Massive Rotator Cuff Tear

There are two primary ways to describe the size of a rotator cuff tear, one being the size of the tear (measured in centimeters) and one being the number of tendons involved in the tear.  Generally speaking, massive rotator cuff tears involve two or more tendons and are approximately 5 centimeters or greater in size.

The treatment for a massive rotator cuff tear depends on several factors, and the decision making process is individualized for each patient.  First is an assessment of the tear characteristics and prognostic factors about whether the tear is still repairable.  Not every patient with a massive tear necessarily benefits from surgery, and sometimes the best treatment is a course of physical therapy or home exercises to improve the activation of the shoulder blade musculature and improve the function of the remaining rotator cuff tissue.  Injections and oral medications (anti-inflammatories) are often temporarily helpful. Sometimes nonsurgical management is also appropriate for patients with more limited activity demands, medical conditions that make surgery a risky proposition, or that have tolerable pain and functional complaints.

When nonsurgical treatment fails or if there is evidence of an acute functional deterioration such as after a fall or a work injury, there are instances that advanced arthroscopic techniques offered by Dr. Obermeyer may still be able to repair a massive tear.  There are features on imaging, including xrays and MRI, such as the centering of the ball in the socket and the tear size and presence of muscle atrophy, respectively, that help Dr. Obermeyer counsel you on whether a massive tear is likely repairable or not.  This information is used in conjunction with the physical examination of the arm including whether you can lift the arm overhead anymore and what the power can be generated by your remaining rotator cuff tissue.

If your tear is too large to be repaired, the tear is referred to as irreparable, and there are still very favorable surgical treatment options.  One of these options is reverse total shoulder replacement, which is the preferred treatment for patients who have substantial impairments and ongoing pain.  Generally reverse total shoulder replacement is reserved for patients older than 65 years but as the technology continues to improve and the outcomes are increasingly favorable, it is used in younger patients as well.

Reverse total shoulder replacement works for irreparable tears, even when there is no arthritis in the shoulder joint, because the reverse prosthesis has the ability to capture the arm and activate the big muscle on the outside of the arm called the deltoid to become the primary motor of shoulder function, effectively bypassing the torn and deficient rotator cuff.  The torn and damaged rotator cuff tissue is left in place, and stops causing pain because the replacement moves the humerus away from the area of impingement and rubbing at the acromion (roof bone at the top of the shoulder).  By capturing the humerus bone and activating the deltoid, the weakness and pain from a massive rotator cuff tear is corrected, allowing patients to return to their activities and improve pain symptoms permanently.

Depending on your individual circumstances, if you have an irreparable tear and still have overall preserved function in your shoulder, you still might be a candidate for arthroscopy.  Arthroscopy for an irreparable tear has a goal primarily of pain relief and preservation of the function and use you still have.  This procedure is performed to alleviate the pain generators in your shoulder, including the bone spur at the acromion, the bursa which is inflamed and irritated, and the biceps tendon, which is the thin noodle-like tendon that sits next to the torn rotator cuff and can become damaged and a cause of pain itself.  Even if the complete rotator cuff cannot be repaired, often some of the tissue can be, and that repair is performed to restore some muscle balance to the shoulder and prevent the tear that is already present from continuing to worsen.

Another treatment option for irreparable tears in younger patients with substantial functional loss is a tendon transfer in the lower trapezius.  This procedure has selected indications because it is more invasive than arthroscopy, has additional risks, and is sometimes less predictable than options like reverse total shoulder replacement, especially in patients that are older.

A new and emerging option for an irreparable tears includes the arthroscopic superior capsular reconstruction (SCR).  The SCR was initially described in Japan as a way of capturing the humerus bone in the socket when the rotator cuff was irreparable and deficient with a piece of tissue from a cadaver or from the patient’s leg.  To accomplish this, the replacement tissue is sewn like a trampoline to the glenoid socket and to the humerus to hold the ball in position, effectively replacing the deficient rotator cuff.  The initial enthusiasm for the SCR procedure has waned amongst experienced shoulder surgeons in recent years because it is noted that functional improvements are sometimes unpredictable, although pain relief remains favorable in patients undergoing SCR.  One way the SCR can help pain is thought to be because the new tissue pads and protects the humerus from rubbing on the acromion.

Lastly, a recently developed “balloon spacer” has been developed to function like the SCR by using a saline-filled sac to push the humerus away from the acromion bone.  This balloon is inserted arthroscopically and is thought to hold the humerus ball in position while the remaining muscles of the shoulder are rehabilitated in hopes of avoiding the need for shoulder replacement.  This procedure has an uncertain durability and studies are currently underway to further understand its role in the management of patients with irreparable tears.

Irreparable tears are an increasingly encountered diagnosis and the treatment options continue to expand.  If you have been diagnosed with an irreparable tear, you may find it helpful to discuss your condition with a shoulder subspecialist like Dr. Obermeyer.   Dr. Obermeyer’s training and experience allows him to offer you all options without bias and give you a realistic assessment of your prognosis.