Massive rotator cuff tear

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Massive rotator cuff tears are large full-thickness tears usually leading to glenohumeral joint destabilization. Different definitions of a massive rotator cuff tear exist in regard to tear size or the involvement of tendons.

Epidemiology

They constitute up to 40% of all rotator cuff tears .

Clinical presentation

Clinical symptoms may vary and can be categorized e.g. with the modified UCLA scoring system. In a massive tear, there will be, however, probably some functional deficit .

Pathology

Massive tears are larger full-thickness tears which involve more than one tendon and can be classified as follows :

supraspinatus and superior subscapularis tears
supraspinatus and entire subscapularis tears
supraspinatus, superior subscapularis, and infraspinatus tears
supraspinatus and infraspinatus tears
supraspinatus, infraspinatus and teres minor tears

Radiographic features

Ultrasound

Large hypoechoic or anechoic defect in the area of the torn tendons.

MRI

Larger full-thickness tear with the presence of fluid signal intensity in the location of the rotator cuff on fat-saturated T2-weighted or intermediate-weighted images of a defined size extension into one of the other tendons e.g. posterosuperior cuff tear and/or rotator interval.

Radiology report

The report of rotator cuff tears, particularly if massive should include the following :

the lesion size – anteroposterior and mediolateral
description of tendon retraction e.g. Patte classification
the number and description of tendons involved
the tear pattern – crescent shape / L-shape / U-shape
tendon delamination
the number and description of tendons involved
muscular atrophy assessed with the tangent sign or scapular ratio
description and grading of fatty degeneration using the Goutallier classification
superior humeral head subluxation

Treatment and prognosis

Treatment options include interval slides, margin convergence, partial repair or tendon transfer e.g. from latissimus dorsi or pectoralis major tendons, superior capsular reconstruction in young people and several treatment strategies from conservative management over arthroscopic debridement up to reverse prosthesis of the glenohumeral joint in the older patients .

There are many and more options but no consensus on the ideal treatment for massive or irreparable rotator cuff tears .