Rotator Cuff Tears: Large

Large Rotator Tears shall be defined as rotator cuff tears that involve more than 1 rotator cuff tendon. These tears may be acute or chronic or a combination of both (acute on chronic). If surgery has been suggested as a treatment option it is important to differentiate between acute, chronic or acute on chronic. An MRI scan (or CT arthrogram if claustrophobic) can be helpful with this differentiation.

Acute large tears may occur from a trauma such as a fall and may accompany shoulder dislocations in people over 50 years of age. If there have been no previous shoulder symptoms or injuries, then these large tears are more easily repaired. The retracted tendon will not have firmly scarred into its new position and is more easily pulled back to their bony attachment. The muscle bellies of the detached tendon will not have shrunk in size or been replaced by fat, as in prolonged tendon detachment (>6 months).

Chronic tears can occur over many years. A gradual loss of tendon attachment can be compensated by the remaining rotator cuff and deltoid muscles. More than half the population over 70 years of age has a full thickness tear in the rotator cuff tear and most have no symptoms. After a critical amount of tendon loss or a fall (acute on chronic) the tear may cause pain and loss of function. These tears are harder to repair. The retraction can be harder to overcome. If there is minimal residual muscle belly there may be little point in repairing the tendon. Ultimately the ability to repair some tears can only be determined at surgery after mobilising the tear. If a full repair is not possible a partial repair may help balance forces around the shoulder.

Most tears can be repaired with a keyhole technique although some may require a combination of keyhole and traditional open exposures. Other procedures addressing abnormal biceps tendon, acromial spurs and/or AC joint arthritis are commonly performed at the same time to assist with pain relief.

The main benefit of surgery is pain relief. Function is harder to improve, especially in chronic tears. Compared with single tendon repairs, large rotator cuff repairs are more likely to have incomplete healing or retear. The rehabilitation is therefore slower. Tendon healing is also harder to achieve in smokers and the very elderly.