Skip to main content
SpringerLink
Log in

Large to Massive Rotator Cuff Tears

  • Chapter
  • First Online:
Shoulder Arthroscopy

  • 447 Accesses

Abstract

Tears of the rotator cuff are a common indication for shoulder surgery when they reach large to massive size. A detailed history, physical exam, and appropriate imaging workup are key to elucidating the diagnosis and constructing a treatment plan. Magnetic resonance imaging (MRI) is a fundamental tool in determining the presence and size of the tear. Arthroscopic surgical repair can reliably improve pain but is less predictable in terms of restoring strength and function. The authors’ preferred technique is described, along with recent developments in biologic scaffolds and augmentation, as well as biceps tendon supplementation. Postoperative rehab of large to massive tear repairs can be a lengthy process.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 189.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Bishop J, Klepps S, Lo IK, Bird J, Glastone JN, Flatow EL. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg. 2006;15(31):290–9.

    Article  PubMed  Google Scholar 

  2. Koh KH, Kang KC, Lim TK, Shon MC, Yoo JC. Prospective randomized clinical trial of single versus double row suture andrer repair in L to Y centimeter rotator cuff tears. Clinical and magnetic resonance imaging results. Arthoscopy. 2011;27(4):453–62.

    Article  Google Scholar 

  3. Lo IK, Burkhart SS. Arthroscopic repair of massive, contracted, immobile rotator cuff tears using single and double interval slides: technique and preliminary results. Arthroscopy. 2004;20(1):22–33. https://doi.org/10.1016/j.arthro.2003.11.013.

    Article  PubMed  Google Scholar 

  4. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77:10–5.

    Article  CAS  PubMed  Google Scholar 

  5. Hansen ML, Otis JC, Johnson JS, Cordasco FA, Craig EV, Warren RF. Biomechanics of massive rotator cuff tears: implications for treatment. J Bone Joint Surg Am. 2008;90(2):316–25.

    Article  PubMed  Google Scholar 

  6. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically-repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219–24.

    Article  PubMed  Google Scholar 

  7. Liu SH, Baker CL. Arthroscopically-assisted rotator cuff repair: correlation of functional results with integrity of the cuff. Arthroscopy. 1994;10(1):54–60.

    Article  CAS  PubMed  Google Scholar 

  8. Maman E, Harris C, White L, Tomlinson G, Shashank M, Boynton E. Outcome of nonoperative treatment of symptomatic rotator cuff tears managed by magnetic resonance imaging. J Bone Joint Surg Am. 2009;91(8):1898–906.

    Article  PubMed  Google Scholar 

  9. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82(4):505.

    Article  CAS  PubMed  Google Scholar 

  10. Keener JD, Patterson BM, Orvets N, Chamberlain AM. Degenerative rotator cuff tears: refining surgical indications based on natural history data. J Am Acad Orthop Surg. 2019;27(5):156–65. https://doi.org/10.5435/JAAOS-D-17-00480.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Menge TJ, Byram IR, Boykin RE, Bushnell BD. Labrum and rotator cuff injuries in the throwing athlete. Phys Sportsmed. 2015;43(1):65–72. https://doi.org/10.1080/00913847.2015.1005546.

    Article  PubMed  Google Scholar 

  12. Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg. 2001;10(3):199–203. https://doi.org/10.1067/mse.2001.113086.

    Article  CAS  PubMed  Google Scholar 

  13. Bartolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Relat Res. 1994;308:90–7.

    Article  Google Scholar 

  14. Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am Acad Orthop Surg. 2007;15(6):340–9.

    Article  PubMed  Google Scholar 

  15. Davidson J, Burkhart S. The geometric classification of rotator cuff tears: a system linking tear pattern to treatment and prognosis. Arthroscopy. 2010;26(3):417–24.

    Article  PubMed  Google Scholar 

  16. Dabija DI, Gao C, Edwards TL, Kuhn JE, Jain NB. Genetic and familial predisposition to rotator cuff disease: a systematic review. J Shoulder Elbow Surg. 2017;26(6):1103–12. PMID:PMC5438768. https://doi.org/10.1016/j.jse.2016.11.038.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Bryant L, Shnier R, Bryant C, Murrell GAC. A comparison of clinical estimation, ultrasonography, magnetic resonance imaging, and arthroscopy in determining the size of rotator cuff tears. J Shoulder Elbow Surg. 2002;11(3):219–24.

    Article  PubMed  Google Scholar 

  18. Green A. Chronic massive rotator cuff tears: evaluation and management. J Am Acad Orthop Surg. 2003;11(5):321–31.

    Article  PubMed  Google Scholar 

  19. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease: a comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88(8):1699–704.

    Article  PubMed  Google Scholar 

  20. Kim HM, Teefey SA, Zelig A, Galatz LM, Keener JD, Yamaguchi K. Shoulder strength in asymptomatic individuals with intact compared with torn rotator cuffs. J Bone Joint Surg Am. 2009;91(2):289–96. PMID:PMC2663343. https://doi.org/10.2106/JBJS.H.00219.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Boykin RE, Friedman DJ, Higgins LD, Warner JJ. Suprascapular neuropathy. J Bone Joint Surg Am. 2010;92(13):2348–64. https://doi.org/10.2106/JBJS.I.01743.

    Article  PubMed  Google Scholar 

  22. Mahjoub S, Lahmar AA, Zaraa M, Ahmed BM, Abdelkafi M, Mbarek M. A rare cause of compression of the suprascapular nerve: the paraglenoid cyst. J Orthop Case Rep. 2018;8(5):40–2. PMID:30740373. https://doi.org/10.13107/jocr.2250-0685.1202.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Bak K, Sorensen AK, Jorgensen U, et al. The value of clinical tests in acute full-thickness tears of the supraspinatus tendon: does a subacromial lidocaine injection help in the clinical diagnosis? A prospective study. Arthroscopy. 2010;26(6):734–42. https://doi.org/10.1016/j.arthro.2009.11.005.

    Article  PubMed  Google Scholar 

  24. Neer CS. Impingement lesions. Clin Orthop Relat Res. 1983;173:70–7.

    Article  Google Scholar 

  25. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8(3):151–8.

    Article  CAS  PubMed  Google Scholar 

  26. Hippensteel KJ, Brophy R, Smith MV, Wright RW. A comprehensive review of physical examination tests of the cervical spine, scapula, and rotator cuff. J Am Acad Orthop Surg. 2019;27(11):385–94. https://doi.org/10.5435/JAAOS-D-17-00090.

    Article  CAS  PubMed  Google Scholar 

  27. Murthi AM, Vosburgh CL, Neviaser TJ. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg. 2000;9(5):382–5. PMID:11075320. https://doi.org/10.1067/mse.2000.108386.

    Article  CAS  PubMed  Google Scholar 

  28. Kuptniratsaikul V, Laohathaimongkol T, Umprai V, Yeekian C, Prasathaporn N. Pre-operative factors correlated with arthroscopic reparability of large-to-massive rotator cuff tears. BMC Musculoskelet Disord. 2019;20(1):111. PMID:PMC6421693. https://doi.org/10.1186/s12891-019-2485-4.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Ladermann A, Denard PJ, Collin P. Massive rotator cuff tears: definition and treatment. Int Orthop. 2015;39(12):2403–14. https://doi.org/10.1007/s00264-015-2796-5.

    Article  PubMed  Google Scholar 

  30. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures: pre and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78–83.

    Article  Google Scholar 

  31. Kuzel BR, Grindel S, Papandrea R, Ziegler D. Fatty infiltration and rotator cuff atrophy. J Am Acad Orthop Surg. 2013;21(10):613–23. PMID:24084435. https://doi.org/10.5435/JAAOS-21-10-613.

    Article  PubMed  Google Scholar 

  32. Motamedi AR, Urrea LH, Hancock RE, Hawkins RJ, Ho C. Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears. J Shoulder Elbow Surg. 2003;11(1):6–10. https://doi.org/10.1067/mse.2002.120139.

    Article  Google Scholar 

  33. Callaghan JJ, McNiesh LM, DeHaven JP, Savory CG, Polly DW. A prospective comparison study of double contrast computed tomography (CT) arthrography and arthroscopy of the shoulder. Am J Sports Med. 1988;16(1):13–20. PMID:3344875. https://doi.org/10.1177/036354658801600103.

    Article  CAS  PubMed  Google Scholar 

  34. Oh JH, Kim JY, Choi JA, Kim WS. Effectiveness of multidetector computed tomography arthrography for the diagnosis of shoulder pathology: comparison with magnetic resonance imaging with arthroscopic correlation. J Shoulder Elbow Surg. 2010;19(1):14–20. https://doi.org/10.1016/j.jse.2009.04.012.

    Article  PubMed  Google Scholar 

  35. Oh JH, Kim SH, Choi JA, Kim Y, Oh CH. Reliability of the grading system for fatty degeneration of rotator cuff muscles. Clin Orthop Relat Res. 2010;468(6):1558–64. PMID:PMC2865616. https://doi.org/10.1007/s11999-009-0818-6.

    Article  PubMed  Google Scholar 

  36. Oh JH, Kim YS, Kim JM, Yoo TW. Learning curve of office-based ultrasonography for rotator cuff tendon tears. Knee Surg Sports Traumatol Arthrosc. 2013;21(7):1593–7. https://doi.org/10.1007/s00167-012-2105-4.

    Article  Google Scholar 

  37. Sipola P, Niemitukia L, Kroger H, Hofling I, Vaatainen U. Detection and quantification of rotator cuff tears with ultrasonography and magnetic resonance imaging: a prospective study in 77 consecutive patients with a surgical reference. Ultrasound Med Biol. 2010;36(12):1981–9. https://doi.org/10.1016/j.ultrasmedbio.2010.09.001.

    Article  PubMed  Google Scholar 

  38. Wall LB, Teefey SA, Middleton WD, et al. Diagnostic performance and reliability of ultrasonography for fatty degeneration of the rotator cuff muscles. J Bone Joint Surg Am. 2012;94(12):e83. PMID:PMC3368496. https://doi.org/10.2106/JBJS.J.01899.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Bakti N, Antonios T, Phadke A, Singh B. Early versus delayed mobilization following rotator cuff repair. J Clin Orthop Trauma. 2019;10(2):257–60. PMID:PMC6382997. https://doi.org/10.1016/j.jcot.2019.01.016.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Tashjian RZ, Hollins AM, Kinitton TSA, Middleton WD. Factor affecting healing rates after arthroscopic double row rotator cuff repair. Am J Sports Med. 2010;38:2435–42.

    Article  PubMed  Google Scholar 

  41. Zingg PO, Jost B, Sukthankar A, Buhler M, Pfirrmann CWA, Gerber C. Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am. 2007;89(9):1928–34.

    Article  CAS  PubMed  Google Scholar 

  42. Abrams JS. Arthroscopic approach to massive rotator cuff tears. Instr Course Lect. 2006;55:59–66.

    PubMed  Google Scholar 

  43. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy. 1994;10(4):363–70.

    Article  CAS  PubMed  Google Scholar 

  44. Duralde XA, Bair B. Massive rotator cuff tears: the result of partial rotator cuff repair. J Shoulder Elbow Surg. 2005;14(2):121–7.

    Article  PubMed  Google Scholar 

  45. Malahias MA, Kostretzis L, Chronopoulos E, Brilakis E, Avramidis G, Antonogiannakis E. Arthroscopic partial repair for massive rotator cuff tears: does it work? A systematic review. Sports Med Open. 2019;5(1):13. PMID:PMC6459454. https://doi.org/10.1186/s40798-019-0186-z.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, Trojani C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007;89(4):747–57. PMID:17403796. https://doi.org/10.2106/JBJS.E.01097.

    Article  PubMed  Google Scholar 

  47. Kim JK, Jeong HJ, Shin S-J, et al. Rapid progressive osteonecrosis of the humeral head after arthroscopic rotator cuff surgery. Arthroscopy. 2018;34(1):41–7. PMID: 28969947. https://doi.org/10.1016/j.arthro.2017.06.051.

    Article  PubMed  Google Scholar 

  48. Park I, Lee HJ, Choi YH, Kim YS. Arthroscopic repair of large to massive rotator cuff tears in patients younger than 60 years. J Orthop Sci. 2019; https://doi.org/10.1016/j.jos.2019.02.016.

  49. Abrams JS, Song FS. Arthroscopic repair techniques for massive rotator cuff tears. Instr Course Lect. 2012;61:121–30.

    PubMed  Google Scholar 

  50. Bedi A, Dines J, Warren RF, Dines DM. Massive tears of the rotator cuff. J Bone Joint Surg Am. 2010;92(9):1894–908. PMID:20686065. https://doi.org/10.2106/JBJS.I.01531.

    Article  PubMed  Google Scholar 

  51. Greenspoon JA, Petri M, Warth RJ, Millett PJ. Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes. J Shoulder Elbow Surg. 2015;24(9):1493–505. PMID:26129871. https://doi.org/10.1016/j.jse.2015.04.005.

    Article  PubMed  Google Scholar 

  52. Saccomanno MF, Sircana G, Cazzato G, Donati F, Randelli P, Milano G. Prognostic factors influencing the outcome of rotator cuff repair: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;24(12):3809–19. PMID:26197937. https://doi.org/10.1007/s00167-015-3700-y.

    Article  PubMed  Google Scholar 

  53. Hussain N, Goldar G, Ragina N, Banfield L, Laffey JG, Abdallah FW. Suprascapular and interscalene nerve block for shoulder surgery: a systematic review and meta-analysis. Anesthesiology. 2017;127(6):998–1013. https://doi.org/10.1097/ALN.0000000000001894.

    Article  PubMed  Google Scholar 

  54. Joshi GP, Hawkins RJ, Frankle MA, Abrams JS. Best practices for periarticular infiltration with liposomal bupivacaine for the management of pain after Shoulder surgery: consensus recommendation. J Surg Orthop Adv. 2016;25(4):204–8.

    PubMed  Google Scholar 

  55. Levy BJ, Tauberg BM, Holtzman AJ, Gruson KI. Reducing lateral femoral cutaneous nerve palsy in obese patients in the beach chair position: effect of a standardized positioning and padding protocol. J Am Acad Orthop Surg. 2019;27(12):437–43. https://doi.org/10.5435/JAAOS-D-17-00624.

    Article  PubMed  Google Scholar 

  56. Clement X, Baldairon F, Clavert P, Kempf JF. Popeye sign: tenodesis vs. self-locking "T" tenotomy of the long head of the biceps. Orthop Traumatol Surg Res. 2018;104(1):23–6. PMID:29055727. https://doi.org/10.1016/j.otsr.2017.09.016.

    Article  CAS  PubMed  Google Scholar 

  57. Mazzocca AD, Bollier M, Fehsenfeld D, et al. Biomechanical evaluation of margin convergence. Arthroscopy. 2011;27(3):330–8. PMID:21144695. https://doi.org/10.1016/j.arthro.2010.09.003.

    Article  PubMed  Google Scholar 

  58. Kim YS, Lee HJ, Jin HK, Kim SE, Lee JW. Conventional En masse repair versus separate double-layer double-row repair for the treatment of delaminated rotator cuff tears. Am J Sports Med. 2016;44(5):1146–52. PMID: 26912284. https://doi.org/10.1177/0363546516628869.

    Article  PubMed  Google Scholar 

  59. Mori D, Kizaki K, Funakoshi N, et al. Clinical and radiographic outcomes after arthroscopic lamina-specific double-row repair of large delaminated rotator cuff tears in active patients. Orthop J Sports Med. 2019;7(4):2325967119838249. PMID:PMC6477774. https://doi.org/10.1177/2325967119838249.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Albritton MJ, Graham RD, Richards RS, Basamania CJ. The anatomic study of the effects on the suprascapular nerve due to retraction of the supraspinatus muscle after a rotator cuff tear. J Shoulder Elbow Surg. 2003;12(5):497–500. https://doi.org/10.1016/S1058274603001824.

    Article  PubMed  Google Scholar 

  61. Momaya AM, Kwapisz A, Choate WS, et al. Clinical outcomes of suprascapular nerve decompression: a systematic review. J Shoulder Elbow Surg. 2018;27(1):172–80. PMID:29221575. https://doi.org/10.1016/j.jse.2017.09.025.

    Article  PubMed  Google Scholar 

  62. Tsikouris GD, Bolia IK, Vlaserou P, Odantzis N, Angelis K, Psychogios V. Shoulder arthroscopy with versus without suprascapular nerve release: clinical outcomes and return to sport rate in elite overhead athletes. Arthroscopy. 2018;34(9):2552–7. PMID:29937345. https://doi.org/10.1016/j.arthro.2018.03.046.

    Article  PubMed  Google Scholar 

  63. Ross D, Maerz T, Lynch J, Norris S, Baker K, Anderson K. Rehabilitation following arthroscopic rotator cuff repair: a review of current literature. J Am Acad Orthop Surg. 2014;22(1):1–9. https://doi.org/10.5435/JAAOS-22-01-1.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Harbin Clinic, Rome, GA, USA

    Brandon D. Bushnell

  2. Princeton Orthopaedic Associates, Princeton, NJ, USA

    Jeffrey S. Abrams

  3. Seton Hall University, S. Orange, NJ, USA

    Jeffrey S. Abrams

  4. Department of Orthopedic Surgery, Medical College of Georgia, Augusta University, Augusta, GA, USA

    Brandon D. Bushnell

Authors
  1. Brandon D. Bushnell
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jeffrey S. Abrams
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Department of Joint and Bone Surgery, University of Brescia, Brescia, Brescia, Italy

    Giuseppe Milano

  2. Department of Orthopaedics and Traumatology, Casa di Cura Villa Valeria, Rome, Roma, Italy

    Andrea Grasso

  3. Shoulder and Upper Limb Department, St. Luke's Hospital, Bielsko-Biała, Poland

    Roman Brzóska

  4. Department of Traumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia

    Ladislav Kovačič

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Bushnell, B.D., Abrams, J.S. (2023). Large to Massive Rotator Cuff Tears. In: Milano, G., Grasso, A., Brzóska, R., Kovačič, L. (eds) Shoulder Arthroscopy. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-66868-9_37

Download citation

  • DOI: https://doi.org/10.1007/978-3-662-66868-9_37

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-662-66867-2

  • Online ISBN: 978-3-662-66868-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation