Why Can't My Rotator Cuff Be Repaired?

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Rotator cuff problems are a common cause of shoulder pain and difficulty with activities that require normal strength and mobility of the shoulder joint. One of the more common rotator cuff problems is a tear of the tendon of the rotator cuff. Many people who find out they have a tear in the rotator cuff may presume that surgery is an inevitable step in treatment. The reality is, for better or worse, repair of the damaged rotator cuff may not be the best treatment, and in many cases it may not even be a possible treatment.

Rotator Cuff Tears

The rotator cuff is the group of four muscles that directly surround the shoulder joint. Each of those muscles is attached to the bone through a structure called the tendon. When a rotator cuff tear occurs, the tendon has detached from the bone. This can lead to pain, difficulty moving the shoulder, and weakness. Treatment of a rotator cuff tear typically begins with simple steps including physical therapy, activity modifications, anti-inflammatory medications, and possibly a cortisone injection.

If people do not respond to typical nonsurgical treatments, there is a question as to whether or not the tendons can be surgically repaired. In many cases, rotator cuff repair is a reasonable treatment option.  However, some people with a rotator cuff tear may be surprised to learn that surgical repair is not a reasonable treatment.

Why No Repair?

Surgical repair of a rotator cuff tear may not be possible for a few different reasons:

  • The tendon damage is too severe: If the rotator cuff tear is very large (a massive rotator cuff tear) and has been present for a long time, there is a chance that surgical repair is not possible. In these situations, the tendon is often contracted and cannot be reattached in its normal position. Furthermore, the muscle that pulls on the rotator cuff tendon is often atrophied (weakened) and even if the tendon were able to be repaired, the muscle would not function normally.
  • The shoulder has become arthritic: There is a condition called a rotator cuff tear arthropathy. In this situation not only is a rotator cuff tear present, but the shoulder joint has become arthritic. This is a situation where repairing the rotator cuff would not address the underlying issue of the damaged shoulder joint.

Treatment Options

The fact that the rotator cuff tear may not be able to be repaired does not mean that no treatment can be considered, and it does not mean that people need to resolve to simply live with their discomfort. While it may mean that a surgical repair of the rotator cuff is not possible, there are certainly other treatment options, both surgical and nonsurgical treatments.

Nonsurgical treatments include ice, anti-inflammatory medications, cortisone injections, activity modifications, and physical therapy. It is important for people to understand that even in the situation of a massive rotator cuff tear, there are still numerous muscles and tendons across the shoulder joint and can compensate for the damaged rotator cuff tendon. The focus of any treatment should be on therapeutic activities to restore the normal mechanics of the shoulder joint.

Is Any Surgery An Option?

Even if rotator cuff repair surgery is not a treatment option in your situation, that is not to say that surgery cannot be considered.

 There are surgical interventions that might be considered even in the setting of irreparable rotator cuff tears. These treatment options may include:

  1. Shoulder debridement surgery (abrasion arthroplasty): In this situation, your surgeon is doing a "cleanup" procedure on the shoulder. A shoulder debridement is typically performed as an arthroscopic shoulder surgery. Your surgeon uses instruments to remove damaged or inflamed tissue, smooth uneven surfaces, and clean out loose cartilage or other damage within the shoulder. 
  2. Partial rotator cuff repair: When a large rotator cuff tear is determined to be beyond repair, surgery to make the tear smaller may be possible. During a surgery when debridement is performed, some portion of the rotator cuff may be repaired. While this may not be a complete repair of the damaged tendons, sometimes even partial repair helps to restore some function to the shoulder joint.
  1. Tendon transfers: When the rotator cuff tendons have been chronically torn and contracted, and cannot be repaired, there may be an option to transfer neighboring tendons to take the place of the damaged rotator cuff.
  2. Reverse shoulder replacement: In situations where the shoulder joint has become arthritic and painful, and the rotator cuff is damaged beyond repair, a specific type of shoulder replacement may be performed. This surgery called a reverse shoulder replacement is performed to alter the mechanics of the shoulder joint in order to allow for a functioning replacement despite the damage to the rotator cuff.

Recovery & Expectations

Despite having a rotator cuff tear that may not be able to be fixed, most people with irreparable rotator cuff tears can find relief from pain and improvement in function. People should expect that with appropriate treatment over a course of several months, they should be able to find pain relief and improved ability to perform normal activities. Surgical intervention may sometimes be necessary, but the reality is the vast majority of people can improve with nonsurgical treatments. Certainly, nonsurgical treatments should be attempted for at least several months, if not longer, prior to considering any type of invasive surgical treatment.

A Word From Verywell

Rotator cuff tears are incredibly common problems. Especially as we age, rotator cuff tears eventually become an expected finding. As people enter their 60s and 70s, rotator cuff tears become essentially a normal finding on an MRI. Some people who have a rotator cuff tear will not be good candidates for surgical repair of this damage. In these situations, there may be surgical options, but a rotator cuff repair may not be a good option.

Sources:

Kuzel BR, Grindel S, Papandrea R, Ziegler D. Fatty infiltration and rotator cuff atrophyJ Am Acad Orthop Surg. 2013 Oct;21(10):613-23. doi: 10.5435/JAAOS-21-10-613

Schmidt CC, Jarrett CD, Brown BT. Management of Rotator Cuff TearsThe Journal of Hand Surgery. 2015;40(2):399-408. doi:10.1016/j.jhsa.2014.06.122.

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