Massive Rotator Cuff Tear Treatment Options

A massive rotator cuff tear is one of the most complex shoulder injuries an orthopedic surgeon treats. A tear is considered “massive” when it involves two or more of these tendons or when the tear is greater than five centimeters in size. Because these injuries significantly affect function, strength, and comfort, proper treatment is essential to restoring quality of life and returning to daily activities.  The choice of treatment is based on what is appropriate for each patient.

Non-surgical treatments

Not every patient with a massive rotator cuff tear requires surgery. For some, especially those who are older, less active, or experiencing only mild discomfort, non-surgical management may provide significant relief.

The main goal of conservative treatment is to reduce pain, restore as much motion as possible, and allow patients to continue with their daily routines. This includes:

• Physical therapy
• Medications
• Steroid injections
• Activity modification

Surgical treatment options

When symptoms are severe, daily function is impaired, or conservative care is not effective, surgical treatment is often the best option. Dr. Brian Waterman, a board-certified and fellowship-trained orthopedic surgeon in Winston-Salem, North Carolina, offers advanced surgical approaches tailored to each patient’s needs.

1. Arthroscopic rotator cuff repair

When possible, a torn tendon can be repaired using minimally invasive arthroscopic techniques. Small incisions allow the surgeon to reattach the torn tendon to the bone using sutures and anchors. For massive tears, repair can be more complex and at high risk for retearing, but for the right candidate this procedure can restore strength, reduce pain, and improve mobility.

2. Arthroscopic debridement with biceps tenotomy or tenodesis.

Arthroscopic debridement with biceps tenotomy or tenodesis is a minimally invasive procedure often used when a massive rotator cuff tear cannot be fully repaired. During the surgery, damaged tissue is cleaned out to reduce pain and improve shoulder function. If the biceps tendon is also contributing to pain, it may be released (tenotomy) or reattached to a different spot on the arm bone (tenodesis). This approach helps relieve discomfort, improve range of motion, and maintain shoulder stability, particularly in patients who are not candidates for full rotator cuff repair.

3. Partial repair

In some cases, the entire rotator cuff cannot be repaired because of the size of the tear or the quality of the tissue. Surgeons may perform a partial repair, addressing the most critical areas to improve shoulder mechanics and decrease pain. While this does not fully restore the rotator cuff, it often leads to meaningful improvements in comfort and daily function.

4. Patch Augmentation

Patch augmentation is a surgical technique sometimes used in the treatment of massive rotator cuff tears when the tendon tissue is weak or insufficient for a strong repair. In this procedure, a biological or synthetic patch is placed over the repair site to reinforce the tendon and promote healing. The patch provides additional strength and support, helping reduce the risk of re-tear and improving overall shoulder function, especially in patients with poor tissue quality.

5. Tendon transfer

For patients with irreparable tears where the native rotator cuff tissue cannot be brought back to the bone, tendon transfer may be considered. This involves taking a tendon from a nearby muscle and repositioning it to help restore balance and function to the shoulder.This option is typically reserved for younger, active patients who need significant strength recovery.

6. Superior capsule reconstruction (SCR)

This is a relatively newer technique designed for patients with massive, irreparable rotator cuff tears. A graft, either from donor tissue or from the patient, is used to reconstruct the top portion of the shoulder capsule. By stabilizing the joint, SCR helps restore shoulder mechanics and reduces pain. It is most effective in patients who have good range of motion but lack strength due to the tear.

7. Reverse shoulder replacement

For patients with advanced rotator cuff damage and associated arthritis, a reverse shoulder replacement may be the best solution. Unlike traditional shoulder replacement, this procedure switches the position of the ball and socket, allowing other muscles—particularly the deltoid—to take over for the torn rotator cuff. Reverse replacement is often very effective at reducing pain and restoring the ability to lift the arm overhead, even in cases of massive, irreparable tears.

What are the factors that influence treatment choice?

The right treatment for a massive rotator cuff tear depends on several factors, including:

• Tear size: When rotator cuff damage is so extensive that it cannot be repaired, Dr. Waterman may need to use alternative measures.
• Age: Younger patients often benefit from surgical repair or tendon transfer, while older patients may do well with conservative measures or reverse shoulder replacement.
• Activity level: Athletes or individuals with physically demanding jobs may require more aggressive treatment to restore shoulder strength.
• Tissue quality: The condition of the torn tendon and surrounding muscles plays a key role in whether repair is possible.
• Associated conditions: The presence of arthritis or stiffness in the shoulder may guide the choice between repair and replacement.

Each patient’s treatment plan is highly individualized, ensuring the best chance for pain relief and functional recovery.

Rehabilitation and recovery

Regardless of whether treatment is surgical or non-surgical, rehabilitation plays a central role in recovery. Physical therapy focuses on restoring motion, strength, and shoulder stability. Commitment to therapy is critical for achieving the best outcomes.

If you are struggling with shoulder pain, weakness, or loss of mobility, a massive rotator cuff tear could be the cause. These injuries can limit your ability to work, exercise, and enjoy life, but advanced treatment options are available to help you regain function and reduce discomfort. Dr. Brian Waterman, board-certified and fellowship-trained in orthopedic surgery and sports medicine, provides expert evaluation and personalized treatment for rotator cuff injuries in Winston-Salem, North Carolina.

Don’t let shoulder pain hold you back. Contact Dr. Waterman’s office today to schedule a consultation and learn which treatment approach is right for you.