Massive Rotator Cuff Tears

Massive rotator cuff tears are defined as tears greater than 5cm in size or involving 2 or more complete tendon ruptures. These present unique challenges for treatment.

Assessment

MRI: Tear size, retraction, tendon involvement. Muscle quality (Goutallier grade).

Goutallier Classification:

• Grade 0: Normal
• Grade 1: Fatty streaks
• Grade 2: Fat less than muscle
• Grade 3: Fat = muscle
• Grade 4: Fat greater than muscle

Grade 3-4 has poor prognosis for repair (muscle cannot recover).

Tangent Sign: Supraspinatus muscle atrophy (does not reach tangent line on scapular spine).

Progressive Tear Enlargement

• Mechanical failure cascade: Initial tear increases stress on remaining tendon
• Stress concentration: Adjacent tendon margins bear increased load
• Tear propagation: Anterior-to-posterior or medial progression common
• Critical size threshold: Tears greater than 3cm have higher progression rates

Muscle Changes

Retraction:

• Tendon retracts medially after rupture
• Static retraction indicates chronic irreducible tear
• Retraction beyond glenoid rim = poor repair outcome

Fatty Infiltration (Steatosis):

• Occurs within 3-6 months of complete tear
• Progressive and IRREVERSIBLE
• Goutallier Grade 3-4 fatty changes preclude successful repair
• Muscle replaced by fat cannot regenerate contractile function

Muscle Atrophy:

• Cross-sectional area decreases with disuse
• Tangent sign positive when supraspinatus atrophied
• Atrophy partially reversible if repaired early; fatty infiltration is not

Biomechanical Consequences

• Force couple disruption: Loss of balanced compression of humeral head
• Superior migration: Unopposed deltoid pull causes humeral head ascent
• Acetabularization: Erosion of undersurface of acromion (cuff tear arthropathy)
• Femoralization: Humeral head becomes smooth, rounded (loss of greater tuberosity)

History

Weakness with overhead activities. May have history of acute on chronic pain. Difficulty sleeping on side. Progressive loss of function.

Examination

Pseudoparalysis: Cannot actively elevate arm (often less than 90°). Indicates loss of force couple.

Horn-blower's Sign: Cannot externally rotate in abduction (infraspinatus/teres minor dysfunction).

External Rotation Lag Sign: Cannot maintain externally rotated position (posterior cuff failure).

Belly Press Test: Cannot maintain hand pressure on belly (subscapularis).

Imaging

Plain Radiographs:

• AP, axillary lateral, scapular Y views
• Acromiohumeral interval (AHI): Less than 7mm suggests massive tear with superior migration
• Acetabularization: Concave erosion of undersurface of acromion
• Femoralization: Smooth, rounded humeral head
• Glenohumeral arthritis: Suggests cuff tear arthropathy

MRI (Gold Standard):

• Tear size measurement in coronal and sagittal planes
• Tendon retraction (medial to glenoid = poor prognosis)
• Fatty infiltration grading (Goutallier):

• Grade 0: No fat
• Grade 1: Fatty streaks
• Grade 2: Fat less than muscle
• Grade 3: Fat equals muscle
• Grade 4: Fat greater than muscle

• Tangent sign: Positive when supraspinatus does not reach scapular spine tangent (atrophy)
• Occupation ratio: Less than 50% suggests significant atrophy

CT Arthrography:

• Alternative if MRI contraindicated
• Excellent for bone detail
• Can assess fatty infiltration

Classification Schemes

Repair Complications

Tendon Transfer Complications

• Failure of transfer healing: Especially latissimus dorsi
• Nerve injury: Thoracodorsal (lat dorsi), spinal accessory (trapezius)
• Persistent weakness: Transfer may not fully restore function
• Loss of donor function: Rarely clinically significant

RSA (Reverse Shoulder Arthroplasty) Complications

Massive rotator cuff tears represent a significant clinical challenge in Australian orthopaedic and shoulder surgery practice, affecting an estimated 4-6% of the general population over age 60, with higher prevalence in manual laborers and overhead workers (tradespersons, painters, electricians). The condition has important implications for work capacity and disability in Australia's aging workforce, particularly as the retirement age extends and older workers remain in physically demanding occupations longer. Massive tears are more common in males (2:1 ratio) and are frequently associated with workplace injury claims under WorkCover schemes, though many patients present with chronic degenerative tears without a clear traumatic event.

In the Australian public hospital system, management of massive rotator cuff tears varies significantly between metropolitan tertiary centres and regional hospitals. Major shoulder surgery units in Sydney, Melbourne, Brisbane, Perth, and Adelaide offer the full spectrum of treatment options including arthroscopic repair attempts, margin convergence techniques, superior capsular reconstruction (SCR), latissimus dorsi transfers, and reverse shoulder arthroplasty (RSA). However, these advanced techniques require specialized shoulder surgeons and equipment - SCR requires dermal allograft (expensive, limited availability) or autograft fascia lata, while RSA requires specific implant systems and surgical expertise. Regional and rural patients with massive tears often require referral to tertiary centres, with waiting times in the public system potentially 6-12 months for non-urgent cases, during which tears may progress and muscle quality deteriorate (fatty infiltration advancing from Goutallier 2 to 3-4, making repair less likely to succeed).

From a RACS training perspective, massive rotator cuff tears are heavily emphasized in both written and clinical examinations. Trainees must demonstrate systematic assessment: history (duration, trauma vs degenerative, functional limitations, pseudoparalysis), examination (lag signs, external rotation strength, subscapularis function), and imaging interpretation (MRI assessment of tear size, retraction, Goutallier grading of fatty infiltration, presence of arthritis). The decision-making algorithm is critical exam content: attempt repair if tear is reducible to footprint and muscle quality acceptable (Goutallier 0-2), consider SCR or tendon transfer if irreparable but no arthritis and younger patient (less than 65-70), proceed to RSA if cuff tear arthropathy present or pseudoparalysis in older patient (greater than 70). The Goutallier classification (Grades 0-4 based on ratio of fat to muscle on sagittal MRI) is essential knowledge - Grade 3 (equal fat and muscle) is the critical threshold where repair outcomes decline significantly, and Grade 4 (more fat than muscle) predicts repair failure.

The emergence of reverse shoulder arthroplasty over the past 15 years has revolutionized treatment of massive irreparable tears in Australia, particularly for cuff tear arthropathy and pseudoparalysis in older patients. RSA converts the deltoid into the primary shoulder elevator (reversing the ball-socket relationship, medializing and distalizing the center of rotation), allowing functional arm elevation even without a functioning rotator cuff. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) data shows increasing utilization of RSA for rotator cuff arthropathy (now comprising approximately 40% of all shoulder arthroplasties performed in Australia), with 10-year survival rates of 85-90% comparable to international data. However, RSA is not without complications - instability (5-10%), scapular notching (30-40% radiographically, usually asymptomatic), infection (2-3%), and mechanical complications (loosening, fracture) - and is generally reserved for patients over 65-70 years given concerns about long-term implant survival and revision options in younger patients.

WorkCover and compensation considerations are particularly relevant for massive rotator cuff tears in the Australian context. Many patients sustain acute-on-chronic tears during manual work (lifting, overhead activities) and seek compensation for surgery and lost income. Determining work-relatedness versus pre-existing degenerative disease is often contentious - the presence of Goutallier Grade 3-4 fatty infiltration on initial MRI indicates chronic muscle atrophy predating any acute event, which may complicate compensation claims. Surgeons must provide detailed functional capacity evaluations for WorkCover insurers, including specific limitations (no overhead work, lifting restrictions, no repetitive shoulder use) and return-to-work timelines. The medicolegal implications are significant - failure to properly assess muscle quality and offer appropriate treatment (attempting repair of irreparable tear with Goutallier 4 changes, or conversely denying surgery to a patient who would benefit from RSA) can result in poor outcomes and potential negligence claims.