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ROTATOR CUFF REPAIR & RECONSTRUCTION

A rotator cuff tear is a common cause of shoulder pain and disability among adults. Each year, almost 2 million people in the U.S. visit their doctors because of rotator cuff tears.
A torn rotator cuff may weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.

Anatomy

The shoulder is a ball-and-socket joint made up of 3 bones; 

  • The humerus (upper arm bone)

  • The scapula (shoulder blade)

  • The clavicle (collar bone)

Your arm is kept in your shoulder socket by several structures, including the rotator cuff. The rotator cuff is a group of 4 muscles – supraspinatus, infraspinatus, teres minor, and subscapularis - that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm. 

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There is a lubricating sac called a bursa between the rotator cuff and the bone on top of the shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move our arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful. 

Rotator Cuff Tears

When one or more of the rotator cuff tendons is torn, the tendon becomes partially or completely detached from the bone (the head of the humerus). Most tears occur in the supraspinatus tendon, but other tendons also can be involved. 
In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes from lifting a heavy object.

There are 2 different types of tears.

  • Partial tear: This type of tear does not completely detach the tendon from the bone. It is called partial because the tear goes only partially through the thickness of the tendon. The tendon is still attached to the bone, but it is thinner than normal.

  • Full-thickness tear: With this type of tear, there is complete detachment of part of the tendon from the bone. With a full-thickness complete tear, there is essentially a hole in the tendon.

Cause of Rotator Cuff Tears

There are two main causes of rotator cuff tears: injury (acute) and wear (degeneration).

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Injury-Related (Acute) Tear
If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other injuries, such as a broken collarbone, a dislocated shoulder, or a wrist fracture.

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Wear-Related (Degenerative) Tear
Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age and in most cases is relatively painless.
Rotator cuff tears are more common in the dominant arm — the arm you prefer to use for most tasks (e.g., your right arm if you are right-handed). If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder — even if you have no pain in that shoulder.

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Several factors contribute to degenerative, or wear-related, rotator cuff tears.

  • Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.

  • Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons decreases. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.

Risk Factors of Rotator Cuff Tears

Because most rotator cuff tears are largely caused by the normal wear and tear that goes along with aging, people over 50 are at greater risk.
People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.
Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.

Symptoms of Rotator Cuff Tears

The most common symptoms of a rotator cuff tear include:

  • Pain at rest and at night, especially if you are lying on the affected shoulder

  • Pain when lifting and lowering your arm or with specific movements

  • Weakness when lifting or rotating your arm

  • Crepitus, or a crackling sensation, when moving your shoulder in certain positions

Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm. 

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Tears that develop slowly due to overuse may also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm, or pain that moves down your arm. At first, the pain may be mild, and you may feel it only when lifting your arm over your head, such as reaching into a high cabinet. Over time, the pain may become more noticeable at rest and no longer goes away with medications. The pain and weakness in the shoulder may make routine activities, such as combing your hair or reaching behind your back, more difficult.

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It should be noted that some rotator cuff tears are not painful. These tears, however, may still result in arm weakness and other symptoms.

Clinical Examination

After collecting information about patient’s symptoms and history, Dr. Kim will perform a focused shoulder examination. 

  • In pure rotator cuff tear conditions, X-rays are typically normal, but X-rays are routinely done to make sure there are no other reasons for shoulder pain, such as arthritis. An MRI, CT arthrogram, or ultrasound can definitively show a rotator cuff tear if there is one. These imaging tests will show the location and size of the rotator cuff tear.

  • An MRI can also give a better idea of how old or new a tear is because it can show the quality of the rotator cuff muscles.

  • Those tests can also show other soft tissues in the shoulder that may be causing pain.

Treatment

If you have a rotator cuff tear and keep using your shoulder despite increasing pain, you may cause further damage. A rotator cuff tear can get larger over time.
Chronic shoulder and arm pain are good reasons to see an orthopedic surgeon. Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine quicker.
The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In planning your treatment, Dr. Kim will consider:

  • Your age

  • Your activity level

  • Your general health

  • The type of tear you have

Nonsurgical Treatment

In about 80 to 85% of patients, nonsurgical treatment relieves pain and improves function in patients with rotator cuff tear. 
Nonsurgical treatment options may include:

  • Rest. Rest and limiting overhead activities. 

  • Activity modification. Avoid any activities that cause shoulder pain.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). Anti-inflammatory drugs like ibuprofen and naproxen can reduce pain and swelling.

  • Strengthening exercises and physical therapy. Specific exercises will restore movement and strengthen the shoulder. The exercise program will also include stretches to improve flexibility and range of motion. Strengthening the muscles that support your shoulder can relieve pain and prevent further injury. 

  • Steroid injection. If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic combined with cortisone may be helpful. Cortisone is a very effective anti-inflammatory medicine; however, it is not effective for all patients. In addition, there is no way to know how long the effects will last. On average, injections can be expected to provide pain relief in about two-thirds (about 67%) of patients for a period of at least 3 months. There are potential risks from repeated, long-term injections, so you should talk to Dr. Kim about the pros and cons.

  • PRP injection: In some patients with a partial-thickness rotator cuff tear, PRP injection can be considered. PRP is a reasonable non-operative option for partial tears, particularly when steroid injection is undesirable (e.g., concern for tendon degeneration or planned future surgery). It offers a more durable, though modest, benefit compared with corticosteroid at 3–6 months, with a better safety profile. However, it should not be expected to provide rapid relief, and long-term superiority over steroid injection remains unproven. 

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The main advantage of nonsurgical treatment is that it avoids the major risks of surgery, such as infection, anesthesia complications, and sometimes lengthy recovery time.

The disadvantages of nonsurgical treatment are: 

  • The size of the tear may increase over time, which can lead to further and irreversible deterioration of the tendons and

  • muscles. 

  • The tear may not be reparable later on due to the above tissue deterioration, in which situation, other bigger reconstructive procedures like tendon transfer, graft augmentation, or reverse shoulder replacement become necessary. 

  • You may need to limit activities permanently.

Surgical Treatment 

Surgery is recommended if your pain does not improve with nonsurgical treatment. Continued pain and worsening night pain are the main reasons for having surgery. However, surgery can be considered early if you are very active and/or use your arms for overhead work or sports. 
Other signs that surgery may be a good option for you include:

  • You have a full-thickness tear involving the front part of the rotator cuff tendon (the supraspinatus) and the quality of the rotator cuff muscles is still good.

  • You have significant weakness and loss of motion in your shoulder

  • Your tear was caused by a recent, acute injury

  • Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). There are a few options for repairing rotator cuff tears. Dr. Kim will discuss with you the best procedure to meet your individual needs.

Surgical Repair Options

Open vs. Arthroscopic Repair
Rotator cuff repair can be performed through an open incision or arthroscopically through several small incisions.

  • Open repair uses a larger incision to access the torn tendon directly. It may be appropriate for certain complex tears or when additional reconstruction is needed.

  • Arthroscopic repair uses a small camera, called an arthroscope, and specialized instruments inserted through small stab incisions. The camera allows the surgeon to examine the shoulder and repair the tendon while limiting disruption to surrounding tissues. Because only small stab incisions are used, the post-surgery recovery following arthroscopic repair is faster and less painful with lower complication rates compared to open repair. 

Both approaches can provide good results. The best option depends on the tear, the quality of the tendon, and the patient’s individual needs.

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Arthroscopic Rotator Cuff Repair with Dr. Kim
Dr. Kim is an expert in rotator cuff repair and performs 99% of his rotator cuff repairs arthroscopically. He has performed more than 2,000 arthroscopic rotator cuff repairs with high success rates. During arthroscopic repair, Dr. Kim places sutures in the torn tendon and secures it to the bone using small anchors. Surgery typically takes 1–2 hours and is performed under general anesthesia. 
When the rotator cuff tendon is weak or damaged, it is more likely to tear again after repair. In these cases, a donor tissue graft may be used to reinforce the repair and help reduce the risk of another tear.
For tears that cannot be repaired directly, Dr. Kim will discuss whether a reconstruction procedure or another treatment is appropriate.

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Recovery and Rehabilitation
Recovery involves protecting the repair while gradually restoring shoulder movement and strength.

  • Sling: 4–6 weeks. The duration depends on the size of the tear and the repair performed.

  • Rehabilitation: typically, 3½–4 months. Physical therapy progresses according to your healing and Dr. Kim’s instructions.

  • Return to unrestricted activity: a minimum of 5 months. Larger tears, heavy lifting, and demanding sports may require a longer recovery.

Completing rehabilitation does not necessarily mean the tendon is ready for unrestricted activity. Dr. Kim will assess your healing, movement, and strength before clearing you to return. Recovery times and results vary from person to person.

Reconstructive Surgery for Unrepairable Rotator Cuff Tears

Some rotator cuff tears cannot be repaired directly because the tendon has pulled too far away from the bone, the tissue is severely damaged, or the muscle has weakened over time. These are called unrepairable rotator cuff tears. Although a standard repair may not be possible, other surgical options may help relieve pain and improve shoulder function.

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Dr. Kim is an expert in the reconstructive procedures described below, with particular expertise in tendon transfers for unrepairable rotator cuff tears. He tailors treatment to the location of the tear, the condition of the remaining muscles and tendons, the degree of arthritis, and each patient’s goals.

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1. Arthroscopic Partial Repair
Sometimes, part of the rotator cuff can still be repaired even when the entire tear cannot be closed. The goal is to improve the balance of the muscles around the shoulder, reduce pain, and improve movement. A partial repair leaves some of the tear unrepaired and may not restore normal strength. 

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2. Subacromial Balloon Spacer
A balloon spacer is a temporary, biodegradable implant placed arthroscopically between the upper arm bone and the acromion—the bony roof of the shoulder. It is filled with sterile saline and is designed to provide a cushion and help the shoulder move more smoothly.
The spacer gradually dissolves and does not repair the torn tendon. It may be considered for selected patients, but research has shown mixed results, including a randomized trial that found no added benefit over surgical cleaning alone. Dr. Kim will discuss its potential benefits and limitations when considering this option. 

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3. Superior Capsular Reconstruction
Superior capsular reconstruction uses a tissue graft to rebuild the stabilizing structure at the top of the shoulder joint. The graft is secured between the top of the shoulder socket and the upper arm bone.
This reconstruction helps limit upward movement of the upper arm bone, allowing the remaining muscles to work more effectively. It may be an option for selected patients with an irreparable tear at the top and back of the shoulder and little or no shoulder arthritis. It provides stability rather than replacing the torn muscle’s ability to contract. 

Superior capsular reconstruction. A donor graft is placed to bridge the gap between the greater tuberosity (the top portion of the upper arm bone) and the top of the glenoid (the socket of the shoulder joint).

4. Biologic Acromiotuberoplasty (BAT) procedure
Biologic acromiotuberoplasty uses a donor tissue graft to cover the greater tuberosity (the prominent area of the upper arm bone where the rotator cuff normally attaches) and the undersurface of the acromion (the bony roof of the shoulder).
The graft acts as a cushion between this bone and the acromion, helping reduce painful contact during shoulder movement. The main goal is pain relief and improved comfort with daily activities. It does not restore the missing tendon’s strength. Early results are encouraging, but long-term evidence remains limited.

Biologic Acromiotuberoplasty (BAT) procedure. A donor graft is placed on the greater tuberosity (the top portion of the upper arm bone) and at the undersurface of the acromion (the bony roof of the shoulder), acting as a cushion between the bones.

5. Arthroscopically Assisted Lower Trapezius Transfer
For an irreparable posterosuperior tear—a tear involving the tendons at the top and back of the shoulder—a lower trapezius tendon transfer may help improve the ability to rotate the arm outward.
The lower trapezius is a muscle in the upper back. Its tendon is redirected to the upper arm bone, usually with a donor tendon graft to extend its reach. The transferred muscle takes over part of the function of the damaged rotator cuff. Rehabilitation helps patients learn to use the muscle in its new role.

Arthroscopically assisted lower trapezius transfer. The lower trap, a muscle in the upper back, is rerouted to the greater tuberosity of the upper arm bone with a donor tendon graft.

6. Tendon Transfers for Irreparable Subscapularis Tears
The subscapularis is the rotator cuff tendon at the front of the shoulder. It helps rotate the arm inward and stabilize the joint. When it cannot be repaired, a tendon transfer may replace part of its function.

  • Latissimus dorsi tendon transfer: A tendon from a large back muscle is redirected to the front of the upper arm bone to help restore inward rotation and support shoulder stability.

  • Pectoralis major tendon transfer: Part of the tendon from the large chest muscle is moved to the upper arm bone to help compensate for the damaged subscapularis.

The choice depends on the tear pattern, shoulder alignment, remaining tendon function, and the patient’s needs. 

Latissimus dorsi tendon transfer for unrepairable subscapularis tear: The muscle is rerouted toward the lesser tuberosity of the upper arm bone to help with inward rotation of the shoulder.

7. Reverse Shoulder Replacement
Reverse shoulder replacement can be a viable treatment option for unrepairable rotator cuff tear in certain conditions like coexisting arthritis or poor tissue healing potential (e.g., advanced age, other medical conditions, tissue degeneration, etc.). 

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Choosing the Right Procedure
These procedures serve different purposes: some primarily relieve pain, some improve stability, and tendon transfers can restore part of the lost muscle function. They are often considered when preserving the natural shoulder joint is a priority.
Dr. Kim will explain which options fit your shoulder and what improvement you can reasonably expect. Recovery and rehabilitation vary by procedure, and no reconstruction can guarantee normal strength or function. If substantial arthritis is present, shoulder replacement may be more appropriate.

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