Patients with a suspected partial tear should be initially treated in the standard manner for patients with impingement syndrome. Inflammation of the subacromial bursa is controlled through activity modification, nonsteroidal medication, and the judicious use of injectable corticosteroid. Physical therapy is advanced as inflammation diminishes and pain subsides. Therapy should be first directed at eliminating capsular contractures and regaining full motion. Progressive stretching in adduction and internal rotation and horizontal adduction exercises (cross body) may improve contracture of the posterior capsule. Rehabilitation of the periscapular musculature may contribute to restore normal scapulothoracic mechanics and minimize dynamic impingement secondary to scapulothoracic dyskinesis. Restoration of proper shoulder mechanics is especially important in overhead athletes.

Wolff et al. [19] retain that conservative treatment is successful in most patients. They will improve with conservative measures over 6 months and that some of them continue to improve for up to 18 months.

In a systematic review, Strauss et al. [20] identified seven studies [3, 14, 21–25] using operative debridement, with or without concomitant subacromial decompression, for partial rotator cuff tears that comprised less than 50 % of the tendon’s thickness and were Ellman grade II or less. Good to excellent results as measured by validated shoulder scoring system were obtained with this procedure [22–25]. Kartus et al. [23] referred that outcomes obtained with debridement may not remain in optimal range over the long term, noting that the Constant score fell nearly 20 points below with respect to the contralateral normal shoulder at longer follow-up. Acromioplasty did not significantly affect the overall outcome of patients submitted to debridement; in fact, satisfactory results were reported in studies that did not use this adjunct [3, 13, 21]. Return to high-level athletic activity was variable when debridement was used. Raynolds et al. [13] reported 45 % rate of return to play at the same or higher level before the rotator partial tear. Of about 57 % of Budoff’s [21] patients were able to return to preoperative levels of sport activity; 22 % were unable to participate because of persistent shoulder discomfort; while 20 % had shoulder pain with this activities. Andrews reported good or excellent results, at short-term follow-up, in 85 % of overhead athletes suffering of partial rotator cuff tear treated with debridement alone [10]. In a later series, the author noted that the 76 % of professional pitcher was able to return to competitive pitching; however, only 55 % returned to the same or a higher level of competition [13].

Considering these data, partial tears of less than 50 % of Ellman grade II or less can be successfully treated with debridement alone without acromioplasty.

Initially, an intra-articular diagnostic arthroscopy is performed. The thickness of the lesion is measured off the footprint. Average thickness of the rotator cuff footprint has previously been determined by Ruotolo et al. [26]. Authors retain that it corresponds to 14 mm. If the tear is >7 mm, it is judged to be >50 % thickness (Fig. 2a, b). Once the patient is determined to be a partial thickness rotator cuff tear, a marking suture is placed (using a 18 gauge spinal needle as a guide) (Fig. 3a, b) and the arthroscope is moved to the subacromial space. Subacromial decompression is performed only if an impingement lesion, defined by observable fraying and abrasion on the undersurface of the coracoacromial ligament with or without a kissing abrasive lesion on the superior aspect of the rotator cuff, is visualized (Fig. 3c). Bursectomy is performed, by using a shaver and radio frequencies, taking care not to damage the marking suture (Fig. 4a, b). The cuff is then evaluated around the marking suture (Fig. 4c, d). Once the lesion was localized, the tear is completed utilizing a shaver or radio frequency (Fig. 4e, f). The tear edges are freshened. The footprint is cleared of soft tissue and cortical bone left intact. A single row anchors is placed in an anatomical position, as determined by reducing the torn rotator cuff to the greater tuberosity and noting the repair location that allowed anatomic recreation of supraspinatus tendon direction and tension and the cuff sutured. If adequate tissue remained, the repair is extended laterally with additional suture beyond the original anchor, using a second row of anchors.

Patients are treated post-operatively in an internal rotation shoulder immobilizer for 25 days, coming out of the sling for passive range of motion. Active motion is initiated at 4 weeks, with no resistive rotator cuff exercises until 12 weeks and return to normal activities at 6 months.

In order to accurately describe the technique as proposed by the authors, we used fragments extracted from the original work [18]. Diagnostic gleno-humeral arthroscopy is performed. Partial thickness rotator cuff tear will reveal degeneration and fraying of a portion of the cuff insertion. After debridement, the medial aspect of the footprint will be observable. Before repairing the tear, scope is moved into subacromial space; bursectomy and acromioplasty, if necessary, are done. Attempting to debride the bursa after anchor replacement can easily lead to inadvertent damage to or resection of the sutures [18]. The presence of an eventual and concomital bursal-sided tear has to be verified. To allow correlation of the articular surface tear to the bursal side, a suture marker is used to help locate the lesion on the bursal surface. If a concomitant bursal tear is present, tear is completed and a standard repair is performed. After bursectomy, scope is reintroduced into the gleno-humeral joint. Foot print is carefully abraded with an acromionizer. To place transtendon anchors, a 18-gauge spinal needle has to be used. The angle of insertion is usually directly adjacent to the lateral aspect of the acromion, allowing the anchor to be placed at the dead man’s angle of 45° or less into the medial margin of the rotator cuff footprint [18–27]. In some cases, adducting the arm can improve the dead man’s angle for anchor insertion. A percutaneous incision parallel to the spinal needle is done; by maintaining the same angle of the needle, a suture anchor is the placed transtendon into the abraded foot print. If the tear involves <1.5 cm of the foot print (in an anterior to posterior direction), 1 anchor for the repair is sufficient; however, if the tear involves >1.5 cm of the footprint, then 2 anchors are employed.

For a 1 anchor repair (Fig. 5), because the suture limbs all pass through the same puncture (used for anchor insertion) in the rotator cuff, one must create a bridge of tissue to compress against the bone bed. A Shuttle Relay (Fig. 6a–c) or a bird beak suture passer may be used to pass one limb of each suture retrograde through a more posterior area of the tear. The sutures can be tied in a routine fashion in the subacromial space (Fig. 7a–c).

For a 2 anchor repair, one limb of suture of the same color from each anchor is grasped and retrieved through the lateral portal. These sutures are then tied together over a probe (or another instrument). By pulling the opposite limbs of the same sutures (same color), the tied knot will be drawn through the cannula, into the joint, and over the top of the rotator cuff. In this manner, the eyelet of the two anchors are used as pulleys to draw the tied knot into the joint, creating a bridge of suture over the rotator cuff that compress it against the abraded footprint. To secure this construct, the free limbs of the suture pair that were previously tied are retrieved through the lateral portal for tying. A nonsliding knot must be tied because sliding has been precluded by the previously placed knot in the suture pair. The other sutures (different color) are similarly tied extracorporeally first, pulled into the joint and then tied again (the opposite limbs). A final evaluation of the construct is performed both subacromially and intraarticularly.