Bursal sided cuff tears, should they be repaired?

 A comparative study of arthroscopic debridement versus repair for Ellman grade II bursal-side partial-thickness rotator cuff tears

These authors compared clinical outcomes of arthroscopic debridement vs. repair for Ellman grade II bursal-side partialthickness rotator cuff tears (i.e. those 3-6 mm deep and not exceeding one half of the tendon thickness). 

On the basis of preoperative findings and patient preference, 20 patients underwent debridement whereas 26 underwent arthroscopic repair. 

The rehabilitation program was over twice as long for the patients having repair in contrast to those having debridement:

In patients who underwent arthroscopic debridement, the affected arm was kept in a sling at 15 of abduction and a neutral-rotation brace for 3 weeks. Pendulum and passive ROM exercises were initiated on postoperative day 1. After 3 weeks, patients were encouraged to start self-assisted passive and active ROM exercises. Active strengthening exercises using an elastic band were started at 4-10 weeks postoperatively. Nearly full active ROM was allowed starting at 2.5 months postoperatively.

In patients who underwent RCT repair, the affected arm was kept in an abduction brace for 6 weeks. Pendulum and passive ROM exercises were initiated on postoperative day 1. Self-assisted passive exercises were started at 6-12 weeks postoperatively, and active ROM exercises were conducted starting at 12 weeks postoperatively. Active strengthening exercises using an elastic band were started at 3-6 months postoperatively. Nearly full active ROM was allowed starting at 6 months postoperatively.

All patient-reported outcomes improved in both groups. Outcome scores were better for the debridement group at 6 months postoperatively. 

The authors concluded that arthroscopic debridement and repair of Ellman grade II bursal-side partial-thickness rotator cuff tears achieved comparable clinical scores and low retear rates during 2 years of follow-up. Debridement achieved better results, especially within 6 months postoperatively, and achieved a favorable prognosis up to 2 years postoperatively.

Comment: This study demonstrates the value of simple debridement in the management of burial sided cuff tears: (1) the outcomes are reported to be better at 6 months,  (2) the cost of suture anchors and increased surgical time is avoided, and (3) the protracted rehabilitation program associated with a cuff repair is avoided.

The technique and value of debridement in the management of cuff tears, including those that are irreparable is shown in this link on the smooth and move procedure.

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Association of bursal sided cuff degeneration with degenerative changes of the coracoacromial ligament

Grade of coracoacromial ligament degeneration as a predictive factor for impingement syndrome and type of partial rotator cuff tear.

These authors assessed 96 patients (mean age, 50.1 years [17-76]; 34 men, 62 women) diagnosed with bursal-side and articular-side rotator cuff tears with a history of failed conservative treatment and persistent shoulder pain who underwent arthroscopic surgery.

Normal appearance of the coracoacromial ligament (CAL) was  grade 0, minor fraying as grade 1, major fraying as grade 2, and visualization of the bare bone under the CAL as grade 3.

Most of the patients with articular-side tears demonstrated grade 0 and grade 1 coracoacromial ligament degeneration, whereas patients with bursal-side tears had grade 1 and grade 2. 

There was a significant positive correlation between the grade of coracoacromial ligament degeneration and bursal-side partial rotator cuff tears, whereas no correlation was observed with articular-side tears. 

There was no significant difference between bursal-side and articular-side partial cuff tears regarding acromioglenoid angle, supraspinatus glenoid angle, and subacromial distance.

The authors state that , "Although the factors that are purely related to articular side partial tears are poorly understood, its inconsistency with CAL degeneration in the current study suggests that ... subacromial impingement is not an etiologic cause of articular-side tears."
Comment: While this research shows the association of CAL degeneration with bursal sided cuff deterioration, it does not necessarily clarify the cause of either.

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