What is the recommended evaluation and management for a full‑thickness tendon tear?

Evaluation and Management of Full-Thickness Tendon Tears

Diagnostic Imaging Approach

MRI is the gold-standard imaging modality for confirming full-thickness tendon tears and should be obtained when clinical suspicion exists. 1, 2

Location-Specific Imaging Protocols

For distal biceps tendon tears:

• Standard MRI demonstrates 76% sensitivity and 50% specificity for detecting tears 2
• The flexion-abduction-supination (FABS) MRI view provides superior diagnostic accuracy and inter-rater reliability for grading tear severity 1, 2
• FABS positioning is particularly valuable for distinguishing high-grade partial versus complete tears by identifying subtle residual tendon fibers 1
• Ultrasound shows inferior performance (62.5% sensitivity, 20% specificity) and should not be relied upon as the primary diagnostic tool 1, 2

For rotator cuff tears:

• Interruption of tendon continuity is the most specific MR finding (96% specificity) for full-thickness tears 3
• Subacromial fluid is the most sensitive indicator (93% sensitivity) 3
• Additional findings include focally increased signal equivalent to water (87% of cases) and musculotendinous retraction (77% of cases) 3

For triceps tendon tears:

• MRI effectively identifies both complete and partial tears 1
• Indirect injuries (fall on outstretched hand) typically involve lateral and long heads with intact medial head 1
• Direct injuries have 1.75 odds ratio for full-thickness rupture 1

---

Initial Management Strategy

Non-Surgical Treatment (First-Line for Rotator Cuff Tears)

All symptomatic patients with full-thickness rotator cuff tears should begin with a 3-6 month trial of conservative management before considering surgery. 4, 5

The conservative regimen includes:

• Physical therapy focused on shoulder strength, flexibility, and function (Level II evidence) 4, 5
• NSAIDs for pain and inflammation control 5
• Activity modification to avoid overhead activities and aggravating movements 4, 5
• Corticosteroid injections may provide temporary relief, though evidence shows no significant difference versus lidocaine alone at 6 weeks 4

Adjunctive modalities (ice, heat, massage, TENS) have limited evidence but are not harmful and may be incorporated 5

---

Surgical Indications and Timing

Surgery is indicated when:

• Conservative treatment fails after 3-6 months 4
• Significant functional limitations persist despite non-surgical treatment 4
• Complete distal biceps tendon rupture is present (surgical repair is standard of care) 6

For rotator cuff tears specifically:

• One Level III study demonstrated 81% excellent results with surgery versus 37% with non-surgical treatment, with statistically significant improvements in pain during range of motion and at night 4

---

Surgical Technique Considerations

Primary Surgical Goals

The primary biologic goal is achieving tendon-to-bone healing, which correlates with improved clinical outcomes. 1, 4

Technical Approach

No single surgical technique (arthroscopic, mini-open, or open repair) can be recommended over another for rotator cuff tears due to inconclusive evidence (Grade: Inconclusive) 1

For fixation method:

• No recommendation can be made between suture anchors versus bone tunnels due to lack of comparative studies 1

Acromioplasty considerations:

• Acromioplasty is not required for normal acromial bone (including type II and III morphology) as studies show no significant difference in outcomes with or without acromioplasty 4, 5

Graft Augmentation

Surgeons should NOT use non-cross-linked porcine small intestine submucosal xenograft patches (Grade: Moderate recommendation) due to:

• Less favorable pain and function outcomes versus primary repair alone 1
• 20-30% complication rate from hypersensitivity reactions 1

No recommendation can be made for or against other soft-tissue allografts or xenografts due to insufficient evidence 1

---

Management of Irreparable Tears

When complete repair cannot be achieved, several options demonstrate clinical improvement:

• Partial repair of the tear shows improvement in pain and function 1
• Arthroscopic debridement with or without biceps release demonstrates clinically important improvement 1
• Latissimus or teres major transfer for irreparable supraspinatus and infraspinatus tears shows improvement in pain and function 1

Common pitfall: Muscle transfer complications include temporary complex regional pain syndrome and cosmetic biceps deformity 1

---

Prognostic Factors Affecting Outcomes

Negative prognostic indicators include:

• Workers' compensation status correlates with less favorable outcomes 4, 5
• Muscle atrophy and fatty degeneration on MRI correlate with worse healing potential 4, 5
• Age negatively correlates with healing (though magnitude not specified in guidelines) 1

---

Postoperative Management

Immobilization

No specific recommendation can be made regarding abduction pillow versus standard sling due to absence of clinical data (Grade: Inconclusive) 1

Sling immobilization for 4-6 weeks is standard practice followed by months of rehabilitation 4, 5

Rehabilitation Timing

No evidence-based recommendations exist for:

• Specific duration of immobilization before ROM exercises (Grade: Inconclusive) 1
• Timing of active resistance exercises (Grade: Inconclusive) 1

Consensus recommendation: Local cold therapy is beneficial for pain relief after rotator cuff surgery (Grade: Consensus) 1

---

Long-Term Outcomes

For complete distal biceps tears managed operatively at median 14.7-year follow-up: 6

• 98% return to work rate, with 85% returning without restrictions 6
• Maintained near-normal range of motion (median 140° flexion/extension arc, 80° supination/pronation) 6
• 91% achieved full elbow flexion strength 6
• 76% achieved full supination strength 6
• 24% overall complication rate (infection, rerupture, heterotopic ossification, nerve complications) 6