Rotator Cuff Injuries Surgical Treatment

Surgery is typically recommended for:

• Acute traumatic tears in active patients: Early repair produces better healing and strength than a delayed operation.
• Full-thickness tears with weakness: Tears that meaningfully limit lifting, reaching, or overhead function.
• Tears that fail nonoperative treatment: Persistent pain or weakness despite a dedicated therapy program.
• Tears that are enlarging: Progression on follow-up imaging, which underscores the importance of regular follow-up for patients managing a tear conservatively.
• Subscapularis tears: These rarely improve without repair and tend to progress.
• Rotator cuff tear arthropathy or irreparable tears with loss of function: Patients who cannot lift the arm, in whom reconstruction, tendon transfer, or shoulder replacement is considered.

Arthroscopic Rotator Cuff Repair

Dr. Rynecki Baker most commonly performs rotator cuff repair arthroscopically, through small incisions using a camera and specialized instruments. The torn tendon is mobilized and reattached to its footprint on the humeral head using small anchors placed in the bone. The repair configuration is customized to the specific tear pattern and tissue quality of each patient. Any contributing factors identified at the time of surgery, such as bone spurs, bursitis, or biceps tendon pathology, are addressed at the same time to optimize the overall outcome.

Subscapularis Repair

The subscapularis is repaired to its footprint on the front of the humerus, most often arthroscopically. Some subscapularis tears are better addressed through an open approach at the front of the shoulder, particularly when the tendon is chronically torn and retracted toward the socket, when the lesser tuberosity has been pulled off with the tendon, or when the tendon must be freed from surrounding scar to be brought back to bone. Because the biceps tendon runs in a groove immediately alongside the subscapularis and is frequently unstable or torn when the subscapularis is, it is addressed at the same time with either a tenotomy or a tenodesis. Dr. Rynecki Baker discusses the approach with each patient beforehand and selects it based on the tear pattern seen on imaging and confirmed at surgery.

Augmentation for Rotator Cuff Repair

In certain patients, particularly those with large tears, poor tissue quality, or a history of prior failed repair, Dr. Rynecki Baker may augment the repair to reinforce the reconstruction. Biologic and synthetic patch grafts can bridge gaps in the tendon or reinforce a repair that would otherwise be at risk of re-tearing. In some patients the biceps tendon, which runs through the front of the shoulder and is frequently involved in rotator cuff pathology, can be repurposed as an augment, adding biological tissue and mechanical strength to the repair while simultaneously addressing the biceps pathology. The decision to incorporate augmentation is made on an individual basis, guided by the findings at the time of surgery and Dr. Rynecki Baker’s assessment of what will give each patient the most durable result.

When a tear cannot be brought back to bone, several options restore function without a conventional repair. Which one is appropriate depends on the patient’s age, activity level, which tendons are involved, whether the joint surface is preserved, and whether the subscapularis is intact.

Superior capsular reconstruction

A graft is secured between the top of the socket and the humeral head to restrain upward migration of the ball and restore the mechanics that a missing supraspinatus can no longer provide. This is generally considered in younger patients with a preserved joint surface.

Lower trapezius tendon transfer

For irreparable tears at the back of the rotator cuff, where loss of the infraspinatus leaves a patient unable to rotate the arm outward, the lower trapezius tendon is transferred, typically extended with a graft, to the back of the humerus. Because the lower trapezius pulls in a direction similar to the infraspinatus, the transfer restores active external rotation in a way that reproduces the shoulder’s normal mechanics. It is best suited to younger, active patients with a preserved joint surface and an intact subscapularis.

Biodegradable subacromial spacer

A soft, balloon-shaped implant is placed arthroscopically into the space beneath the acromion and filled with saline, where it acts as a cushion that keeps the humeral head from riding upward and allows the remaining intact tendons to work more efficiently. It dissolves over the course of about a year. The appeal is the recovery: there is no repair or transfer to protect, so the sling period is short and motion begins immediately, which makes it worth considering in older or lower-demand patients who still have reasonable overhead elevation and who want to avoid a larger operation.

Partial repair and debridement

In lower-demand patients whose main complaint is pain rather than weakness, repairing what can be repaired, removing inflamed tissue, and addressing the biceps tendon can provide meaningful relief.

Reverse Total Shoulder Arthroplasty

Reverse shoulder replacement is the procedure for rotator cuff tear arthropathy and for irreparable tears in patients who have lost the ability to lift the arm, particularly older or lower-demand patients and those in whom a tendon transfer or reconstruction is not appropriate.

The operation reverses the anatomy of the joint: a ball is fixed to the socket and a socket to the top of the humerus. This changes the mechanics of the shoulder so that the deltoid, rather than the rotator cuff, elevates the arm. Patients who could not raise the arm before surgery are often able to do so afterward, and the procedure is highly effective for the pain of cuff tear arthropathy.

After rotator cuff repair

Recovery requires patience. The repaired tendon must heal to the bone, a

process that takes time regardless of surgical technique.

• Sling protection: Most patients wear a sling for four to six weeks. Repairs of the subscapularis are protected from outward rotation during this period to avoid stressing the front of the repair.
• Early motion: Gentle, protected motion begins early, with the therapist moving the arm before the patient does.
• Active motion: Patients typically begin lifting the arm under their own power around four to six weeks.
• Strengthening: Progressive strengthening usually begins around three months.
• Return to activity: Return to demanding overhead work and sport is generally between six and nine months and is guided by strength and motion rather than the calendar. Large tears, augmented repairs, and revisions follow a longer timeline.

After tendon transfer or reconstruction

These procedures are protected longer, often in a brace that holds the arm in a specific position, and rehabilitation includes retraining the transferred muscle to fire in its new role.

After a subacromial spacer

Recovery is considerably faster, as there is nothing healing to bone. The sling is used briefly for comfort, motion begins immediately, and strengthening progresses as symptoms allow, with most patients returning to daily activity within several weeks.

After reverse shoulder replacement

The sling period is typically shorter and active motion begins sooner than after a repair, since there is no tendon healing to bone to protect. Therapy focuses on deltoid strength and functional range, and permanent activity guidelines apply to protect the implant.