Full-thickness rotator cuff tears are a type of rotator cuff tear that extends from the bursal surface to the articular surface.
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Epidemiology
Full-thickness tears are common. Their reported prevalence increases with age and ranges from 5-17%. They are less common than partial-thickness tears 5.
Clinical presentation
Clinical symptoms are very variable and include various degrees of pain and/or a loss in strength and/or function 2.
Pathology
A full-thickness rotator cuff tear is characterized by a focal transmural tendon discontinuity, with a resultant connection between the glenohumeral joint and the subacromial-subdeltoid bursa.
Location
Each of the rotator cuff muscles can be affected; the supraspinatus muscle is most commonly affected, followed by the infraspinatus, the subscapularis and the teres minor muscles.
Footprint (tendon insertion): often degenerative
Critical zone: degenerative or trauma related
Myotendinous junction: full-thickness tears are rare and are only described in the supra- and infraspinatus muscles. 3
Classification
They can be classified according to their shape, or rather, their geometry 2:
- crescentic
- longitudinal: L-shaped or U-shaped
- massive
- Fosbury flop tear
- cuff arthropathy
Radiographic features
Ultrasound
They usually appear as hypoechoic or anechoic defects where fluid occupies the area of the torn tendon. Fluid in the region of the torn tendon can also allow increased through-transmission of the ultrasound beam and can thus accentuate the appearance of the underlying cartilage.
MRI
The most sensitive finding in full-thickness tears is thought to be the presence of fluid signal intensity in the location of the rotator cuff on fat-saturated T2-weighted or intermediate-weighted images 5.
Indirect signs on MRI are - subdeltoid bursal effusion, particularly if anterior, medial dislocation of biceps, fluid along biceps tendon and diffuse loss of peribursal fat planes.
Sensitivity and specificity are 92% and 93%, respectively 4.
Tendon retraction can be graded using the Patte classification. Muscle atrophy and fatty replacement might be seen in chronic cases.
MR/CT arthrography
MR arthrography can additionally detect the communication between glenohumeral joint and subacromial-subdeltoid bursa by contrast-extravasation through the tear.
Sensitivity and specificity for MR arthrography are 95% and 99%, respectively 4.
Radiology report
The report of rotator cuff tears, particularly if massive, should include the following 1:
- lesion size – anteroposterior and mediolateral
- description of tendon retraction e.g. Patte classification
- tear pattern – crescent shape, longitudinal (L-shape / U-shape), massive
- tendon delamination
- number and description of tendons involved
- muscular atrophy assessed with the tangent sign or scapular ratio
- description and grading of fatty degeneration using the Goutallier classification
Treatment and prognosis
In full-thickness tears, surgery is indicated in many patients. The type of surgery depends on the tear pattern, presence of muscle atrophy and/or fatty replacement of the rotator cuff muscles, as well as co-existing injuries such as biceps tendon tears or instability, labral tears, glenohumeral arthritis, glenohumeral instability and acromioclavicular joint disease. In addition, tendon delamination has a negative effect on tendon quality and treatment outcome 1,2,5.
Crescent-shaped tears can be repaired with end-to-bone repair 2 and longitudinal tears can be repaired with margin convergence, whereas massive tears require more sophisticated treatment, such as interval slides, or partial repair.
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