Is reverse shoulder arthroplasty (RSA) or rotator cuff repair indicated for a patient with a full-thickness tear of the supraspinatus tendon and associated muscle atrophy?

Rotator Cuff Repair is Indicated for This Patient

This patient with a 3.4 cm full-thickness supraspinatus tear and moderate muscle atrophy should undergo rotator cuff repair rather than reverse shoulder arthroplasty, as RSA is specifically reserved for massive, unrepairable tears with pseudoparalysis or rotator cuff tear arthropathy—neither of which is described in this case. 1, 2

Key Decision Factors Against RSA

RSA Indications Are Not Met

• The American Academy of Orthopaedic Surgeons specifically states that reverse shoulder arthroplasty is indicated for patients with massive, unrepairable rotator cuff tears with pseudoparalysis who have failed other treatments 1, 2
• Pseudoparalysis is defined as preserved deltoid contraction but loss of active elevation 3
• RSA is also indicated for rotator cuff tear arthropathy (massive tear combined with glenohumeral arthritis), which is not mentioned in this case 1, 2
• The presence of full active shoulder elevation with a massive rotator cuff tear is actually a contraindication to RTSA 3

This Tear Appears Repairable

• The imaging describes intact posterior fibers of the supraspinatus, indicating this is not a complete tendon loss 1
• A 3.4 cm transverse gap with some intact fibers represents a large but potentially repairable tear, not the "massive, unrepairable" category that defines RSA candidacy 1, 4
• The American Academy of Orthopaedic Surgeons reports that 81% of surgical patients with full-thickness tears achieved excellent results with rotator cuff repair 1

Rotator Cuff Repair Approach

Surgical Candidacy

• Rotator cuff repair is an option for patients with chronic, symptomatic full-thickness tears 1
• The primary indication for rotator cuff repair is significant pain, not tear size alone 1
• Patients treated surgically demonstrated statistically significant less pain on shoulder range of motion and at night compared with nonsurgical treatment 1

Important Prognostic Considerations

• The moderate muscle atrophy of supraspinatus and infraspinatus is a negative prognostic factor but does not preclude repair 5
• Fatty infiltration status (not mentioned in your imaging) is critical to assess, as advanced fatty degeneration influences treatment decisions 5
• Multiple level IV studies suggest overall positive outcomes of repair despite muscle disease often present in chronic rotator cuff disease 1

Critical Pitfalls to Avoid

Do Not Prematurely Choose RSA

• RSA should not be performed for isolated supraspinatus tears 3
• Severely impaired deltoid function is an absolute contraindication to RSA, as the deltoid must power shoulder motion after this procedure 2
• Patients under 50 years face increased risks of prosthetic loosening and decreased survivorship with arthroplasty 2

Assess for True Irreparability

• Before considering RSA, the patient must have failed at least 6 months of nonoperative treatment 4
• True irreparability typically involves at least a two-tendon tear with specific functional criteria 4
• Common RSA candidates present with either: (1) <90° arm elevation without anterosuperior escape (66.6% of cases), (2) <90° elevation with anterosuperior escape (26.7%), or (3) irreparable tear with pain despite >90° elevation (6.7%) 4

Consider Conservative Management First

• If the patient is asymptomatic or minimally symptomatic, surgery may not be warranted at all 1
• NSAIDs, acetaminophen, and a single corticosteroid injection may provide adequate relief 5
• Multiple steroid injections should be avoided as they may compromise rotator cuff integrity and affect subsequent repair 1

Algorithm for Decision-Making

Step 1: Assess symptom severity—is there significant pain limiting function? If no, consider conservative management 1

Step 2: Evaluate active shoulder elevation—can the patient actively elevate the arm >90°? If yes, RSA is contraindicated 3

Step 3: Determine repairability—are there intact tendon fibers that can be mobilized? If yes (as in this case), proceed with rotator cuff repair 1

Step 4: Check for glenohumeral arthritis—is there rotator cuff tear arthropathy? If no (as in this case), RSA is not indicated 1, 2

Step 5: Assess deltoid function—is the deltoid intact and functional? If impaired, RSA is contraindicated 2