Rotator Cuff Tear Classification - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes the shoulder rotator cuff muscles tear classification.
Is the rotator cuff tear a partial thickness tear or a full thickness tear?
• Full thickness teat: divided according to the size
- Small size: up to 1cm
- Medium size: 1-3cm
- Large size: 3-5cm
- Massive size: greater than 5cm or involves multiple tendons or tears with retraction to the glenoid.
• Partial thickness tear: divided according to the location
- Bursal
- Articular
Also divided according to the size into:
- Less than 55% of the tendon thickness.
- More than 50% of the tendon thickness.
Partial thikness tears are associated with internal impingement in overhead throwing athletes, they call it: PASTA (Partial articular Surface Tendon Avulsion).
It usually affect the posterior cuff and it is a partial articular surface tear, it usually occurs at the junction of the supraspinatus and infraspinatous tendon insertion.
The second classification is the anatomic classification:
The supraspinatus, infraspinatus, and teres minor make up the majority of rotator cuff tears.
Mechanism of the injury:
- Degenerative tear in older patients.
OR
- If the patient has a shoulder dislocation and is above the age of 40 years.
- Some tears may be traumatic in younger patients with high energy trauma.
- Subscapularis tears usually occur as an acute avulsion in younger patients after a fall with hyperabduction/ external rotation injury.
- It can also happen post-surgery due to failure of the repair, and usually it is due to excessive external rotation of the shoulder after surgery that involve repair of the subscapularis tendon.
Timing of the rotator cuff tears:
• Acute tear: less than 3 months.
• Chronic tear: longer than 3 months.
• Acute/Chronic tear: combination of the two: A small tear becomes enlarged and becomes a bigger tear.
Mechanism:
• Chronic/ Degenerative:
- Usually in older patients.
- It usually involves the supraspinatus, infraspinatus, and the teres minor.
- It could also involve the superior part of the subscapularis tendon if the tear is large.
• Acute/ Traumatic:
- Usually involves a subscapularis tear: seen in young patients.
- Sometimes see in patients with shoulder dislocation if they are above 40 years of age.
• Iatrogenic:
- Due to failure of the repair.
- If you do shoulder surgery that involves repair of the subscapularis tendon and the patient does external rotation of the shoulder excessively, then the tendon may tear.
- It is very difficult to diagnose failure of the repair.
• Fatty infiltration and muscle atrophy:
0- Normal
1- Some fatty streaks
2- More muscle than fat
3- Equal fat and muscle
4- More fat than muscle
- MRI; especially in the sagittal plane, will reveal retraction of the tendon.
- MRI will show the muscle atrophy and the fatty infiltration of the muscle.
- This can decide the timing and chronicity of the retator cuff tear.
One important thing about the sagittal view is that you need to know the orientation of the muscles, and train yourself to be able to recognize the sagittal view anatomical content and to mark the muscles.
Another classification is: The cuff tear shape:
• Crescent:
- Usually doesn’t retract medially.
- Tear is mobile so it can be pulled laterally.
- It can be repaired directly to the bone with very little tension.
• U- shaped:
- Similar to the crescent shaped tear but goes further medially with the apex very close to the glenoid or even medial to it.
- Repair this tear side to side first using margin conversion.
- Then repair the remaining crescent part into the bone.
• L- shaped:
- Similar to the U-shaped tear, one side is more mobile than the other.
- Use margin conversion in the repair and then repair the rest of the tear to the bone.
The idea for repair of the U-shaped and the L-shaped tears is to repair these tears without creating a lot of tension that can make the repair impossible or fail.
The last type is: Massive and Immobile:
- It may be longitudinal or U-shaped.
- This tear is difficult to repair often requires an interval slide.
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