What is the management approach for a complete supraspinatus (rotator cuff) tear?

Management of Complete Supraspinatus Tear

For complete supraspinatus tears, initial conservative management with physical therapy is recommended as the primary treatment approach, particularly in patients over 55 years of age, as operative treatment has not demonstrated superior outcomes compared to conservative management. 1, 2

Initial Assessment and Conservative Management

First-line Treatment (0-4 weeks):

• Pain management:
  • NSAIDs at lowest effective dose for shortest duration necessary
  • Acetaminophen (paracetamol) administered regularly to prevent pain escalation
  • Local cold therapy for pain relief
  • Opioids reserved only for rescue analgesia when other methods fail 1

Physical Therapy (4-8 weeks):

• Gentle range of motion exercises initially
• Progress to strengthening exercises including:
  • Rotator cuff strengthening
  • Scapular stabilization exercises
  • Eccentric strengthening exercises 1

Advanced Conservative Management (8-12 weeks):

• Consider a single corticosteroid injection with local anesthetic if pain limits rehabilitation progress
  • Caution: Multiple injections may compromise rotator cuff integrity and impair healing if surgical repair is later needed 1
• Continue physical therapy with progressive loading

Indications for Surgical Referral

Surgical intervention should be considered when:

1. Patient demonstrates increased weakness and loss of function not recoverable by physiotherapy 3
2. Persistent pain and functional limitation after 8-12 weeks of conservative management 1

Surgical Options

When surgery is indicated, options include:

1. Complete Repair: Attempt to achieve tendon-to-bone healing when possible 4

2. Partial Repair Options for Irreparable Tears:

   • Partial rotator cuff repair
   • Debridement
   • Muscle transfers (e.g., latissimus or teres major for irreparable tears involving supraspinatus and infraspinatus) 4

3. For Elderly Patients with Irreparable Tears:

   • Debridement ("smooth-and-move" procedure)
   • Biodegradable subacromial balloon spacer
   • Biologic tuberoplasty or bursal acromial reconstruction 5

Surgical Technique Considerations

• No specific technique (arthroscopic, mini-open, or open repair) has demonstrated clear superiority 4
• Evidence is inconclusive regarding preferential use of suture anchors versus bone tunnels 4
• Non-cross-linked porcine small intestine submucosal xenograft patches should NOT be used (associated with less favorable outcomes and 20-30% hypersensitivity reactions) 4

Prognostic Factors

Factors associated with poorer surgical outcomes:

• Older age
• Comorbidities (e.g., diabetes)
• Rotator cuff muscle quality (fatty degeneration and muscle atrophy)
• Workers' compensation status 4, 1

Post-Surgical Rehabilitation

• Evidence is inconclusive regarding the preferential use of an abduction pillow versus a standard sling 1
• Careful progression of rehabilitation is essential as most retears occur between 6-26 weeks post-repair (peak around 19 weeks) 1

Important Considerations

1. Tear size and symptoms are not always correlated with pain, function, or ultimate outcome 3

2. For patients over 55 years with small, nontraumatic supraspinatus tears, operative treatment has not shown better outcomes than conservative treatment and does not protect against glenohumeral joint degeneration 2

3. When high-grade partial thickness tears are completed to full-thickness tears and then repaired, they demonstrate lower retear rates compared to primary repair of full-thickness tears 6