What is the treatment for full-thickness tears of 3 out of 4 rotator cuff tendons (Rotator Cuff), specifically the supraspinatus, infraspinatus, teres minor, and subscapularis tendons?

From the Guidelines

Treatment of full thickness tears involving three out of four rotator cuff tendons typically requires surgical repair using an arthroscopic approach, as it is associated with reduced postoperative pain 1. The recommended approach is arthroscopic rotator cuff repair surgery, which should be performed within 3-6 months of injury for optimal outcomes. Before surgery, patients may receive pain management with NSAIDs like ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily), along with physical therapy to maintain range of motion. The surgical procedure involves reattaching the torn tendons to the humeral head using suture anchors, followed by a structured rehabilitation protocol. Some key points to consider in the management of these patients include:

• The use of systemic analgesia, including paracetamol and NSAIDs, administered pre-operatively or intra-operatively and continued postoperatively 1
• The use of interscalene brachial plexus blockade as the first-choice regional analgesic technique, with suprascapular nerve block as an alternative 1
• The administration of a single dose of intravenous dexamethasone to increase the analgesic duration of interscalene brachial plexus block and decrease analgesic use 1
• The reservation of opioids for rescue analgesia in the postoperative period 1 Post-surgery, patients will wear a sling for 4-6 weeks, begin passive range of motion exercises at 2-4 weeks, active motion at 6-8 weeks, and strengthening exercises at 8-12 weeks. Full recovery typically takes 6-12 months. This surgical approach is necessary because extensive rotator cuff tears significantly impair shoulder function and strength, and the remaining intact tendon cannot compensate for the three torn tendons. Without repair, patients face progressive weakness, pain, and potential development of rotator cuff arthropathy with permanent shoulder dysfunction. It is worth noting that while a previous study found no single comparative study that included all three techniques (arthroscopic, mini-open, or open repair) for rotator cuff repair surgery 1, the most recent and highest quality study recommends an arthroscopic approach 1.

From the Research

Treatment Options for Full Thickness Tears of 3 out of 4 Rotator Cuff Tendons

• The treatment of full thickness tears of 3 out of 4 rotator cuff tendons is challenging and requires a comprehensive approach 2.
• Surgical repair is often indicated for full thickness tears, and the goal of surgery is to eliminate pain and improve function with increased shoulder strength and range of motion 3.
• Different surgical options are available, including open, mini-open, and all-arthroscopic rotator cuff repair, each with its own advantages and disadvantages 3.
• The choice of surgical method depends on various factors, including the size and location of the tear, patient age, and surgeon preference 3.

Rehabilitation after Rotator Cuff Repair

• Rehabilitation after rotator cuff repair is crucial for optimal outcomes, and a gentle rehabilitation protocol with limits in range of motion and exercise times is recommended to promote tendon healing without compromising repair integrity 4.
• Early passive range of motion (ROM) following arthroscopic cuff repair can help decrease postoperative stiffness and improve functionality, but early aggressive rehabilitation may compromise repair integrity 4.
• A close communication between the surgeon, the patient, and the physical therapy team is essential for optimal patient education and outcomes 4, 3.

Outcomes of Surgical Treatment

• The outcomes of surgical treatment for full thickness tears of the rotator cuff are generally good, with most patients experiencing improved pain and function 5.
• However, the outcomes can vary depending on factors such as patient age, tear size, and surgical technique 5.
• A study of patients under 40 years of age with full thickness tears found that 79% reported diminished pain and 63% were able to function with the extremity above shoulder level after surgery 5.

Clinical Assessment and Diagnosis

• Clinical assessment can be challenging in differentiating between partial and full thickness tears of the rotator cuff tendons 6.
• A study found that greater abduction strength, as measured by the Constant Power Score, was associated with partial thickness tears, but other clinical assessment items did not differentiate between partial and full tears 6.
• The results suggest that pathoanatomical diagnosis may not adequately direct non-surgical treatment, and movement-based diagnoses or treatment classification systems may be more effective in selecting appropriate conservative treatment 6.