Muscle Advancement and Suprascapular Nerve Release for Massive IrreparablePosterosuperior Rotator Cuff Tears: Functional and Clinical Outcomes

Abstract

Introduction: The management of massive irreparable posterosuperior rotator cuff tears (MIRCTs) without significant glenohumeral arthritis remains challenging. Conventional repairs often fail due to tendon retraction, fatty atrophy, and chronicity. Muscle advancement (MA) allows anatomical reduction and tension-free repair, potentially improving reparability and outcomes.

Purpose: To assess the clinical and functional outcomes of patients with massive irreparable cuff tears who underwent rotator cuff repair with Muscle Advancement.

Methods: This was a retrospective case series of 26 patients with massive irreparable posterosuperior cuff tears who underwent the arthroscopic muscle advancement technique between January 2022 and August 2024, with a minimum follow-up of 12 months. Preoperative MRI evaluated tear chronicity, tendon retraction, and Goutallier grade. Patients were assessed using the Constant-Murley (CMS), American Shoulder and Elbow Surgeons (ASES) scores, Visual Analogue Scale (VAS) for pain, and range of motion (ROM) at baseline and 12 months postoperatively.

Results: The mean CMS improved from 40 preoperatively to 74 at 12 months, while the ASES improved from 39 to 68. VAS scores decreased significantly from 7.2 to 2.1. Mean active forward elevation improved from 90° to 150°, and external rotation from 20° to 45°. No clinical evidence of retears were observed during followup. .

Conclusion: Arthroscopic muscle advancement with suprascapular nerve release provides a reliable, joint-preserving option for MIRCTs, restoring function and reducing pain without graft augmentation.

Keywords: Irreparable rotator cuff tear; muscle advancement; suprascapular nerve release;

Introduction

Massive irreparable posterosuperior rotator cuff tears (MIRCTs) represent one of the most complex clinical challenges in shoulder surgery . These injuries, typically involving two or more tendons, lead to a profound disruption of the glenohumeral joint's biomechanics, often resulting in significant pain, loss of strength, pseudoparalysis, and progressive superior humeral head migration.¹ This condition, if left uncorrected, can lead to advanced cuff tear arthropathy and poor shoulder function.²

The primary challenge in managing MIRCTs is the high failure rate associated with conventional repair techniques. Reported retear rates range from 40% to over 80% in general population.³ Factors causing the failure of repair include chronic tendon retraction, poor tendon tissue quality, and advanced fatty infiltration of the cuff musculature, as described by Goutallier.⁴ In cases where the rotator cuff tendon is markedly retracted but demonstrates adequate muscle bulk, achieving mobilization of the tendon to its anatomic footprint can be challenging. Under such circumstances, the conventional surgical options considered are partial repair, medialized repair, or single-row repair performed under high tension on the cuff muscles..

In response to these poor outcomes, numerous alternative surgical strategies have been developed.These include Superior capsular reconstruction,Tendon transfers ,Patch augmentation,Subacromial balloon spacers . Superior capsular reconstruction (SCR) aims to restore the superior constraint of the humeral head, and has shown good outcomes but relies on costly allografts or autografts, which have their own failure modes and potential for non-integration.⁵,⁶ Tendon transfers, such as the Latissimus dorsi, teres major and Lower trapezius transfer are non-anatomic procedures that attempt to restore the external rotation force-couple. However, these are technically demanding, associated with donor site morbidity, and require extensive rehabilitation for neuromuscular re-education.⁷,⁸Other options, such as partial repair⁹ or graft augmentation, have also met with mixed success.

Anatomic muscle advancement (MA) has emerged as a biologic solution. First described in an open fashion by Debeyre et al.,¹⁰ this technique involves mobilizing the entire supraspinatus and infraspinatus muscle-tendon units from their scapular fossae. By releasing the muscles from their origin, the surgeon can gain significant length, allowing for a tension-free, anatomic restoration of the tendon-to-bone footprint.⁸ This converts a biomechanically "irreparable" tear into a reparable one .

A critical component of this pathology, and of the advancement procedure itself, is the suprascapular nerve (SSN). Chronic, massive retraction of the supraspinatus can place the SSN under traction at the suprascapular notch, leading to a traction neuropathy that exacerbates muscle atrophy and weakness.¹² Furthermore, the surgical act of advancing the supraspinatus muscle laterally can create an acute iatrogenic traction injury if the nerve is not protectively released. Therefore, a prophylactic release of transverse scapular ligament at the suprascapular notch is an essential step to both treat pre-existing neuropathy and prevent iatrogenic nerve injury.¹³

This study aims to analyse the functional and clinical outcomes of arthroscopic muscle advancement with suprascapular nerve release for MIRCTs. We hypothesized that this combined approach would achieve tension free double row repair and effectively improve shoulder function.

Materials and Methods

Study Design and Patient SelectionThis is a retrospective case series (Level IV evidence).Following Institutional Review Board (IRB) approval, we conducted a retrospective review of 26 patients treated by the senior author between January 2022 and August 2024.

Inclusion criteria were: (1) symptomatic MIRCTs involving both supraspinatus and infraspinatus tendons, with Patte 3 retraction (2) tears confirmed to be irreparable intraoperatively , defined after complete arthroscopic release and mobilization as the inability of the torn tendons to be advanced to within 10 mm of the native greater tuberosity footprint or to achieve >50% footprint coverage without excessive tension, (3) moderate fatty infiltration of Goutallier </=3 (4) absence of advanced glenohumeral arthritis (Hamada grade <3) (5) Functional or repairable Subscapularis tear (6) minimum of 12 months' clinical follow-up.

Exclusion criteria included: (1) prior shoulder arthroplasty or rotator cuff surgery; (2) active or recent infection; (3)Isolated Infraspinatus / Subscapularis tear (4) significant pre-existing neurological deficits affecting the extremity; and (5) advanced cuff tear arthropathy (Hamada grade 3 or higher).

Preoperative Evaluation

All patients underwent a comprehensive preoperative evaluation, including a standardized history and physical examination. Clinical assessment included documentation of active and passive range of motion (ROM), strength testing for forward elevation and external and internal rotation, and evaluation for lag signs (external rotation lag sign, Hornblower's sign).

Standardized shoulder radiographs (true anteroposterior, outlet and axillary lateral views) were obtained to assess for glenohumeral arthritis (Hamada grade). All patients received a preoperative 3T Magnetic Resonance Imaging (MRI) scan to confirm the diagnosis and evaluate tear characteristics. A fellowship-trained musculoskeletal radiologist assessed all MRIs to determine tendon retraction (Patte classification) and the degree of fatty infiltration of the rotator cuff muscles (Goutallier classification)

Preoperative functional status was quantified using the Constant-Murley Score (CMS),¹⁵ the American Shoulder and Elbow Surgeons (ASES) score,¹⁶ and a Visual Analogue Scale (VAS) for pain (0-10)³.

Surgical Technique

All procedures were performed by the senior author with the patient in beach chair position under general anesthesia and an interscalene block.

1. Diagnostic Arthroscopy & Assessment: Under general anaesthesia with an interscalene block, the patient is placed in a beach-chair position using an open-backed shoulder positioner table attachment with head support . The involved extremity is placed in a pneumatic arm holder (Spider; Smith & Nephew). Surgical preparation to the midline posteriorly is performed and draping of the entire ipsilateral half of the back allows easy access to the medial border of the scapula . Standard posterior,anterosuperior and subacromial portals were established. Diagnostic arthroscopy was performed to confirm the tear pattern. A standard subacromial decompression and bursectomy were performed. An extensive arthroscopic release (adhesiolysis) was then performed, releasing the supraspinatus and infraspinatus tendons from any adhesions to the glenoid, coracoid, and joint capsule.
2. Assessment of Irreparability: Traction sutures (No. 2 high-strength Ethibond suture) were placed in the tendon edges to assess mobility^. The tear was confirmed as "irreparable" if the tendon edge could not be mobilized to the medial margin of the greater tuberosity footprint despite the extensive arthroscopic release.
3. Suprascapular Nerve Release: Attention was turned to the suprascapular notch. Using the subacromial portal for visualization and an accessory portal (e.g., Neviaser portal) for instrumentation, the base of the coracoid was identified. Medial to coracoclavicular ligament ,the transverse scapular ligament (TSL) was identified spanning the suprascapular notch. Suprascapular nerve scissors was used to cut the Transverse scapular ligament freeing the Suprascapular nerve . This step was performed before muscle advancement to prevent iatrogenic nerve traction.
4. Muscle Release and Advancement: An "arthroscopic-assisted" approach was used. A 2-cm vertical skin incision was made along the medial border of the scapular spine. Care must be taken not to go more medial to avoid injury to the spinal accessory nerve, typically found 4 cm medial to this point. A Cobb elevator is used to bluntly dissect and completely free the supraspinatus medial attachment superior to the scapular spine and infraspinatus inferior to the spine. This "outside-in" dissection was carried laterally to meet the previously performed arthroscopic release, creating a single, fully mobilized muscle-tendon unit.
5. Rotator Cuff Repair: After adequate release and tendon advancement, tension-free mobilization was achieved,and standard double row repair was done after preparing the greater tuberosity footprint.

Postoperative Rehabilitation

All patients followed a standardized, protection-based rehabilitation protocol.

• Phase I (Protection, Weeks 0-6): The arm was immobilized in an abduction splint at 60 degrees for the first 3 weeks, then adjusted to 30 degrees for the next 3 weeks. This position was chosen to minimize tension on the repaired muscle-tendon units. Passive ROM, including pendulum exercises and gentle forward elevation, began at 3 weeks.
• Phase II (Active-Assist, Weeks 6-12): The splint was discontinued. Active-assisted ROM was initiated, progressing to full active ROM as tolerated. Isometric strengthening began.
• Phase III (Strengthening, Weeks 12+): Progressive resistive strengthening was initiated, focusing on the rotator cuff and periscapular stabilizers. Shoulder rehabilitation programme was then initiated with Therabands .A return to heavy lifting or overhead activities was not permitted for at least 6 months.

Outcome Measures and Statistical Analysis

Functional outcomes (CMS, ASES), VAS pain score, and active ROM (forward elevation, external rotation) were recorded preoperatively and at the 12-month postoperative visit.

Statistical analysis was performed using SPSS Statistics Version 28.0. Descriptive statistics (means, standard deviations [SD]) were calculated. Paired t-tests were used to compare pre- and postoperative values for all continuous outcome measures. A p-value of < .05 was considered statistically significant^.

Results

Patient Demographics and Preoperative Data

A total of 26 patients (16 males, 10 females) met the inclusion criteria and completed the minimum 12-month follow-up . The mean age at the time of surgery was 63 years (range, 55–72 years). The dominant arm was involved in 20 patients (77%) . The mean duration of symptoms prior to surgery was 10 months (Range of 6-18 months).

Preoperative MRI analysis confirmed massive retracted tears in all patients. The mean Goutallier grade was 2 for the supraspinatus .

Functional and Clinical Outcomes

At the 12-month follow-up, all functional outcome scores and range of motion measurements showed statistically significant improvements compared with preoperative baseline values. The mean Constant–Murley Score (CMS) increased from 40 ± 6 preoperatively to 74 ± 8 at 12 months, with a mean improvement of 34 points (95% CI, 29–39; p < .001). Similarly, the American Shoulder and Elbow Surgeons (ASES) score improved from 39 ± 7 to 68 ± 9, corresponding to a mean increase of 29 points (95% CI, 24–34; p < .001).

Pain intensity, assessed using the Visual Analog Scale (VAS), demonstrated a significant reduction from a preoperative mean of 7.2 ± 1.1 to 2.1 ± 0.8 at final follow-up, representing a mean decrease of 5.1 points (95% CI, 4.4–5.8; p < .001).

Range of motion also showed significant improvement at 12 months. Mean active forward elevation increased from 90° ± 25° to 150° ± 20°, with a mean gain of 60° (95% CI, 48°–72°; p < .001). Mean active external rotation at the side improved from 20° ± 10° to 45° ± 15°, corresponding to a mean increase of 25° (95% CI, 18°–32°; p < .001).

Complications

There were no intra-operative complications. No patient experienced postoperative infection or nerve palsy (SSN ). One of the patient developed terminal stiffness during the postoperative period which could be corrected with prolonged physiotherapy but none of them had significant stiffness requiring manipulation under anaesthesia. At the final follow-up, no patient had undergone or was scheduled for revision surgery, and there were no clinical signs of retear like return of pain, loss of strength, or positive lag signs.

Discussion

This study demonstrates that an arthroscopic-assisted muscle advancement combined with a prophylactic suprascapular nerve release is a safe and effective technique that yields significant improvements in pain, function, and range of motion for patients with MIRCTs. The primary finding is that this anatomic, joint-preserving procedure successfully addresses the challenges of high-tension repairs, resulting in excellent clinical outcomes at short-term follow-up.

The concept of releasing the entire supraspinatus muscle from its scapular attachment and advancing it laterally was first introduced by Debeyre et al. in 1965.¹⁰ Their technique involved an extensive open approach utilizing an acromial osteotomy, which was associated with a relatively high incidence of osteotomy nonunion. In recent years, many arthroscopically assisted muscle advancement techniques have evolved , demonstrating lower failure rates and significant improvements in shoulder function.˒Morihara et al.⁶ reported favorable clinical outcomes in a series of 34 patients, supporting the feasibility and efficacy of this minimally invasive approach.

The technique described in our study modernizes this concept by using an "arthroscopic-assisted" approach. The 2-cm incision made medial to medial border of Scapula provides the direct access to muscle belly of Supraspinatus and Infraspinatus muscles. This helps in safe and rapid subperiosteal elevation of the muscle with minimal stripping and morbidity.

Our results compare favourably to other contemporary MIRCT treatments. The 29-point improvement in our mean ASES score is clinically significant and compares well with outcomes reported for both SCR⁵,¹⁷ and tendon transfers.⁷ However, MA offers distinct advantages over these alternatives. Unlike SCR, MA is a purely biologic, anatomic repair that uses the patient's native, vascularized muscle-tendon units, avoiding allograft costs, potential disease transmission, and graft-related healing complications. Unlike tendon transfers, MA restores the original muscle-tendon units to their anatomic insertion, preserving normal joint kinematics and avoiding the donor site morbidity and complex neuromuscular re-education associated with transfers.

Modern arthroscopic or assisted-advancement techniques have shown good results . Kim et al.¹⁹ and Morihara et al.¹¹ reported high healing rates and significant functional improvements with similar "muscle-advancing slide" techniques. Our study contributes to this body of evidence, reinforcing that gaining length from the muscle belly's origin is a viable and effective strategy. The absence of clinical retears in our series although in short term , suggests that the tension-free nature of the repair provides a favourable environment for tendon-to-bone healing.

A unique and critical component of our technique is the prophylactic SSN release done in all cases. The SSN is notoriously vulnerable in MIRCTs due to chronic medial traction.¹² Furthermore, the act of advancing the muscle laterally by 2-3 cm can place acute, traction on the nerve. We believe the SSN release serves a dual purpose: (1) it treats any pre-existing occult, traction neuropathy, and (2) it protects the nerve from iatrogenic injury during advancement. Meticulous dissection to prevent iatrogenic injury is paramount, but in our view, releasing the nerve is safer than creating tension blindly.

Limitations

We acknowledge several limitations. First, this study is a retrospective case series done in a single centre . Without a comparative control group, we cannot definitively claim superiority over other techniques. Second, our follow-up period is short-term (minimum 12 months). While the results are excellent, longer-term follow-up is necessary to assess the durability of the repair and the potential for late failure or the onset of arthritis. Third, repair integrity was evaluated clinically, as routine postoperative MRI imaging was not performed. Consequently, the reported absence of retear is based on clinical assessment alone, which may underestimate the true rate of structural failure when compared with radiographic evaluationFinally, all procedures were performed by a single, experienced surgeon, which may limit the generalizability of these results.

Further comparative studies with larger sample sizes and longer follow-up periods are required to accurately assess the efficacy and long-term outcomes of this procedure. Multi-centre studies would help validate these findings and enhance the generalizability of the results.

Conclusion

Arthroscopic-assisted muscle advancement combined with routine suprascapular nerve release is a feasible and reproducible joint-preserving technique for the management of massive irreparable posterosuperior rotator cuff tears in patients without advanced glenohumeral arthritis. In this case series, the technique enabled anatomical tendon mobilization, improved footprint coverage, and tension-free double-row repair, with encouraging short-term functional and clinical outcomes.

By preserving the native shoulder joint and avoiding grafts or tendon transfers, this technique will be useful in carefully selected patients. However, larger comparative studies with longer follow-up are required to validate its effectiveness, durability, and to define its role relative to other reconstructive procedures.

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