The massive rotator cuff tear includes at least three tendons. Many surgeons have incorrectly referred to the massive tear as one that is irreparable. Today, the massive rotator cuff tear has many surgical options, including arthroscopic repair (1, 2 and 3). It is critical that the treating physician carefully evaluate the characteristics of the muscle, tear pattern, patient’s comorbidities, and degree of disability to determine the best method of management. The etiology of a massive tear may be trauma or an extension of an existing medium-sized tear following a specific event. These tears may be found at times in an older population with chronic changes noted on imaging studies. With improved imaging studies, rotator cuff tears are being diagnosed prior to significant muscular changes following trauma. This may present an opportunity to treat and repair symptomatic shoulders prior to permanent changes developing within the muscles and tendons. The possibility of successful healing and a “watertight” closure is best in the younger individual with minor changes to the detached cuff tendons. Delays in treatment may lead to tear extension and retraction, muscular atrophy, fatty changes within the muscles, superior migration of the humeral head, decreased tendon vascularity, and tuberosity osteopenia—all of which can impact the ability of healing.

Tear pattern recognition is important to understand how some small and medium tears can extend into a massive tear. Most rotator cuff tears begin along the anterior edge of the supraspinatus tendon. Tear extension is most common in a posterior direction, which eventually causes disruption of the entire supraspinatus and extends through the overlapping infraspinatus insertion. Some tears will also extend anteriorly across the rotator cuff interval to include the subscapularis. The massive cuff tear pattern is most often a crescent-shaped tear. The medial extension along the intervals, either anteriorly into the subscapularis or posteriorly into the infraspinatus, may create delaminations and a multilayered tear. In order to consider a repair that has minimal tension, these complex tear patterns need to be recognized and anatomically addressed when possible. The rotator interval may be included in this tear pattern, and disruption of the biceps pulley system is common (4). Treatment of biceps tears or instability may need to be included in the treatment of the massive rotator cuff tear.

Patients with a massive rotator cuff tear may exhibit a number of complaints ranging from resting pain to complete loss of function (Fig. 11.1). One role of the rotator cuff is to stabilize the glenohumeral articulation during functional elevation created by the deltoid. As the tear extends, certain shoulders are unable to compress the humeral head into the glenoid. This is rarely found with a
single tendon tear and is more likely attributed to tears that include the superior portion of the subscapularis and the majority of the infraspinatus (5). This condition has been compared with a boutonniere deficiency seen with extensor capsule disruption of a finger. The remaining tendons sublux inferior to the axis of the joint creating an adductor force during an attempt of arm abduction. This results in a shrug sign. Over time, this dynamic loss may evolve into a fixed deformity reducing the humeral head acromion interval on a sitting or standing radiograph (Fig. 11.2).

An arthroscopic evaluation of a massive rotator cuff tear allows a thorough examination without deltoid detachment or retraction. There have been studies that recommend an open approach to a large and massive tear; however, these have been challenged by newer arthroscopic techniques, which mobilize tears and create secure repairs to the tuberosities (6,7). Advantages of arthroscopy include (1) reduced risk of infection, (2) reduced risk of postoperative stiffness, (3) reduced risk of deltoid injury, and (4) reduced morbidity during the early postoperative period.