Overview
The prevalence of full-thickness rotator cuff tears is about 25% after 60 years and 50% after 80 years; a patient with a symptomatic tear has a 50% chance of an asymptomatic full-thickness tear in the other shoulder (Campbell). Because many tears are asymptomatic, retear is common and nonoperative care often succeeds, treatment must be individualized (Campbell).
Clinical Evaluation (Campbell)
Anterolateral shoulder pain radiating to the deltoid region, pain with overhead activity and lifting with the arm outstretched, night pain and sleep disturbance.
MRI characterizes location, size, retraction, atrophy, fatty infiltration and any tendon stump left on the tuberosity (a stump shortens tendon available for repair). It is indicated in young active patients with acute tears and in chronic tears after failed nonoperative treatment.
Fatty infiltration (Goutallier, modified by Fuchs for MRI) (Campbell)
Grade | Muscle |
|---|---|
0 | Normal |
1 | Some fatty streaks |
2 | More muscle than fat |
3 | Equal muscle and fat |
4 | More fat than muscle |
Grades 3-4 indicate long-standing tears with a higher risk of failure and are often irreparable. Goutallier III-IV tears with a tendon stump shorter than 15 mm and a positive tangent sign have a 90% failure rate (Campbell).
Treatment Decision (Campbell)
Nonoperative treatment succeeds in about 60% and is generally used first in chronic tears, especially over 65 years; tear progression is about 50% at 2 years, and enlargement correlates with symptoms.
Repair is indicated for acute full-thickness tears and for chronic tears after failed nonoperative care. Acute tears are ideally repaired within 6 weeks to 3 months; repairs more than 4 months after injury have inferior outcomes.
Failure risk rises with larger tears, more retraction, higher Goutallier grade, older age, smoking, osteoporosis, diabetes, hypercholesterolemia and aggressive early rehabilitation.
Best healing potential: under 70 years, acute small tears (under 3 cm), healthy tendon-bone interface, compliance with sling and a 6- to 9-month rehabilitation. Carefully selected patients over 70 also improve as much as younger patients.
Irreparable tears (marked retraction, Goutallier III-IV): debridement, tendon transfer, superior capsular reconstruction or reverse shoulder arthroplasty.
Repair Principles (Campbell)
Anatomic, tension-free reduction to the footprint is the goal; if impossible without tension, a medialized repair can be used. Strong fixation must resist gapping under cyclic and rotational loading.
Single row covers about 50% of the footprint; double row nearly 100%, with higher load to failure, better compression and less gapping (especially at the anterior edge where the rotator cable inserts) and higher MRI healing rates. No clinical difference in small and medium tears; large and massive tears do better with double-row or transosseous-equivalent repair, although overconstraint can cause failure at the musculotendinous junction (type 2 failure).
Double-row fixation has been found more cost-effective than single row because of lower retear risk; triple-loaded anchors may reduce the number of medial anchors.
Marrow stimulation of the tuberosity (2.0-mm or smaller drill or bone punch, "crimson duvet") should be considered, avoiding planned anchor sites.
Tear patterns: crescent (good medial-lateral mobility), U-shaped and L-shaped (good anterior-posterior mobility; use margin convergence from medial to lateral), chronic massive contracted tears (releases and interval slides, possibly graft augmentation; single-row fixation just lateral to the articular surface to avoid overload).
Biologic augmentation (platelet-rich plasma, stem cells) has limited evidence of benefit. The authors prefer arthroscopic double-row or transosseous-equivalent repair.
Technique 57.21: Arthroscopic Rotator Cuff Repair (Campbell)
Setup and diagnostic arthroscopy
Beach-chair with an articulated arm holder, or lateral decubitus with the arm in 30 degrees of abduction and 10 degrees of flexion in balanced suspension; lower-extremity compression devices.
Mark landmarks and portals. Usually four portals: posterior and anterior (suture retrieval and storage), lateral (working) and posterolateral (viewing); a 70-degree scope from posterior may make the posterolateral portal unnecessary. Anchors are inserted percutaneously just off the lateral acromion.
Perform diagnostic glenohumeral arthroscopy and treat biceps, subscapularis, labral and cartilage pathology.
Move the scope into the subacromial space and create the lateral working portal at the center of the tear with spinal needle localization.
Preparation and mobilization
Perform a complete bursectomy (lateral to medial) with shaver and electrocautery, making sure the posterior extent of the tear is visible; acromioplasty as indicated.
Define tear depth and configuration (crescent, U, L) and assess retraction and mobility with a grasper or traction suture.
If mobility is poor, release the articular side with an elevator or blunt trocar and, if needed, around the scapular spine and coracoid base. Protect the suprascapular neurovascular bundle medial to the superior glenoid during articular-sided release; bursal releases are safer but bleed.
Establish the posterolateral viewing portal.
Lightly decorticate the footprint and abrade the undersurface of the cuff, avoiding planned all-suture anchor sites.
Medial row
Space anchor insertion points about 1 cm apart to avoid tuberosity fracture. Percutaneously insert medial row anchors just off the articular surface, flush with bone (double- or triple-loaded all-suture or screw-in anchors depending on bone quality).
Through an 8.25-mm notched cannula in the lateral portal, pass sutures starting anteriorly. Pass mattress sutures through the tendon about 4 mm lateral to the musculotendinous junction, about 7 mm apart, retrieving limbs out the anterior portal.
Then pass sutures from the posterior medial anchor, posterior to anterior, retrieving them out the posterior portal; all in a horizontal mattress configuration.
Lateral row and completion
Double row: tie medial knots posterior to anterior (alternating half-hitches if sutures do not slide), then retrieve the limbs. Transosseous equivalent: pass but do not tie the medial sutures.
Bring one limb from each suture group out the lateral cannula, tension them to choose the lateral anchor site, clear the lateral cortex of soft tissue, load the limbs into a knotless lateral anchor and insert it under tension; repeat anteriorly.
Take the arm through motion to check for anterior gapping or acromial impingement.
If anatomic repair is impossible, use releases and margin convergence: pass No. 2 nonabsorbable sutures through both leaves with a crescent shuttle, starting at the apex and working medial to lateral, aligning the tear anatomically.
Massive contracted tears (Technique 57.22, Tauro) (Campbell)
Anterior interval slide (between supraspinatus and rotator interval/coracohumeral ligament) followed, if needed, by a posterior interval slide between supraspinatus and infraspinatus to mobilize the tendons; repair the supraspinatus to a lateral bed tension-free, advance infraspinatus and teres minor and close residual defects side to side.
Postoperative Care (Campbell)
Sling for 6 weeks after almost all repairs.
Strengthening is generally delayed until about 10 weeks to avoid overloading the healing repair.
References
Brolin TJ, Lamplot JD. Arthroscopy of the upper extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 57, Techniques 57.21-57.22.