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

Authors' Preferred Treatment Algorithm

Treatment is individualized to each patient, taking into account factors including age, preoperative function, shoulder pathology, and patient goals and demands. Initial treatment is nonsurgical, involving physical therapy, activity modification, oral medications, and cortisone injections. If nonsurgical treatment fails, surgical options are discussed according to our preferred treatment algorithm (Figure 5).

Figure 5.

Authors' current treatment algorithm for the irreparable posterosuperior rotator cuff tear assuming failure of nonsurgical treatment and that the tear is truly irreparable intraoperatively. RSA = reverse total shoulder arthroplasty, SCR = superior capsular reconstruction.

The RSA is our preferred treatment option for patients with intermediate- to advanced-stage rotator cuff arthropathy (Hamada grade 3 or greater). We also favor RSA for those with anterosuperior escape, pseudoparalysis, and/or lower demand individuals older than 65 years. The RSA provides the most reliable pain relief and restoration of function in these situations, although we will consider nonarthroplasty options such as SCR in younger patients with pseudoparalysis or older patients with high functional demands.

For patients with Hamada grades 1 and 2 younger than 65 years without pseudoparalysis, our preferred treatment is arthroscopic SCR, assuming that the rotator cuff is truly irreparable intraoperatively. The authors' experience has been that SCR with an acellular dermal allograft offers reliable pain relief and more consistent functional improvements than alternative techniques such as tendon transfers or partial rotator cuff repair. In the uncommon situation of an irreparable subscapularis tear combined with irreparable posterosuperior rotator cuff tear, we would generally perform RSA, although SCR with combined split pectoralis major transfer to address the subscapularis deficiency could be an option for a patient who wished to avoid arthroplasty. We have limited experience with balloon arthroplasty and interpositional grafts, although these are also promising nonarthroplasty treatment options.