Surgical Management of Irreparable Rotator Cuff Tears

Patient Selection and Evaluation

The American Academy of Orthopaedic Surgeons recommends that surgery for rotator cuff tears should only be considered in patients with significant pain, and asymptomatic tears should not be operated on regardless of imaging findings 3, 1
Patients with severe fatty infiltration and atrophy of the rotator cuff muscles, such as the supraspinatus and infraspinatus, are at high risk for poor surgical outcomes and may not benefit from standard rotator cuff repair 1, 2
The presence of superior humeral head migration and acetabularization of the acromion indicates loss of the rotator cuff's depressor function and is a hallmark of massive irreparable tears 2, 3
Moderate glenohumeral osteoarthritis suggests progression toward rotator cuff arthropathy, which fundamentally changes the treatment paradigm 3

The initial approach for patients with significant pain and functional limitation should be comprehensive conservative management, including NSAIDs or COX-2 inhibitors combined with acetaminophen for pain control 2, 4
Supervised physical therapy focusing on maintaining range of motion and strengthening remaining intact muscles, such as the teres minor and deltoid, is also recommended 4
A single corticosteroid injection with local anesthetic may be considered for short-term pain relief, but multiple injections should be avoided as they compromise tissue integrity 1, 2, 4

Reverse total shoulder arthroplasty is a suitable surgical option for elderly patients with irreparable cuff tears and rotator cuff arthropathy, as it bypasses the need for intact rotator cuff function 3
The American Academy of Orthopaedic Surgeons consensus recommendation states that no surgery should be performed on asymptomatic patients, regardless of imaging severity 3, 1

One level III study showed that 81% of surgical patients reported excellent results compared to 37% with nonsurgical treatment for chronic symptomatic full-thickness tears 3
However, the strength of evidence for surgical management of irreparable rotator cuff tears is limited, and more research is needed to determine the best course of treatment 3