Overview
An irreparable rotator cuff tear occurs when a rotator cuff tear has become too large, too retracted, or has been present for too long to be repaired successfully. As time passes, the tendon retracts, the muscle atrophies, and tissue quality deteriorates.
I often compare this to a crack in a windshield. A small crack can often be repaired, but once it spreads too far the windshield must be replaced. Likewise, once a rotator cuff tear becomes irreparable, treatment shifts from repairing the tendon to replacing the mechanics of the shoulder. Unlike a repairable rotator cuff tear, an irreparable tear is no longer on the clock. Treatment decisions are based primarily on pain, function, and quality of life.
Presentation
Patients typically present with pain, weakness, and significant loss of function. Many have difficulty raising the arm overhead or performing routine daily activities. As arthritis develops, some patients develop pseudoparalysis, where they can no longer actively raise the arm. These tears usually develop over many years, even if a recent fall is what finally brings the patient to the office.
Conservative Treatment
Treatment may include activity modification, therapy to maintain motion and strengthen the remaining muscles, and corticosteroid injections. Because the tendon is no longer repairable, injections may be repeated when appropriate to provide pain relief.
Surgical Treatment
When pain becomes unacceptable, injections no longer help, or pseudoparalysis develops, a reverse total shoulder arthroplasty is recommended. In this procedure, the ball is placed on the socket (glenoid) side and the socket is placed on the arm (humeral) side, placing the shoulder in a position where it can function well without a normal rotator cuff. The procedure is performed through an open incision, generally takes 30-45 minutes, and most patients return home the same day.
Recovery
Patients begin light use of the arm in front of the body immediately while following lifting restrictions. Typical milestones include sling removal around six weeks, moderate activities by three months, and maximum recovery around six months. The primary goal is pain relief, with many patients also regaining the ability to raise the arm.