What is the recommended management for a high‑grade articular‑sided partial tear of the distal supraspinatus tendon?

Management of High-Grade Articular-Sided Partial Supraspinatus Tendon Tears

For high-grade articular-sided partial tears of the distal supraspinatus tendon, surgical repair is strongly recommended using either tear completion with repair or transtendon repair techniques, as both approaches yield equivalent clinical outcomes and high healing rates. 1

Surgical Approach

The American Academy of Orthopaedic Surgeons provides strong evidence supporting the use of either conversion to full-thickness tear with repair OR transtendon repair for high-grade partial-thickness rotator cuff tears. 1 This represents the highest level of guideline recommendation, meaning practitioners should follow this unless a compelling rationale exists for an alternative approach.

Choice Between Repair Techniques

Both surgical techniques produce comparable results:

• Transtendon repair and tear completion repair show no significant differences in postoperative patient-reported outcomes, with healing rates of 92.3% and 88.4% respectively. 2
• Retear rates are similarly low: 7.7% for transtendon repair versus 11.6% for tear completion repair (not statistically significant). 2
• No significant differences exist in range of motion (forward flexion or external rotation) or adhesive capsulitis rates (4.7% vs 3.3%) between techniques. 2
• Both techniques achieve good-to-excellent results in 96% of cases based on UCLA scores. 3

Transtendon Repair Specifics

When performing transtendon repair for PASTA (partial articular-sided supraspinatus tendon avulsion) lesions:

• This technique is effective for grade A2-A3 tears (high-grade partial tears involving >50% of tendon thickness). 3
• Significant improvements occur in UCLA scores, Simple Shoulder Test scores, and VAS pain scores at 24-month follow-up. 3
• Patient satisfaction rates are high with low complication rates. 4, 3

Conservative Management Considerations

Arthroscopic debridement alone may be considered for select patients, though the evidence is less robust:

• Debridement showed superior Constant, ASES, and VAS scores compared to repair in one midterm study, with good tendon integrity maintained in most patients. 5
• However, this contradicts the strong guideline recommendation for repair, and debridement should be reserved for patients with contraindications to repair or patient preference after informed discussion. 1

Adjunctive Treatments to Avoid

Do not routinely use platelet-rich plasma (PRP) injections for partial-thickness tears, as limited evidence does not support this intervention. 1

Do not use biological augmentation with platelet-derived products to improve patient-reported outcomes, as strong evidence shows no benefit (though limited evidence suggests possible reduction in retear rates with liquid PRP). 1

Prognostic Factors to Consider

When counseling patients about surgical outcomes:

• Older age is strongly associated with higher failure rates and poorer patient-reported outcomes after rotator cuff repair. 1
• Diabetes leads to higher retear rates and poorer quality of life scores (moderate evidence). 1
• Comorbidities in general are associated with poorer outcomes (moderate evidence). 1

Postoperative Rehabilitation

Early mobilization can be safely implemented rather than delayed immobilization, as strong evidence shows similar clinical outcomes for small- to medium-sized tears whether mobilization begins early or is delayed up to 8 weeks. 1

Common Pitfalls

• Stiff shoulder may develop in approximately 18% of patients at 3 months post-transtendon repair, but typically resolves with full ROM recovery by 6 months. 3
• Medium-sized tears (40-50% tendon width) are at higher risk for progression during strenuous physiotherapy exercises like prone abduction and external rotation at 90° abduction. 6
• Avoid routine acromioplasty, as moderate evidence does not support its use with rotator cuff repair for small- to medium-sized tears. 1