Partial-thickness Posterosuperior Rotator Cuff Tears - Revision history

Alexandre.laedermann at 12:57, 7 June 2021

2021-06-07T12:57:37Z

Alexandre.laedermann at 12:52, 7 June 2021

2021-06-07T12:52:00Z

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Alexandre.laedermann at 12:36, 7 June 2021

2021-06-07T12:36:28Z

Alexandre.laedermann at 12:30, 7 June 2021

2021-06-07T12:30:23Z

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Alexandre.laedermann at 12:16, 7 June 2021

2021-06-07T12:16:10Z

Alexandre.laedermann at 15:07, 17 July 2020

2020-07-17T15:07:32Z

Alexandre.laedermann: /* Articular tears */

2020-01-28T05:44:58Z

Articular tears

Alexandre.laedermann: /* Articular tears */

2020-01-28T05:43:41Z

Articular tears

Alexandre.laedermann: /* Postoperative rehabilitation */

2020-01-07T13:41:05Z

Postoperative rehabilitation

Alexandre.laedermann: /* Joint tears in throwing athletes with posterosuperior impingement */

2020-01-07T13:40:48Z

Joint tears in throwing athletes with posterosuperior impingement

@@ Line 41: / Line 41: @@
 ==Classification==
-While several classifications have been proposed, there is no consensus as to general treatment.<ref>Kuhn JE, Dunn WR, Ma B, et al. Interobserver agreement in the classification of rotator cuff tears. Am J Sports Med 2007;35:437-41.</ref>
+While several classifications have been proposed, there is no consensus as to general treatment.<ref>Kuhn JE, Dunn WR, Ma B, Wright RW, Jones G, Spencer EE, Wolf B, Safran M, Spindler KP, McCarty E, Kelly B, Holloway B Interobserver agreement in the classification of rotator cuff tears. Am J Sports Med 2007;35:437-41.</ref>
 We therefore confine ourselves to the most used; that of Ellman et al., which divides the thickness of the rotator cuff into three more or less equal parts, varying between 10mm and 12mm.
@@ Line 60: / Line 60: @@
 Moreover, Pinkowsky et al. have recently confirmed, in a cadaveric study, that stage III tears affecting the rotator cable can lead to increased glenohumeral translation and altered kinematics.<ref>Pinkowsky GJ, ElAttrache NS, Peterson AB, Akeda M, McGarry MH, Lee TQ. Partial-thickness tears involving the rotator cable lead to abnormal glenohumeral kinematics. J Shoulder Elbow Surg 2017;26:1152-8.</ref>
-Studies assessing rotator cuff vascularization are inconsistent.<ref>Rudzki JR, Adler RS, Warren RF, et al. Contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: age- and activity-related changes in the intact asymptomatic rotator cuff. J Shoulder Elbow Surg 2008;17:96S-100S.</ref>
+Studies assessing rotator cuff vascularization are inconsistent.<ref>Rudzki JR, Adler RS, Warren RF, Kadrmas WR, Verma N, Pearle AD, Lyman S, Fealy S. Contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: age- and activity-related changes in the intact asymptomatic rotator cuff. J Shoulder Elbow Surg 2008;17:96S-100S.</ref>
 Codman et al. describe hypovascularization in an area 5 mm to 10 mm from the rotator cuff insertion.<ref name=":1" />
@@ Line 107: / Line 107: @@
 Conservative treatment is usually the best option.<ref>Kempf JF, Mole D, Gleyze P, Bonnomet F, Rio B, Levigne C, Walch G. [Results of endoscopic treatment of tendinopathies of the rotator cuff (excluding total ruptures). 1: Non-calcifying tendinopathies]. Rev Chir Orthop Reparatrice Appar Mot 1993;79:519-31.</ref>
-This applies to partial-thickness tears causing only moderate functional limitation and when the repair is difficult, sometimes requiring completion along the full thickness of the tendon, which, in 10% of the cases fail to heal.<ref>Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am 2009;91:1055-62.</ref>
+This applies to partial-thickness tears causing only moderate functional limitation and when the repair is difficult, sometimes requiring completion along the full thickness of the tendon, which, in 10% of the cases fail to heal.<ref name=":5">Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am 2009;91:1055-62.</ref>
 The duration of conservative treatment depends on the clinical presentation, physical and imaging observations, the degree of disability and the patient's demands and expectations. Bursal-sided tears in young patients who respond poorly to conservative treatment will be quickly operated. Similarly, an articular-sided tear with retraction of the deep layer, which could result in a very thin and insufficient rotator cuff, will be swiftly treated (Figure 7). Conversely, conservative treatment should be maximised when there is an extensive articular tear in the context of posterosuperior impingement in sports professionals wishing to remain active, and in cases of Ellman I-II type interstitial tears having no substantial extension into the musculotendinous junction.
@@ Line 133: / Line 133: @@
 ====Articular tears in non-overhead throwers====
-Ellman I or II joint tears will simply be debrided. Ellman III tears will either be completed or repaired, conserving the bursal side (transtendinous repair). There is no evidence to prefer either technique.<ref> Shin SJ. A comparison of 2 repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy 2012;28:25-33.</ref>
+Ellman I or II joint tears will simply be debrided. Ellman III tears will either be completed or repaired, conserving the bursal side (transtendinous repair). There is no evidence to prefer either technique.<ref name=":6"> Shin SJ. A comparison of 2 repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy 2012;28:25-33.</ref>
-Nevertheless, incompleted repairs are biomechanically stronger and avoid the risk of non-healing of the bursal layer.<ref>Gonzalez-Lomas G, Kippe MA, Brown GD, Gardner TR, Ding A, Levine WN, Ahmad CS. In situ transtendon repair outperforms tear completion and repair for partial articular-sided supraspinatus tendon tears. J Shoulder Elbow Surg 2008;17:722-8.</ref><ref>Peters KS, Lam PH, Murrell GA. Repair of partial-thickness rotator cuff tears: a biomechanical analysis of footprint contact pressure and strength in an ovine model. Arthroscopy 2010;26:877-84.</ref><ref>Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am 2009;91:1055-62.</ref>
+Nevertheless, incompleted repairs are biomechanically stronger and avoid the risk of non-healing of the bursal layer.<ref>Gonzalez-Lomas G, Kippe MA, Brown GD, Gardner TR, Ding A, Levine WN, Ahmad CS. In situ transtendon repair outperforms tear completion and repair for partial articular-sided supraspinatus tendon tears. J Shoulder Elbow Surg 2008;17:722-8.</ref><ref>Peters KS, Lam PH, Murrell GA. Repair of partial-thickness rotator cuff tears: a biomechanical analysis of footprint contact pressure and strength in an ovine model. Arthroscopy 2010;26:877-84.</ref><ref name=":5" />
-It should be noted, however, that this type of repair leads to a 10% short term incidence of frozen shoulder.<ref>Shin SJ. A comparison of 2 repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy 2012;28:25-33.</ref>
+It should be noted, however, that this type of repair leads to a 10% short term incidence of frozen shoulder.<ref name=":6" />
 For all these mainly articular tears, where the critical shoulder angle (CSA) exceeds 33 degrees, a lateral acromioplasty might be justified in order to reduce the stress on the supraspinatus by limiting overload (intrinsic factor).<ref>Gerber C, Catanzaro S, Betz M, Ernstbrunner L. Arthroscopic Correction of the Critical Shoulder Angle Through Lateral Acromioplasty: A Safe Adjunct to Rotator Cuff Repair. Arthroscopy 2018;34:771-780.</ref>

@@ Line 135: / Line 135: @@
 Ellman I or II joint tears will simply be debrided. Ellman III tears will either be completed or repaired, conserving the bursal side (transtendinous repair). There is no evidence to prefer either technique.<ref> Shin SJ. A comparison of 2 repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy 2012;28:25-33.</ref>
-Nevertheless, incompleted repairs are biomechanically stronger and avoid the risk of non-healing of the bursal layer.<ref>Gonzalez-Lomas G, Kippe MA, Brown GD, et al. In situ transtendon repair outperforms tear completion and repair for partial articular-sided supraspinatus tendon tears. J Shoulder Elbow Surg 2008;17:722-8.</ref><ref>Peters KS, Lam PH, Murrell GA. Repair of partial-thickness rotator cuff tears: a biomechanical analysis of footprint contact pressure and strength in an ovine model. Arthroscopy 2010;26:877-84.</ref><ref>Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am 2009;91:1055-62.</ref>
+Nevertheless, incompleted repairs are biomechanically stronger and avoid the risk of non-healing of the bursal layer.<ref>Gonzalez-Lomas G, Kippe MA, Brown GD, Gardner TR, Ding A, Levine WN, Ahmad CS. In situ transtendon repair outperforms tear completion and repair for partial articular-sided supraspinatus tendon tears. J Shoulder Elbow Surg 2008;17:722-8.</ref><ref>Peters KS, Lam PH, Murrell GA. Repair of partial-thickness rotator cuff tears: a biomechanical analysis of footprint contact pressure and strength in an ovine model. Arthroscopy 2010;26:877-84.</ref><ref>Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am 2009;91:1055-62.</ref>
 It should be noted, however, that this type of repair leads to a 10% short term incidence of frozen shoulder.<ref>Shin SJ. A comparison of 2 repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy 2012;28:25-33.</ref>
-For all these mainly articular tears, where the critical shoulder angle (CSA) exceeds 33 degrees, a lateral acromioplasty might be justified in order to reduce the stress on the supraspinatus by limiting overload (intrinsic factor).<ref>Gerber C, Catanzaro S, Betz M, Ernstbrunner L. Arthroscopic Correction of the Critical Shoulder Angle Through Lateral Acromioplasty: A Safe Adjunct to Rotator Cuff Repair. Arthroscopy 2017.</ref>
+For all these mainly articular tears, where the critical shoulder angle (CSA) exceeds 33 degrees, a lateral acromioplasty might be justified in order to reduce the stress on the supraspinatus by limiting overload (intrinsic factor).<ref>Gerber C, Catanzaro S, Betz M, Ernstbrunner L. Arthroscopic Correction of the Critical Shoulder Angle Through Lateral Acromioplasty: A Safe Adjunct to Rotator Cuff Repair. Arthroscopy 2018;34:771-780.</ref>
 ====Joint tears in throwing athletes with posterosuperior impingement====
@@ Line 151: / Line 151: @@
 ===Postoperative rehabilitation===
-Because these are small tears that risk leading to a frozen shoulder, immediate passive mobilization is recommended. Moreover, because they are unretracted, wearing a simple sling for a maximum of one month should suffice. Once the range of joint movement is re-acquired and allowing for a 6-week healing period, then gradual return to activities favourable to the rotator cuff, and which protect the subacromial space, is recommended; for instance walking with a stick, rowing, elliptical machine, paddle and breaststroke.<ref>Charbonnier C, Lädermann A, Kevelham B, Chague S, Hoffmeyer P, Holzer N. Shoulder strengthening exercises adapted to specific shoulder pathologies can be selected using new simulation techniques: a pilot study. Int J Comput Assist Radiol Surg. 2018 Feb;13(2):321-330.</ref>
+Because these are small tears that risk leading to a frozen shoulder, immediate passive mobilization is recommended. Moreover, because they are unretracted, wearing a simple sling for a maximum of one month should suffice. Once the range of joint movement is re-acquired and allowing for a 6-week healing period, then gradual return to activities favourable to the rotator cuff, and which protect the subacromial space, is recommended; for instance walking with a stick, rowing, elliptical machine, paddle and breaststroke.<ref>Charbonnier C, Lädermann A, Kevelham B, Chague S, Hoffmeyer P, Holzer N. Shoulder strengthening exercises adapted to specific shoulder pathologies can be selected using new simulation techniques: a pilot study. Int J Comput Assist Radiol Surg. 2018;13:321-330.</ref>
 ==References==
 <references />

@@ Line 21: / Line 21: @@
 Shoulder arthroscopy; Partial-thickness rotator cuff tear; Delaminated; Nondelaminated; Debridement; Transtendon repair; Conversion to full-thickness tear; Take-down; En masse.
-== Introduction ==
+==Introduction==
 Partial-thickness rotator cuff tears, characterised by disruption of tendon fibers with no communication between the subacromial bursa and the glenohumeral joint, are known causes of shoulder pain and disability.<ref>Ellman H. Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop Relat Res 1990:64-74.</ref><BR>
-Described by Codman et al., these generally include the supraspinatus and infraspinatus, whereas partial-thickness subscapularis tears have a different pathogenesis and will not be analysed in this section (complete lesion).<ref>Codman E. Lesions of the supraspinatus tendon and other lesions in or about the subacromial bursa. In: Co. TT, ed. The Shoulder. Boston, MA1934:65-7.</REF><ref>Clavert P, Le Coniat Y, Kempf JF, Walch G. Intratendinous rupture of the supraspinatus: anatomical and functional results of 24 operative cases. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie 2016;26:133-8.</ref><ref>Walz DM, Miller TT, Chen S, Hofman J. MR imaging of delamination tears of the rotator cuff tendons. Skeletal radiology 2007;36:411-6.</ref>
+Described by Codman et al., these generally include the supraspinatus and infraspinatus, whereas partial-thickness subscapularis tears have a different pathogenesis and will not be analysed in this section (complete lesion).<ref>Codman E. Lesions of the supraspinatus tendon and other lesions in or about the subacromial bursa. In: Co. TT, ed. The Shoulder. Boston, MA1934:65-7.</ref><ref>Clavert P, Le Coniat Y, Kempf JF, Walch G. Intratendinous rupture of the supraspinatus: anatomical and functional results of 24 operative cases. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie 2016;26:133-8.</ref><ref>Walz DM, Miller TT, Chen S, Hofman J. MR imaging of delamination tears of the rotator cuff tendons. Skeletal radiology 2007;36:411-6.</ref>
 <BR>
-They may be on the bursal side (or superficial), interstitial only, or located in the deep surface adjacent to the joint (articular) (Figure), and are sometimes called partial articular supraspinatus tendon avulsion (PASTA) lesions.<ref>Codman E. Lesions of the supraspinatus tendon and other lesions in or about the subacromial bursa. In: Co. TT, ed. The Shoulder. Boston, MA1934:65-7.</ref>
+They may be on the bursal side (or superficial), interstitial only, or located in the deep surface adjacent to the joint (articular) (Figure 1), and are sometimes called partial articular supraspinatus tendon avulsion (PASTA) lesions.<ref>Codman E. Lesions of the supraspinatus tendon and other lesions in or about the subacromial bursa. In: Co. TT, ed. The Shoulder. Boston, MA1934:65-7.</ref>
 <br />
 [[File:1563466093249-lg.jpg|center|thumb|600x600px|''Figure 1. A, bursal tear; B, interstitial tear; C, joint tear. With permission from Gilles Walch.'']]
-Partial-thickness rotator cuff tears are common, affecting approximately 5% to 20% of patients who present shoulder pain.<ref>Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-5.</ref><ref>Smith C, Corner T, Morgan D, Drew S. Partial thickness rotator cuff tears: what do we know? . Shoulder Elbow 2010;2:77-82.</ref>
+Partial-thickness rotator cuff tears are common, affecting approximately 5% to 20% of patients who present shoulder pain.<ref>Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-5.</ref><ref>Smith C, Corner T, Morgan D, Drew S. Partial thickness rotator cuff tears: what do we know? Shoulder Elbow 2010;2:77-82.</ref>
-The prevalence varies according to the type; 18% have a bursal component, 55% are interstitial and 27% are articular<ref> Fukuda H. The management of partial-thickness tears of the rotator cuff. J Bone Joint Surg Br 2003;85:3-11.</ref>
+The prevalence varies according to the type; 18% have a bursal component, 55% are interstitial and 27% are articular.<ref> Fukuda H. The management of partial-thickness tears of the rotator cuff. J Bone Joint Surg Br 2003;85:3-11.</ref>
-Kim et al. monitored partial-thickness lesions with iterative Magnetic Resonance Images (MRI).
+Kim et al. monitored partial-thickness lesions with iterative Magnetic Resonance Images (MRI). At an average follow-up of 2 years, 26.1% of cases showed tear progression, while a decrease in size was observed in only 6.8% of cases.<ref> Kim YS, Kim SE, Bae SH, Lee HJ, Jee WH, Park CK. Tear progression of symptomatic full-thickness and partial-thickness rotator cuff tears as measured by repeated MRI. Knee Surg Sports Traumatol Arthrosc 2017;25:2073-80.</ref>
-At an average follow-up of 2 years, 26.1% of cases showed tear progression, while a decrease in size was observed in only 6.8% of cases.<ref> Kim YS, Kim SE, Bae SH, Lee HJ, Jee WH, Park CK. Tear progression of symptomatic full-thickness and partial-thickness rotator cuff tears as measured by repeated MRI. Knee Surg Sports Traumatol Arthrosc 2017;25:2073-80.</ref>
+In another study involving more than half of the tendon insertion, at an average follow-up of 20 months, Kong et al. found that the tears had worsened in 16%, improved in 25%, and remained stable in 59% of cases.<ref> Kong BY, Cho M, Lee HR, Choi YE, Kim SH. Structural Evolution of Nonoperatively Treated High-Grade Partial-Thickness Tears of the Supraspinatus Tendon. Am J Sports Med. 2018;46:79-86.</ref>
 ==Classification==
@@ Line 54: / Line 52: @@
 It is a small triangular area measuring 6.9 mm in the coronal plane and 12.6 mm in the sagittal plane, extending to the lesser tubercle in 21% of cases. The infraspinatus insertion had previously been underestimated. It is trapezoidal in shape, covering a large part of the greater tuberostiy, 10.2 mm wide in the coronal plane and 32.7 mm long in the sagittal plane. Near the insertion, the two tendons are superimposed, the infraspinatus enveloping the supraspinatus. These different layers have variable rigidities which account for delamination.<ref>Lee SB, Nakajima T, Luo ZP, Zobitz ME, Chang YW, An KN. The bursal and articular sides of the supraspinatus tendon have a different compressive stiffness. Clinical biomechanics 2000;15:241-7.</ref>
-A study by Pouliart et al. found a superior joint capsule in 27.4% of cases. The complex entanglement of the different fibres from the infraspinatus, supraspinatus and possibly the joint capsule accounts for the different layers and the variability of lesions found within them (Figure).<ref>Pouliart N, Somers K, Eid S, Gagey O. Variations in the superior capsuloligamentous complex and description of a new ligament. J Shoulder Elbow Surg 2007;16:821-36.</ref>
+A study by Pouliart et al. found a superior joint capsule in 27.4% of cases. The complex entanglement of the different fibres from the infraspinatus, supraspinatus and possibly the joint capsule accounts for the different layers and the variability of lesions found within them (Figure 2).<ref>Pouliart N, Somers K, Eid S, Gagey O. Variations in the superior capsuloligamentous complex and description of a new ligament. J Shoulder Elbow Surg 2007;16:821-36.</ref>
 [[File:1563469395536-lg.jpg|center|thumb|600x600px|''Figure 2. Coronal sections from right shoulder (magnetic resonance arthrogram (MRA). A) Millimetric interstitial tear (white arrow) with reactive bone oedema (red arrow); B) Long interstitial tear extending to the musculotendinous junction (black arrows). Reproduced from Lädermann et al.,15 with permission.'']]
-Partial-thickness tears have for long been wrongly considered to have little or no influence on shoulder kinematics. However, Gerber et al. have shown that a partial-thickness tear can have the same biomechanical repercussions as a full-thickness tear.<ref>Gerber C, Zubler V, Hodler J, Catanzaro S, Jost B, Fucentese SF. Dynamic imaging and function of partial supraspinatus tendon tears. Arthroscopy 2011;27:1180-6.</ref>
+Partial-thickness tears have been for long wrongly considered to have little or no influence on shoulder kinematics. However, Gerber et al. have shown that a partial-thickness tear can have the same biomechanical repercussions as a full-thickness tear.<ref>Gerber C, Zubler V, Hodler J, Catanzaro S, Jost B, Fucentese SF. Dynamic imaging and function of partial supraspinatus tendon tears. Arthroscopy 2011;27:1180-6.</ref>
 Moreover, Pinkowsky et al. have recently confirmed, in a cadaveric study, that stage III tears affecting the rotator cable can lead to increased glenohumeral translation and altered kinematics.<ref>Pinkowsky GJ, ElAttrache NS, Peterson AB, Akeda M, McGarry MH, Lee TQ. Partial-thickness tears involving the rotator cable lead to abnormal glenohumeral kinematics. J Shoulder Elbow Surg 2017;26:1152-8.</ref>
@@ Line 95: / Line 93: @@
 Moreover, arthroscopy provides no definitive diagnosis, as it does not reveal interstitial tearing. Only imaging can refine the diagnosis. Ultrasound (US) is an accurate method for assessing partial-thickness tears (Figures), but as usual, the examiner's experience and specialization are crucial.<ref>Kurz AZ, Kelly MJ, Hackett L, Murrell GA. Effect of surgeon-sonographer interaction on ultrasound diagnosis of rotator cuff tears: a five-year cohort study in 775 shoulders. J Shoulder Elbow Surg 2016;25:1385-94.</ref>
-[[File:1563469399128-lg.jpg|center|thumb|600x600px|''Figure 4. Supraspinatus tendon, visualised on its longitudinal axis, and the subacromial-subdeltoid bursa lying superficially to it. Ultrasound (US) image (a) with superimposed anatomy (b), patient/probe position (c), and landmarks for measurement of these two structures (d). Reproduced from Plomb-Holmes et al., with permission.<ref>''Plomb-Holmes C, Clavert P, Kolo F, Tay E, Lädermann A, French Society of A. An orthopaedic surgeon's guide to ultrasound imaging of the healthy, pathological and postoperative shoulder. Orthop Traumatol Surg Res. 2018;104(8S):S219-S232</ref>]]
+[[File:1563469399128-lg.jpg|center|thumb|600x600px|''Figure 4. Supraspinatus tendon, visualised on its longitudinal axis, and the subacromial-subdeltoid bursa lying superficially to it. Ultrasound (US) image (a) with superimposed anatomy (b), patient/probe position (c), and landmarks for measurement of these two structures (d). Reproduced from Plomb-Holmes et al., with permission.<ref>''Plomb-Holmes C, Clavert P, Kolo F, Tay E, Lädermann A, French Society of A. An orthopaedic surgeon's guide to ultrasound imaging of the healthy, pathological and postoperative shoulder. Orthop Traumatol Surg Res. 2018;104(8S):S219-S232''</ref>'']]
 <br />
-[[File:1563469396198-lg.jpg|center|thumb|600x600px|''Figure 5. A) Right coronal section of a supraspinatus tendon on ultrasound. The articular tear, where the tendon is detached from the bone, is very subtle. All that can be seen is a hypoechoic area (yellow arrow) which could be confused with normal Sharpey fibres (fibrocartilage) and a cortical irregularity (red arrow). B) Coronal section of the same shoulder from a magnetic resonance imaging (MRI) arthrogram T2-weighted, fat-saturated sequence, clearly showing a deep surface tear (white arrow). Reproduced from Lädermann et al., with permission.<ref>''Lädermann A, Collin P. Rupture partielle de la coiffe des rotateurs postéro-supérieur. Revue du Rhumatisme Monographies 2018;85(2):88-94</ref>]]
+[[File:1563469396198-lg.jpg|center|thumb|600x600px|''Figure 5. A) Right coronal section of a supraspinatus tendon on ultrasound. The articular tear, where the tendon is detached from the bone, is very subtle. All that can be seen is a hypoechoic area (yellow arrow) which could be confused with normal Sharpey fibres (fibrocartilage) and a cortical irregularity (red arrow). B) Coronal section of the same shoulder from a magnetic resonance imaging (MRI) arthrogram T2-weighted, fat-saturated sequence, clearly showing a deep surface tear (white arrow). Reproduced from Lädermann et al., with permission.<ref>''Lädermann A, Collin P. Rupture partielle de la coiffe des rotateurs postéro-supérieur. Revue du Rhumatisme Monographies 2018;85(2):88-94''</ref>'']]

@@ Line 4: / Line 4: @@
-''Written by Alexandre Lädermann''
+==Bullet points==
 *Partial-thickness rotator cuff tears present partial disruption of tendon fibers with no communication between the subacromial bursa and the glenohumeral joint.
@@ Line 20: / Line 18: @@
 *Surgical treatment: No agreement has been reached on the best surgical treatment, which include: rotator cuff debridement, rotator cuff or labral repair, glenoplasty, and subacromial     decompression if necessary.
-=='''Key words'''==
+==Key words==
 Shoulder arthroscopy; Partial-thickness rotator cuff tear; Delaminated; Nondelaminated; Debridement; Transtendon repair; Conversion to full-thickness tear; Take-down; En masse.
-'''Introduction'''
+== Introduction ==
 Partial-thickness rotator cuff tears, characterised by disruption of tendon fibers with no communication between the subacromial bursa and the glenohumeral joint, are known causes of shoulder pain and disability.<ref>Ellman H. Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop Relat Res 1990:64-74.</ref><BR>
@@ Line 44: / Line 42: @@
 In another study involving more than half of the tendon insertion, at an average follow-up of 20 months, Kong et al. found that the tears worsened in 16%, improved in 25%, and remained stable in 59% of cases.<ref> Kong BY, Cho M, Lee HR, Choi YE, Kim SH. Structural Evolution of Nonoperatively Treated High-Grade Partial-Thickness Tears of the Supraspinatus Tendon. Am J Sports Med. 2018;46(1):79-86</ref>
-=='''Classification'''==
+==Classification==
 While several classifications have been proposed, there is no consensus as to general treatment.<ref>Kuhn JE, Dunn WR, Ma B, et al. Interobserver agreement in the classification of rotator cuff tears. Am J Sports Med 2007;35:437-41.</ref>
@@ Line 51: / Line 49: @@
 Tears <3mm thick are termed stage I, those between 3 and 6 mm thick, stage II, and those affecting more than 50% of tendon thickness, stage III.<ref>Ellman H. Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop Relat Res 1990:64-74.</ref>
-=='''Anatomy and biomechanics'''==
+==Anatomy and biomechanics==
 Because the location of the tear is closely linked to its etiology, a good understanding of the anatomy and biomechanics is crucial. The insertion area of the supraspinatus tendon has recently been re-examined.<ref>Mochizuki T, Sugaya H, Uomizu M, et al. Humeral insertion of the supraspinatus and infraspinatus. New anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg Am 2008;90:962-9.</ref>
@@ Line 70: / Line 68: @@
 This hypovascularization of the torn tendon area and the continuous mechanical stresses to which the rotator cuff is subjected, could be responsible for poor spontaneous healing following a partial-thickness tear. Conversely, in other more recent, notably cadaveric ones, the entire tendinous and bursal insertion appears uniformly vascularized.<ref>Poldoja E, Rahu M, Kask K, Weyers I, Kolts I. Blood supply of the subacromial bursa and rotator cuff tendons on the bursal side. Knee Surg Sports Traumatol Arthrosc 2017;25:2041-6.</ref>
-=='''Etiology'''==
+==Etiology==
 Apart from the usual biological causes of rotator cuff tendinopathies (hyperlipidaemia, smoking, obesity, diabetes, hypertension, alcohol, fluoroquinolones, anti-inflammatories, thyroid disorders), partial damage to the cuff may be due to internal or external impingement, and intrinsic or extrinsic causes.
@@ Line 88: / Line 86: @@
 A new theory has emerged in recent years. It appears that a significant lateral offset of the acromion, reflected by the critical shoulder angle (Figure), can cause an intrinsic mechanical overload to the cuff’s deep surface during arm movements at approximately 30° of abduction.<ref> Moor BK, Wieser K, Slankamenac K, Gerber C, Bouaicha S. Relationship of individual scapular anatomy and degenerative rotator cuff tears. J Shoulder Elbow Surg 2014;23:536-41.</ref>
 [[File:1563469394899-lg.jpg|center|thumb|497x497px|''Figure 3. The critical shoulder angle (CSA) is measured on a frontal shoulder radiograph, between a line passing through the superior and inferior margins of the glenoid fossa, and another connecting the inferior margin of the glenoid with the most inferior-anterior point of the acromion. Reproduced from Lädermann et al., with permission.'']]
 Lastly, joint injury should also be suspected in patients who remain symptomatic after a slightly displaced fracture of the lesser tubercle.<ref> Kim SH, Ha KI. Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. Arthroscopy 2000;16:695-700.</ref>
-=='''Diagnosis'''==
+==Diagnosis==
 The clinical presentation is surprisingly variable, ranging from mild discomfort to chronic pain or decreased throwing velocity. There is no clinical test to differentiate between partial-thckness and full-thickness tears.
@@ Line 107: / Line 104: @@
 Only Magnetic resonance arhtrography (MRA) provides an accurate and complete diagnosis: fat-saturated T2 sequence gives a signal in the tear identical to the intra-articular signal, while fat-saturated T1 sequences signals the absence of gadolinium uptake in the subacromial bursa.<ref>de Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. AJR American journal of roentgenology 2009;192:1701-7.</ref><ref>Schaeffeler C, Mueller D, Kirchhoff C, Wolf P, Rummeny EJ, Woertler K. Tears at the rotator cuff footprint: prevalence and imaging characteristics in 305 MR arthrograms of the shoulder. European radiology 2011;21:1477-84.</ref>
-=='''Treatment'''==
+==Treatment==
 ===Conservative treatment===
@@ Line 116: / Line 113: @@
 The duration of conservative treatment depends on the clinical presentation, physical and imaging observations, the degree of disability and the patient's demands and expectations. Bursal-sided tears in young patients who respond poorly to conservative treatment will be quickly operated. Similarly, an articular-sided tear with retraction of the deep layer, which could result in a very thin and insufficient rotator cuff, will be swiftly treated (Figure). Conversely, conservative treatment should be maximised when there is an extensive articular tear in the context of posterosuperior impingement in sports professionals wishing to remain active, and in cases of Ellman I-II type interstitial tears having no substantial extension into the musculotendinous junction.
 [[File:1563469395600-lg.jpg|center|thumb|600x600px|''Figure 6. A) Preoperative coronal section of a T1 sequence, fat-saturated right shoulder. Deep surface tear (red arrow) with deep layer retraction above the humeral head (white arrow). B) Postoperative coronal section of a right shoulder in T2 sequence with fat saturation. The repair allowed healing of the tendon on the greater tubercle (red arrow), but ignored the deep layer (white arrow) which remained retracted, resulting in a thin, persistently painful rotator cuff (3 mm, green line). Reproduced from Lädermann et al., with permission.''<ref>Lädermann A, Collin P. Rupture partielle de la coiffe des rotateurs postéro-supérieur. Revue du Rhumatisme Monographies 2018;85(2):88-94</ref>]]
 Preferred conservative strategies therefore depend on the type of tear. In general, the patient will be asked to bide his time, to rest his injury by taking-up some other activity, make use of hot and cold compresses, and take non-steroidal anti-inflammatory drugs. Gentle exercises maintaining and increasing range of motion are recommended, as is a physiotherapy program designed to 1) maintain and/or improve normal scapulohumeral and scapulothoracic kinematics, by stretching of the posterior capsule, recentering the humeral head and flexing the periscapular muscles, especially the pectoralis minor, 2) to rebalance muscular strength around the shoulder in order to sustain the corrections (flexing the adductors and internal rotators, overused by throwing, strengthening the external cuff rotators, serratus anterior, trapezius inferior) and 3) to restore the cuff’s compressive strength and a good scapulohumeral/scapulothoracic synergy using neuromotor rehabilitation.
@@ Line 156: / Line 152: @@
 Acromioplasty is not indicated for this etiology.
-==='''Postoperative rehabilitation'''===
+===Postoperative rehabilitation===
 Because these are small tears that risk leading to a frozen shoulder, immediate passive mobilization is recommended. Moreover, because they are unretracted, wearing a simple sling for a maximum of one month should suffice. Once the range of joint movement is re-acquired and allowing for a 6-week healing period, then gradual return to activities favourable to the rotator cuff, and which protect the subacromial space, is recommended; for instance walking with a stick, rowing, elliptical machine, paddle and breaststroke.<ref>Charbonnier C, Lädermann A, Kevelham B, Chague S, Hoffmeyer P, Holzer N. Shoulder strengthening exercises adapted to specific shoulder pathologies can be selected using new simulation techniques: a pilot study. Int J Comput Assist Radiol Surg. 2018 Feb;13(2):321-330.</ref>
 ==References==
 <references />

@@ Line 82: / Line 82: @@
 ===Articular tears===
-Articular-sided tears (Figure) usually occur in throwing athletes and racquet sports players. Thanks to a precise kinematic analysis, the posterosuperior internal impingement syndrome described by Walch et al.<ref>Walch G, Liotard JP, Boileau P, Noël E. [Postero-superior glenoid impingement. Another shoulder impingement]. Rev Chir Orthop Reparatrice Appar Mot. 1991;77(8):571-4</ref> has been dismantled.<ref>Lädermann A, Chagué S, Kolo FC, Charbonnier C. Kinematics of the shoulder joint in tennis players. J Sci Med Sport. 2016 Jan;19(1):56-63</ref> They demonstrated that the original cause is indeed repeated friction during activities when the arm is hyperabducted in external rotation, but not, as previously suggested by other authors, joint movement limitation in internal rotation or subtle posterosuperior static instability or anteroinferior dynamics.<ref>Lädermann A, Chague S, Kolo FC, Charbonnier C. Kinematics of the shoulder joint in tennis players. J Sci Med Sport. 2016;19(1):56-63.</ref>
+Articular-sided tears (Figure) usually occur in throwing athletes and racquet sports players. Thanks to a precise kinematic analysis, the posterosuperior internal impingement syndrome described by Walch et al.<ref>Walch G, Liotard JP, Boileau P, Noël E. [Postero-superior glenoid impingement. Another shoulder impingement]. Rev Chir Orthop Reparatrice Appar Mot. 1991;77(8):571-4</ref> has been dismantled.<ref>Lädermann A, Chagué S, Kolo FC, Charbonnier C. Kinematics of the shoulder joint in tennis players. J Sci Med Sport. 2016 Jan;19(1):56-63</ref> The original cause is repeated friction during activities when the arm is hyperabducted in external rotation, but not, as previously suggested by other authors, joint movement limitation in internal rotation or subtle posterosuperior static instability or anteroinferior dynamics.<ref>Lädermann A, Chague S, Kolo FC, Charbonnier C. Kinematics of the shoulder joint in tennis players. J Sci Med Sport. 2016;19(1):56-63.</ref>
 [[File:Capture d’écran 2020-01-28 à 06.37.02.png|thumb|Articular-side tears.]]

@@ Line 152: / Line 152: @@
 While partial thickness tear repair is effective, the benefit to throwers is still uncertain. In this group, the therapeutic approach has recently changed, insofar that previous hypotheses regarding dynamic anterior instability, static posterosuperior instability, rotational disorders, etc. are still unconfirmed.
-The cuff should not be repaired as it may cause shortening of the muscle-tendon, anatomic and mechanical changes to the shoulder and loss of range, preventing the athlete from throwing. Therefore, if surgery is unavoidable, a glenoplasty with resection or labral repair, depending on the state of the labrum could be proposed.<nowiki><ref> Levigne C, Garret J, Grosclaude S, Borel F, Walch G. Surgical technique arthroscopic posterior glenoidplasty for posterosuperior glenoid impingement in throwing athletes. Clin Orthop Relat Res 2012;470:1571-8.</ref></nowiki>
+The cuff should not be repaired as it may cause shortening of the muscle-tendon, anatomic and mechanical changes to the shoulder and loss of range, preventing the athlete from throwing. Therefore, if surgery is unavoidable, a glenoplasty with resection or labral repair, depending on the state of the labrum could be proposed.<ref> Levigne C, Garret J, Grosclaude S, Borel F, Walch G. Surgical technique arthroscopic posterior glenoidplasty for posterosuperior glenoid impingement in throwing athletes. Clin Orthop Relat Res 2012;470:1571-8.</ref>
 Acromioplasty is not indicated for this etiology.