Evolution of Nonoperatively Treated
Symptomatic Isolated Full-Thickness Supraspinatus Tears

SF, von Roll AL, Pfirrmann CWA, Gerber C, Jost B. J Bone Joint Surg Am.

data exists to guide clinicians in prescribing treatment for patients with
rotator cuff tears.  It is believed that
without surgery, rotator cuff tears will progress in size; however, few studies
have investigated this theory of tear progression in small (single tendon)
rotator cuff tears.  In this study, 24 patients
(20 male, 4 female; 20 traumatic etiology, 4 degenerative etiology; mean age
52 years, range 39-61 years) who had been diagnosed with a full-thickness
supraspinatus tear but declined surgery were reevaluated at a median of
forty-two months post-diagnosis using MRI and functional Constant and Murley scoring.  Functional scoring included subjective
variables (pain, daily living, etc.), objective assessment of shoulder motion,
and quantitative measurement of abduction strength.  Interestingly, the tear size on average did
not increase over time; in 16 of 24 patients, the tear size, measured from MRI
images, remained unchanged or even decreased. 
The initial tear size of patients whose tear did progress was no
different from those whose tear did not progress, contrasting the traditional
belief that tear size is a predominating factor in predicting tear
progression.  When examining the supraspinatus
muscle, fatty infiltration, measured using an MRI-adapted version of the
Goutallier score, did increase and was greatest in larger tears.  Functionally, the flexion, abduction, and
external rotation angles remained unchanged from initial diagnosis.  Correlations were not found between follow-up
tear size and pain, abduction strength, or subjective shoulder score.  Additionally, there were no correlations
between fatty infiltration and abduction strength. 

It is
commonly believed that all rotator cuff tears are at risk for tear propagation,
making surgery the recommended treatment. 
This is the first clinical study that suggests isolated supraspinatus
tears may not always increase in tear size, challenging the recommendation for
surgery.  The number of traumatic versus
degenerative cases studied was skewed towards traumatic etiology.  While the authors did not investigate
potential differences between these groups (likely due to the low number of
degenerative etiology patients), one may question whether an increased sample
size would reveal differences that would imply different treatments for
traumatic and chronic tears.  It is of
concern that the fatty infiltration increased over time.  This finding indicates that while the tendon tear
may not have progressed, muscle degeneration has occurred; however, this did
not correlate with abduction strength, and shoulder function did not worsen
over time.  On the other hand, even with
surgical repair, fatty infiltration has been shown to be irreversible.  This article is another example of how little
is known about rotator cuff tendon tears and both tendon and muscle degeneration.  Perhaps not surprisingly, the authors were
unable to identify correlations between pain and other parameters that they
measured (similar to previous studies), highlighting the need for research in
this area.  Clinically, have you noticed
differences in how patients with tears due to a traumatic event respond to
treatment compared to those due to chronic degeneration?  Given that fatty infiltration may continue to
slightly advance despite the lack of tear progression, would you still
recommend conservative (non-surgical) treatment?  Overall, what treatment plan do you recommend
to your patients with full-thickness, isolated supraspinatus tears?

by: Sarah Ilkhani-Pour
by:  Stephen Thomas


Fucentese SF, von Roll AL, Pfirrmann CW, Gerber C, & Jost B (2012). Evolution of nonoperatively treated symptomatic isolated full-thickness supraspinatus tears. The Journal of Bone and Joint Surgery. American volume, 94 (9), 801-8 PMID: 22552669