What is the treatment approach for a partial interstitial or rim-rent tear of the articular surface of the supraspinatus tendon at its footplate, also known as a partial articular supraspinatus tendon avulsion (PASTA)?

Treatment of Partial Articular Supraspinatus Tendon Avulsion (PASTA Lesions)

Begin with a trial of conservative management for 3-6 months, and proceed to arthroscopic surgical repair if conservative treatment fails or if the patient has significant functional limitations. 1

Initial Conservative Management (First-Line Treatment)

Start with non-surgical treatment for all PASTA lesions, particularly those involving less than 50% of tendon thickness. 1

Core Conservative Interventions:

• Physical therapy is the primary treatment modality, focusing on strengthening, flexibility, and functional restoration of the shoulder 1
• Relative rest by reducing activities that involve repetitive loading of the damaged tendon, while avoiding complete immobilization to prevent muscular atrophy 2
• NSAIDs (topical or oral) for pain relief, though their role is primarily analgesic since chronic tendinopathy involves degeneration rather than acute inflammation 2
• Activity modification to eliminate repetitive stresses and overhead movements that aggravate the tendon 2
• Cryotherapy applied through a wet towel for 10-minute periods to reduce pain 2

Adjunctive Conservative Options:

• Corticosteroid injections may provide temporary relief in the acute phase but do not alter long-term outcomes and should be used cautiously due to potential deleterious effects on tendon healing 2, 1
• Eccentric exercise programs have proven beneficial in other tendinopathies and may be helpful for rotator cuff conditions 2

Duration and Monitoring:

Continue conservative management for 3-6 months before considering surgical intervention 1. Monitor for improvement in pain, range of motion, and functional capacity during this period.

Surgical Management (When Conservative Treatment Fails)

Proceed to arthroscopic repair when conservative treatment fails after 3-6 months or when the patient has significant functional limitations. 1

Surgical Technique Options:

Two primary arthroscopic approaches exist with equivalent clinical outcomes and retear rates (approximately 13.7% overall) 3:

1. Transtendon repair - Preserves the intact bursal layer of the supraspinatus tendon while repairing the articular-side tear through the tendon substance 4, 3, 5

   • Advantages: Maintains tendon integrity, superior biomechanical strength 5
   • Technique: All-arthroscopic transosseous mattress suture using curved hollow needle to restore anatomical tendon-to-bone contact at the footprint 4

2. Completion and repair - Completes the partial tear and repairs the full-thickness defect 3

   • Equivalent functional outcomes to transtendon repair at long-term follow-up 3

Key Surgical Principles:

• Do NOT perform acromioplasty for normal acromial bone (including type II and III morphology), as studies show no significant difference in outcomes with or without acromioplasty 6, 1
• Primary surgical goal is achieving tendon-to-bone healing, which correlates with improved clinical outcomes 6, 1
• Surgical approach (arthroscopic, mini-open, or open) can be selected based on surgeon preference, as no specific technique has proven superiority 1

Factors Predicting Surgical Outcomes:

• Muscle atrophy and fatty degeneration of the supraspinatus correlate with worse outcomes and reduced healing potential 1
• Younger patients and males demonstrate higher postoperative functional scores 3
• Workers' compensation status correlates with less favorable outcomes 1

Postoperative Recovery Protocol

• Sling immobilization for 4-6 weeks immediately post-surgery 6, 1
• Structured rehabilitation program lasting several months is essential for optimal recovery 1
• Long-term outcomes show significant pain relief and functional improvement, with mean Constant-Murley scores improving from 47.7 preoperatively to 84.2 postoperatively at 6-year follow-up 3
• Patient satisfaction rates reach 95% following arthroscopic repair 3

Common Pitfalls to Avoid

• Avoid complete immobilization during conservative treatment, as this leads to muscular atrophy and deconditioning 2
• Avoid intratendinous corticosteroid injections, as they may inhibit healing and reduce tensile strength, predisposing to spontaneous rupture 2
• Avoid premature surgical intervention before completing an adequate trial of conservative management (3-6 months minimum) 1
• Avoid routine acromioplasty during rotator cuff repair, as it provides no additional benefit 6, 1