Massive Rotator Cuff Tears:
A massive rotator cuff tear is a just as it sounds--a large tear of the rotator cuff. That said, there is often disagreement of what exactly defines a massive rotator cuff tear. Several definitions have been proposed. Some say that a massive rotator cuff tear involves at least two of the four rotator cuff tendons. Others use a definition that a massive rotator cuff tear is at least 5 centimeters in diameter.
Exactly how a rotator cuff tear is defined may not matter too much to an individual, and if your doctor is using the word "massive tear" to describe your shoulder, you probably know that the prognosis to return to normal may not be ideal. That said, there are options for people with massive rotator cuff tears, and many patients are able to find both pain relief and good function.
Even with massive rotator cuff tears, most often non-surgical treatment is not only the right place to start, but also the most effective. Many patients find relief with appropriate treatment that may never involve an operation. Most people don't realize how common rotator cuff tears are, and the truth is, that most never require surgery at all. Studies have shown that as we age, rotator cuff tears become extremely common. After the age of 60, some studies have found evidence of rotator cuff tears in over 50% of the population--and that is in groups of people with no shoulder pain!
Most people find excellent results with non-surgical treatments for a torn rotaotr cuff. These treatments may include rest, medications, physical therapy, injections, or other treatments. While surgery is sometimes a recommendation after diagnosis, most commonly invasive treatments are reserved for the few patients who do not find relief with these simpler treatment options.
Rotator Cuff Debridement:
In some patients, rather than try to repair the rotator cuff, your surgeon may recommend to simply clean up inflammation within the shoulder, called a subacromial decompression. This surgery does nothing to repair the torn tendon, but it can remove inflammation that may be the source of pain. This surgery is often combined with a biceps tenodesis to alleviate potential sources of pain in the joint.
Rotator Cuff Repair:
A rotator cuff repair is a surgical treatment to repair the torn tendon. The surgery is performed under general anesthesia and can either be done through a normal incision, or as an arthroscopic repair. The difficulty with surgical repair of a massive rotator cuff tear, is that the tendons and muscle may have been damaged beyond the point of repair.
There are two scenarios that generally make a massive rotator cuff tear irreparable. The first is degeneration and damage to the tendon tissue. In these cases the tendon is often thin, frayed, retracted (pulled back), and weak. Sutures may not hold the tissue and the normal elasticity of the tendon is lost.
The second scenario is atrophy of the rotator cuff muscle. While the muscle itself was not the initial problem, longstanding rotator cuff tears may lead to a non-functioning muscle. If the tendon is torn for a long time, the muscle that controls the tendon becomes weak and atrophied. Over time, the normal muscle is replaced by fat, and these changes are not reversible. If the muscle is damaged in this way, a repair is unlikely to give any good results.
A muscle transfer procedure is performed when the rotator cuff muscles and tendons are not repairable, and the patient is young and active. In these patients, a shoulder replacement may not be an option, but improved function of the shoulder is needed for work or recreational activity.
Muscle transfers are usually performed using either the latissimus or pectoralis muscles. The tendons of these muscles are removed from their normal attachment, and reattached to the bone around the shoulder. The muscles then function to replace some of the lost muscle function of the shoulder joint.
Muscle transfers tend to be a good option in young patient, with massive rotator cuff tears, that cannot be surgically repaired. Surgery is a major procedure, with a long rehabilitation. Furthermore, shoulder function after surgery may be improved, but it is not normal. Patients should also have a normal shoulder joint with no signs of arthritis.
Shoulder Replacement Surgery:
In these situations, a standard shoulder replacement is not the ideal type of implant, and can lead to early failures of the replacement. Therefore, special implants, such as a reverse shoulder replacement, are preferred for surgical treatment. These implants are designed for a shoulder joint that has arthritis, and rotator cuff insufficiency.
Omid R and Lee B "Tendon Transfers for Irreparable Rotator Cuff Tears" J Am Acad Orthop Surg August 2013 ; 21:492-501.
Ecklund KJ, et al. "Rotator Cuff Tear Arthropathy" J. Am. Acad. Ortho. Surg., June 2007; 15: 340 - 349.