Which patients with partial rotator cuff tears require surgical intervention?

Surgical Indications for Partial Rotator Cuff Tears

Partial rotator cuff tears involving >50% of tendon thickness should be surgically repaired, while tears <50% can be treated with debridement alone, particularly for articular-sided tears. 1

Primary Decision Algorithm

Tear Depth Classification

For tears >50% thickness:

• Surgical repair is indicated after failed conservative management 1, 2
• The rationale is that intra-tendinous strain increases significantly once >50% of tendon thickness ruptures 3
• In situ repair produces excellent long-term functional outcomes with low revision rates 2

For tears <50% thickness:

• Articular-sided tears can reliably be treated with debridement 1
• Bursal-sided tears require a more aggressive approach—consider repair even when <50% 1
• Debridement with or without acromioplasty produces favorable outcomes for low-grade tears 2

Critical Symptom Requirements

Surgery is only indicated when:

• Patients have persistent pain and disability after failed conservative management 2
• Significant pain is present, as this is the primary indication for any rotator cuff surgery 4
• Asymptomatic tears should never be operated on, regardless of tear size 4

Conservative Management Prerequisites

Before considering surgery, ensure adequate trial of:

• NSAIDs and acetaminophen for pain control 5
• Physical therapy and activity modification 6
• A single corticosteroid injection with local anesthetic for short-term improvement 5

Important Clinical Pitfalls

Bursal-sided tears are more problematic:

• Worse results are noted with debridement alone for bursal-sided defects 3
• These require lower threshold for repair compared to articular-sided tears 1

Natural history considerations:

• Partial tears have limited self-healing capacity 3
• They demonstrate propensity to enlarge over time and progress to full-thickness defects 3
• Tear progression can occur even after debridement 3

Avoid multiple corticosteroid injections:

• Limit to single injection for short-term relief 5
• Multiple injections may compromise rotator cuff integrity and affect subsequent repair 7

Prognostic Factors to Assess

Evaluate these factors before surgery:

• Tendon retraction extent 5
• Muscle atrophy degree 5, 7
• Fatty infiltration status 5, 7
• Patient age (older age associated with higher failure rates) 5