHLETES. Medicine & Science in Sports & Exercise. 30(5) Supplement:260, May 1998.

3.       ITOI, EIJI M.D.; TABATA, SHIRO M.D. Incomplete Rotator Cuff Tears: Results of Operative Treatment. Clinical Orthopaedics & Related Research. (284):128-135, November 1992.

4.       ELLMAN, HARVARD M.D. Diagnosis and Treatment of Incomplete Rotator Cuff Tears. Clinical Orthopaedics & Related Research. 254:64-74, May 1990.

5.       FUKUDA, HIROAKI M.D. *; MIKASA, MOTOHIKO M.D. *; YAMANAKA, KAORU M.D. Incomplete Thickness Rotator Cuff Tears Diagnosed by Subacromial Bursography. Clinical Orthopaedics & Related Research. 223:51-58, October 1987.

Results :

The first Article to be discussed titled (Incomplete Rotator Cuff Tears: Results of Operative Treatment).  The aim of the study was to analyze the features and operative results of the patients with incomplete rotator cuff tears. This study was a retrospective study between January 1979 and June 1989 looking at 50 shoulders with incomplete rotator cuff tears. 38 Shoulders of 36 patients were then followed up for an average period of 4.9 years and the rest of the patients were excluded as they couldn’t be personally interviewed. The Tears were diagnosed using Arthrography, Bursogram and arthroscopic direct inspection. The author pointed out that accurate diagnosis using arthrography and bursogram wasn’t always possible, and that some cases were diagnosed as impingement of the rotator cuff, until it was examined using arthroscopic surgery.  

The outcome measure used was the UCLA (6), which looks at subjective findings (Pain and function) and objective findings (motion and strength). The maximum score possible was 35 points. Results were stratified into excellent (34-35), good (29-33), fair (21-28) and poor(less than 20 points).

The overall results were excellent in 16 shoulders, good in 15, fair in 2 and poor in 5 shoulders. The Author (2) Divided partial rotator cuff tears into superficial, intratendinous and deep tears. The pre operative and post operative scores were analyzed according to type of tear and further categorized into four groups representing the UCLA scoring criteria. There was a significant improvement when looking at pain and function, but when looking at motion and strength intratendinous tears showed some improvement which was not significant. Most deep tears were associated with traumatic onset 86% comparing to 50% in superficial ones. When looking at the operative technique all shoulders repaired using side to side method had good to excellent results, while 2 cases repaired using side to bone method and 5 cases repaired using a graft was graded unsatisfactory (poor to fair).

To conclude this paper, partial thickness tears are more common than have been known and deep incomplete tears were more common in young patients as it was associated with trauma. The later was explained by two theories the first theory refers to is the deeper shorter fibres (7), the second theory is about the hypovascularity of the deep layer (8).

The second paper (3) is looking at the diagnosis and treatment of incomplete rotator cuff tears by Harvard Ellman. Systemic grading of partial thickness will aid in the effort of comparing different arthroscopic treatments. The purpose of this paper is to present the available literature looking at the diagnosis and treatment options, and to lay out a classification system.

Two main types of rotator cuff tears were identified which were: degenerative tears and traumatic ones. Further anatomical classification was necessary, so it was classified into two types: Articular surface tears and bursal surface tears.

Deep or Articular surface tears develop on the deep surface of the supraspinatus tendon at its insertion point. There is a marked increase of deep tears with age as shown by the study done by DePalma (9). Diagnostic methods vary from arthrography using single (Contrast alone) or double contrast (Contrast and air), to bursography, to MRI and ultrasonography, which can be accurate but is usually operator dependant.

Treatment options included Conservative, open and arthroscopic repair. The principles of conservative treatment are rest, non steroidal anti-inflammatory medications, and physiotherapy. The use of up to three steroidal sub-acromial injections can be beneficial. Neer has described open acromioplasty in patients with impingent syndrome (10), he encountered a variety of rotator cuff tears, which sometimes was obscured by the bursal surface and could be diagnosed by probing the supraspinatus, which allowed the thinning or bulging of the supraspinatus to be visualised and distinguished. Arthroscopy can offer minimal invasive direct visualization of incomplete tears from two sides: the glenohumeral joint and the sub-acromial space. The early signs of cuff pathology can be made out looking for aspects such as fraying of the tendinous fibres’. Bursal surface tears can be problematic when it comes to Arthroscopy as it’s commonly associated with impingement, which can lead to extensive bursal hypertrophy, thus warranting bursectomy. Classically those superficial tears are seen as a dark red vascular zone as described by Codman (11). Intratendinous tears can be diagnosed by Arthroscopic direct examination, and by using Magnetic Resonance Imaging or ultrasonography. The arthroscopic treatment technique that was used involved a basic debridement of the incomplete tear followed by sub-acromial decompression, with the release of the corocoacromial ligament as described by Ellman (12).

Combined Arthroscopic and open repair of incomplete tears have been described by Neviaser and neviaser (13). Methylene blue was injected into the tear arthroscopically, the shoulder is then opened and acromioplasty is performed. The tear is excised and the margins are advanced then sutured.

Incomplete rotator cuff tear in young athletes associated with shoulder instability is a common finding, and stabilisation of these shoulders can have good results, this can be established with conservative methods.

The Author presented a sub classification system of rotator cuff tears looking at location, grade and area of defect. Partial thickness tears were given letters in accordance with the location. A: for articular surface, B for bursal and C for interstitial. The grading system categorised it to: grade 1 for tears less than 3 mm deep, grade 2 for 3-6 mm deep tears and grade 3 for more than 6 mm ones. The depth of the tears was assessed arthroscopically using a 3 mm probe.  

The aim of the final paper to be discussed (14) was to describe the authors’ experience using sub –acromial bursography for the diagnosis of bursal side rotator cuff tears. The article is titled (Incomplete Thickness Rotator cuff tears diagnosis by sub-acromial bursography). The author chose to do a prospective study looking at patients from 1979 to 1985. Data was collected by looking at the pre operative signs and symptoms of six patients. All patients had arthrography which was normal in all cases, and then they underwent bursography which revealed an incomplete superficial tear of the rotator cuff. All patients had conservative treatment which was unsuccessful; subsequently surgery was performed in all six patients. 

Bursograms can be very difficult to read and can have misleading results. The author used a standardised injecting manoeuvre in all patients, which involved injecting the contrast medium while the patient is in a supine position. The patient is then turned into prone position and the head was tilted downwards for 30 seconds. Bursal tears were will viewed using this method as most usually lie on the anterior aspect of the supraspinatus muscle.

Data collected showed that preoperatively all patients had pain with shoulder movement and limitation of the shoulder movements. Using Neer’s criteria (15), as an outcome measure, it was noticed that all cases that a satisfactory rating, without any complications. There was a slight residual stiffness in one of the cases.

The Author selected two case reports to display the work that was done in the surgical repair of superficial tears. The first case was a female patient with left sided palsy, who complained of a painful abduction arc in her right shoulder. Bursogram was performed and it showed a superficial tear which was treated first conservatively with little improvement, eventually she was treated surgically which yielded excellent results. The second case report was in connection with a male patient who developed non traumatic pain in the right shoulder. His shoulder was treated first with steroid injections. The patient then developed a non infectious effusion at the sub-acromial bursa, and clinically painful arc and positive impingement in the affected shoulder. Bursal rotator cuff tear was diagnosed using contrast injections in the sub-acromial space. The tear was treated surgically with very good results.

Discussion :

Looking at the first paper by ITOI (2) we can see that the study was carried out at the author’s own institute with no employment of blinding, which might have resulted in data errors. There is no reference to an independent assessor, which if present might have made the study stronger. The author didn’t clearly point out if all patients had conservative treatment, and there is no information on the process of conservative treatment. On the other hand cases were stratified and categorised which helped in developing better understanding of the results. The Statistical results were clearly presented in tables, and the five cases with unsatisfactory outcome were discussed and explained. Different surgical options used by the author to repair partial tears were considered and the results of each were made clear.

As noticed from the second paper (3) there was excellent and clear layout of literature reviews, but the paper lacked the methodology used in the literature search and no inclusion or exclusion criteria mentioned. Furthermore there was good use of diagrams and concentration on arthroscopy related papers. Unfortunately the referencing process fell short in some instances. There was extensive description of partial tears and an attempt to classify it. This classification system didn’t contain any therapeutic indications and one can doubt its true usefulness. Overall the author addressed most of the key questions that was posed in the beginning of his article.

The third paper by Fukuda (14) displayed numerous images to aid in the understanding of incomplete tears. The author didn’t use any blinding and didn’t use any randomisation, but he was successful in using two case reports giving the symptoms and signs of two rotator cuff tears. On the other side there was no clear identification of the way patients were selected. The study would have been stronger if the number of the patients was high enough and if the data collected was run through a test of significance to either reject or accept a proposed null hypothesis. The final point in this paper is the labelling of conservative treatment as having poor results, which was not supported with evidence.

Conclusion :

Precise definition of partial or incomplete rotator cuff tears can be difficult. The diagnosis of such tears can become challenging, especially with the intratendinous tears where painful arc was frequently observed. Arthroscopy in intratendinous tear revealed a bulge with the arm being elevated. Bursography is recommended if the patient is complaining of impingement like syndrome with a normal arthrogram. In addition, bursograms can be more accurate if the patient’s position was changed after injecting the contrast material, this will help spreading the contrast material in the sub-acromial space. MRI and Ultrasonography can offer a method of visualization of the structure and integrity of the rotator cuff.

In young patients trauma is one of the main causes of deep rotator cuff tears. Surgical approach can offer very good results in the management of incomplete rotator cuff tears when conservative treatment fails. The surgical options can range from simple suture to a wedge resection of the diseased area.

More research is needed to answer the questions asked in this paper and to develop a treatment-targeted classification system of rotator cuff partial tears. A comparative study of operative verses no operative management would be a good starting point. Non surgical options were not discussed in this paper due to the insufficient number of articles. This again points to the fact that this subject is in fact an uncharted territory.


Reference :


2. Incomplete Rotator Cuff Tears: Results of Operative Treatment. ITOI, EIJI M.D. and TABATA, SHIRO M.D. s.l. : Clinical Orthopaedics & Related Research, November 1992, Vol. (284), pp. 128-135.

3. Diagnosis and Treatment of Incomplete Rotator Cuff Tears. ELLMAN, HARVARD M.D. 254:64-74, s.l. : Clinical Orthopaedics & Related Research., May 1990. .


5. NONOPERATIVE TREATMENT OF PARTIAL-THICKNESS ROTATOR CUFF TEARS IN OVERHEAD ATHLETES. Selvanetti, A. *, Giombini, A. [degrees] and Caruso, I. s.l. : Medicine & Science in Sports & Exercise, May 1998., Vol. 30(5) Supplement:260.

6. Repair of the rotator cuff tears: end result study of factors influancing reconstruction. Ellman, H.,Hanker, G., and Bayer. 1986, JBJS, p. 68A:1136.

7. Cuff tears in athletes. J.E, Bateman. s.l. : Orthop.clin.north am, 1973. 4:721.

8. the microvascular pattern of the supraspinatustendon. Lohr J.F., & Uhthoff, H.K. s.l. : clin.orthop., 1990, Vol. 254:35.

9. Surgery of the Shoulder. De Palma, A. F. s.l. : Philadelphia, J. B. Lippincott, 1950.

10. Impingment lesions. S., Neer C. s.l. : Clin. Orthop., 1983, Vol. 173:70.

11. The shoulder A., Codman. E.. Buston .

12. Arthroscopic subacromial decompression. Ellman, H. s.l. : Parisien, 1988, Vol. p 243.

13. The diagnosis and treatment of incomplete rotator cuff tears. Neviaser, T. J and Neviaser R. J. las vegas : American shoulder and elbow surgeons 5th meeting, 1989.

14. Incomplete Thickness Rotator Cuff Tears Diagnosed by Subacromial Bursography. . FUKUDA, HIROAKI M.D. *, MIKASA, MOTOHIKO M.D. * and YAMANAKA, KAORU M.D. 223:51-58., s.l. : Clinical Orthopaedics & Related Research., October 1987.

15. Anterior acromioplasty for he chronic impengment syndrome in the shoulder. Neer, C. S. 54a:41, s.l. : J.B.J.S., 1972. 


This is a peer reviewed paper 

Please cite as :Al Ahmad W: Operative Versus Non-Operative Treatment Of Partial Thickness Rotator Cuff Tears

J.Orthopaedics 2008;5(4)e13





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