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Education · shoulder

Cuff Arthropathy Info In-depth Evidence

Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed

Related shoulder topics. Rotator cuff repair , Rotator cuff disorders , Subacromial decompression and Subacromial impingement .

What you're feeling

You may notice a deep ache in your shoulder that settles at the base of your neck or along the shoulder blade. This pain often flares up at night, making it hard to find a comfortable sleeping position. You might also feel stiffness when you first wake up, which slowly eases as you move through your day.

Simple daily tasks can become surprisingly difficult. Reaching for a cup in a high cupboard may feel blocked or painful. Putting on a jacket or pulling up a zip on your trousers can be challenging because lifting your arm feels restricted. You might find that reaching into the back seat of a car or picking up a bag from the floor requires you to lean your whole body rather than just using your arm.

The pain tends to worsen with activity, especially if you try to lift anything overhead. You may feel a sudden loss of strength or a sharp increase in pain if you push too hard. This is because the wear-and-tear arthritis and damaged tendons mean your shoulder joint is not gliding smoothly. Instead of the ball and socket working together, the bones rub against each other or the damaged tendons strain against the joint.

Some people describe a catching sensation or a feeling that the shoulder might slip out of place. This instability can be worrying, but it is a common part of cuff tear arthropathy. You might also notice swelling or tenderness along the top of the shoulder blade, particularly if there has been any recent increase in activity.

It is important to listen to your body. If you experience a sudden, severe change in pain or a complete loss of function, this could signal a more serious issue like a fracture. However, for most people, the symptoms develop gradually. You may find that resting the arm helps reduce the ache, but prolonged inactivity can make the stiffness worse. Understanding these patterns helps you manage your day-to-day life while you prepare for treatment.

What's actually happening

In a healthy shoulder, the rotator cuff tendons act like a strong net, holding the ball of your upper arm bone firmly into the socket. In cuff arthropathy, this net is torn and worn out. Without that support, the ball rides too high and grinds against the roof of your shoulder blade. Over time, this friction wears away the cartilage and bone, changing the shape of your joint. This is why you feel pain and find it hard to lift your arm. The movement becomes stiff because the bones are rubbing where they should glide smoothly.

To fix this, your surgeon replaces the damaged joint with a reverse total shoulder replacement. This is not a standard joint replacement. It flips the ball and socket positions. The metal ball is attached to your shoulder blade, and the plastic cup is attached to your upper arm bone. This design does not rely on your torn rotator cuff. Instead, it uses your deltoid muscle—the large muscle on the side of your shoulder—to lift your arm. By moving the pivot point, the surgery gives your deltoid muscle a better mechanical advantage. This allows you to raise your arm again, even without the rotator cuff.

However, this new setup changes how forces travel through your shoulder. The deltoid works harder, which can increase stress on the shoulder blade bone. In some cases, this stress can lead to bone wear or, rarely, a fracture of the shoulder blade. This is why your surgeon carefully plans the implant size and position. The goal is to restore your ability to lift your arm while keeping the new joint stable. You will need to follow specific rehabilitation steps to protect the bone and muscle as they adapt to this new mechanics.

What we can do about it

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment (history, examination, and imaging where needed) establishes the diagnosis. For degenerative or long-standing problems we usually try non-operative care — activity change, physiotherapy or hand therapy, splinting, and injections — and consider surgery when that has not given enough improvement. For structural or acute problems, surgery may be recommended straight away, without a preceding non-operative trial.

You can begin by adjusting your daily activities to avoid movements that cause pain. Physiotherapy aims to maintain your shoulder’s range of motion and strengthen the surrounding muscles to support the joint. We may also discuss pain management options, such as anti-inflammatory medications or cortisone injections, to help reduce swelling and discomfort. These treatments can provide relief for a period of time, allowing you to stay active while you monitor your symptoms.

Surgery is considered when conservative care has reached its limit and pain or stiffness continues to affect your life. In these cases, we may recommend a reverse total shoulder arthroplasty. This procedure replaces the damaged joint surfaces to restore function and relieve pain. It is particularly effective for patients with rotator cuff deficiencies or complex fractures. The implant is designed to work with your shoulder muscles even if the rotator cuff is not fully functional. Revision procedures, where a previous replacement is updated, show an implant survival rate of 85% at ten years. Patients typically achieve maximum medical improvement at 1 postoperative year. We will discuss whether this option is suitable for you based on your specific condition and goals.

What to expect

Your outlook depends largely on whether this is your first shoulder replacement or a revision after a previous surgery has failed. If you are having a primary reverse total shoulder replacement, you can expect significant long-term improvement. The implant survives in 85% of cases at ten years. Most patients reach their maximum medical improvement at one year after surgery. You will likely notice steady gains in pain relief and the ability to lift your arm.

If you are having a revision surgery because a previous anatomic replacement has failed, the picture is more complex. Your surgeon will explain that these procedures carry higher complication and revision rates than primary replacements. Clinical outcomes, including pain relief and satisfaction, tend to be worse compared to a first-time replacement. However, reverse shoulder replacement remains a versatile option to restore function even after other procedures have not worked.

For those managing the condition without surgery, conservative treatment offers less functional benefit than replacement for severe arthritis or cuff tear arthropathy. If you do not undergo surgery, symptoms of wear-and-tear arthritis and rotator cuff failure typically persist or worsen over time. You may experience ongoing pain and limited movement that affects daily activities.

Recovery is a process, not an event. Six distinct recovery paths exist, with 83.7% of patients experiencing very low pain scores after just two weeks. This is known as the 'Faster group'. However, full functional recovery takes longer. You might return to walking and swimming within months, but maximum strength and elevation continue to improve up to a year. Driving is usually possible between six and twelve weeks post-surgery, depending on your progress.

It is important to note that reverse shoulder replacement is not suitable for everyone. If you have primary osteoarthritis with an intact rotator cuff, this specific procedure may not offer functional benefits over other options. Your surgeon will assess your specific anatomy to determine if this approach is right for you.

When to see someone

Ask for a specialist review if you experience persistent pain that does not improve with rest, or if your shoulder feels weak or unstable. Sudden worsening of symptoms, locking, or the joint giving way are also key signs. You should seek urgent care if you notice a sudden loss of function or a sharp increase in pain, especially if this occurs within two years of surgery. New pain at the base of the shoulder blade or visible deformity may indicate a fracture. If your symptoms interfere with sleep or daily work, do not wait. Early assessment helps your surgeon identify the cause and plan the right treatment for your recovery.

Advanced reading: the deeper science (optional)

This section goes further than you need for your own treatment decisions. Cuff tear arthropathy and massive irreparable tears are worth the extra reading because the number of operations described for them is itself the most informative fact — when many procedures compete, none is clearly best.

Everything works a bit, and nothing works clearly better

Across 2,000 patients, clinically important treatment effects were seen for all eleven different treatment modalities studied for irreparable posterosuperior cuff tears — with variation in patient characteristics, co-interventions, outcome reporting and follow-up length complicating any sound comparison [1]. A separate review of 3,363 patients found all six non-arthroplasty options produced statistically significant improvements in range of motion and patient-reported outcomes at a year or more, with low revision rates [2].

Eleven modalities, six options, all producing improvement, none demonstrably superior. That pattern usually indicates two things: the natural history includes some improvement regardless, and the studies are too heterogeneous to separate the treatments.

Improvement early, decline later

One finding deserves emphasis because it is easily missed in short-term reports. Across 2,790 patients undergoing superior capsule reconstruction, partial repair, graft interposition and related procedures, there were large initial improvements in shoulder scores for all techniques despite high retear rates — and shoulder scores may decline at mid- to long-term follow-up [3].

So the same operation can look successful at one year and less so at five. When you read that a technique has good results, the follow-up interval matters as much as the number.

A 2026 analysis of 4,963 patients attempted to resolve this by ranking treatments on failure rate rather than outcome scores, and while it did not identify a single best treatment, it produced a hierarchy of reliability [4]. Ranking by failure is arguably the more honest measure when early scores converge.

Why the joint wears out once the cuff is gone

The mechanism explains why this is a distinct condition rather than simply a large tear. The rotator cuff holds the humeral head centred in the socket while the deltoid lifts. Without it, the deltoid's pull drives the head upwards against the underside of the acromion.

That produces a characteristic pattern: the head rides up on X-ray, the acromion and head wear against each other where they were never meant to contact, and the joint surfaces degenerate secondarily. It is arthritis caused by mechanics rather than by primary joint disease, which is why treating the arthritis without addressing the mechanics does not work.

It is also why reverse shoulder replacement solved the problem — it makes the deltoid sufficient without needing a cuff. Where the arthropathy is established, that operation is covered on its own page.

Reading the outcome figures with the right expectation

One caution for interpreting results: outcomes following reverse replacement in this setting are decreased compared with other indications across 6,698 patients [5]. The operation works, but a shoulder replaced for cuff arthropathy should not be expected to match one replaced for straightforward arthritis with an intact cuff — the starting point is worse.

Reviewed by Dr Kieran Hirpara · 7 August 2026.

Talk to your treating clinician for advice specific to you.

References for the advanced reading
  1. Kooistra B, Gurnani N, Weening A, van den Bekerom M, van Deurzen D. Low level of evidence for all treatment modalities for irreparable posterosuperior rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. 2019;27(12):4038-48.
  2. Hughes JD, Davis B, Whicker E, Sprowls GR, Barrera L, Baradaran A, et al. Nonarthroplasty options for massive, irreparable rotator cuff tears have improved patient-reported outcomes. Knee Surg Sports Traumatol Arthrosc. 2022;31(5):1883-902.
  3. Davies A, Singh P, Reilly P, Sabharwal S, Malhas A. Superior capsule reconstruction, partial cuff repair, graft interposition, subacromial balloon spacers or tuberoplasty: a systematic review. J Orthop Surg Res. 2022;17(1).
  4. Cooke SP, Koh JL, Amirouche F. An analysis of failure rates for treatment options for large to massive irreparable rotator cuff tears. J Shoulder Elbow Arthroplasty. 2026;10(1-2):100019.
  5. Yazdanpanah S, Soth BT, Eskew JR, Dancy M, Fu MC, Taylor SA, et al. Decreased clinical and functional outcomes following reverse total shoulder arthroplasty for cuff tear arthropathy: a systematic review. JSES Rev Rep Tech. 2026;6(2):100691.
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Patients with irreparable massive rotator cuff tears without osteoarthritis have a high likelihood of achieving a painless shoulder and functional improvements after reverse shoulder arthroplasty [1].
  • Reverse shoulder arthroplasty provides optimal outcomes with low complication rates across a short term of follow-up for glenohumeral osteoarthritis with an intact rotator cuff [2].
  • Subacromial balloon spacers for massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures in the short term [3].
  • Arthroscopic repairs of chronic, massive rotator cuff tears, whether complete or partial, are associated with significant improvements in pain, function, and objective outcome scores with a low rate of re-tear [5].
  • Differences in postoperative patient-reported outcomes and improvement from baseline show a trend toward lower outcomes in patients with prior rotator cuff repair undergoing reverse shoulder arthroplasty, but these differences may be below the minimal clinically important difference [7].
  • Superior capsular reconstruction serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion irrespective of tissue source [8].
  • For patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis, graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains [10].
  • Nonarthroplasty treatment options for irreparable rotator cuff tears result in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty [14].
  • Anatomic total shoulder arthroplasty displays equal functional results and postoperative complications compared to reverse total shoulder arthroplasty in patients over 70 without a full-thickness rotator cuff tear [17].
  • Higher revision rates were identified following anatomic total shoulder arthroplasty compared to reverse total shoulder arthroplasty in patients over 70 without a full-thickness rotator cuff tear, although this finding is within retrospective studies [17].
  • Complications for primary reverse shoulder arthroplasty using augmented baseplates are within an acceptable range, with a low rate of revision [18].
  • Patients undergoing reverse total shoulder arthroplasty for glenohumeral osteoarthritis, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure [24].
  • The rate of satisfaction is highest in patients undergoing reverse total shoulder arthroplasty for glenohumeral osteoarthritis [24].

Anatomy & Pathophysiology

  • Reverse total shoulder arthroplasty (RTSA) is indicated for patients with irreparable massive rotator cuff tears who do not have osteoarthritis [1].
  • RTSA is indicated for patients with rotator cuff arthropathy (RCA) [40].
  • RTSA yields slightly lower shoulder function, range of motion, and a higher dislocation-related revision risk compared to its use for proximal humerus fractures (PHF) [40].
  • RTSA results in an increased contribution of scapulothoracic rotation relative to glenohumeral motion throughout arm elevation compared to asymptomatic shoulders [30].
  • RTSA is associated with no significant deterioration in shoulder function and outcome scores between 5 and 20 years of follow-up [15].
  • Shoulder scores may decline at mid- to long-term follow-up for patients with large and massive irreparable rotator cuff tears treated with soft tissue reconstruction techniques [4].
  • Soft tissue reconstruction for irreparable anterosuperior rotator cuff tears is associated with improved clinical outcomes [19].
  • For patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis, graft interposition repair, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains [10].
  • Subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure in cadaveric studies [36].
  • Subacromial balloon spacer implantation results in improved shoulder function and decreased pain at 24 months post-procedure [44].
  • The majority of painful complications after RTSA, including instability, fractures, and infection, can be successfully treated to maintain a functional implant [20].
  • There are no differences in abduction, internal rotation, or external rotation strength after RTSA with or without subscapularis repair [37].
  • There appears to be a trend suggesting improved postoperative clinical outcomes and active range of motion for patients with a subscapularis repair versus without a repair after primary RTSA [45].
  • Studies analyzing the impact of subscapularis repair on internal rotation following RTSA report conflicting results [41].
  • Measures and reporting of shoulder internal rotation after RTSA vary widely, making it difficult to assess associations between postoperative internal rotation limitation and functional abilities [38].
  • The anterosuperior approach for RTSA offers better forward flexion, while the deltopectoral approach is associated with a lower glenoid loosening rate [35].
  • Changes in humeral stem inclination in RTSA are accompanied by less scapular notching and dislocations, with no clear impact on functional outcome measures [32].

Classification

  • Reverse shoulder arthroplasty is indicated for patients with irreparable massive rotator cuff tears without the presence of osteoarthritis [1].
  • Reverse shoulder arthroplasty provides optimal outcomes with low complication rates for glenohumeral osteoarthritis with an intact rotator cuff [2].
  • Subacromial balloon spacer implantation is an alternative for patients with massive irreparable rotator cuff tears [3].
  • Primary arthroscopic repair is a treatment option for massive rotator cuff tears [5].
  • Osteoporosis is a risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
  • Rheumatoid arthritis is a risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
  • Female sex is a risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
  • Rotator cuff arthropathy is a risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
  • Graft interposition repair techniques are a treatment option for patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis [10].
  • Superior capsular reconstruction using the long head of the biceps tendon is a treatment option for patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis [10].
  • Arthroscopic debridement is a treatment option for patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis [10].
  • Balloon arthroplasty is a treatment option for patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis [10].
  • Inflammatory arthritis is a risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
  • Female gender is a risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
  • Previous rotator cuff repair is a risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
  • Reverse total shoulder arthroplasty may be required to recover a functional shoulder in cases of complications or revision [12].
  • Patients with previous rotator cuff repair undergoing reverse shoulder arthroplasty have worse postoperative functional scores and pain scores than those without prior repair [13].
  • Nonarthroplasty options for massive, irreparable rotator cuff tears include treatments that result in improvements in range of motion and patient-reported outcomes at short-term follow-up [14].
  • Anatomic total shoulder arthroplasty is a treatment option for patients aged over 70 without a full-thickness rotator cuff tear [17].
  • Reverse total shoulder arthroplasty is a treatment option for patients aged over 70 without a full-thickness rotator cuff tear [17].
  • Failed rotator cuff repair prior to reverse shoulder arthroplasty is associated with lower functional outcomes scores, higher pain scores, and worse range of motion compared to primary reverse shoulder arthroplasty without prior rotator cuff repair [21].
  • Subscapularis repair techniques are relevant for reverse total shoulder arthroplasty [22].
  • The humeral neck-shaft angle is an important variable in choosing the reverse shoulder arthroplasty implant design for patients with rotator cuff arthropathy [42].
  • Bridging grafts are a treatment option for large to massive rotator cuff tears [43].

Clinical Presentation

  • Shoulder scores may decline at mid- to long-term follow-up for interventions such as superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement, or balloon spacers for large and massive irreparable rotator cuff tears [4].
  • Arthroscopic repairs of chronic, massive rotator cuff tears, whether complete or partial, are associated with significant improvements in pain, function, and objective outcome scores [5].
  • Osteoporosis is a commonly cited risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
  • Rheumatoid arthritis is a commonly cited risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
  • Female sex is a commonly cited risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
  • Rotator cuff arthropathy is a commonly cited risk factor for acromial stress fractures following reverse total shoulder arthroplasty [6].
  • Differences in postoperative patient-reported outcomes and improvement from baseline demonstrate a trend toward lower outcomes in patients with prior rotator cuff repair undergoing reverse shoulder arthroplasty, but these differences may be below the minimal clinically important difference [7].
  • Superior capsule reconstruction serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion irrespective of tissue source [8].
  • Better evidence from reports with greater detail is necessary to show that patients are realizing progressively better outcomes from shoulder arthroplasty [9].
  • Osteoporosis is an identified risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
  • Inflammatory arthritis is an identified risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
  • Female gender is an identified risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
  • Previous rotator cuff repair is an identified risk factor for acromial and scapular fractures following reverse shoulder arthroplasty [11].
  • Although patients may require multiple procedures, it is often possible to conserve or replace the reverse total shoulder arthroplasty to recover a functional shoulder [12].
  • Patients with prior rotator cuff repair undergoing reverse shoulder arthroplasty have worse postoperative functional scores and pain scores than those without prior repair [13].
  • Shoulder function and outcome scores showed no significant deterioration between 5 and 20 years of follow-up for reverse total shoulder arthroplasty in patients with rotator cuff dysfunction [15].
  • The presence of os acromiale does not appear to have a negative impact on the clinical outcomes after reverse total shoulder arthroplasty [16].
  • Reverse total shoulder arthroplasty remains a safe and effective treatment option for patients with os acromiale [16].
  • The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant [20].
  • Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement [26].
  • Patients undergoing primary reverse shoulder arthroplasty demonstrated clinically significant improvements in both range of motion and clinical outcome scores [27].
  • Arthroscopic debridement with a combination of subacromial decompression, tuberoplasty, subacromial bursectomy, and biceps tenotomy produces good functional outcomes and improvement in pain at mid to long term follow up for the low-demand population greater than 65 years of age looking for pain relief over substantial increase in function [28].
  • Tuberosity healing may be a major contributing factor to the difference in clinical outcomes between elective indications and acute 3- and 4-part proximal humeral fractures treated with reverse total shoulder arthroplasty [34].

Investigations

  • Reverse total shoulder arthroplasty provides optimal outcomes with low complication rates across a short term of follow-up for glenohumeral osteoarthritis with an intact rotator cuff [2].
  • The most commonly cited risk factors for acromial stress fractures following reverse total shoulder arthroplasty include osteoporosis, rheumatoid arthritis, female sex, and rotator cuff arthropathy [6].
  • Other risk factors for acromial and scapular fractures following reverse shoulder arthroplasty include osteoporosis, inflammatory arthritis, female gender, and previous rotator cuff repair [11].

Treatment

Reverse Shoulder Arthroplasty (rTSA)

  • Reverse shoulder arthroplasty provides a high likelihood of achieving a painless shoulder and functional improvements in patients with irreparable massive rotator cuff tears who do not have osteoarthritis [1].
  • Reverse shoulder arthroplasty provides optimal outcomes with low complication rates in the short term for glenohumeral osteoarthritis with an intact rotator cuff [2].
  • Patients undergoing reverse total shoulder arthroplasty for glenohumeral osteoarthritis, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with satisfaction rates being highest in glenohumeral osteoarthritis [24].
  • Differences in postoperative patient-reported outcomes and improvement from baseline show a trend toward lower outcomes in patients with prior rotator cuff repair, but these differences may be below the minimal clinically important difference [7].
  • The presence of os acromiale does not appear to have a negative impact on clinical outcomes after reverse total shoulder arthroplasty, which remains a safe and effective treatment option [16].

Non-Arthroplasty Options for Massive Irreparable Rotator Cuff Tears

  • Subacromial balloon spacer implantation for massive irreparable rotator cuff tears demonstrates clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures in the short term [3].
  • Subacromial balloon spacer implantation achieves satisfactory clinical outcomes in the short and middle term (between 3 months and 3 years) for massive irreparable rotator cuff tears [31].
  • Placement of the subacromial balloon spacer is a minimally invasive, technically simple procedure associated with favorable patient-reported outcomes at limited short-term follow-up [33].
  • Patients undergoing subacromial spacer implantation for massive irreparable rotator cuff tears have satisfactory outcomes at 2- to 3-year follow-up with a low rate of complications [23].
  • All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year or more, with low rates of revision and conversion to arthroplasty [14].
  • Arthroscopic debridement with subacromial decompression, tuberoplasty, subacromial bursectomy, and biceps tenotomy produces good functional outcomes and improvement in pain at mid to long term follow-up for low-demand patients greater than 65 years of age seeking pain relief over substantial increase in function [28].
  • Primary arthroscopic repair of massive rotator cuff tears results in significant improvements with a low rate of re-tear [5].
  • Superior capsular reconstruction serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion [8].
  • Superior capsular reconstruction is associated with significantly improved functional outcome scores and preserved or increased mean acromiohumeral distance [46].

Proximal Humerus Fractures (Elderly Population)

  • Reverse shoulder arthroplasty is a better option than hemiarthroplasty for proximal humerus fractures in the elderly [39].
  • Clinical decision for reverse shoulder arthroplasty in proximal humerus fractures should be preferred on the condition that the patient's medical conditions are indicated [39].
  • Consideration may be given to an initial trial of nonoperative treatment for acute proximal humeral fractures in the elderly, saving reverse total shoulder arthroplasty for those in whom nonoperative treatment fails without compromising the ultimate outcome [47].

Complications

Complications

  • Complications are within an acceptable range for primary reverse shoulder arthroplasty using augmented baseplates, with a low rate of revision [18].
  • Complications do not appear to be appreciably higher in the reverse shoulder arthroplasty group compared to other treatments for proximal humeral fractures in older adults in existing follow-up [51].
  • Shoulder scores may decline at mid- to long-term follow-up for treatments including superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement, or balloon spacers for large and massive irreparable rotator cuff tears [4].
  • Patients undergoing subacromial spacer implantation for massive irreparable rotator cuff tears have a low rate of complications at 2- to 3-year follow-up [23].
  • Anatomic total shoulder arthroplasty displayed equal postoperative complications compared to reverse total shoulder arthroplasty in patients over 70 without a full-thickness rotator cuff tear [17].
  • Failed rotator cuff repair prior to reverse shoulder arthroplasty was associated with lower functional outcomes scores, higher pain scores, and worse range of motion compared to primary reverse shoulder arthroplasty without prior rotator cuff repair [21].
  • Further long-term studies are needed to assess the durability of stemless versus stemmed reverse total shoulder arthroplasty as primary treatment in the elderly [25].

Recovery

  • Shoulder scores may decline at mid- to long-term follow-up for procedures such as superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement, or balloon spacers for large and massive irreparable rotator cuff tears [4].
  • Differences in postoperative patient-reported outcomes and improvement from baseline demonstrate a trend toward lower outcomes in patients with prior rotator cuff repair, but these differences may be below the minimal clinically important difference [7].
  • Irrespective of tissue source, superior capsular reconstruction serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion [8].
  • There was no radiological evidence of humeral loosening at the latest follow-up for stemless reverse total shoulder arthroplasty in short- and mid-term results [29].
  • Although early results for arthroscopic superior capsular reconstruction are promising, further studies are necessary to determine the long-term success of this technique and to better delineate the clinical indications, survivorship, and risk factors for failure [52].

Key Evidence

  • [L1] Patients with irreparable massive rotator cuff tears without presence of osteoarthritis have a high likelihood of achieving a painless shoulder and functional improvements after reverse shoulder arthroplasty. [1] (10.1016/j.jse.2017.03.039)
  • [L4] Reverse shoulder arthroplasty provides optimal outcomes with low complication rates across a short term of follow-up for glenohumeral osteoarthritis with an intact rotator cuff. [2] (10.1016/j.jse.2021.06.010)
  • [L4] The short-term results of subacromial balloon spacers for management of massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures. [3] (10.1016/j.arthro.2023.05.028)
  • [L1] Shoulder scores may decline at mid- to long-term follow-up. [4] (10.1186/s13018-022-03411-y)
  • [L2] Arthroscopic repairs of chronic, massive RCTs, whether complete or partial, are associated with significant improvements in pain, function and objective outcome scores. [5] (10.1007/s00167-020-06190-3)
  • [L4] The most commonly cited risk factors for ASFs following rTSA include osteoporosis, rheumatoid arthritis, female sex, and rotator cuff arthropathy. [6] (10.1016/j.jse.2025.02.032)
  • [L4] Differences in postoperative patient-reported outcomes and improvement from baseline demonstrate a trend toward lower outcomes in patients with prior rotator cuff repair, but these differences may be below the minimal clinically important difference. [7] (10.1177/17585732241268712)
  • [L1] Irrespective of tissue source, SCR serves as a reasonable joint-preserving option for massive, irreparable rotator cuff tears, with favorable short- to midterm improvements in patient-reported outcomes and range of motion. [8] (10.1016/j.asmr.2020.09.002)
  • [L2] Better evidence from reports with greater detail will be necessary to show that patients are realizing progressively better outcomes from shoulder arthroplasty. [9] (10.1007/s00264-017-3443-0)
  • [L3] For patients younger than 70 years with massive irreparable rotator cuff tears without significant arthritis or pseudoparalysis, graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains. [10] (10.1177/03635465231204623)
  • [L1] Other risk factors identified included osteoporosis, inflammatory arthritis, female gender, and previous rotator cuff repair. [11] (10.1016/j.xrrt.2025.08.015)
  • [L4] Although patients may require multiple procedures, it is often possible to conserve or replace the RTSA to recover a functional shoulder. [12] (10.1016/j.otsr.2015.06.031)
  • [L1] Patients with prior rotator cuff repair undergoing reverse shoulder arthroplasty have worse postoperative functional scores and pain scores than those without prior repair. [13] (10.1016/j.xrrt.2023.01.006)
  • [L4] All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty. [14] (10.1007/s00167-022-07099-9)
  • [L1] Shoulder function and outcome scores also showed no significant deterioration between 5 and 20 years of follow-up. [15] (10.1016/j.jse.2018.10.005)
  • [L4] The presence of os acromiale does not appear to have a negative impact on the clinical outcomes after surgery and rTSA remains a safe and effective treatment option. [16] (10.1016/j.xrrt.2025.01.002)
  • [L1] Higher revision rates were identified following aTSA in our study population, although admittedly this is within retrospective studies. aTSA displayed equal functional results and postoperative complications compared to rTSA in patients over 70 without a full-thickness rotator cuff tear. [17] (10.1177/24715492231206685)
  • [L4] Complications are within an acceptable range for primary reverse shoulder arthroplasty, with a low rate of revision. [18] (10.1016/j.xrrt.2022.08.008)
  • [Paper] Soft tissue reconstruction for irreparable AS rotator cuff tears is associated with improved clinical outcomes. [19] (10.1177/17585732261431826)
  • [L4] The majority of painful complications after reverse shoulder arthroplasty, including instability, fractures, and infection, can be successfully treated to maintain a functional implant. [20] (10.1177/1758573217702333)
  • [L1] Failed rotator cuff repair prior to reverse shoulder arthroplasty was associated with lower functional outcomes scores, higher pain scores, and worse range of motion compared to primary reverse shoulder arthroplasty without prior rotator cuff repair. [21] (10.1177/17585732231194785)
  • [L3] This information can help guide future studies in this area and highlights the need for high quality studies comparing different subscapularis repair techniques. [22] (10.1016/j.jisako.2022.05.001)
  • [L1] Patients undergoing subacromial spacer implantation for the treatment of massive irreparable rotator cuff tears have satisfactory outcomes at the 2- to 3-year follow-up with a low rate of complications. [23] (10.1016/j.arthro.2018.08.006)
  • [L4] This systematic review demonstrated that patients who undergo rTSA for either GHOA, cuff tear arthropathy, or massive rotator cuff tear are generally satisfied with their procedure, with the rate of satisfaction highest in GHOA. [24] (10.1016/j.jse.2024.03.036)
  • [L1] Further long-term studies are needed to assess durability. [25] (10.1177/17585732251388447)
  • [L4] Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement. [26] (10.1016/j.jse.2020.10.003)
  • [L1] Additionally, patients demonstrated clinically significant improvements in both range of motion and clinical outcome scores. [27] (10.1016/j.jse.2022.06.005)
  • [L1] Arthroscopic debridement with a combination of subacromial decompression, tuberoplasty, subacromial bursectomy, and biceps tenotomy produces good functional outcomes and improvement in pain at mid to long term follow up for the low-demand population greater than 65 years of age looking for pain relief over substantial increase in function. [28] (10.1016/j.xrrt.2021.08.012)
  • [L1] There was no radiological evidence of humeral loosening at the latest follow-up. [29] (10.1177/17585732211013356)
  • [L1] There is an increased contribution of scapulothoracic rotation relative to glenohumeral motion throughout arm elevation following TSA compared to asymptomatic shoulders. [30] (10.1016/j.jse.2025.08.010)
  • [L1] Subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears may achieve satisfactory outcomes between 3 months and 3 years of follow-ups. [31] (10.1007/s00167-019-05834-3)
  • [L1] This change in range of motion is accompanied by less scapular notching and dislocations, with no clear impact on functional outcome measures. [32] (10.1016/j.xrrt.2021.02.002)
  • [L4] Placement of the subacromial balloon spacer is a minimally invasive, technically simple procedure with favorable patient-reported outcomes at limited short-term follow-up. [33] (10.1177/2325967119875717)
  • [L1] Tuberosity healing may be a major contributing factor to the difference in clinical outcomes. [34] (10.1016/j.jse.2021.07.014)
  • [L1] One of the two approaches did not bring a better result than the other; one has strength for better forward flexion and the other for a lower glenoid loosening rate. [35] (10.1186/s13018-022-03414-9)
  • [L1] In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. [36] (10.1016/j.asmr.2020.06.011)
  • [L4] There were no differences in abduction, internal rotation, or external rotation strength after rTSA with or without subscapularis repair. [37] (10.1016/j.xrrt.2021.11.004)
  • [L4] Measures and reporting of shoulder internal rotation after reverse total shoulder arthroplasty varied widely, making it difficult to assess associations between postoperative internal rotation limitation and functional abilities. [38] (10.1016/j.jses.2019.10.109)
  • [L1] Clinical decision should be preferred to RSA on the condition that patients ' medical conditions are indicated. [39] (10.1007/s00264-015-2811-x)
  • [L2] RTSA for PHF yields slightly lower shoulder function, range of motion, and a higher dislocation-related revision risk compared with RCA; though, absolute differences were modest. [40] (10.1016/j.xrrt.2026.100691)
  • [L4] Studies that analyzed the impact of subscapularis repair reported conflicting results. [41] (10.1016/j.jse.2023.10.006)
  • [L2] The HNSA represents an important variable in choosing the RSA implant design for patients with rotator cuff arthropathy. [42] (10.3390/jcm11133641)
  • [L4] Bridging grafts may be considered for this difficult patient population with large to massive rotator cuff tears. [43] (10.1016/j.arthro.2016.08.030)
  • [L1] Despite overall fair MCMS scores, at 24‐m post‐SBSI, shoulder function improved and pain decreased. [44] (10.1002/ksa.12331)
  • [L1] However, there appears to be a trend suggesting improved postoperative clinical outcomes and active range of motion for patients with a subscapularis repair vs. without a repair. [45] (10.1016/j.xrrt.2022.01.003)
  • [L1] This review demonstrates that SCR is a useful treatment modality for patients with irreparable rotator cuff tears, associated with significantly improved functional outcome scores and preserved or increased mean AHD. [46] (10.1016/j.otsr.2019.07.022)
  • [L1] Given the risks associated with surgery in the elderly population, consideration may be given to an initial trial of nonoperative treatment in these patients, saving RTSA for those in whom nonoperative treatment fails without compromising the ultimate outcome. [47] (10.1016/j.jse.2018.10.004)
  • [L4] Complications do not appear to be appreciably higher in the RSA group in the existing follow-up. [51] (10.1016/j.jse.2013.08.021)
  • [L1] Although early results are promising, further studies are necessary to determine the long-term success of this technique and to better delineate the clinical indications, survivorship, and risk factors for failure in this population. [52] (10.1016/j.arthro.2018.09.033)

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