Massive Retracted Rotator cuff tear

What are Massive Rotator Cuff Tears?

A tear in the rotator cuff can cause pain and disability. It can occur from degeneration of the rotator cuff due to overuse or from a sudden injury. Massive rotator cuff tears involve tears in two complete tendons of the rotator cuff. A tear of more than 5 cm is described as massive, and it means involvent of 2 or more rotator cuff tendons. A massive tear may be associated with degeneration and retraction of the tendon and can be difficult to repair if treatment is delayed.

The patient usually presents with Drop arm sign and inability to actively lift the arm. (In single tendon tears the patient will be able to elevate the arm normally, although with some pain. This power can last for few months, until eventially the second tendon is included in the tear due to traction of the torn tendon.)

Complications of Massive, Retracted Rotator Cuff Tears

Massive rotator cuff tears may be associated with:

• Fatty infiltration of muscle (accumulation of fats) causing loss of elasticity
• Humeral head subluxation (partial dislocation)
• Impingement of tissues
• Formation of bone spurs
• Osteoarthritis 

Diagnosis of Massive, Retracted Rotator Cuff Tears

Your doctor will review your medical history and perform a physical examination to assess pain, movement, and strength. An MRI scan may be ordered to visualize the rotator cuff injury.  X-rays may be performed to look at associated bone injuries or defects.

Treatment of Massive, Retracted Rotator Cuff Tears

Surgery is necessary to treat the most massive, retracted rotator cuff tears. Without treatment, shoulder movement becomes abnormal and structures within the shoulder can undergo further damage. Non-surgical treatment may be recommended for elderly patients with limited functional goals.

Surgical goals can often be achieved by arthroscopic surgery. The procedure is performed with the help of a pencil-sized instrument called an arthroscope that contains a miniature camera which relays images to a monitor. The Arthroscopic repair for massive tears usually involves:

• Extensive debridement of tissue fragments at the detached edge of the rotator cuff.
• Mobilization to bring the detached muscle to its original attachment on the humerus.
• Reconstruction of the tendons with a suitable graft may be necessary.
• Attachment of the tendon to bone with the help of suture anchors.

Treatment of Massive Retracted Irreparable Rotator cuff tears

A rotator cuff tear is called Irreparable when most of the muscle belly is infiltrated with fat. This is graded by Goutallier grading. The grades above the (c) in picture is called irreparable, because the muscle mass is too less to allow movements of the shoulder even if repaired by arthroscopic releases.

In such scenarios we resort to Tendon transfers or Superior capsular reconstruction or a Reverse shoulder replacement depending on multiple factors including age, functional requirements etc