Massive Cuff Tears

Massive rotator cuff tears are tears greater than 5cm in size and involve at least both the supraspinatus and infraspinatus components of the rotator cuff. They may extend into the subscapularis and teres minor also.

In addition to the tendon damage, the muscles also degenerate. This is thought to be due to the disuse of the muscle, ageing and programmed cellular damage (inherited). This process is seen as muscle atrophy (wasting of the muscle) and fatty infiltration of the muscle (replacement of muscle by fatty tissue).

Patients with massive tears that show marked atrophy and fatty infiltration have poorer clinical outcomes than those who do not have these changes
Surgical repair of massive rotator cuff tears is not as successful as small or moderate tears (< 5cm). This is because: the healing of the degenerate tendon is not good- if there is more fat than muscle in the muscle belly, the process of reversal back to muscle does not occur after repair-significant loss of muscle bulk (atrophy) is also irreversible- The nerve that powers the rotator cuff muscles (suprascapular) may be damaged, as it gets twisted as the muscles retract. This can also lead to more muscle atrophy and fatty infiltration. This means that even if the tendon can technically be fixed back in place by your surgeon, it may not heal or function.

However, it is recommended that a massive tear in an active patient should be repaired as soon as possible, before any irreversible changes occur to the muscle. A repair will help re-establish a force couple of the rotator cuff. The suprascpaular nerve can recover after a repair. Significant functional improvement is seen in patients with massive tears who undergo even partial repair, and therefore, repair attempts are indicated in patients to improve functional outcomes when feasible.

Massive Tear. Superior migration of the humeral head

Direct tendon repair of these massive degenerative tears has a high failure rate, in excess of 50%. If the fatty infiltration and tear size are too large, then a repair is often futile. In these situations the options are listed below. The decision on which treatment to use depends on: patient age, general medical health, time from injury, functional requirements, surgeon's expertise and available facilities. These include:

Deltoid rehabilitation programme  - training the deltoid muscle to take over the functions of the failed rotator cuff muscles.

Injections - for pain relief, combined with a deltoid rehabilitation programme. Steroids are a strong anti-inflammatory, but have short-term benefit only and there is a risk further weakening of the tendons with repeated injections. Hyaluronans are safer and may last longer, but are a weaker anti-inflammatory.

tendon repair with Orthobiologic materials - many new biological materials have been developed to try augment and attempt to improve the healing of the rotator cuff. This technology is new and not widely used, as the benefits are not yet clear due to insufficient clinical studies so far. We currently use Platelet Rich Plasma (PRP), but only in selected cases. [Funk]

Muscle Transfer procedures - This surgery involves moving a strong muscle from its original position to the shoulder joint to improve certain functions of the shoulder. This is only used in certain cases, mainly younger people who have demanding jobs.

Arthroscopic Subacromial Decompression, Debridement and Biceps Tenotomy - this keyhole operation is over 80% effective in resolving pain in people with a massive cuff tear, however it is not effective in improving function or strength of the shoulder.

Reverse Shoulder Replacement - This is indicated for a condition called 'Cuff Arthropathy'. This is when the massive tear is associated with arthritis of the joint. It is only performed on older people, as the lifespan of the replacement is probably limited (approx. 10 years). [ Gohlke]
Despite all these options, massive irreperable rotator cuff tears are difficult to manage and treat effectively.