by William N. Levine, MD
Although the main treatment option for
partial thickness rotator cuff repair is nonoperative
treatment, especially for the throwing-athlete, there are occasions when
surgical treatment is the preferred course.
We have learned a lot about rotator cuff tears over the past several
decades. From cadaveric studies we know that they are very common, about
one-third of cadavers studied had a partial thickness tear. We know from
Payne’s work that they are typically on the articular side compared to the
bursal side. We also know that
overhead athletes as a subset, need to be viewed completely
differently — 40% of these asymptomatic athletes had either partial of
full-thickness tears compared to none in their nondominant shoulders, according
to Connor and colleagues. So if you get an MRI on an overhead athlete, you can
expect there will be a good chance of a cuff problem.
The question is what do you do with that information?
Harvey Elman first introduced the classification that many still use
today: Grade 1 for tears less than 3 mm; grade 2 for tears 3 mm to 6 mm; and
grade 3 for those greater than 6 mm. The other way to think about these
injuries are to consider them as “high-grade” (greater than 50%
thickness) or “low-grade” (less than 50% thickness).
Partial tears can be further classified as articular-sided or
bursal-sided tears, where the medial footprint is intact and you can only see
it from the bursal side.
In 2001, Snyder introduced the partial articular surface tendon avulsion
(PASTA) lesion, and Conway added partial thickness articular surface
intra-tendinous (PAINT) tears, a specific tear pattern seen in overhead
athletes in which the footprint is usually intact but it is an extension of a
tear that is intra-laminar, starting at the posterior part of the supraspinatus
and often going into the infraspinatus.
You have to understand the type of patient you are treating and that
will dictate which type of repair that is appropriate.
Know your patient
Partial tears in throwers are different and cannot be managed the same
as in the non-throwing population. If you perform a tendon-to-bone PASTA repair
in a 23-year-old, that will likely lead to loss of terminal external rotation
and they probably won’t return to their desired level of performance.
The physical exam for partial tears is challenging as there is not one
test that will be diagnostic. The Jobe relocation for internal impingement can
be helpful. That will cause pain, not apprehension, when the arm is in the
hyper-extended, abducted externally rotated position. That pain will go away
when the arm is brought in front of the body. Instability testing should be
performed in all of these patients - although they may not have them - and of
SLAP examination should always be performed as these lesions
are often found in conjunction with a partial cuff tear in the overhead
For the procedure, Levine identifies the partial
tear (left), assesses the footprint down to the bone to evaluate the
possibility of completing the tear (center) and then places a marking suture
that will aid in assessing the bursal side of the tear (right).
Images: Levine WN
These patients, who tend to be younger and participate in overhead
sports, may or may not have external impingement signs. Selective injections
into the subacromial space (external impingement) or into the glenohumeral
joint (internal impingement) can be helpful to differentiate where their pain
is coming from in unclear situations.
Surgery is usually indicated if the patient’s pain is not relieved
by 3 to 6 months of nonoperative treatment, including activity modification
— avoidance of overhead or pain-provoking actions — NSAID use,
physical therapy, strengthening, and subacromial or
glenohumeral steroid injections.
There are several surgical options including: 1) debridement in
isolation; 2) debridement with an acromioplasty; or 3) rotator cuff repair.
There are three options for managing the cuff. The partial-tear can be
converted to a full-tear and repaired; a trans-tendon in-situ repair can be
performed (which would be considered for a PASTA lesion in a non-throwing
athlete); or an intra-laminar repair for the athlete who has an intact
footprint — the so-called PAINT lesion.
to use the beach chair position for his rotator cuff surgeries.
During the assessment, he probes the defect to determine its
size relative to the 3-mm probe tip.
Should you take down intact tendon and then repair the entire tendon, do
a trans-tendon in-situ repair, or perform an intra-laminar repair for throwers?
Completing the tear involves the excision of potentially normal tissue
— so the question that needs to be asked is how “high-grade” is
the tear. Knowledge of the normal footprint anatomy helps to determine the
“grade” of involvement since the supraspinatus medial-lateral
footprint is 12 to 16 mm. Therefore, if there is 6 to 7 mm of intact tendon, we
consider it a high-grade tear?
First, I identify the articular-sided tear by probing the defect to get
a sense of how deep the tear is. Assess the footprint for exposed bone and if
there is too much exposed it is safer and more reliable to just convert to a
full thickness tear. Since most probe tips are 3 mm, it is fairly
straightforward to determine the depth of the tear.
An important step at this point is to percutaneously place a marking
suture which will allow bursal side assessment of the tear.
Levine uses two different colored sutures for easier
identification and suture management.
Here, he used blue sutures anteriorly and white for the
posterior. Following the anchor and suture placement, Levine recommends pulling
on the sutures — if they have been properly placed, the medial row should
A technical pearl at this point is to do a thorough bursectomy so when
you go back to repair the tear it will be easier to find your sutures. This is
also a good time to assess the tendon and to see if there is any communication
to the bursal side.
Then footprint abrasion should be performed to enhance the healing.
Suture anchors can then be placed through the intact bursal-side tendon
(trans-tendon) and the type of anchor is surgeon dependent (bioabsorbable,
PEEK, or metal).
On final evaluation of the glenohumeral
joint, Levine checks to make sure the entire tear has been repaired and for any
synovitis that may have been missed earlier.
In terms of suture management, it is always best to have two different
color sutures. By routine I use the blue suture anteriorly and a striped suture
posteriorly to assist in suture management.
I use a percutaneously placed suture shuttle device, although a number
of different devices including a spinal needle can be used. The typical repair
strategy is to use one anchor and one suture from each pair is placed through
the medially retracted articular tear. Then I test the repair by pulling all
four sutures — if the sutures have been appropriately placed — the
medial row should anatomically reduce. If the medial row does not reduce,
however, the other two limbs should also be placed through the articular tissue
and then this pre-suture tying step should be re-checked.
Then attention is re-directed to the subacromial space and because a
thorough bursectomy was previously performed, clear visualization of the
sutures is enhanced and the sutures are retrieved and tied. It is important to
go back into the joint to make sure the repair is anatomic. This is also a good
time to check for synovitis that has been pulled laterally now that an anatomic
repair has been performed.
The PAINT repair uses all the same technical aspects, but suture anchors
are not used so it’s basically a soft tissue repair.
- Conway JE. Arthroscopic repair of partial-thickness rotator cuff
tears and SLAP lesions in professional baseball players. Orthop Clin
North Am. 2001;32(3):443-456.
- Ellman H. Diagnosis and treatment of incomplete rotator cuff tears.
Clin Orthop Relat Res. 1990;254:64-74.
- Payne LZ, Altcheck DW, Craig EV, Warren RF. Arthroscopic treatment
of partial rotator cuff tears in young athletes. A preliminary report. Am
J Sports Med. M1997;25(3):299-305.
- William N. Levine, MD, professor of orthopedic surgery and chief of
sports medicine, can be reached at Columbia at New York-Presbyterian Hospital,
622 West 168th St., PH 11, New York, NY, 10032; 212-305-0762.; e-mail: