Management of the Irreparable Rotator Cuff Tear

Gregory L. Cvetanovich, MD; Brian R. Waterman, MD; Nikhil N. Verma, MD; Anthony A. Romeo, MD


J Am Acad Orthop Surg. 2019;27(24):909-917. 

In This Article

Identification of the Irreparable Rotator Cuff Tear

Preoperatively, irreparable tears can frequently be difficult to distinguish from large or massive repairable tears based on examination and imaging studies alone, although certain criteria have been proposed.[9,10] Irreparable rotator cuff tears are generally large (in both AP and medial-lateral dimensions) and retracted with poor or attenuated tissue quality, muscular atrophy, and fatty infiltration.[10,11] The ultimate assessment of reparability is determined intraoperatively after tendon mobilization and interval releases. Burkhart found that 85% of massive rotator cuff tears were completely repairable, although only 57% of tears with Goutallier 3 to 4 fatty infiltration of the supraspinatus were repairable.[12,13] Nevertheless, a thorough preoperative assessment is critical in surgical planning to identify tear patterns that are potentially irreparable to prepare for alternative treatment strategies.

Patient Evaluation

Patients undergo a detailed history to assess for pain and disability of the affected shoulder. Occupational demands, involvement in leisure or sporting activities, hand dominance, tobacco use, and medical comorbidities are assessed. The degree of pain and disability may not correlate with the size and reparability of the associated rotator cuff tear.[14] Traumatic versus atraumatic onset and symptom chronicity are important variables to assess because traumatic tear or those with more acute presentation may be more likely to be repairable, particularly when associated with pseudoparalysis. Finally, previous surgical history, including advanced radiographic imaging, arthroscopic images, and surgical reports, should be obtained and scrutinized to determine initial tear pattern, tissue quality, concomitant procedures, untreated pathology, and potential technical errors (eg, violation of the myotendinous junction and implant prominence).

Physical examination starts with inspection of the affected shoulder and periscapular musculature, with care to assess for atrophy of the supraspinatus and infraspinatus in their respective fossae. Visible atrophy on examination is suggestive of chronicity and advanced rotator cuff fatty infiltration that contribute to poor tissue mobility and difficulty with primary repair. Neurovascular examination is performed to assess axillary nerve function with sensation and deltoid motor function.

Active and passive range of motion are then evaluated and compared with the unaffected, contralateral shoulder, while bearing in mind that patients may present with bilateral rotator cuff pathology. Patients with disrupted rotator cuff force couples or cable involvement due to a massive or irreparable tear may exhibit significant losses of active range forward elevation with relatively preserved passive range of motion.[15] When the patient is unable to elevate the arm beyond 90° actively despite intact passive motion, the patient is commonly said to have pseudoparalysis, although we prefer the more nuanced terminology of pseudoparesis for active elevation that falls short of 90° with pseudoparalysis reserved for patients essentially without active elevation and anterior translation on attempted elevation consistent with anterior-superior escape or migration.[15] It is important to attempt to distinguish true weakness-mediated pseudoparalysis from pain-mediated and effort-mediated false positives. Subacromial injection or lidocaine challenge can reduce the contribution of pain in equivocal cases and help to discern between effort- and pain-mediated etiologies and structural deficits. Ultimately, the identification of pseudoparalysis is based on a combination of clinical examination and imaging studies confirming massive cuff pathology with superior humeral migration.

Rotator cuff strength is evaluated and compared with the contralateral side, with significant weakness present in patients with poorly compensated massive or irreparable tears. The supraspinatus is assessed with resisted forward elevation in the scapular plane and maximal internal rotation. The infraspinatus is assessed with resisted external rotation with the arm adducted. The subscapularis is assessed with belly press, lift-off, and bear hug testing, which may differentially assess the upper and lower aspects of the subscapularis.[16] Resisted external rotation or a Hornblower test is performed in 90° of abduction and 90° of external rotation to assess the teres minor.[17] Furthermore, increased passive motion and lag signs may be identified, including increased passive internal rotation and external rotation lag for infraspinatus, increased passive external rotation and internal rotation lag for subscapularis, and drop arm sign for supraspinatus.


Patients are initially evaluated with standard, three-view radiographic series of the shoulder, including a true AP (Grashey), outlet (scapular Y), and axillary lateral images. Radiographs are used to identify associated glenohumeral arthritis or rotator cuff arthropathy according to the Hamada classification,[18] reciprocal remodeling changes in the greater tuberosity and corresponding undersurface of the acromion, acromiohumeral distance, presence of subluxation or anterosuperior escape, and acromial morphology (Figure 1). Narrowing of the acromiohumeral distance below 5 to 6 mm has been associated with massive tears with advanced fatty infiltration that may render tissue irreparable.[19]

Figure 1.

Hamada classification of rotator cuff arthropathy. (Reproduced with permission from Hamada K et al: A radiographic classification of massive rotator cuff tear arthritis. Clin Orthop Relat Res 2011;469[9]:2452–2460.)

MRI is the predominant advanced imaging modality used for evaluation of the potentially irreparable rotator cuff tear, used to define tear size, shape, involved tendons, and fatty infiltration. However, CT or CT arthrography is generally reserved for patients with contraindications to MRI, metal artifact, or severe rotator cuff arthropathy where glenoid version, bone stock in the glenoid vault, and/or digital templating is to be performed for RSA. Although initially described by Goutallier et al[20] on the basis of CT, the Fuchs modification assessing rotator cuff fatty infiltration on the T1 sagittal oblique image immediately lateral to the scapular spine's attachment to the body of the scapula given the predominant role of MRI in evaluating rotator cuff pathology.[21] Grade 3 and 4 represent severe fatty infiltration with equal or greater amounts of fat compared with muscle, respectively, and are generally found in irreparable tears.

Several authors have correlated preoperative MRI findings with reparability of rotator cuff tears. Sugihara et al[11] found that irreparable tears correlated with tear length or width over 4 cm, severe fatty infiltration of the supraspinatus and infraspinatus. Similarly, Yoo et al[10] found that irreparabile tears correlated with grade 4 supraspinatus fatty infiltration, grade 3 or 4 infraspinatus fatty infiltration, and tear length and width over 3.1 to 3.2 cm. Dwyer et al[9] ascertained that retraction of the tear to or beyond the glenoid, severe fatty infiltration of the supraspinatus and infraspinatus, a positive tangent sign, and superior humeral migration were associated with irreparable tears. A recent study by Kim et al[22] analyzed multiple MRI factors finding that the best predictors of reparable tears were infraspinatus fatty infiltration grade <3 and tear retraction to the humeral head or less. Therefore, surgeons should be aware that irreparable rotator cuff tear is likely in patients with narrowing of the acromiohumeral distance below 5 to 6 mm, severe (grade 3 and 4) fatty infiltration of the supraspinatus and infraspinatus, and tears retracted to the glenoid (Figure 2).

Figure 2.

MRI sagittal and coronal images showing findings suggestive of irreparable rotator cuff tear including grade 4 atrophy of the supraspinatus and infraspinatus with massive tear retracted to the glenoid.