Rotator cuff tears do not always require surgical repair. The decision depends on factors like the patient's age and activity level as well as the size and chronicity of the tear. Smaller tears in younger, more active patients may heal with non-operative treatment or repair, while larger, chronic tears in older individuals often do not heal after repair. When repair is not indicated for massive, irreparable tears, options include tendon transfers, superior capsular reconstruction, augmented repairs, and InSpace balloon spacers. Ultrasound is useful for initial evaluation and post-operative monitoring but MRI may better assess tear size and tissue quality factors that predict repair outcomes.

1. @thearmclinic
Rotator Cuff Tears
Full Thickness
Lennard Funk

2. Tear = Repair (?)
• Radiology report:
• “There is a large rupture of the supraspinatus
tendon with significant retraction”
• “Recommend Surgical referral”

3. @thearmclinic
Find x
x
3cm
4cm
The simplest solutions are often the cleverest
They are also usually wrong!
Here it is!

4. Natural History - AGE
• 54% Asymptomatic cuff tears over 60yrs [Sher. 1995]
» 28% - Full thickness (on MRI)
• 34% Apoptosis in Degenerate Supraspinatus
[Yuan & Murrell. 2002]
• Tendon Matrix Degeneration increases with Age
[Riley et al. 2001]

5. Natural History - TEAR SIZE
• Small tears attempt to heal:
– Increased fibroblast cellularity
– Blood vessel proliferation
– Significant inflammatory component.
– Healing diminishes as the size of the tear and the amount of
tendon degeneration increase.
– Progressive tendon degeneration is characterised by:
– Thinning of the collagen fibres
– Loss of collagen structure
– Myxoid degeneration, hyaline degeneration,
chrondroid metaplasia & fatty infiltration.
Matthews, et al. JBJS. 2006.

6. Natural History - TEAR PROGRESSION
Partial thickness articular surface cuff tears
Arthrography
(n=40; fu=14 months)
10 % healed
10% decreased
80% enlarged/full thickness tears
- Yamanaka (Clin Orthop. 1994)

7. Natural History - SYMPTOMS
• Asymptomatic tears become Symptomatic [Yamaguchi. 2001]
» 10 year follow-up of asymptomatic cuff
tears
» 50% developed symptomatic cuff tears
» 50% of tears increased in size
▪ Symptoms ⌿ Tear Size

8. Summary
• Asymptomatic ‘tears’ common
• 50% become symptomatic in 10yrs
• 80% small tears get bigger
• BUT: Size doesn’t correlate with Symptoms
• Small tears can heal
• Large, chronic won’t heal

9. @thearmclinic
Clinical Examination

10. Investigations - Ultrasound
• Immediate
• Quick
• Convenient
• Cheap
• Safe
• Dynamic
• Post-op

11. Predictors (Metanalysis, 2014)
• Age
• Tear Size
• Fatty Infiltration
• Smoking
• Chronicity
• Obesity
• Comorbidities
Jack Turnbull, 4th Year Medical Student, 2014.

12. Effect of Age & Tear Size on healing
SMALL MEDIUM LARGE MASSIVE
50YRS OLD 74% 78% 63% 43%
60 YRS OLD 65% 70% 52% 33%
70YRS OLD 54% 60% 41% 24%
80YRS OLD 43% 49% 31% 17%
MS Rashid et al. Acta Orthop 88 (6), 606-611. 2017 Sep 07.

13. Indications for Repair
PATIENT:
• Physiological Age
• Active
• Trauma
• Compliant
TEAR:
• Not Massive
• <50% Fatty
infiltration
SURGEON:
• Skills
• Facilities
• Equipment
BEWARE:
• Smokers
• Corticosteroids
• Stiffness
• Arthritis

14. Non-operative Treatment
• 63 Full thickness tears
• Mean Age 60 (40-085)
• Home-based programme
• 75% symptom free @ 5yrs
• RCQALY = 83%
• Operative grp = 89%
Boorman et al. JSES, 2018

15. Traumatic v Non-Traumatic
• No difference:
– Outcome scores
– Retear / healing rates (12 v 14%)
– Only:
• “Those patients with a history of shoulder trauma
who waited longer than 24 months had higher retear
rates (20%) than those who had their surgery earlier
(13%) (P 1⁄4 .040).”
Tan et al. JSES, 2015

16. Massive Tear Options
1. InSpace Balloon
2. Tendon Transfers
3. Superior Capsular Reconstruction
4. Augmented Repairs

17. InSpace Balloon

18. @thearmclinic
RCT: InSpace vs Repair for MRCT
ClinicalTrials.gov: NCT02208440; REC ref: 13/NW/0754; Protocol: IS-CL-02-UK; IRAS: 122315

19. Superior Capsular Recon

20. Lat Dorsi Transfer Gerber: 1988, 1992, 2006

21. Bioinductive Augment
• REGENETAN
• Smith & Nephew

22. Bioinductive Augment
Collagen graft 3 weeks
3 months 6 months

23. Bioinductive Augment
6 months

24. @theshoulderdoc
REPAIR
YOUNG
OLD
LAT
DORSI
SSN/
DEBRIDE
DELTOID
REHAB
REVERSE
SCRISB
PAIN WEAK
HORN-
BLOWERAGE
Massive Cuff Tears - Decision Making

25. Summary
• Not all tears require repair
• Indications:
– Patient: Age, Activity level
– Tissues: Muscle quality, Tear size
• Ultrasound vs. MRI
• Massive Tear Options

26. THANK YOU
Balloon
SCR
Deltoid
RehabRepair
SSN
Tenotomy
RSA
Inject
ASD
SCR
Patch
Dunno

27. @thearmclinic
THANK YOU
LENFUNK@SHOULDERDOC.CO.UK