What is the treatment for a partial interstitial or rim-rent tear of the articular-surface supraspinatus tendon at its foot plate, also known as a partial articular supraspinatus tendon avulsion?

Treatment of Partial Articular Supraspinatus Tendon Avulsion (PASTA Lesions)

Begin with conservative management for 3-6 months, including physical therapy focused on strengthening and flexibility, NSAIDs for pain control, activity modification, and relative rest—only proceeding to arthroscopic repair if conservative treatment fails or significant functional limitations exist. 1, 2

Initial Conservative Management (First-Line Treatment)

All PASTA lesions, particularly those involving less than 50% of tendon thickness, should start with non-surgical treatment. 1, 2

Physical Therapy Protocol

• Physical therapy is the primary treatment modality, focusing on strengthening, flexibility, and functional restoration of the shoulder 1, 2
• Incorporate eccentric exercises, which have proven beneficial in tendinopathies, to stimulate collagen production and guide normal alignment of newly formed collagen fibers 3
• Stretching exercises are widely accepted and should be included 3

Activity Modification and Rest

• Implement relative rest by reducing activities involving repetitive loading of the damaged tendon, particularly overhead movements 1, 2
• Avoid complete immobilization, as this leads to muscular atrophy and deconditioning—tensile loading stimulates healing 3, 1
• Allow patients to continue activities that do not worsen pain 3

Pain Management

• Use NSAIDs (topical or oral) primarily for analgesic purposes, recognizing that chronic tendinopathy involves degeneration rather than acute inflammation 1
• Topical NSAIDs eliminate the increased risk of gastrointestinal hemorrhage associated with systemic NSAIDs 3
• Apply cryotherapy through a wet towel for 10-minute periods to reduce pain and swelling 3, 1

Critical Pitfall to Avoid

• Do NOT use intratendinous corticosteroid injections, as they may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 1
• While corticosteroid injections may provide temporary relief for inflammation 2, the risk of tendon weakening outweighs potential benefits in PASTA lesions 1

Surgical Management Indications

Proceed to arthroscopic repair when conservative treatment fails after 3-6 months OR when the patient has significant functional limitations. 1, 2

Surgical Technique Considerations

• The primary surgical goal is achieving tendon-to-bone healing, which correlates with improved clinical outcomes 1, 2
• Both transtendon repair (leaving the bursal layer intact) and completion-repair techniques achieve high rates of repair integrity with no significant differences in outcomes, retear rates, or patient satisfaction at long-term follow-up 4, 5, 6
• Transtendon arthroscopic repair using transosseous mattress sutures restores anatomical tendon-to-bone contact at the footprint without damaging the intact bursal portion 4, 5
• 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 1, 2

Factors Affecting Surgical Outcomes

• Presence of muscle atrophy and fatty degeneration in the supraspinatus correlates with worse outcomes and healing potential 2
• Younger patients and males demonstrate higher postoperative functional scores 6
• Workers' compensation status correlates with less favorable outcomes 2

Postoperative Recovery Protocol

Sling immobilization for 4-6 weeks immediately post-surgery is mandatory. 1, 2

• A structured rehabilitation program lasting several months is essential for optimal recovery 1, 2
• Patient compliance with home exercises significantly impacts success of recovery 7

Key Clinical Pitfalls to Avoid

• Avoid premature surgical intervention before completing an adequate 3-6 month trial of conservative management 1
• Avoid complete immobilization during conservative treatment 1
• Avoid routine acromioplasty during rotator cuff repair 1, 2
• Avoid intratendinous corticosteroid injections 1