What is the management for full-thickness tears of the subscapularis and supraspinatus tendons?

From the Guidelines

Surgical repair is the recommended management for full thickness tears of the subscapularis and supraspinatus tendons, especially for acute traumatic tears or when conservative management fails, as it offers the best chance for improving morbidity, mortality, and quality of life. The management of these tears typically involves a multidisciplinary approach, including surgical repair, physical therapy, and pain management. According to the study by Robert A. Pedowitz, MD, PhD, et al 1, early surgical repair after acute injury is an option for patients with a rotator cuff tear, and the patients repaired within 3 weeks of injury had better results than did those repaired after 3 weeks.

Key Considerations

• The timing of surgery is crucial, with better outcomes reported when surgery is performed within 3 weeks of injury 1.
• Increasing patient age has been identified as a potential factor influencing outcomes and healing after rotator cuff surgery, with several studies determining that the Constant-Murley score was negatively correlated with increasing age after rotator cuff repair 1.
• Workers’ compensation status has also been shown to correlate with less favorable outcomes after rotator cuff repair, with studies reporting significantly worse UCLA scores and VAS pain scores in patients receiving workers’ compensation 1.

Treatment Approach

• Conservative measures such as physical therapy, anti-inflammatory medications, and activity modification may be considered initially, but surgical repair is often necessary for optimal outcomes.
• Arthroscopic surgical repair is a common approach, using suture anchors to reattach the tendons to the humeral head.
• Post-surgical rehabilitation is critical, involving 4-6 weeks of immobilization in a sling, followed by progressive physical therapy for 3-6 months.

Outcomes and Prognosis

• Surgical repair can improve shoulder function, reduce pain, and prevent progressive weakness and muscle atrophy.
• However, outcomes may be influenced by factors such as patient age, tear size, and workers’ compensation status, highlighting the importance of individualized treatment planning and rehabilitation.

From the Research

Management of Full Thickness Tears

• The management of full thickness tears of the subscapularis and supraspinatus tendons often requires surgical intervention 2, 3, 4, 5.
• Arthroscopic techniques are commonly used for the repair of full thickness tears, with advantages including smaller skin incisions, access to the glenohumeral joint, and less soft tissue dissection 4, 5.
• The postoperative rehabilitation program for arthroscopic rotator cuff repair typically involves three phases:
  • Phase 1: immediate postoperative or protective phase
  • Phase 2: progressive strengthening phase
  • Phase 3: advanced conditioning and return-to-sport phase 4.
• For combined tears of the subscapularis, supraspinatus, and infraspinatus tendons, an arthroscopic-plus-open approach may be used, where arthroscopic repair of the posterosuperior rotator cuff is followed by an open subscapularis repair 5.
• A structure-based classification of subscapularis tendon tears can be made based on objective criteria, including horizontal superior tendon edge visibility, lesser tuberosity bone exposure, and lateral tendon edge visibility 6.

Surgical Approaches

• Open repair had been performed with success, but most subscapularis repairs can be accomplished with arthroscopic techniques 2.
• The arthroscopic-plus-open approach offers advantages such as the ability to address concomitant pathology, relative ease of repair, and creation of a strong, reliable construct 5.
• The choice of surgical approach may depend on factors such as patient age, size and chronicity of tear, and fixation method 3.

Rehabilitation

• Effective communication and coordination of care between the physical therapist and surgeon are essential for optimal patient education and outcomes 3.
• An accelerated postoperative rehabilitation program may be recommended for patients who have undergone an all-arthroscopic rotator cuff repair 3.
• The rehabilitation program should involve early, safe motion to allow optimal tendon healing, while maintaining joint mobility with minimal stress 3, 4.