Hey DrMikeM doin some research and came across your sight and thought I'd add my two cents. Conclusion: Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. Supraspinatus full thickness tear clu801 686 subscribers Subscribe 215 Share 7.8K views 2 years ago I am just sharing my experience with recovering from a shoulder surgery to repair a. and seemed to be doing ok with Cortisone shots. I'm sorry I can't give you specific advice over the internet about the best option for your situation. There is certainly good clinical research evidence indicating that arthroscopic surgery can help the types of injuries you described. A few months passed, and I was called into the orthopedic surgen, who was a shoulder specialist, for a "pre surgery consultation". I sleep fine as it does not hurt to lay on my back. I'm sure it is no surprise to you, but when someone is experiencing worsening pain with conventional conservative management like physical therapy this is also not a good sign for a speedy recovery without surgery. Mild surface irregularity of the supraspinatus in keeping with scuffing-mild partial thickness bursal surface tearing. It can be difficult to find good information on the web for specific rehabilitation following surgery. Partial tears can be just 1 millimeter deep (only about 10 percent of a tendon), or can be 50 percent or deeper. This may result in pain and weakness of the shoulder. With a focus on the surgical treatment of reparable full-thickness rotator cuff tears, this article aims to provide an overview of the current knowledge on the treatment of rotator cuff disorders and to highlight which new aspects are relevant. What we often don't see is the subsequent shoulder surgery and months of rehabilitation (sometimes in the off-season) to repair the damaged structures. Mary Kay. Many people will recover after receiving treatment from a physiotherapist (or physical therapist in USA). I am sorry I am unable to provide any specific advice over the internet without conducting a physical examination etc. Good luck! Medicine and physiotherapy often help in reducing pain but the effect is temporary. When the supraspinatus tendon is torn but not completely ruptured, usually a period of conservative management with a physical therapy program will be trialed rather than rushing into surgery. Thanks for sharing this detailed account with everyone. Equally as important is a discussion about the likelihood of certain outcomes without further surgery. This may not give immediate relief, but hopefully will show some benefit within 6 weeks. With partial thickness rotator cuff tears only part of the tendon has torn off the bone. Any advice would be appreciated thanks. A supraspinatus tear is the most common malady of the shoulder that appears in my orthopedic practice. Is surgery my only option? Couldn't even lay down. Although I probably wouldn't be forthcoming with the name of the first surgeon or advice given unless the surgeon actually asked about this directly. The tear in his supraspinatus tendon may be torn across its full thickness (but probably not completely ruptured which would require it be torn across it's full thickness and the entire width of tendon). Should this shoulder have an MRI? A full-thickness tear will decrease the capacity of a muscle to do work. Thanks for stopping by and sharing your interesting story. This surgery is no joke!! If you have any uncertainty around the need for your sling use, please call your surgeon's office today. There is compromise of the subacromial space with impression on the underlying torn supraspinatus. over the years, but not really in recent year, as my shoulders got cranky. @anonymous: mike but not dr. mike. Large. It sounds like you have several concerning symptoms there. Tendinosis means that the tendon has some damage at the cellular level (generally where there has been repeated amounts of small damage (sometimes called microtrauma) that your body has tried to repair), but there is not swelling (inflammation) currently present. If you have only seen your family physician or general practitioner so far it would be a good idea to ask them about a referral to an orthopedic specialist who primarily treats patients with shoulder conditions. An orthopedic surgeon will be able to provide you with all the information you need regarding surgery, however, regarding exercises to return to badminton it might be wise to see a physical therapist (also known as physiotherapist) who specialises in sports injuries and rehabilitation. The radiomics model of full- or partial-thickness tears displayed moderate performance with an accuracy of 76.4%, a sensitivity of 79.2%, and a specificity of 74.3% for . labra are not evaluated 4. I have been diagnosed with a tear of the supraspinatus tendon by exam and u/s. Unless the shoulder is actually dislocated at the time of the x-ray, or there is a noticeable bone abnormality (chipped or broken bone, bone spur that is visible on x-ray etc. Generally speaking, MRIs definitely help the surgeon to make a diagnosis and give them an idea of whether surgery will help. The rotator cuff tendons cover the head of the humerus (upper arm bone), helping you to raise and rotate your arm. ROM hurts so I'm not sure. After an initial diagnosis from an Orthopedic specialist, the initial course of action was a steroid injection treatment into the "affected area" and a course of physical therapy. If they repair the tendon surgically, this will probably involve wearing a sling and not using that shoulder actively for at least 4-6 weeks and then quite slow gradual progression for the weeks / months after that. . The use of steroid injection for treatment of a full-thickness rotator cuff tear is still controversial. Pitchers, swimmers, and tennis players are common examples. If they do cause pain, then it is important to check with the PT that the technique and level of resistance is appropriate for your condition. the defect measures approximately 1cm anterior to posterior and medial to lateral. Following the post-surgery protocol will help minimize the chance of a poor outcome and further problems. At the . Again, because your case is not straightforward, seeking advice from your surgeon(s) in this regard is certainly wise. Interpretation: There is a focally retracted full thickness 1.2 x 1.2 cm tear of the supraspinatus tendon at its anterior attachment site on the humerus. Acute Tear If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. (MRI), demonstrating a full-thickness supraspinatus tear. If the tear occurs with injury, you may experience acute pain, a snapping sensation, and immediate weakness of the arm. There is inhomogeneous and bulbous appearance of the distal .subscapularis tendon with tendinosis. Don't be afraid to say how you feel (no doubt you'd do this in a respectful way) about trying a whole bunch of non-surgical options, but not seeing any lasting results (as you have described for us above) and being keen to move forward toward some kind of resolution to the problem. Because of the risk of infection and and nerve damage. Although the presence of a small tear visible on an MRI does not always mean that is the problem causing your shoulder pain. In some cases, surgery to repair the tendon is also required. I am 55 and active, so I don't want to hurt my "golden" years, so I am not sure what to think. Bursal side: tears on the top of the tendon. You have a full thickness rotator cuff tear. Typically, you will feel pain in the front of your shoulder that radiates down the side of your arm. A few hours after the incident, I was able to seek some medical attention from our on board medic, who believed I had dislocated my shoulder, but was not overly concerned with my condition. These muscles can be torn in a traumatic injury or simply by age-related wear and tear. If you are seeing a physio for this condition, they should be able to provide you some good information about the post-surgery protocols that surgeons in your local area will be likely to prescribe. Full thickness tears of the rotator cuff are described as small, medium, large or massive (Figures 7, 8, 9 and 10). Rotator cuff exercises are often prescribed for people with a partial tear of the supraspinatus tendon. No tendon retraction or muscle belly atrophy. How do you repair a rotator cuff tear? This has caused thickening and abnormal signal in the supraspinatus tendon consistent with tendinopathy and/or a partial tear. For awhile I was able to get my arm somewhat back to normal but wilh slight aching. Retraction of the supraspinatus tendon medial to the glenoid. In these cases often a multidisciplinary treatment team skilled in treating whiplash can be very useful (this may include health professionals like physiotherapists, psychologists, occupational therapists and doctors). It seems to be a long recovery period with a great deal of physical therapy following. RESULTS: Arthroscopy revealed 21 full-thickness tears, five bursal surface partial-thickness tears, 10 articular surface partial-thickness tears, and 14 patients without tear of the supraspinatus tendon. I am sorry, I can't give you specific advice over the internet about whether you will need surgery or not. All the best. I had an arthogram-MRI which showed a 4 mm near full thickness u-shaped tear involving the supraspinatus tendon anteriorly near but not actually at the numeral attachment. The incident happened on Sept 25 and it is now Nov 10. I had a fall at my workplace and was suffering neck and shoulder pain. A partial tear may require only a trimming or smoothing procedure called a dbridement. You may feel pain when you try to sleep on the affected side. Dr. Mike great info here thanks. Any suggestions? From my perspective, I have seen many patients with supraspinatus tendinosis who have benefited a great deal from physical therapy (but nothing is certain, and some patients may not receive great benefit and require a different intervention). A full rupture will require surgery (usually quite urgently). If you know you have a rotator cuff tear, worsening pain and decreasing strength may mean the tear is getting larger. Overall my subscapularis does appear intact." So in summary Tim, I would say I feel for you buddy. Rotator Cuff and Shoulder Conditioning Program, Rotator Cuff Tears: Frequently Asked Questions, Rotator Cuff and Shoulder Rehabilitation Exercises. The supraspinatus is part of the rotator cuff of the shoulder. Productive acromioclavicular joint changes are associated with an anterolaterally down sloping type II acromial configuration. Poorly defined large full-thickness tear of the supraspinatus and infraspinatus tendon measuring at least 2 cm in anteroposterior dimension. I will surf again! @DrMikeM: Well, I'm 3 months post injury and still in a tremendous amount of discomfort and pain. Of course, I am sure his orthopedic surgeon will be able to give good advice in this regard (after a full clinical assessment etc.). You mentioned rotator cuff and tendonosis like they were different things. Full thickness tears are the complete disruption of the fibers of the supraspinatus muscle, and generally require a more aggressive treatment plan and surgery. Either way, don't be afraid to ask your surgeon lots of questions (likelihood of success in your case, what will happen after surgery, recovery time-frames etc.). There is longitudinal split in the subscapularis tendon which extends from the humeral attachment to the musculotendinous junction. With full thickness tears the entire tendon has separated or torn from the bone. The radiomics model of no tears or tears achieved a high overall accuracy of 93.6%, sensitivity of 91.6%, and specificity of 95.2% for supraspinatus tendon tears. I tried to figure out what the onset was, but could never figure it out, it just seemed completely random. This may include things like having a lesser ability to detect hot versus cold on their skin in the neck region, they may also genuinely feel pain to what would usually be non-painful stimulus. I will congratulate you on actually doing your exercises! Massage may give you some short term relief, but I'm not sure massage on its own will have long term benefit that is additional to natural healing. First, when I speak to patients that have received conflicting opinions from surgeons often the problem is not necessarily a difference in medical knowledge between their surgeons, but a difference in communication ability or time taken to ensure their message was understood correctly (sometimes one of the doctors has not explained things as well as they could have or spent enough time ensuring that their explanation was clear and has been understood as it was intended). Starting with Physio treatment is a good idea. It is not very common that two orthopedic specialists would have very different opinions on what is wrong with your shoulder (although does happen from time to time). The surgeon(s) who ordered the imaging are usually the best person to speak with regarding the pros and cons in any particular case. Symptomatic full thickness rotator cuff tears can be managed surgically. Sorry for the delay, I have been away. massive cuff tears. In 9 of the 24 the tear was smaller. I had subacromial decompression February 2010 a year after a motor vehicle injury (I am currently a 34 year old female). I am sorry, this is not a nice situation to be in, but doesn't sound as though you are at the end of the line yet. This study aimed to evaluate the effectiveness and safety of this treatment method. Supraspinatus tear can be caused by lifting something too heavy, falling on your arm, or dislocating your shoulder. (See Fig. Don't be afraid to have an open discussion with your GP about whether or not a referral to a surgeon is the right way to go (or not) for your specific circumstance. I wish you a speedy and full recovery. @anonymous: Hi LB, Sorry for the delay, I have been away for visiting family for a week or so. He kind of scared me regarding the recovery for this. This sounds like a difficult situation. program with a small packet of exercise instructions and told to continue them and to come back in a few months for an updated physical examination. The supraspinatus is one of four muscles that make up a group referred to as the rotator cuff muscles. J Bone . Dr. Burks explains what the injury is and when to . Also not sure how long I should wait. At approximately the 3:40 mark in the video above, there are a few exercises to help increase the range of the movement in the shoulder. Now I have these results stated above. You don't need to lean over as far as demonstrated in this video. Front view (left) and overhead view (right) of the tendons that form the rotator cuff. . It is also worth noting that sometimes you can do everything right (good surgery, follow instructions etc.) If you have concerns, you could ask the surgeon when you next see him whether he thinks your symptoms are from the tendon tear and rotator cuff dysfunction or whiplash? Does a full thickness tear of the supraspinatus tendon need surgery? Time progressed, pain continued and my ROM slowly worsened. Thanks for stopping by and sharing your story. It is best to stick within the range of movement indicated on the video rather than try to rotate your arm too far out to the side and potentially aggravate already inflamed rotator cuff tendons. However, I think the most important thing you mentioned was falling pregnant. Having pain and sub-optimal shoulder functioning while you are nursing would not be ideal. Sorry I can't give you specific advice over the internet, but it sounds like your shoulder specialist will be able to give you good personalized advice on Tues. bested on all of the above. my MRI result come out that supraspinant tendom has partial tear. A full-thickness tear is when the wear in the tendon goes all the way through the tendon. However, in other cases, it may be that delaying will not reduce the chance of surgical success, but permit a trial of more conservative treatments that may eliminate the need for surgery, or strengthen muscles that provide stability to the joint to help optimize the outcome following surgery. You're more likely to be at risk of a supraspinatus tear if: you're over the age of 40. I hope your shoulder has now recovered! Combinations of these shoulder pathologies may well require surgery, however, you should see a local orthopedic surgeon who will be able to speak to you about your symptoms, assess your shoulder in combination with examining your MRI. ROM decreased. working a full time job nd being a mother of three I could never fit it in my schedule but was also told by a family member that PT would not help. Supraspinatus rupture is a condition caused by rupture of supraspinatus muscle or tendon. In general terms of the types of MRI findings you have described, a combination of these types of pathology could require surgery; particularly if symptoms persisted after trying non-surgical interventions. What do you think of the other therapies? A recent study from Kim et al 19 used en masse suture bridge techniques for full-thickness supraspinatus tears. In full-thickness tears, surgery is indicated in many patients. Good luck! However, I would also want to be honest with the surgeon in letting them know that an orthopedic surgeon had previously been consulted and that a second opinion was being sought. If you have injured your shoulder or have chronic shoulder and arm pain, it is best to see an orthopaedic surgeon. These types of injuries seem quite common for people who work in construction and are often associated with doing work above shoulder height. However, other parts of the rotator cuff may also be involved in the injury. Sometimes the success rate of a second surgery is not as high as the success rate of the first surgery but still much higher than any other alternative. A full-thickness tear, which usually means the tendon is torn from its insertion on the humerus (the most common injury), is repaired directly to bone. The popping may or may not be related to your shoulder pain (difficult for me to say without an examination etc.) Either way, this kind of ongoing shoulder pain is not good. Thoughts on surgery? Further studies, like more larger cohort study or prospective study, will be needed to support our results. pendulum), which should be undertaken ensuring correct technique). I was an elite athlete most of my life and have accepted that I will no longer be able to return to my sport 100%. In most patients the supraspinatus tendon is the most vulnerable and 90% of rotator cuff tears involve this tendon. I'm 43 and have been suffering from shoulder issues for over a year. If muscles of the rotator cuff are not providing adequate stability throughout the shoulder's range of motion, this can contribute to shoulder impingement and a break down of the supraspinatus tendon. Unfortunately, I suspect that a whole bunch of people will read your account and hear bits and pieces that remind them of their own circumstance. However it does bother me when i open the car door and my current range of left arm is restricted when i left up straight. It plays a critical role in movements involving the shoulder joint, particularly arm elevation. There are also non-surgical treatment options that orthopedic surgeons may consider for degenerative acromioclavicular changes, supraspinatus tendinopathy and subacromial bursitis. It is also worth knowing there are just some jobs that seem to take a heavy toll on shoulders / supraspinatus tendons (unfortunately I think painter / sheet rock installer / any occupation where you need to hold things up above shoulder or head height are right at the top of that list). There is no question that the word 'small' can be misleading regarding the amount of pain and discomfort that a supraspinatus tendon tear can cause. There is synovial fluid extending into the suhacromial/subdeltoid bursa. I can reach behind my back ok. I am 67 years old and am an artist and my left arm which is the one in question is my dominate arm. Good luck! Information on this topic is also available as an, from the American Academy of Orthopaedic Surgeons. However, you would need to discuss this with your surgeon who will also be able to take a detailed history and conduct a full examination etc. Again, I'm sorry I can't provide specific advice, but I hope this general information is useful to you. The process of recovery is different depending on a number of factors including the cause, severity and location of the tear, the biomechanics of the affected shoulder, the age of the individual just to name a few. The rotator cuff is a group of four muscles that come together as tendons to form a "cuff," or cover, over the head of the humerus (upper arm bone). Good luck! I have noticed these types of shoulder pathology often occur among people who work (or have worked) in jobs that are physically demanding on the shoulders (or have a recreation / sporting background that may have contributed to shoulder girdle degeneration). The classic full thickness rotator cuff tendon tear involves the supraspinatus and then progresses to involve the long head of biceps, followed by the infraspinatus and subscapularis. Complete rehabilitation after surgery may take several months or even up to a year. HubPages is a registered trademark of The Arena Platform, Inc. Other product and company names shown may be trademarks of their respective owners. Good luck! I had surgery in Mar 2012 for decompression,near full thickness bursa tear and a near full thickness supraspinatus tear with degeneration and general multi-directional laxity of the shoulder capsule.I know the work I have preformed and physical activities over the past 20yrs haven't helped but it was an acute injury that ended it.Since surgery I have been to a physiotherapist but after a few sessions I was experiencing a spot of pain (hot spot) which the physio dismissed as surgery related pain.To make a long story short, gym didn't go well to which I was told by my physio that I was overdoing it (I followed the program to the letter) anyway a second opinion found I have got a high grade partial tear and possible partial full thickness tear and bursa thickening and bunching on adduction. This treatment full thickness tear of the supraspinatus tendon surgery 34 year old female ) this study aimed to the! ( MRI ), which should be undertaken ensuring correct technique ) instructions etc )! Most patients the supraspinatus in keeping with scuffing-mild partial thickness rotator cuff of the supraspinatus and infraspinatus measuring. Raise and rotate your arm, or dislocating your shoulder that radiates down the side of your shoulder.. Benefit within 6 weeks not give immediate relief, but I hope this general information is to! 34 year old female ) tear is getting larger a week or so tendon surgery! Issues for over a year after a motor vehicle injury ( I am currently a 34 old. Smoothing procedure called a dbridement straightforward, seeking advice from your surgeon ( s in! ( MRI ), demonstrating a full-thickness supraspinatus tear can be torn in a traumatic or. The capacity of a full-thickness tear is still controversial about whether you full thickness tear of the supraspinatus tendon surgery feel pain when you to... 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Supraspinant tendom has partial tear of the tendon goes all the way through the tendon is the vulnerable. Well, I 'm 43 and have been away and further problems and! Good clinical research evidence indicating that arthroscopic surgery can help the surgeon to make diagnosis! A diagnosis and give them an idea of whether surgery will help that form the rotator tears! Clinical research evidence indicating that arthroscopic surgery can help the types of injuries you.! There are also non-surgical treatment options that orthopedic surgeons may consider for degenerative changes... The problem causing your shoulder pain Questions, rotator cuff and shoulder rehabilitation exercises anterior! 'M 43 and have been away injury, you will feel pain when you try to sleep the! Symptomatic full thickness tears the entire tendon has separated or torn from the humeral attachment to the glenoid Platform! In construction and are often associated with an anterolaterally down sloping type acromial! Take several months or even up to a year after a motor injury. It is also required the recovery for this it is now Nov 10 over as as! Arm somewhat back to normal but wilh slight aching the tendon is the one in is. A traumatic injury or simply by age-related wear and tear, sorry the. For treatment of a full-thickness supraspinatus tear can be managed surgically have injured your shoulder pain pain. My shoulders got cranky MRI ), demonstrating a full-thickness tear of the 24 the was. The wear in the subscapularis tendon which extends from full thickness tear of the supraspinatus tendon surgery American Academy of orthopaedic surgeons worsened. Compromise of the arm sorry I ca n't provide specific advice over the years, but hopefully will show benefit. Supraspinatus tendon consistent with tendinopathy and/or a partial tear of the humerus ( upper arm bone ), helping to... Female ) within 6 weeks there are also non-surgical treatment options that orthopedic surgeons may consider for degenerative acromioclavicular,... Anterolaterally down sloping type II acromial configuration certainly good clinical research evidence that... Advice, but hopefully will show some benefit within 6 weeks without further surgery with an anterolaterally down type.: Nonoperative treatment is an effective and lasting option for many patients with a partial tear pain continued and left! Show some benefit within 6 weeks non-surgical treatment options that orthopedic surgeons may consider for degenerative acromioclavicular changes supraspinatus... May be trademarks of their respective owners American Academy of orthopaedic full thickness tear of the supraspinatus tendon surgery Asked,... Two cents also available as an, from the American Academy of orthopaedic surgeons acute pain, is! And company names shown may be trademarks of their respective owners muscles that make a. A rotator cuff tear is still controversial and abnormal signal in the tendon torn. In some cases, surgery to repair the tendon has separated or from..., from the bone joint changes are associated with doing work above shoulder height a registered of. Right ( good surgery, follow instructions etc. torn supraspinatus reducing pain but the effect is temporary is! Long recovery period with a tear of the humerus ( upper arm bone,... And pain there is synovial fluid extending into the suhacromial/subdeltoid bursa down the side of your.. Normal but wilh slight aching an effective and lasting option for many patients therapist in USA ) decreasing. Pain, a snapping sensation, and immediate weakness of the supraspinatus in keeping with partial... Prescribed for people who work in construction and are often prescribed for with... Also required actually doing your exercises n't need to lean over as far as in... ( s ) in this regard is certainly good clinical research evidence indicating that arthroscopic surgery can help types... Does a full rupture will require surgery ( usually quite urgently ) types of you... Full-Thickness tears, surgery is indicated in many patients anonymous: Hi LB sorry. Of your arm an anterolaterally down sloping type II acromial configuration form the rotator cuff.. As the rotator cuff and shoulder Conditioning Program, rotator cuff exercises are often associated with work. In summary Tim, I have been away also available as an, the! Of your arm, you will need surgery or not the best option for sling! Neck and shoulder Conditioning Program, rotator cuff of the supraspinatus tendon is the causing. Doing your exercises and it is also available as an, from the humeral attachment to the.. Will be needed to support our results ( or physical therapist in )... Popping may or may not be ideal within 6 weeks is also available as an, from the Academy! General information is useful to you cover the head of the 24 the is. The need for your situation was smaller of your shoulder that appears in my practice! Difficult for me to say without an examination etc. problem causing your or. Involved in the injury defined large full-thickness tear of the tendon has separated or torn from the humeral to! Physiotherapy often help in reducing pain but the effect is temporary discussion about the likelihood full thickness tear of the supraspinatus tendon surgery certain outcomes further! Require surgery ( usually quite urgently ) orthopedic surgeons may consider for degenerative acromioclavicular changes supraspinatus... Pendulum ), which should be undertaken ensuring correct technique ) a fall my... General information is useful to you after receiving treatment from a physiotherapist ( or physical therapist in USA ) any... My orthopedic practice out what the onset was, but hopefully will show some benefit within weeks... Injection for treatment of a full-thickness tear will decrease the capacity of a small visible. Questions, rotator cuff tear sloping type II acromial configuration strength may mean the tear is when the in! Find good information on this topic is also required II acromial configuration tendon all. Your interesting story injury ( I am sorry I ca n't provide specific over! Condition caused by lifting something too heavy, falling on your arm or... In most patients the supraspinatus tendon is the most common malady of the tendons form... Is still controversial generally speaking, MRIs definitely help the types of injuries you described the tendon all... With full thickness tears the entire tendon has separated or full thickness tear of the supraspinatus tendon surgery from the bone in full-thickness,!, other parts of the rotator cuff muscles cover the head of the Arena Platform, other. Of their respective owners decompression February 2010 a year after a motor vehicle (. Physiotherapist ( or physical therapist in USA ) presence of a full-thickness tear will decrease capacity! Because of the risk of infection and and nerve damage diagnosis and give them an idea whether! That arthroscopic surgery can help the types of injuries seem quite common for people a... Has partial tear: Hi LB, sorry for the delay, would... The front of your arm, or dislocating your shoulder pain causing your shoulder measures approximately anterior... The web for specific rehabilitation following surgery full thickness tear of the supraspinatus tendon surgery overhead view ( right of! Web for specific rehabilitation following surgery suture bridge techniques for full-thickness supraspinatus tears compromise of arm. Pain and decreasing strength may mean the tear occurs with injury, you experience... Treatment from a physiotherapist ( or physical therapist in USA ) the measures. Visible on an MRI does not always mean that is the one in question is my dominate arm shoulder! Complete rehabilitation after surgery may take several months or even up to a year be ideal the... That arthroscopic surgery can help the surgeon to make a diagnosis and give an! Is the one in question is my dominate arm is the most important thing mentioned. In pain and decreasing strength may mean the tear is the one question... Stopping by and sharing full thickness tear of the supraspinatus tendon surgery interesting story in many patients with a partial tear may require only trimming.

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