With the advent of improved techniques and instrumentation, and increased experience, arthroscopic rotator cuff repair has become as effective as traditional open and miniopen approaches for a variety of tear sizes ranging from small to massive (3,26,27,31,34). Arthroscopic techniques also have several distinct advantages over traditional open methods including less soft tissue violation, decreased risks of injury to the axillary nerve and deltoid origin, and a decreased infection rate. By decreasing the amount of dissection with arthroscopic repairs, patients can be immobilized safely postoperatively for a longer period of time with less concern for the development of acquired postoperative stiffness compared to open repairs. Arthroscopic approaches also allow for accurate inspection of the glenohumeral joint and treatment of intra-articular pathology including injuries to the biceps tendon and labrum. Accurate determination of rotator cuff tear anatomy is also facilitated when repairs are performed arthroscopically. Because of these advantages, we now rarely resort to open techniques and repair most rotator cuff tears, including most massive tears, arthroscopically with consistently good results. We present here one of our current double-row techniques for repairing full-thickness medium to large and simple massive rotator cuff tears.

We routinely perform double-row rotator cuff repairs for most medium, large, and massive tears. Several biomechanical studies suggest that double-row repairs are stronger than single-row repairs (19,22,23). Despite these biomechanical advantages, current clinical studies do not clearly indicate the superiority of double-row repairs over single-row repairs with respect to final functional outcomes. There is some clinical evidence supporting the idea that double-row constructs lead to higher healing rates compared to single-row repairs (1,6,20,29). Other authors report no difference between single- and double-row repairs with regard to healing (5,9). Nevertheless, potentially higher healing rates do not necessarily translate into improved clinical outcomes in all cases. We have anecdotally noticed in our own patients that younger patients who fail to heal often have worse function and pain control compared to similar older patients. Since the clinical benefit of a double-row repair has still not been proven with regard to final functional outcomes and because of the added cost, some surgeons choose to perform single-row repairs in all patients, or at least in older patients where a retear may not have as significant of a clinical effect. At this time, we still prefer a double-row construct for most patients and in particular younger ones because of the theoretical improvements in healing.

Our main indication for rotator cuff repair is presence of a painful full-thickness tear in a young patient or a tear that is refractory to conservative management in older patients. We will not review the management of partial-thickness tears in this chapter. Three factors have a significant influence on rotator cuff repair healing and therefore the decision-making algorithm for treating full-thickness rotator cuff tears. These include patient age, tear
size, and muscle quality (degree of fatty degeneration and atrophy). Along with taking into consideration these factors, knowledge of the natural history of tears treated nonoperatively will guide surgical indications.

The rotator cuff has limited capabilities for healing without repair, and there is a significant prevalence of tear progression over time with nonoperative treatment of full-thickness tears (33). Older and more sedentary patients tolerate tears and lack of healing after repair better than younger and more physically active patients (11,18). Younger patients heal rotator cuff repairs more reliably than older patients (2,7,11,17,24). Larger and more complex tears have higher retear rates after repair than smaller tears (8,12,25). Fatty degenerative changes of the rotator cuff occur over time as the tendon remains detached (13). These changes can be halted in the setting of a healed repair although they are not reversible (14). In some more advanced cases, rotator cuff repair may not prevent progression of fatty degeneration and muscle atrophy (15,16,28). Finally, preoperative atrophy and fatty infiltration of the rotator cuff muscles negatively influences the ability of a rotator cuff repair to heal (21).

In considering these factors, we tend to be more aggressive in repairing any sized full-thickness tear in patients <60 years of age. In this patient population, negating all other confounding factors such as smoking, we know that the chances of healing are much better than in older patients. We also know that without surgical intervention, there is a 50% chance that the symptomatic tear will increase in size and become more symptomatic (33). Younger patients with a cuff tear, and those who fail to heal a repair, are more often dissatisfied and symptomatic compared to patients older than 60 years (32). This may be in part due to the fact that younger patients are more active and have higher functional demands. We are less aggressive in repairing very large, chronically retracted tears with extensive muscle changes even in a younger age population because of poor healing capabilities of severely affected muscles. We are also less aggressive in repairing tears in patients older than 65 because of the poorer healing capabilities in this older population. However, if prolonged conservative management fails in these older patients or younger patients with very large tears with extensive muscle changes, rotator cuff repair is considered.

Contraindications to arthroscopic rotator cuff repair include ongoing or recent infection, inability to comply with postoperative requirements, advanced glenohumeral joint arthritis, superior migration of the humeral head in the setting of rotator cuff-tear arthropathy, serious life-threatening comorbidities, and some neuromuscular disorders such as advanced Parkinson disease and cerebral palsy. Massive retracted tears with extensive fatty degeneration and scarring is also a relative contraindication. Patients older than 70 with low activity demands and with massive retracted and scarred cuff muscle remnants who present with pain that is refractory to conservative management as the chief complaint may be most reliably treated with either an arthroscopic débridement with biceps tenotomy or a reverse total shoulder arthroplasty dependent on their baseline shoulder function. Younger patients with irreparable massive rotator cuff tears and an intact subscapularis in the absence of glenohumeral arthritis may be candidates for a latissimus dorsi tendon transfer, with or without the teres major. Patients with painless rotator cuff tears, or those with very mild pain, and without any significant functional disability, are usually observed. In this scenario, younger patients are followed more vigilantly with yearly examination and imaging studies (magnetic resonance imaging [MRI] or ultrasound) to ensure that the tear is not progressing. In cases of rotator cuff tear arthropathy with massive irreparable tears and an intact deltoid muscle, the reverse total shoulder arthroplasty is a reliable option for pain relief and optimal recovery of function.

Patients with symptomatic rotator cuff tears often complain of pain with overhead activities and reaching behind their back. Patients usually either report an insidious onset of symptoms or an acute traumatic event. Often, the pain is described as radiating from the shoulder along the lateral aspect of the upper arm, sometimes to the elbow and proximally to the neck. Patients routinely describe pain at night that interrupts sleep. In addition, depending on the tear size and chronicity, there may be variable degrees of functional deficits.

The physical examination includes inspection of the shoulder for supraspinatus and infraspinatus wasting that is present with very large rotator cuff tears. Passive motion is tested in all directions. Limitation of internal rotation is very common with any rotator cuff pathology and reflects a posterior capsular contracture. Inferior contracture can occur with large tears and superior migration of the humeral head, which should be released prior to repair through manipulation. Significantly increased external rotation at the side compared to the opposite shoulder can indicate a very large subscapularis tear. Rotator cuff strength is tested using a variety of maneuvers. The abdominal compression test or lift off test can be used to evaluate subscapularis strength. Resisted thumbs-down abduction in the scapular plane evaluates the supraspinatus, while external rotation strength with the elbows at the side evaluates infraspinatus function. The hornblower’s test and resisted external rotation with the shoulder abducted 90 degrees examine teres minor function. Pain with palpation of the acromioclavicular (AC) joint and crossbody adduction can point toward the AC joint as a potential source of pathology. The biceps contour should be evaluated for a Popeye sign seen with rupture of the tendon of the
long head of the biceps. Other biceps provocation test, such as Yergason or Speed maneuver, can be performed although the specificity of these tests to indicate biceps pathology is limited. Pain with direct palpation over the proximal biceps can be indicative of disease.