Rotator Cuff Tear, ABOS Oral Boards Preparation

This is a 55-year-old right-hand-dominant male commercial painter with a four-month history of progressive right shoulder pain and weakness. He noticed difficulty reaching overhead at work and night pain that wakes him from sleep. No acute injury, but he does heavy overhead work daily. His only medical comorbidity is hypertension.

He completed a six-week course of physical therapy focused on rotator cuff strengthening and scapular stabilization. His pain improved somewhat, but he had persistent weakness that was limiting his ability to work. He also tried a subacromial corticosteroid injection three months ago with temporary relief lasting about two weeks. Conservative management failed to restore his function.

On exam, active forward elevation was 140 degrees on the right compared to 170 on the left. External rotation strength was 4 out of 5 versus 5 out of 5 on the left. Jobe test produced pain and weakness. He had a positive lag sign, indicating a substantial tear. Hornblower sign was negative, so the teres minor was intact. No significant atrophy in the supraspinatus or infraspinatus fossae, that told me the muscle quality was likely reasonable.

MRI with intra-articular contrast showed a full-thickness supraspinatus tear measuring 2.5 centimeters in the AP dimension with 1.5 centimeters of retraction to the glenoid face. Goutallier grade 1 fatty infiltration, early changes but still a repairable tendon. The infraspinatus and subscapularis were intact. The long head of the biceps was subluxated medially, consistent with an incompetent rotator interval. Type II acromion.

Given the failed conservative management, his occupational demands, the repairable tear with minimal fatty infiltration, and his age, he has many years of overhead work ahead of him, we discussed operative and non-operative options. He understood that without repair, the tear would likely progress, fatty infiltration would worsen, and the window for a durable repair would close. He elected for surgery.

I performed an arthroscopic rotator cuff repair using a suture bridge double-row construct, a biceps tenodesis for the subluxated biceps, and a subacromial decompression.

Post-operatively, he was placed in an abduction sling for six weeks with pendulum exercises only. At six weeks, we started passive range of motion. At three months, active motion was progressing well, forward elevation to 150 degrees. Strengthening began at four months. At six months, he had functional range of motion and was back to painting with minimal discomfort. At one year, MRI showed an intact repair and he was doing well.

He was very satisfied, he was back to painting full days without significant pain or weakness. In retrospect, I would have considered a longer period of immobilization before starting passive motion. I followed the standard protocol, but given the tear size and retraction, an extra one to two weeks of protection may have further reduced the re-tear risk. The literature supports early motion for stiffness prevention, but the balance is always patient-specific. I watched closely for re-tear on his follow-up MRI and was reassured that the repair was intact and the tendon had healed to the footprint.