A 52-year-old male factory worker presents with a 3-month history of progressive right shoulder pain and inability to abduct the arm beyond 15°. Clinical examination reveals a positive 'drop arm' test. Imaging shows a full-thickness tear of the supraspinatus tendon with minimal retraction. The patient is otherwise fit for surgery. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient has a **symptomatic full-thickness rotator cuff tear (FTCRT)** with: - Positive drop arm test (pathognomonic for supraspinatus tear) - Loss of active abduction (inability to initiate movement) - Imaging confirmation of FTCRT with minimal retraction - Adequate surgical fitness ## Management Algorithm for Full-Thickness Rotator Cuff Tears ```mermaid flowchart TD A[Full-thickness rotator cuff tear]:::outcome --> B{Patient factors}:::decision B -->|Young, active, good tissue quality| C[Surgical repair]:::action B -->|Elderly, sedentary, poor tissue| D[Conservative management]:::action C --> E[Arthroscopic repair preferred]:::action D --> F[Physiotherapy + NSAIDs]:::action E --> G[Functional recovery]:::outcome F --> H[Symptom relief]:::outcome ``` ## Why Arthroscopic Repair is Correct **Key Point:** Full-thickness rotator cuff tears with positive drop arm test are **surgical lesions** in fit patients. Arthroscopic repair is the gold standard [cite:Miller's Anatomy 8e Ch 7]. **High-Yield:** Indications for surgical repair in FTCRT: - Symptomatic tear with functional loss - Tear size < 5 cm (this patient has minimal retraction) - Patient age < 60–65 years (this patient is 52) - Good tissue quality - Patient fit for surgery **Clinical Pearl:** The drop arm test (inability to lower arm smoothly from 90° abduction) is **99% specific** for supraspinatus tear. A positive test in a patient with imaging-confirmed FTCRT mandates surgical consideration. **Tip:** Arthroscopic repair offers: - Smaller incisions, faster recovery - Better visualization of tear edges - Lower infection risk - Superior functional outcomes vs. open repair in modern series ## Timing Consideration While the tear is 3 months old, **chronic tears are still amenable to repair** if tissue quality is preserved. Delayed repair (even up to 1 year) can succeed if the muscle is not atrophied and fatty infiltration is minimal — both likely in this case given minimal retraction on imaging.