Can a patient with a full-thickness rotator cuff tear and associated shoulder degeneration be treated surgically?

Surgical Management of Massive Rotator Cuff Tear with Advanced Degeneration

This patient is a poor surgical candidate for standard rotator cuff repair due to the presence of multiple unfavorable prognostic factors: full-thickness full-width tears with retraction, severe fatty infiltration and atrophy of both supraspinatus and infraspinatus muscles, superior humeral head migration, acetabularization of the acromion, and moderate glenohumeral osteoarthritis—all indicating an irreparable rotator cuff tear with rotator cuff arthropathy. 1, 2, 3

Critical Assessment of Surgical Candidacy

Unfavorable Prognostic Factors Present

This patient demonstrates essentially all the negative predictors for poor surgical outcomes:

• Massive tear with retraction: Full-thickness full-width tears of both supraspinatus and infraspinatus with retraction significantly reduce healing potential and functional recovery 3
• Advanced muscle degeneration: Severe fatty infiltration and atrophy of the infraspinatus and supraspinatus muscle bellies are associated with poor surgical outcomes and represent irreversible changes that prevent meaningful functional recovery 1, 2, 3
• Superior humeral head migration: This finding indicates loss of the rotator cuff's depressor function and is a hallmark of massive irreparable tears 2
• Acetabularization of the acromion: This adaptive change to the undersurface of the acromion from chronic superior migration indicates long-standing, severe rotator cuff pathology 4
• Glenohumeral osteoarthritis: Moderate degenerative changes suggest progression toward rotator cuff arthropathy, which fundamentally changes the treatment paradigm 4

Primary Indication Assessment

• Surgery requires significant pain as the primary indication according to the American Academy of Orthopaedic Surgeons, and asymptomatic tears should never be operated on regardless of imaging findings 4, 1
• The question states "chronic shoulder pain" but does not specify severity or functional limitation—this must be quantified before any surgical consideration 4, 1

Treatment Algorithm

If Patient Has Significant Pain and Functional Limitation

Initial approach should be comprehensive conservative management:

• Begin with NSAIDs or COX-2 inhibitors combined with acetaminophen for pain control 2, 5
• Implement supervised physical therapy focusing on maintaining range of motion and strengthening remaining intact muscles (teres minor, deltoid) 5
• Consider a single corticosteroid injection with local anesthetic for short-term pain relief, but avoid multiple injections as they compromise tissue integrity 1, 2, 5
• Monitor for 3-6 months, as approximately 75% of patients with full-thickness tears remain successfully managed nonoperatively at 5 years 6

If Conservative Management Fails

Standard rotator cuff repair is contraindicated in this patient due to irreparable tear characteristics 3. Alternative surgical options include:

• Reverse total shoulder arthroplasty: This is the appropriate surgical intervention for elderly patients with irreparable cuff tears and rotator cuff arthropathy, as it bypasses the need for intact rotator cuff function 7
• Superior capsular reconstruction or partial repair may be considered in younger patients, though outcomes are unpredictable with this degree of muscle degeneration 3

If Patient Has Minimal or No Pain

• No surgery should be performed according to the American Academy of Orthopaedic Surgeons consensus recommendation, as asymptomatic rotator cuff tears should not undergo surgical repair regardless of imaging severity 4, 1

Evidence Regarding Surgery vs Conservative Treatment

• One level III study showed 81% of surgical patients reported excellent results compared to 37% with nonsurgical treatment for chronic symptomatic full-thickness tears 4
• However, a 2017 meta-analysis of RCTs found no clinically significant difference between surgery and conservative treatment at 1-year follow-up, with pain reduction favoring surgery by only 0.93 cm on a 0-10 scale—below the minimal clinically important difference 8
• These studies evaluated repairable tears in patients without advanced muscle degeneration—this patient's imaging findings place them outside the population where standard repair would be beneficial 3, 8

Critical Pitfalls to Avoid

• Do not attempt standard rotator cuff repair in the presence of severe fatty infiltration and muscle atrophy, as healing rates are extremely poor and functional outcomes disappointing 1, 3
• Do not use multiple corticosteroid injections, as they compromise rotator cuff integrity and may affect subsequent surgical options 1, 5
• Do not operate based on imaging alone—significant pain is the primary indication for any rotator cuff surgery 4, 1
• Do not delay consideration of reverse total shoulder arthroplasty if the patient has failed conservative management and has significant functional limitation, as this addresses both the irreparable tear and the glenohumeral arthritis 7