Treatment options for massive rotator cuff tears
Christian Gerber, MD, FRCS*, Stephan H. Wirth, MD, Mazda Farshad, MD
Balgrist University Hospital, Zurich, Switzerland
Various classifications of rotator cuff tears have been
proposed.18,53,68,81Many authors currently define a tear as
massive if there is a detachment of at least 2 complete
tendons.38Whereas small tears can occur without symp-
toms,73,87massive tears are always associated with weak-
ness60and, especially in young patients, often with painful
disability.38,78Massive tears are only rarely due to an
acute injury; rather, they are usually chronic and are
associated with myotendinous retraction,71,112,113
of musculotendinous elasticity,56
muscles,47static (superior) subluxation of the humeral
head,22,50,53,85,98,102and ultimately, osteoarthritis.112If
fatty infiltration of the respective muscles is beyond
Goutallier stage 247,49and/or if there is cranial migration
of the humerus resulting in an acromiohumeral distance of
less than 7 mm,98the probability that successful cuff repair
can be achieved becomes so low that these massive tears
are called irreparable.
Whereas small tears with no or little retraction rela-
tively frequently remain small,109large, reparable tears
usually increase in size and can rapidly become irrepa-
rable with no further increase in pain or disability.112,114
It is therefore important to determine the definitive
treatment of a massive, reparable tear at the time of its
identification. The key parameters that are decisive for the
definitive treatment are the patient’s symptoms, repar-
ability of the lesion, and short- and longer-term functional
fatty infiltration of
Assessment of key parameters in
If it appears acceptable to define decisive parameters for
treatment selection, a simple listing of these parameters is
insufficient. These parameters should be quantitatively and
reproducibly assessed. Unfortunately, even with quantita-
tive clinical and imaging information, the scientific litera-
ture does not contain enough data to allow establishment of
an evidence-based, universally acceptable treatment algo-
rithm. Any proposed assessment and treatment algorithm
therefore includes personal experience and scientific data.
The following criteria have proven helpful in the assess-
ment of the key parameters in the decision-making process
for massive rotator cuff tears in our experience and are
offered for consideration.
Assessment of symptoms
Assessment of pain must most importantly ascertain that the
Stiffness caused by adhesive capsulitis often accompanies
rotation tested with the arm at the side or limitations of
passive glenohumeral abduction are never due to a cuff tear
but are signs of concomitant adhesive capsulitis. Conserva-
tive treatment of stiffness is almost universally successful
and, surprisingly, often results in sufficient pain relief and
restoration of function, making operative treatment super-
fluous. Acromioclavicular joint pain, though different from
the usual rotator cuff pain,39is the second most common
cause of pain that is not caused by, but is occasionally
Investigational Review Board approval was not necessary for this review
*Reprint requests: Christian Gerber, MD, FRCS, Forchstrasse 340,
8008 Zurich, Switzerland.
E-mail address: firstname.lastname@example.org (C. Gerber).
J Shoulder Elbow Surg (2011) 20, S20-S29
1058-2746/$ - see front matter ? 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.
found cervical spine problems to be a rare cause of pain
occurring concurrently with rotator cuff failure.
If the surgeon has determined that the pain is related to
cuff failure and if glenohumeral stiffness and acromiocla-
vicular pain are excluded, the patient determines whether
he or she is willing and able to cope with the type and
intensity of pain. If the patient believes that the pain is
beyond his or her tolerance, treatment becomes mandatory,
and the type of treatment will be determined by the other
The main disability caused by rotator cuff tears is weakness
with the arm away from the body. Although weakness of
internal rotation is present in anterosuperior tears,62,82it is
rarely sufficiently disabling to warrant treatment. Ante-
rosuperior tears usually require treatment for painful weak-
can be quantified by various semi-objective means84,111and
reaches from hardly perceived weakness to so-called pseu-
doparalysis of elevation and/or external rotation. Pseudo-
paralysis of anterior elevation describes the inability to
elevate the arm to 90?in the presence of unrestricted passive
range of glenohumeral motion and in the absence of any
Pseudoparalysis of external
rotation describes complete loss of active external rotation
power in the presence of unrestricted passive external rota-
tion and in the absence of neurologic impairment. It is
synonymous with the Neer drop-arm sign,77with the
inability to actively externally rotate the adducted arm
beyond 0?despite the absence of stiffness or neurologic
impairment,77,94or a severe external rotation lag sign.57
Winging of the elbow away from the body, while attempt-
ing external rotation, with concurrent internal rotation of the
forearm is also known as hornblower’s sign.4,43,94
The disability has to be assessed after successful treat-
ment of stiffness or after relief of acromioclavicular pain by
injection of a local anesthetic into the joint. Even though
loss of strength can then be measured111and correlated to
disability scores,20,67it is ultimately the patient who
determines whether this disability is acceptable for him or
her or whether he or she desires improvement. Only if the
patient does not wish to accept his or her disability or if
a highly likely progression of a currently acceptable
disability could be halted by an operative procedure should
operative treatment be considered.
Assessment of tear reparability
If a tear is sufficiently disabling to warrant operative
treatment, repair is the preferred method of treatment
because it provides lasting pain relief and improves
strength over the preoperative state.7,38,65Attempts at repair
that result in persistence or even enlargement of the tear
should, however, be prevented.
A tear is irreparable if the defect cannot be closed
intraoperatively or if it has empirically been determined
that a successful closure during surgery will almost
certainly be associated with structural failure of the repair.
The following clinical and imaging criteria have been
identified as predictors of irreparability.
Clinical findings indicating irreparability of rotator
We have found that anterosuperior tears, with obvious,
static anterosuperior subluxation with the head under the
skin in front of the anterior acromion and associated
pseudoparalysis of anterior elevation (Fig. 1), cannot be
repaired. In addition, tears associated with dynamic ante-
rosuperior subluxation of the humerus upon resisted
abduction (Fig. 2) have been found to have a very low
likelihood for healing after attempted repair. For poster-
osuperior and global tears, a pseudoparalysis of anterior
elevation is suggestive of irreparability if it is chronic, if it
is not associated with pain, and if the arm that is passively
elevated to 90?of elevation cannot actively be stabilized by
the patient. A true dropping sign indicates that the infra-
spinatus muscle has Goutallier stage 2 fatty infiltration or
greater49,94and will not heal after attempted, direct repair.
If, in addition, there is a hornblower’s sign, the teres minor
has likely undergone substantial fatty infiltration and will
not be amenable to successful repair.94Thus, static and
dynamic clinical subluxations of the glenohumeral joint
and chronic, very substantial lag signs are the key clinical
predictors of irreparability of a tear.
Imaging findings suggesting irreparability of rotator
Static superior subluxation of a glenohumeral joint with an
acromiohumeral interval of 7 mm or less (Fig. 3) on an
anteroposterior radiograph with the arm in neutral rotation
is associated with an exorbitantly high repair failure
rate26,99and considered indicative of irreparability of
Static anterior subluxation, as detected on
computed tomography (CT)
imaging (MRI), though less well studied, appears to be
indicative of irreparability of an anterosuperior tear.
Stage 3 or 4 fatty infiltration of the rotator cuff
muscles47(Fig. 4) as determined by CT or MRI has
repeatedly been associated with irreparability of rotator
cuff tears.48,49Thus an acromiohumeral interval of less than
7 mm and fatty infiltration of muscle of stage 3 or greater
indicate irreparability of a tear.
As opposed to the results of repair, the results of biceps
tenotomy, subacromial debridement, partial repairs, tendon
transfers, and reverse total shoulder arthroplasty (rTSA)
have not been documented to be strongly dependent on the
delay between rupture and treatment. Therefore, the diag-
nosis of an irreparable tear provides the patient and surgeon
with time for observation of the natural history, as well as
attempts at conservative treatment including physical
Treatment options for massive rotator cuff tearsS21
therapy and subacromial (and thereby intra-articular)
corticosteroid injection, because the possible operative
treatment options can also be applied with a very similar
prognosis at a later date.
Assessment of functional demands
Rotator cuff disease does not cause disability with the arm at
the side. Therefore, functional demands are considered high
away from the body). Conversely, if the patient accepts the
demands are considered low. Thus, the relevance of the
documented or expected dysfunction is determined by
informed about the natural history of large tears112and the
it is their responsibility to match their demands with the
expected outcome of the possible treatment options. The
the treatment expectations of the patient remain unrealistic
despite optimal counseling.
Acute, traumatic massive tears
Massive tears are only exceptionally purely traumatic and
often constitute case reports.36,95Massive trauma may
exceptionally avulse the entire, healthy cuff or the cuff of
a patient with predisposing factors such as severe osteo-
penia due to, for example, long-term administration of
systemic steroid medication. Patients with a truly traumatic,
massive tear present in the emergency department with
a completely pseudoparalytic
imaging excludes a fracture but may document a wide joint
space due to interposition of an avulsed cuff. MRI or CT is
used to exclude previously asymptomatic rotator cuff
degeneration with atrophy and fatty infiltration. If massive
tendon failure and absence of fatty muscle infiltration
greater than stage 1 are documented, earliest possible repair
is the most rational approach.
Chronic massive tears
Chronic massive tears are defined as tears with detachment
of at least 2 tendons and chronic degenerative changes of
tendon and muscle. A traumatic event may have enlarged
a smaller pre-existing tear, and the so-called acute-on-
chronic tears are considered chronic, because they usually
exhibit substantial degenerative musculotendinous changes
as evidenced by imaging studies. Exceptionally, a very
major trauma. Then, the imaging criteria (no fatty infiltra-
tion of the respective muscles, no static subluxation) for a
(A); upon resisted abduction of the minimally abducted arm, the
humeral head subluxates anterosuperiorly (B). This suggests
irreparable anterosuperior rotator cuff failure.
In the resting position, both shoulders appear centered
right humeral head and associated, chronic pseudoparalysis of
anterior elevation, indicating an irreparable, massive tear.
Patient with clinically visible superior subluxation of
S22 C. Gerber et al.
chronic tear are not fulfilled, and the tear is considered an
The value of nonoperative treatment using physical therapy
or subacromial corticosteroid injection (which is also
intra-articular in massive tears) is not well estab-
lished.2,12,44,55,105There is also no proof that conservative
treatment substantially alters the course of the natural
history of massive tears. In a small cohort, Zingg et al112
have documented a surprisingly good clinical outcome
using nonoperative treatment but substantial structural
deterioration of cartilage, tendon, and muscle. This is in
agreement with studies of cuff debridement that also
documented good clinical outcome but increase in tear size
and joint deterioration after conservative treatment.114It is
therefore our interpretation of current knowledge that
conservative treatment may lead to a very satisfactory
clinical situation in selected, mainly low-demand patients
but to an inevitable increase in joint degeneration. There-
fore, conservative treatment is often appropriate if a tear is
already irreparable but should not be used for reparable
tears in patients with high midterm to long-term functional
Biceps tenotomy and tenodesis
The biomechanical role of the tendon of the long head of
the biceps (LHB) is still controversial. However, tendin-
opathy of LHB has been identified as a common source of
pain in patients with rotator cuff tears,89and arthroscopic
tenotomy of the biceps was introduced as a routine pain
treatment in rotator cuff disease by Walch et al97in 1997.
confirmed in a multicenter study involving 210 rotator cuff
tears, which identified a major benefit of LHB tenotomy
particularly in the subgroup of patients with massive
tears.63A review of 307 patients in which arthroscopic
biceps tenotomy was the sole procedure for the treatment of
rotator cuff pain showed an 87% satisfaction rate after
a mean of 57 months. Somewhat less success was observed
in shoulders with fatty infiltration of the subscapularis and
a very low preoperative Constant-Murley score. Despite the
excellent clinical outcome, this study did show progression
of degenerative joint disease over time.96These results
have further been confirmed by another independent study
that showed a satisfaction rate of 78% irrespective of
whether biceps tenotomy or tenodesis was selected.8
Scientifically speaking, the current literature provides
only fair evidence in favor of biceps tenotomy,5but clinical
experience supports the value of this procedure and we are
unaware of any report contesting good results of biceps
tenotomy or tenodesis for the treatment of pain in massive
rotator cuff tears. It is also currently uncontested that biceps
tenotomy does not lead to pseudoparalysis or loss of
function; rather, it is very often associated with functional
improvement, which may be a result of improved pain.
scapular spine in a patient with a massive cuff tear. Fatty infil-
tration of the infraspinatus muscle is stage 4; of the supraspinatus
muscle, stage 4; and of the subscapularis, stage 2. If fatty infil-
tration exceeds stage 2, repair failure is extremely likely.
Magnetic resonance parasagittal image at level of
a standing patient, who has his arm near neutral rotation, the
acromiohumeral distance (achd) is about 1 mm. An acromio-
humeral distance of less than 7 mm is associated with an exor-
bitantly high repair failure rate.
On an anteroposterior radiograph of the shoulder of
Treatment options for massive rotator cuff tearsS23
Isolated tenotomy of the biceps, however, has not proven to
prevent further degeneration of the joint, and therefore, it
may not be an ideal long-term option for patients with
reparable tears and high functional demands.
Subacromial debridement and decompression
In one study of 50 patients, debridement of rotator cuff
tendon stumps with subacromial decompression led to
satisfactory clinical results in 83% of those studied.83
Although this approach appears to decrease pain and
increase range of motion, it also appeared to decrease
strength of elevation in another series of patients under-
going a similar procedure.35Today, the coracoacromial
ligament is considered to be a major restraint against
superior migration of the humeral head,31,108and at most, it
should be detached but not resected, especially not in
massive rotator cuff tears. Tuberoplasty has been suggested
as an alternative to achieve a higher degree of sphericity of
the acromiohumeral articulation during elevation29
acromioplasty does not suffice. A similar approach has
been named reverse arthroscopic subacromial decompres-
sion and led to a minimal superior humeral head migration
of less than 1 mm with a mean follow-up of 40 months.86
These treatment options appear to have lost their indica-
tions somewhat and to have mostly been superseded by
either biceps tenotomy or rTSA.
In a randomized trial of large but reparable lesions,
debridement resulted in substantially less clinical success
and in significantly more glenohumeral joint degeneration
than tendon repair.76
Cuff debridement of rotator cuff tears is associated
with a satisfactory short-term outcome24in patients with
low demands.64,66,69,79It has previously been established,
however, that subacromial debridement is much less
effective in massive tears than in small tears,27,114and
there is no proof that debridement is superior to biceps
tenotomy alone. Furthermore, there is no evidence of the
efficacy of debridement in shoulders with massive tears
and rupture of the LHB. In contrast, debridement alone
has been associated with progressive joint degeneration,
so its role is limited in the treatment of massive rotator
Rotator cuff repair
and long-term clinical results are excellent and joint degener-
ation is halted or at least markedly decelerated.1,5-7,14,19,38,80
There is a lack of strong evidence showing that either arthro-
scopic or open rotator cuff repair is superior. If the repair heals
of repair of massive tears can and does occur but does not
evidence that repairs that do not structurally heal yield better
results than biceps tenotomy.
The rate of healing of a repair is closely related to the size
of the tear, the acromiohumeral distance, the degree of
muscular atrophy,91and the amount of fatty infiltration. All
these degenerative changes inevitably progress in unre-
paired, massive tears and transform reparable tears into
the time between tearing and repair. A reparable tear in
a patient with high functional demands, as previously
Patients with low functional demands are informed that
treatment of pain will also be possible in the future but that
functional restoration may later be less reliable.
The role of augmentation devices or scaffolds is
currently considered to be undetermined and is the subject
of various reviews by authors with laboratory and clinical
expertise.23Whereas there is substantial interest and very
encouraging early results have been reported with some of
these augmentation devices,13,107
evidence that some materials such as porcine small intes-
tine submucosa are detrimental rather than helpful.58We
therefore do not exclude that new horizons of repair may
have been opened, but further results have to be seen before
widespread use of these scaffolds can be recommended.
there is conclusive
Tendon transfers are palliative procedures that are used to
treat irreparable tears. Their role in augmentation of
Treatment algorithm for patients with documented massive rotator cuff tears who can accept their symptoms.
S24 C. Gerber et al.
reparable tears is not established. Although various tendon
transfers, including transferof the middle thirdofthe deltoid
insertion to the stump of the posterosuperior cuff,3,90as well
as transfer of the trapezius insertion to the greater tuberosity,
passing underneath the acromion,46,72,110
have been latissimus dorsi transfer43and its modifica-
tions16,52for posterosuperior lesions and pectoralis major
transfer40,82,93,106for irreparable subscapularis tears.
Latissimus dorsi transfer
Latissimus dorsi transfer has been used as a salvage
procedure for irreparable superolateral rotator cuff tears for
over 20 years.43Multiple authors have concurred that it is
a valuable treatment option for painful or pain-free pseu-
doparalysis of external rotation provided that the sub-
scapularis is intact.17,41,52,59,74,101Results are better if there
is no chronic pseudoparalysis of anterior elevation and
if the teres minor does not show advanced fatty
Pectoralis major transfer
Pectoralis major transfer either above93,106or below82the
conjoined tendon is a valuable salvage procedure for iso-
lated, irreparable subscapularis lesions.34,40,82In massive,
anterosuperior tears, pain can be improved but functional
restoration is rather disappointing,34,62,106and it appears
that the transfer is even somewhat disappointing in the
revision of isolated subscapularis failures after deltopec-
toral approachesfor unconstrained
a massive anterosuperior rotator cuff tear is associated with
pseudoparalysis of anterior elevation, it appears that rTSA
or arthrodesis is a better alternative.
Humeral head replacement
Hemiarthroplasty has been used to treat painful massive
rotator cuff tears associated with glenohumeral and/or
subacromial osteoarthritis. Although some centers report
acceptable results,45most reports indicate fair to good pain
relief and poor restoration of lost function.30,104
a massive rotator cuff tear is associated with pseudopar-
alysis, the results of hemiarthroplasty are so much inferior
to those of rTSA that hemiarthroplasty has almost lost its
role in the treatment of massive rotator cuff tears, although
level I studies comparing the two are lacking.28
Reverse total shoulder arthroplasty
rTSA has proven to be the best short-term solution for
treatment of the disability caused by irreparable rotator cuff
tearing and rotator cuff arthropathy.10,11,23,92It reliably and
often dramatically improves function and pain in patients
with irreparable rotator cuff tears associated with pseudo-
paralysis of anterior elevation,32,75,88,100,103
satisfactory results can even be obtained in patients who
have undergone a previously failed rotator cuff repair.10
The long-term prognosis of rTSA for irreparable tears is
considered somewhat guarded, but the currently available
literature documents an implant survival rate of 91% at
120 months.51Therefore, the currently available literature
external; rot. ¼ rotation; lat. ¼ latissimus; RTSA ¼ reverse total shoulder replacement
Treatment algorithm for patients who are not willing to accept their symptoms. ant. ¼ anterior; elev. ¼ elevation; ext. ¼
Treatment options for massive rotator cuff tearsS25
documents not only that irreparable rotator cuff tears are
the most successful indication for rTSA but also that rTSA
is the most successful and reliable treatment for irreparable
rotator cuff tears with pseudoparalysis of anterior elevation.
For patients aged 70 years or greater, it has, indeed,
replaced the other procedures.
Unfortunately, rTSA alone is biomechanically unable to
correct the often subjectively important pseudoparalysis of
external rotation so that in the case of combined pseudo-
paralysis of anterior elevation and external rotation, func-
tional restoration must be obtained by combining rTSA
with variants of latissimus dorsi transfer.9,42
With precise understanding of the potential of the different
treatment possibilities, a thorough evaluation of the patient’s
symptoms and functional demands, and assessment of the
reparability of the cuff, the most adapted treatment option is
proposed to the patient following a treatment algorithm. We
have found the algorithms presented in Figures 5 and 6 to be
helpful. It is understood that during the course of treatment,
a patient can change his or her decision because symptoms
change from acceptable to unacceptable (or vice versa) and
he or she may change from the lowefunctional demand
group to the high-demand group (or vice versa). In addition,
a tear may change from reparable to irreparable. Accord-
ingly, the treatment options have to be reconsidered and
adapted to the actual situation.
There are currently multiple treatment options. Their
technical details are described elsewhere, and often, the
choice of the best treatment option is more difficult than
the execution of a procedure. Therefore, a careful
analysis of the patient’s situation and of the potential of
the different treatment options is mandatory.
The authors, their immediate families, and any research
foundations with which they are affiliated have not
commercial entity related to the subject of this article.
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