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
OvidSP.uk (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
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)
2 or 3
[mp=title, abstract, full text, caption text]
[mp=title, abstract, full text, caption text]
[mp=title, abstract, full text, caption text]
[mp=title, abstract, full text, caption text]
5 or 6 or
7 or 8
1 and 4
"Clinical Orthopaedics & Related Research" [Journals]
Showing the result of the search (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
& Science in Sports & Exercise. 33(5) Supplement 1:S275, May
Selvanetti, A. *; Giombini, A. [degrees]; Caruso,
TREATMENT OF PARTIAL-THICKNESS ROTATOR CUFF TEARS IN
& Science in Sports & Exercise. 30(5) Supplement:260, May
ITOI, EIJI M.D.; TABATA, SHIRO M.D.
Cuff Tears: Results of Operative Treatment.
Orthopaedics & Related Research. (284):128-135, November
ELLMAN, HARVARD M.D.
Treatment of Incomplete Rotator Cuff Tears.
Orthopaedics & Related Research. 254:64-74, May 1990.
HIROAKI M.D. *; MIKASA, MOTOHIKO M.D. *; YAMANAKA, KAORU M.D.
Incomplete Thickness Rotator Cuff Tears Diagnosed by
Clinical Orthopaedics & Related Research. 223:51-58, October
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
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
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
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
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
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
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.
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
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
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.
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
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AND MRA IN DIAGNOSIS OF PARTIAL TEARS OF THE ROTATOR CUFF.
Nuccion, S 1, et al.
TREATMENT OF PARTIAL-THICKNESS ROTATOR CUFF TEARS IN OVERHEAD
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Codman. E.. Buston .
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14. Incomplete Thickness
Rotator Cuff Tears Diagnosed by Subacromial Bursography. .
FUKUDA, HIROAKI M.D. *, MIKASA, MOTOHIKO M.D. * and YAMANAKA,
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