Full thickness tear (FTT)

- variable amount retraction from insertion


Rotator Cuff Tear Large


Partial thickness tear (PTT)

- incomplete

- bursal or articular sided


Articular sided tearBursal Tear




Older patients

- average age 60

- uncommon < 40

- cadavers  30%


Milgrom & Schaffer JBJS Am 1995

- rotator cuff changes In asymptomatic adults

- 50% at 50 years

- 80% at 80 years




Blood Supply


Proximal from muscle belly

- suprascapular artery

- subscapular artery


Distal from bone

- branch of anterior circumflex humeral


Vessels more abundant on bursal side than articular side




1.  Healing

- full thickness tears don't heal because of presence of synovial fluid


2.  Progression

- tears do not necessarily extend


3.  OA

- 5% FTT go on to cuff arthropathy if untreated




Chronic Tears

- 95% 

- abnormal tendon


Acute tears

- trauma 

- 5% 

- normal tendon




No evidence inflammation at tear site

- tendinosis / angiofibrotic dysplasia



- most common involves supraspinatus

- infraspinatus / T minor maybe torn

- subscapularis seldom torn




1.  Size 



- Small       < 1 cm

- Moderate  1-3 cm

- Large       3-5 cm

- Massive    > 5 cm


2.  Extent


Partial Thickness


Quite common

- patients present with pain, not weakness

- difficult to differentiate from impingement

- MRI with gadolinium


A.  Intra-tendinous

- in tendon

- no communication with bursa / joint


Supraspinatous Tendinosis MRISubscapularis TendinosisInfraspinatous Tendinosis


B.  Articular side

- most common

- blood supply poor

- healing decreased by synovial fluid 

- seen post traumatic in young

- probably due to intrinsic causes in elderly


Supraspinatous articular sided tear


C.  Bursal side

- on subacromial surface

- less common

- likely to be secondary to impingement


Full Thickness


One tendon 

- supraspinatus only


Multiple Tendons 

- more likely OA if multiple tendons involved


3.  Topography


Sagittal Plane


Superior - SS alone

Anterosuperior - SS & SSC

Posterosuperior - SS & IS

Total cuff - All 3 tendons


Coronal Plane


A. Minimal retraction

- close to insertion


Supraspinatous Tear Minimal Retraction


B. Moderate retraction

- humeral head


Supraspinatous Tear Moderate Retraction 1Supraspinatous Tear Moderate Retraction 2


C.  Significant retraction

- at glenoid


Supraspinatous Tear Retraction to GlenoidSupraspinatous Tear Retracted to Glenoid T1







- 2° to tear

- can be limited by pain

- can use LA to differentiate


History of injury, especially dislocation

- minimal pre-injury symptoms

- suggests acute tear of normal tendon


Chronic Tear 95%

-  long history impingement

-  no history of injury




SS IS Clinical Photo 1SS IS Clinical Photo 2



- supraspinatus & infraspinatus

- rapid wasting with acute tears

- gradual wasting with chronic tears


Weakness related to

- size of lesion

- amount of pain

- grade 3 (MRC) or less indicates large tear




1.  Patient's arm held elevated at 90°

- arm in 30° forward flexion with thumb down

- test resistance to inferior pressure

- palpate


2.  Drop arm sign

- passively abduct arm

- get them to put it back to their side slowly

- apply small amount of pressure

- will drop arm at 30o


3.  Shoulder hiking

- usually means massive cuff tear


Shoulder Hiking




1.  Resisted ER


2.  Lag

- put in arm in maximum ER

- ask patient to hold that position and release arm

- unable to maintain ER / arm lags


3.  Hornblowers

- abduct and ER arm

- arm drops as unable to maintain ER

- Teres minor


Involvement of IS can often indicate a large or massive tear




1.  Gerber lift-off test

- IR hand to back pocket

- patient should be able to maintain hand away from bottom if SSC intact

- need sufficient IR for this test

- otherwise need belly press test


2.  Belly press test

- fists on belly

- elbows forward / to eliminate deltoid

- resist force lifting fists away from belly


3. Increased ER compared with other arm


Subscapularis tear increased ER




Improves pain and allows physio



- ensures pain from shoulder pathology




Views as for impingement

- assess acromion / GHJ OA / high riding head





- non invasive

- cost effective

- dynamic image

- can be used in orthopedic office

- useful and simple for assessment of cuff integrity post surgery



- user dependant

- accuracy increases with skill and experience

- may miss small tears / partial thickness tears

- still images not easily interpreted by surgeon (c.f. MRI)




O de Jesus Am J Roentengology meta-analysis MRI v MRA v US

- MRA most accurate

- MRI and US comparable




Shoulder Ultrasound Normal SupraspinatousShoulder Ultrasound Infraspinatous NormalShoulder Ultrasound Subscapularis Normal




Shoulder Ultrasound Supraspinatous Tear




Arthrogram Intact RC




Look for

- SS / IS / SSC / biceps

- PT v FT

- size of tear

- retraction

- atrophy / fatty infiltration 


Shoulder MRI Supraspinatous Fatty Infiltration


Partial thickness tears 

- best seen on T1 with gadolinium 

- see if communicates from GHJ to SA space


For more MRI see

- massive tears

- partial thickness tears

- full thickness tear




Gold Standard

- assess for partial articular tears in GHJ

- assess for bursal sided tears in subacromial space


Management Guidelines


1. Repair all acute full thickness tears


2 Repair chronic full thickness tears

- young patients

- after failure non operative management

- with disability 2° weakness or pain


3. Observe chronic tears with no disability

- especially in elderly


Non-operative Management


As per impingement

- satisfactory outcome in 50%

- no symptoms of pain or weakness

- both PT and FT tears