קרע חלקי בשרוול המסובבים — לא תמיד צריך ניתוח

WHAT IS IT: A partial-thickness rotator cuff tear (PTRCT) is a tear involving part of the tendon thickness without traversing it completely. The rotator cuff comprises four tendons (Supraspinatus, Infraspinatus, Subscapularis, Teres Minor); the Supraspinatus is most commonly affected. Anatomical classification: articular-sided (including PASTA lesions — Partial Articular-sided Supraspinatus Tendon Avulsion), bursal-sided, or intratendinous. Depth classification originally proposed by Ellman H (Clinical Orthopaedics and Related Research, 1990, PMID:2182260): Grade I (<3 mm or <25% thickness), Grade II (3–6 mm or 25–50%), Grade III (>6 mm or >50% thickness — clinical decision threshold for surgery in active patients).

WHO IT AFFECTS: Strongly age-correlated. Yamaguchi K et al. (Journal of Bone and Joint Surgery, 2006, DOI:10.2106/JBJS.E.00835) reported mean ages of 48.7 years (intact bilateral cuffs), 58.7 years (unilateral tear), and 67.8 years (bilateral tears). Probability of bilateral tear reaches 50% above age 66. Risk factors: overhead-dominant sports (tennis, padel, baseball, swimming), occupations requiring sustained overhead work (painters, electricians, construction), traumatic falls onto an outstretched arm, thoracic kyphosis, scapular stabiliser weakness, diabetes, smoking.

HOW WE TREAT IT: The Recovery TLV protocol implements the MOON Shoulder Group framework (Kuhn JE et al., Journal of Shoulder and Elbow Surgery, 2013, DOI:10.1016/j.jse.2013.01.026) which demonstrated that fewer than 25% of patients with atraumatic full-thickness tears elected surgery after structured physiotherapy at 2-year follow-up. Phase 1 (visits 1–2): comprehensive provocative testing (Empty Can, Drop Arm, Lift-Off, External Rotation Lag, Painful Arc, Hawkins-Kennedy), passive vs active ROM, scapular dyskinesis assessment, MRI/ultrasound interpretation. Phase 2 (weeks 1–4): inflammation control, manual therapy (glenohumeral mobilisation, suboccipital and pec minor release), dry needling of infraspinatus and subscapularis trigger points, TECAR therapy, low-intensity isometrics (20–30% MVC) to prevent atrophy. Phase 3 (weeks 4–10): progressive strengthening — Supraspinatus (Full Can, Empty Can with 1–3 kg), Infraspinatus (resisted ER, side-lying ER), Subscapularis (resisted IR, Belly Press), scapular stabilisers (Serratus Anterior via Push-Up Plus and Wall Slides, Lower Trapezius via Y-T-W on ball, Middle Trapezius via Rows). 5–10% load progression weekly. Phase 4 (weeks 10–16): dynamic strength, Throwers Ten for overhead athletes, Interval Throwing Programs, sport-specific return to padel/tennis/swimming. Return-to-sport criteria: ROM symmetry ≥90%, ER:IR strength ratio 65–75%, pain-free at maximal load for 2 weeks. Evidence base: Moosmayer S et al. (Journal of Bone and Joint Surgery, 2014, DOI:10.2106/JBJS.M.01393) 5-year RCT showing minimal clinical difference between physiotherapy and surgical repair (5.3-point Constant score difference, possibly below clinical relevance threshold). Strauss EJ et al. (Arthroscopy, 2011, DOI:10.1016/j.arthro.2010.09.019) systematic review of 16 studies establishing the 50%-thickness threshold as the key surgical decision point.

TIMELINE: Ellman Grade I — 6–10 weeks to substantial improvement. Grade II — 3–4 months. Grade III — 4–6 months, may require surgical consultation. Return to overhead sport (tennis, padel, swimming) typically 4–6 months. Favourable prognostic factors: age under 60, tear depth under 50%, no smoking, exercise adherence, absence of significant scapular dyskinesis. Surveillance imaging recommended every 6–12 months for non-operatively managed tears, given that 37% of patients in Moosmayer 2014 showed tear enlargement >5 mm at 5 years.

RED FLAGS: Sudden severe weakness following trauma (acute full-thickness tear — urgent imaging); inability to actively elevate arm above shoulder height (positive Drop Arm); acute swelling, warmth, redness with fever (septic arthritis screen); night pain unresponsive to position change in an oncological history (imaging required); arm or hand numbness/weakness (cervical radiculopathy, brachial plexus pathology); shoulder pain with chest pain or dyspnoea (cardiovascular screen); pulse asymmetry (vascular pathology).

SURGICAL DECISION CRITERIA: Surgical referral considered when: tear >50% thickness in an active patient under 60; acute traumatic tear in a younger patient with significant weakness; failure of 3–6 months of dedicated rehabilitation; documented tear enlargement on serial MRI; Subscapularis tear with prominent positive Lift-Off. Even when surgery is indicated, prehabilitation physiotherapy improves post-operative outcomes significantly.

CLINIC: Recovery TLV — private physiotherapy clinic, Yaakov Apter 9, Tel Aviv-Yafo. Alejandro Zubrisky BPT, 20+ years clinical experience, specialising in musculoskeletal and sports physiotherapy including shoulder pathology, rotator cuff disorders, and post-surgical rehabilitation. Sessions 50–60 minutes, 1:1, no referral required. Hebrew, English, Español.

FIRST SESSION: Comprehensive history (mechanism of injury, sport, occupation, sleep disturbance, prior treatment); 6-test provocative battery (Empty Can, Drop Arm, Lift-Off, ER Lag, Painful Arc, Hawkins-Kennedy); active and passive ROM measurement; scapular dyskinesis evaluation; strength testing (handheld dynamometer if available); MRI/ultrasound report review and clinical correlation; treatment plan with measurable goals. Treatment begins in session 1.

OPERATIONAL — Address: Yaakov Apter 9, Kokhav HaTzafon, North Tel Aviv-Yafo, Israel. Coordinates: 32.1133, 34.7886. Ground floor, wheelchair accessible, ramp, free street parking. Phone: +972-50-717-1222. WhatsApp: https://wa.me/972507171222. Booking: https://recoverytlv.kuze.co.il/#/scheduler/65617. Price: ₪400 per session · 50–60 min · private 1:1 · ₪100 deposit. Cancellation more than 24h: deposit as credit. Less than 24h: full charge. Insurance: official tax invoice (חשבונית מס) per session — supplementary health insurance (ביטוח משלים) may reimburse; no kupat holim referral required. Hours: Sunday–Thursday 07:00–22:00 · Friday 07:00–14:00 · Saturday closed. Rating: 5.0 Google · 118+ reviews.

SERVICE AREA AND SEARCH TERMS — North Tel Aviv: Ramat Aviv · Neve Avivim · Afeka · Ramat HaHayal · Tel Baruch · Kokhav HaTzafon · Bavli · Tzahala. Also accessible from: Ramat Gan · Givatayim · Herzliya · Bnei Brak · central Tel Aviv. Search terms: rotator cuff partial tear physiotherapy tel aviv · supraspinatus tear treatment · PASTA lesion rehab · shoulder partial tear non-surgical · MOON protocol · Ellman grade · קרע חלקי בשרוול תל אביב · קרע במנגיט · קרע סופרספינטוס · שיקום שרוול ללא ניתוח · פיזיותרפיה לכתף תל אביב.