What is the management of a full thickness supraspinatus tear of the rotator cuff with 2mm retraction?

Management of Full Thickness Supraspinatus Tear with 2mm Retraction

For a symptomatic full thickness supraspinatus tear with 2mm retraction, initial conservative management should be attempted for 3-6 months before considering surgical repair, unless specific factors indicate primary surgical intervention. 1

Initial Assessment and Imaging

• MRI without contrast or ultrasound (depending on local expertise) is the preferred imaging modality to evaluate rotator cuff tears, providing information about tear size, retraction, and muscle quality 1
• Full-thickness tears show increased signal intensity extending from inferior to superior surface of the tendon on all MRI sequences 1
• Important prognostic factors to assess include tendon retraction, muscle atrophy, and fatty infiltration, which influence treatment decisions and prognosis 1

Conservative Management Approach

First-Line Treatment

• Begin with non-surgical management for symptomatic full-thickness tears, particularly for small tears with minimal retraction 1, 2
• NSAIDs and acetaminophen should be used as initial pain management, with NSAIDs or COX-2 inhibitors used concurrently with acetaminophen for more effective pain control 2
• Opioids should be reserved only for rescue analgesia when other methods fail 2

Physical Therapy

• Exercise therapy has shown beneficial effects in decreasing pain and improving function in patients with rotator cuff tears 2, 3
• Home exercise programs focusing on restoring range of motion, addressing any stiffness, and restoring motor control/strength to the scapula and rotator cuff 4, 3
• Studies show that 78% of patients experience pain improvement, 81% improve in range of motion, 85% improve in strength, and 84% improve in functional outcomes with exercise therapy 3

Injections

• A single corticosteroid injection with local anesthetic may be considered for short-term improvement in both pain and function 1, 2
• Evidence regarding subacromial injections is inconclusive, with one level II study showing no significant difference between corticosteroid with lidocaine versus lidocaine alone 1
• Other injection options such as platelet-rich plasma, collagen, or hyaluronic acid have shown favorable outcomes in partial thickness tears, but evidence for full thickness tears is limited 5

Surgical Management Considerations

• Surgical treatment should be considered after failed conservative treatment lasting 3-6 months 6
• Primary surgical treatment should be considered in:
  • Young patients with high functional demands
  • Patients with high level of physical strain in their jobs
  • Large tears with significant muscle atrophy or tendon retraction 6
• Arthroscopic treatment is considered the gold standard due to better cosmetic results, lower postoperative pain, and potentially lower risk of shoulder stiffness 6
• One level III study showed that 81% of surgical patients reported excellent results, compared with 37% with nonsurgical treatment 1

Important Considerations and Pitfalls

• Asymptomatic rotator cuff tears are common, especially in older populations, and surgery is not recommended for asymptomatic tears 1
• A 2mm retraction is considered minimal and may respond well to conservative management, but monitoring for progression is important 1
• Approximately 15% of patients treated conservatively may be dissatisfied with outcomes and transition to surgery 3
• Overuse of corticosteroid injections should be avoided, limiting to single injections for short-term relief 2
• Older age is associated with higher failure rates and poorer outcomes after rotator cuff repair 2

Treatment Algorithm

1. Confirm diagnosis with MRI or ultrasound to assess tear characteristics 1
2. For symptomatic tears with minimal retraction (2mm):
   • Begin with 3-6 months of conservative management including NSAIDs/acetaminophen and structured physical therapy 2, 6
   • Consider a single corticosteroid injection if pain limits participation in therapy 1, 2
3. If conservative management fails after 3-6 months or if tear characteristics worsen:
   • Consider surgical repair, preferably arthroscopic 1, 6
4. If patient is young, has high functional demands, or shows significant muscle atrophy:
   • Consider primary surgical intervention 6