Massive Rotator Cuff Tears

Full-thickness tears, also called complete tears, completely sever the tendon from the bone. Full thickness tears can occur in the middle of the tendon or detach the tendon from bone. They may be acute or chronic depending on whether the tear occurred suddenly or developed over time. Full-thickness tears cannot grow back together or reattach to the bone.

Symptoms of massive rotator cuff tears include:

• Severe shoulder pain, often worsening at night or when resting on the affected side.
• Significant weakness in the shoulder, affecting the ability to lift the arm or carry out routine activities that involve overhead motions.
• A noticeable crackling sensation (crepitus) when moving the shoulder due to tendon ends rubbing against each other or other structures.
• Limited range of motion.
• In some cases, atrophy of the shoulder muscles may occur if the tear is longstanding.

Massive rotator cuff tears are caused by multiple factors. They typically involve a combination of degenerative changes and acute injury. Age-related degeneration is a common cause, as the tendons of the rotator cuff weaken over time, making them more susceptible to tears, especially in individuals over age 60. Repetitive overhead activities, common in sports or certain occupations, can also contribute to tendon wear and tear. Acute injuries such as falls or sudden, forceful lifting can cause or exacerbate existing tears.

The treatment of massive rotator cuff tears varies based on the patient’s age, activity level, and overall health. Massive rotator cuff tears require surgical treatment either if they occur acutely (after an injury) or after rehabilitation failure in chronic-degenerative lesions.

The treatment of massive rotator cuff tears is a challenge for both the patient and the treating orthopedic surgeon. Treatment is complicated due to structural failure and a high rate of recurrent tearing after surgical repair. Studies report retear rates of up to 94%!  While it is usually possible to reattach the tendon to bone, the challenge is getting the tendon to then heal.  The selection of the most appropriate treatment for each patient is complex, and a patient-specific approach is required.

There is no consensus on the ideal treatment for massive rotator cuff tears, or even whether a massive tear is repairable. The decision to pursue a particular treatment for a massive rotator cuff tear is based on shared decision making between the surgeon and the patient. Key to this process is the surgeon’s clinical experience, professional judgment, patient factors, patient expectations, and the patient’s ability to complete post-op rehabilitation.

Dr. Daniel Kaplan is a fellowship-trained orthopedic surgeon who specializes in sports medicine and shoulder surgery. His expertise is in minimally invasive arthroscopic and advanced open reconstruction procedures to treat rotator cuff tears. Dr. Kaplan has the experience and expertise to diagnose and determine the optimal treatment for your rotator cuff tears, including massive tears.

Numerous options are available to treat massive rotator cuff tears. The goals of surgery are to alleviate pain and improve range of motion. The ideal rotator cuff repair will restore biomechanics, decrease pain and improve function. A complete anatomic repair of massive rotator cuff tears is not always surgically possible.

Options include:

• Nonoperative Management
• Arthroscopic debridement with a biceps tenotomy- This is viable option for elderly patients with low physical demands. Studies report a majority of patients who underwent debridement and decompression or biceps tenotomy were satisfied with the results. Pain decreased, range of motion and the ability to perform activities of daily living increased.
• Complete or partial arthroscopic surgical repair is designed to restore normal biomechanics and function while decreasing pain, but outcomes for massive cuff repairs are less predictable. Thus, it is often combined with cuff augmentation to reinforce the repair with various materials.
• Tendon transfers – This is suitable for young and active patients with little to no shoulder arthritis. It involves the replacement of the damaged tendons with tendon transfers from another part of the body or from a donor.
• Superior Capsular Reconstruction – This is a technically demanding procedure that involves using grafts and may be considered in younger patients without arthritis.
• Reverse Shoulder Arthroplasty – For slightly older patients, this procedure is well- established for massive irreparable cuff tears and offers predictably good outcomes.