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Revision rotator cuff repair

64 citationsUpdated Oct 2026
Illustration: Revision rotator cuff repair

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Revision rotator cuff repair is a complex procedure indicated primarily for patients with persistent clinical symptoms despite nonsurgical management, provided substantial risk factors for failure are absent [2, 3]. While outcomes are encouraging, failure and complication rates are proportional to the number of prior attempted repairs [1]. Consequently, results are inferior to those of primary repair [6, 8], and the complication rate after arthroscopic revision is approximately twice that of primary rotator cuff repair [15]. Despite these challenges, the procedure provides significant improvement in both pain and function at 5 years postoperation [6] and offers reliable long-term pain relief and functional score improvements [13]. Patient outcomes are significantly improved if cuff healing can be obtained [4], and a revision rotator cuff repair prediction score can be used in patient counseling to identify those most likely to benefit [14].

Arthroscopic revision rotator cuff repair is a reasonable treatment option even after prior open repairs [7] and improves shoulder function [9]. Although retears after arthroscopic revision are frequent, they are usually smaller [9], and the procedure can lead to functional improvement despite a high retear rate [11]. Repeat cuff repair can improve pain and function when indicated [18], though outcomes are poorer than primary procedures if criteria such as small retear, good tissue quality, and no osteoarthritis are not met [18]. For small- and medium-sized tears, open or arthroscopic repair achieves a high success rate (>90%) [38]. In contrast, large or massive tears in older patients are less likely to be repaired successfully and are best treated with reconstructive options such as revision repair, superior capsular reconstruction, subacromial balloon spacers, tendon transfers, and reverse total shoulder arthroplasty [38].

Specific adjuncts and patient populations influence outcomes. Double-row arthroscopic repair with dermal allograft augmentation of complex and revision tears led to improved functional outcomes [5]. Performing concurrent subacromial decompression conferred a 26% relative risk reduction for revision rotator cuff repair compared to arthroscopic rotator cuff repair alone, with a number needed to treat of approximately 4 patients [16]. In workers’ compensation patients, revision repairs continue to fail from 6 months to ≥ 2 years [29], and an onlay bioinductive implant provides no additional benefit to the longer-term health of the repair [29, 39]. Arthroscopic repair can be recommended in patients with massive rotator cuff tears because of the functional gain at midterm follow-up despite a high rate of healing failures [20]. Overall, arthroscopic revision rotator cuff repair results in reliable improvement in shoulder function, pain, and satisfaction [30].

Anatomy & Pathophysiology

Causes of Failure and Revision Complexity

Failed rotator cuff repair may result from surgical complications, diagnostic errors, technical errors, failure to heal, or traumatic failure [10]. Failure to heal is specifically attributed to technical errors, surgical complications, biologically mediated failure, patient noncompliance, and traumatic failure [34]. Revision surgery is technically more difficult than primary repair due to poor tissue quality, tissue adhesions, and retained suture or suture anchor material [10]. The procedure is further complicated by patient factors and expectations, as well as the sequelae of postoperative complications [10]. Poor tissue quality, detachment of the deltoid origin, and multiple previous surgeries are risk factors for poor outcomes in revision rotator cuff repair [10].

Retear Timing and Mechanisms

Postoperative imaging may reveal a rotator cuff tear due to a biomechanically insufficient repair, a failure in the biologic healing process, or a rerupture of the scar despite successful initial healing [27]. Most recurrent tears occur within 3 to 6 months after surgery [27]. In a multiinstitutional prospective study of 113 patients with tears measuring 1 to 4 cm, 18 (94.7%) of 19 retears occurred within 6 months [27]. In a study of 22 patients with large and massive tears, 100% of retears occurred within 6 months of repair [27]. Additionally, in a study of 176 patients after arthroscopic repair, 80% of reruptures had occurred before 6 months [27].

Tissue Quality and Predictors

Rotator cuff tear size, including tear dimensions, area, and thickness, showed stronger associations with retears at 6 months than measures of tissue quality or concomitant shoulder injuries [35]. Young, active patients with good tissue quality and no muscle atrophy have a higher repair success rate compared to more elderly patients with relatively poorer tissue quality [34].

Shoulder Anatomy and Biomechanics

The rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles [61]. These tendons form a sheet closely applied over the shoulder capsule, inserting mainly into the greater tuberosity of the humerus, with the subscapularis inserting into the lesser tuberosity [68]. The cuff muscles serve as depressors of the humeral head, allowing the deltoid to efficiently abduct the humerus [61]. The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator [61]. The rotator cuff stabilizes the glenohumeral joint by pulling the humeral head firmly into the glenoid whenever the deltoid lifts the arm forwards or sideways [68]. It must act simultaneously and synergistically with the deltoid muscle for normal function [72]. The teres minor has heightened attention to its contribution to rotator cuff function, particularly when other cuff tendons fail [73].

The glenohumeral joint depends on static and dynamic stabilizers for movement and stability [72]. The bony anatomy contributes little to stability, often compared to a golf ball on a tee [73]. The glenoid is a convex structure of shallow depth shaped like an inverted pear [60]. The glenoid articular surface and labrum combine to create a socket approximately 9 mm deep superoinferiorly and 5 mm deep anteroposteriorly [73]. The glenoid labrum increases the depth of the socket by 50% around the humeral head and increases stability [73]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [73]. The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [63]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [63].

The humeral head is essentially spherical, with an arc of approximately 160 degrees covered by articular cartilage [72]. The radius of curvature of the humeral head is approximately 25 mm and is slightly larger in men than in women [72]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [72]. The superior margin of the humeral head articular surface is normally superior to the top of the greater tuberosity by 8 to 10 mm [72]. The humeral head averages 19° of retroversion and 41° of inclination (neck-shaft angle) [63]. The humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [74]. The average neck-shaft angle is 45 degrees (±5 degrees), with a range of 30 to 50 degrees [72]. Arthritic shoulders have a flatter neck-shaft angle close to 50 degrees [72]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the measurement method [72].

The glenoid averages 5° of retroversion in relation to the axis of the scapular body [63]. The normal position of the glenoid surface in relation to the axis of the scapular body ranged from 2 degrees of anteversion to 7 degrees of retroversion [72]. The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [72]. A significant decrease in lateral humeral offset reduces the lever arms for the deltoid and supraspinatus muscles, weakening abduction and impairing function [72]. A significant increase in lateral humeral offset causes excessive tension on the soft tissues ("overstuffing" of the joint), resulting in loss of motion and likely accelerating polyethylene wear [72].

The coracoacromial arch is a fibro-osseous canopy formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [68]. The acromion, coracoacromial ligament, and coracoid process form this rigid bony-ligamentous structure, which imparts stability to the shoulder girdle [60]. The subacromial bursa separates the rotator cuff tendons from the coracoacromial arch and allows them to glide [68]. The rotator cuff, subacromial bursa, and subdeltoid bursa pass underneath the coracoacromial arch [60]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency and should be preserved with irreparable cuff tears to prevent anterosuperior escape [74].

The humeroscapular motion interface lies between the inner structures of the proximal humerus, rotator cuff, coracohumeral ligament, and biceps tendon sheath, and the superficial layer of the acromion, deltoid, coracoacromial ligament, coracoid process, and conjoined tendon [66]. Smooth, unrestricted motion at this interface is vital to shoulder mobility, as evidenced when compromised by subacromial adhesions in cuff disease and after proximal humerus fracture [66]. The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [63]. It contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [63]. Laxity of the rotator interval results in inferior laxity (the sulcus sign), while contracture is seen with adhesive capsulitis [63].

The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [73]. The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [73]. The coracohumeral ligament is a thick band of fibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons [73]. The subscapular bursa lies between the subscapularis tendon and the neck of the scapula and communicates with the joint cavity between the superior and middle glenohumeral ligaments [64].

The glenohumeral joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic joints, which work together to allow smooth shoulder function [73]. The scapula is attached to the axial skeleton by the clavicle, specifically via the acromioclavicular (AC) and sternoclavicular (SC) joints [62]. The scapula is separated from the chest wall by thin gliding fibro-fatty tissue, allowing smooth excursion over the chest wall [62]. The glenoid is connected with the flat body of the scapula by the scapular neck [62]. The hook-shaped coracoid process curves forwards from the superior surface of the scapular neck [62]. The scapular spine ends in a flattened bony process, the acromion, which curves forwards [62]. The highest concentration of bony mass in the scapula is in the glenoid, the scapular neck (including the base of the coracoid process), and the lateral border of the scapular body [62]. Two bony pillars extend between the glenoid and the scapular body to transmit compressive forces from the glenoid fossa [62]. The lateral pillar connects the inferior border of the glenoid with the inferior angle [62]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [62]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, i.e., in the infraspinous fossa [62]. The weakest area of the circumference of the biomechanical body of the scapula is the connection of the scapular spine and the medial border of the scapula, the spinomedial angle [62].

The proximal humerus has three centers of ossification: the humeral head (4 to 6 months), the greater tuberosity (1 to 3 years), and the lesser tuberosity (3 to 5 years) [63]. The proximal humeral ossification centers fuse to the shaft at age 17 to 20 years [63]. The greater and lesser tuberosities serve as attachment sites for the rotator cuff tendons [63]. The anatomic neck is directly below the humeral head and serves as an attachment for the shoulder capsule [74]. The surgical neck is more distal and more often involved in fractures [74].

Static stabilizers of the glenohumeral joint include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [63]. The rotator cuff stabilizes the glenohumeral joint via joint compression [63]. The most important force couple involves the subscapularis and posterior rotator cuff, which provide a compressive force that centers the humeral head in the glenoid cavity [73]. The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction and is the primary stabilizer to anterior and posterior stress in the same position [73]. It is also a primary static restraint against anterior translation with the arm at the side [63]. With the coracohumeral ligament, the superior glenohumeral ligament forms a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [63]. The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [63]. The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction [73]. It is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [63]. The inferior glenohumeral ligament is composed of an anterior band that is quite thick, a posterior band that is less thick and distinct, and a thinner intervening axillary pouch, creating a hammock-type sling [73]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [73]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90° of abduction and external rotation (position of apprehension) [63]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [63].

The subscapularis originates from the anterior scapula and inserts anteriorly onto the lesser tuberosity [67]. The greater tuberosity provides attachment superiorly and posteriorly for the supraspinatus, infraspinatus, and teres minor, all of which originate from the posterior scapula [67]. The deltoid forward flexes and abducts the shoulder and courses from the clavicle and acromion superiorly, coalescing into a common tendinous insertion onto the lateral upper third of the humeral shaft [67]. The pectoralis major powers adduction and internal rotation due to its tendinous insertion anteriorly onto the lateral wall of the bicipital groove [67]. The pectoralis major forms the roof of the distal continuation of the bicipital tunnel, which is a closed space that extends proximally to the glenohumeral joint [67]. The transverse humeral ligament is an important stabilizer of the biceps tendon [74]. The capsule of the glenohumeral joint extends from the glenoid rim, progressing laterally toward the surgical neck of the humerus and blending with the tendons of the rotator cuff musculature [67].

The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [60]. The anterior and posterior humeral circumflex arteries provide a rich blood supply to the proximal humerus [67]. 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [67]. The major blood supply to the humeral head is through the ascending branch of the anterior humeral circumflex artery, which penetrates the head at the bicipital groove and becomes the arcuate artery [61]. The anterior humeral circumflex artery provides vascular inflow to the humeral head by way of its terminal anterolateral branch known as the artery of Laing (also known as the arcuate artery) [60]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [63]. The terminal intraosseous portion of the artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [63].

The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [63]. The suprascapular artery runs superior to the superior transverse scapular ligament; the nerve runs deep to the ligament [63]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [63]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [63]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [63]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [67].

Classification

Mechanism of Failure: A failed rotator cuff repair may result from a biomechanically insufficient repair, a failure in the biologic healing process, or a rerupture of scar tissue despite successful initial healing [27]. The timing of these failures is predominantly early; in a multiinstitutional prospective study of 113 patients with sequential MRI studies after repairs of 1 to 4 cm tears, 18 (94.7%) of 19 retears occurred within 6 months after surgery [27]. Similarly, in a study of 22 patients with large and massive tears imaged up to 2 years postoperatively, 100% of retears occurred within 6 months of repair [27]. Ultrasonographic evaluation of 176 patients at 3, 6, and 12 months after arthroscopic repair confirmed that 80% of reruptures had occurred before the 6-month mark [27].

Subscapularis Status: Among revision rotator cuff repairs, 43.1% presented with neglected subscapularis tears [22]. Fatty infiltration of these initially neglected subscapularis tendons showed further progression at the time of revision [22].

Sugaya Classification: The exact status of Sugaya III tendons remains unclear. However, Sugaya I and II tendons can be considered as healed, while Sugaya type IV and V tendons can be considered as retorn [119].

Clinical Presentation

Symptoms and Signs

Patients presenting with a failed rotator cuff repair typically report persistent pain, night pain, weakness, stiffness, and regression in recovery milestones [87]. The physical examination must evaluate for muscle atrophy and scapular dyskinesia [87]. Assessment of passive and active range of motion is required for both the affected and unaffected shoulders [87]. The clinical workup should also include provocative maneuvers to identify other shoulder pathology, a thorough cervical spine examination, and a neurovascular examination [87].

Indications

Repeat cuff repair can improve pain and function when indicated, but outcomes are poorer than primary procedures if criteria such as small retear, good tissue quality, and no osteoarthritis are not met [18].

Imaging and Diagnostic Evaluation

Imaging studies are necessary in patients in whom a high index of suspicion for failed rotator cuff repair exists after a thorough patient history and physical examination [87]. Many imaging modalities may aid in the evaluation of patients in whom failed rotator cuff repair is suspected, including: * MRI * Magnetic resonance arthrography * CT arthrography * Ultrasonography

[87] Postoperative MRIs may not be as accurate as preoperative MRIs because of the presence of metal and bioabsorbable suture anchors, altered postsurgical signal changes, and other postoperative artifact [87]. The accuracy of MRI to detect a re-tear or failed rotator cuff repair ranges from 70% to 90% and may be improved with the use of intraarticular contrast [87]. Surgeons must properly evaluate the cartilage, muscle belly quality, and tendon quality and length on MRI [87]. Ultrasonography is another imaging modality commonly used to determine rotator cuff repair failure, especially in the early postoperative period [87].

Risk Factors and Prognostic Indicators

Failure and complication rates are proportional to the number of attempted prior rotator cuff repairs [1]. Compared to primary RCR patients, the revision cohort were more commonly White, had lower mental health status and more severe rotator cuff pathology, though tear severity was not associated with baseline PROMs [26]. Subclinical shoulder infections can be present in more than one-quarter of patients undergoing revision after rotator cuff repair [32, 33]. Among revision rotator cuff repairs, 43.1% had neglected subscapularis tears, and fatty infiltration of these initially neglected subscapularis tendons showed further progression at the time of revision [22].

Investigations

Indications and Risk Factors

Failure and complication rates after revision rotator cuff repair are proportional to the number of attempted prior rotator cuff repairs [1]. Preoperative corticosteroid injections influence reoperation risk; patients who received an injection within 6 months prior to repair were much more likely to undergo a subsequent reoperation within the following 3 years [19, 21]. Conversely, a single shoulder injection within a year prior to arthroscopic repair was not associated with increased revision risk [28, 41], whereas the administration of 2 or more injections within that timeframe was associated with a substantially increased risk of subsequent revision surgery [28]. Compared to primary repair cohorts, revision patients were more commonly White, had lower mental health status, and presented with more severe rotator cuff pathology [26]. Notably, tear severity was not associated with baseline patient-reported outcomes in the revision cohort [26].

Imaging Modalities

Plain radiography: The standard shoulder series includes orthogonal views: a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [85]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration [85]. The axillary view determines humeral head position in the glenoid fossa and may detect occult, locked posterior shoulder dislocation [85]. The scapular Y view visualizes the coracoacromial arch and can reveal coracoacromial spurs associated with rotator cuff pathology [85]. Normal acromiohumeral distance is 7 to 14 mm, and the glenohumeral joint space width should be symmetric superiorly and inferiorly [85]. The normal coracoclavicular distance is 1.1 to 1.3 cm [85]. Neer classified acromial morphology as type I (flat), type II (curved), and type III (hooked) [85]. Type III acromial morphology correlates with the presence of rotator cuff disease, though no direct causal relationship has been demonstrated [85]. The acromial index radiological measurement is not a predictor for recurrent rotator cuff tears after primary arthroscopic repair [142].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [84]. T2-weighted MRI provides better visualization of full-thickness rotator cuff tears [84]. MRI is useful for evaluating pain and loss of function after repair, particularly for identifying full-thickness tears, intact cuffs, ruptures of the biceps tendon, and detachments of the origin of the deltoid muscle [141]. However, MRI is less effective than other modalities for identifying partial-thickness tears in patients with pain and loss of function after rotator cuff repair [141]. There is substantial variability when evaluating MRI scans after rotator cuff repair [128]. MRI and ultrasound provide similar assessments of postoperative rotator cuff healing, although ultrasound is less sensitive [122]. Selective MRI to assess rotator cuff integrity to indicate shoulder arthroplasty is cost-effective if surgical preparedness, patient expectations, and implant availability preclude the ability to switch implants intraoperatively [143].

CT: CT arthrography is indicated when MRI or MR arthrography is contraindicated, such as in patients with pacemakers or vascular clips [84].

Ultrasonography: Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [84]. It provides immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [84]. Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [84].

MR Arthrography: MR arthrography is considered the benchmark for evaluation of labral tears and rarely is indicated for evaluation of rotator cuff pathology [84].

Diagnostic Criteria and Classification

Primary diagnostic arthroscopy allows assessment of tendon tear type (articular, bursal, or full thickness), form (crescent, U, V, L, or L reverse), lesion size (anteroposterior and mediolateral diameters and Snyder’s classification), and tendon injury percentage [25]. The Snyder classification describes the extent, location, and size of the tear [25]. Location is classified as articular (type A), bursal (type B), and complete (type C) [25]. Dimension 1 is a small tear; dimension 2 is a moderate tear less than 2 cm of only 1 tendon without retraction; dimension 3 is a large complete tear usually 3 to 4 cm with minimal retraction; and dimension 4 is a massive rotator cuff tear involving 2 or more rotator cuff tendons with retraction associated [25]. Acromial type is assessed according to the Bigliani-Morrison classification during diagnostic arthroscopy [25]. Tendinosis severity assessed by preoperative MRI was the only factor associated with failure to heal in patients with partial-thickness and small full-thickness rotator cuff tears [132].

Treatment

Operative

Indications: Outcomes following revision rotator cuff repair are encouraging, although failure and complication rates increase proportionally with the number of prior attempted repairs [1]. Preoperative corticosteroid administration influences surgical risk; a single shoulder injection within one year prior to arthroscopic repair is not associated with increased revision risk, whereas the administration of two or more injections is associated with a substantially increased risk of subsequent revision surgery [28].

Surgical Approach / Technique: Arthroscopic revision rotator cuff repair is a reasonable treatment option even after prior open repairs, providing improved pain relief and shoulder function [7]. For rotator cuff retears associated with large uncontained defects of the greater tuberosity, a 2-stage arthroscopic approach using compaction bone grafting is a reliable method. This technique restores the bony scaffold to allow stable suture anchor fixation and sufficient tendon-to-bone contact [136].

Outcomes: Revision rotator cuff repair provides significant improvement in both pain and function at 5 years postoperation, though results are not as good as primary repair [6]. Historically, open revision rotator cuff repair yielded inferior results compared with primary repair; however, more recent studies show 52% to 69% satisfactory results in small-sized or medium-sized tears [10]. Arthroscopic revision rotator cuff repair yields greater than 60% good or excellent results [10]. Clinical results demonstrate improvements in scores and decreased pain, especially in patients treated with a new repair [137].

Adjuncts: Concurrent subacromial decompression (SAD) confers a 26% relative risk reduction (NNT≈4 patients) for revision rotator cuff repair when compared to arthroscopic rotator cuff repair alone in a large cohort of over 60,000 patients with partial or complete rotator cuff tears [16]. Onlay bioinductive implants provide no additional benefit to the longer-term health of the repair in this difficult population, as revision rotator cuff repairs continue to fail from 6 months to ≥ 2 years [29].

Complications

General Complication Rates and Outcomes: The complication rate following arthroscopic revision rotator cuff repair is approximately twice the published rate for primary rotator cuff repair [15]. While revision rotator cuff repair improves clinical outcomes and shoulder function at midterm follow-up [17], and successful outcomes have been observed at long-term follow-up with and without bioaugmentation [49], patients should not expect to see the improvements in range of motion that may occur after primary repair [50]. Although arthroscopic revision rotator cuff repair improved shoulder function, retears were frequent but usually smaller [9].

Risk Factors for Failure and Revision: Patients who had received an injection within 6 months prior to rotator cuff repair were much more likely to undergo a revision cuff repair within the following 3 years [21]. The administration of 2 or more shoulder injections within a year prior to arthroscopic rotator cuff repair was associated with a substantially increased risk of subsequent revision rotator cuff surgery [28], whereas a single shoulder injection within a year prior to arthroscopic rotator cuff repair was not associated with any increased risk of revision surgery [28, 41]. Early use of fluoroquinolones following rotator cuff repair was independently associated with significantly increased rates of failure requiring revision rotator cuff repair [153]. Dyslipidemia should be considered among other risk factors when counseling patients regarding expected rotator cuff repair outcomes [152]. Performing concurrent subacromial decompression conferred a 26% relative risk reduction (NNT≈4 patients) for revision rotator cuff repair when compared to arthroscopic rotator cuff repair alone [16, 40]. The application of bone marrow aspirate concentrate at the time of rotator cuff repair was associated with a significant decrease in the incidence of revision surgery [55].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for manual work, sport, or full range of motion and strength return.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail physical therapy phasing, immobilisation duration, weight-bearing or range of motion progression, or sling and brace removal timing.

Functional milestones: Patient outcomes after revision rotator cuff repair are significantly improved if cuff healing can be obtained [4]. Arthroscopic revision rotator cuff repair provides improved pain relief and shoulder function even after prior open repairs [7]. While arthroscopic revision rotator cuff repair improves shoulder function, retears are frequent [9]. These retears following arthroscopic revision rotator cuff repair are usually smaller than the original tear [9]. Historically, open revision rotator cuff repair yields inferior results compared with primary rotator cuff repair [10]. More recent studies show 52% to 69% satisfactory results in small-sized or medium-sized tears for open revision rotator cuff repair [10].

Other Considerations: A revision rotator cuff repair prediction score can be used in patient counseling and to identify those most likely to benefit from revision repair [14]. Revision rotator cuff repair patients should not expect to see the improvements in range of motion that may occur after primary repair [50]. Latissimus transfer, as a salvage procedure for failed rotator cuff repair with loss of elevation, allows for significant return of active elevation and function with minimal post-operative pain [149].

Key Evidence

  • [L5] Outcomes after revision rotator cuff repair are encouraging; however, failure and complication rates are proportional to the number of attempted prior rotator cuff repairs. [1] (10.1097/bte.0b013e31824c2574)
  • [L4] The major indication for revision rotator cuff repair is the persistence of clinical symptoms, despite nonsurgical management, in the absence of substantial risk factors for failure. [2] (10.1055/b-0041-179892)
  • [L5] The major indication for revision rotator cuff repair is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure. [3] (10.5435/00124635-201111000-00002)
  • [L5] Revision rotator cuff repair is a complex procedure with higher failure rates than initial cuff repair, but patient outcomes are significantly improved if cuff healing can be obtained. [4] (10.1097/bte.0000000000000113)
  • [L4] Double-row arthroscopic repair with dermal allograft augmentation of complex and revision rotator cuff tears led to improved functional outcomes. [5] (10.1177/03635465211015194)
  • [L4] Revision rotator cuff repair provides significant improvement in both pain and function at 5 years postoperation, though not as good as primary repair. [6] (10.1016/j.jse.2019.12.011)
  • [L4] Arthroscopic revision rotator cuff repair may be a reasonable treatment option even after prior open repairs and provides both improved pain relief and shoulder function. [7] (10.1177/0363546509346401)
  • [L4] Although arthroscopic revision RCR improved shoulder function, retears were frequent but usually smaller. [9] (10.1177/03635465221097410)
  • [L5] [10] (10.1016/j.jse.2011.11.029)
  • [L4] The review indicates that arthroscopic revision rotator cuff repair can lead to improvement in functional outcome despite a high retear rate. [11] (10.1136/jisakos-2015-000027)
  • [L4] Revision rotator cuff repair provides significant pain relief and improvement in functional scores at long-term follow-up. [13] (10.1016/j.jse.2023.06.009)
  • [L4] This revision rotator cuff repair prediction score could be used in patient counseling and to identify those most likely to benefit from revision repair. [14] (10.1016/j.jse.2024.12.034)
  • [L4] The complication rate after arthroscopic revision rotator cuff repair is about twice the published rate for primary rotator cuff repair. [15] (10.1016/j.arthro.2013.06.015)
  • [L3] In a large cohort of over 60,000 patients with partial or complete rotator cuff tears, performing concurrent SAD conferred a 26% relative risk reduction (NNT≈4 patients) for revision rotator cuff repair when compared to ARCR alone. [16] (10.1016/j.jisako.2023.03.378)
  • [L4] Revision RCR improves clinical outcomes and shoulder function at midterm follow-up. [17] (10.1177/0363546518786006)
  • [L5] Repeat cuff repair can improve pain and function when indicated, but outcomes are poorer than primary procedures if criteria such as small retear, good tissue quality, and no osteoarthritis are not met. [18] (10.1016/j.otsr.2018.06.012)
  • [L3] Patients who had received a corticosteroid injection within 6 months prior to rotator cuff repair were much more likely to undergo a subsequent reoperation within the following 3 years. [19] (10.1177/2325967118s00006)
  • [L4] Despite a high rate of healing failures, arthroscopic repair can be recommended in patients with massive rotator cuff tears because of the functional gain at midterm follow-up. [20] (10.1177/0363546513485719)
  • [L3] Patients who had received an injection within 6 months prior to RCR were much more likely to undergo a revision cuff repair within the following 3 years. [21] (10.1016/j.arthro.2018.10.107)
  • [L4] Among revision rotator cuff repairs, 43.1% had neglected subscapularis tears, and fatty infiltration of these initially neglected subscapularis tendons showed further progression at the time of revision. [22] (10.1177/03635465211047485)
  • [L1] [25] (10.1177/0363546517695789)
  • [L3] Compared to primary RCR patients, the revision cohort were more commonly White, had lower mental health status and more severe rotator cuff pathology, though tear severity was not associated with baseline PROMs. [26] (10.1016/j.jse.2026.05.007)
  • [L4] [27] (10.2106/jbjs.rvw.19.00039)
  • [L3] A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery. [28] (10.1016/j.arthro.2018.07.043)
  • [L3] This study amplifies those findings and shows that revision rotator cuff repairs continue to fail from 6 months to ≥ 2 years, with the onlay bioinductive implant having no additional benefit to the longer-term health of the repair in this difficult population. [29] (10.1016/j.jse.2025.11.021)
  • [L4] Arthroscopic revision rotator cuff repair results in reliable improvement in shoulder function, pain, and satisfaction. [30] (10.1007/s00167-016-4392-7)
  • [L4] Subclinical shoulder infections can be present in more than one-quarter of patients undergoing revision after rotator cuff repair. [32] (10.1016/j.asmr.2023.100792)
  • [L3] Subclinical shoulder infections can be present in over one-quarter of patients undergoing revision after rotator cuff repair. [33] (10.1016/j.arthro.2024.11.038)
  • [Paper] [34] (10.1016/j.eats.2021.03.028)
  • [L3] Nevertheless, rotator cuff tear size (tear dimensions, tear size area, and tear thickness) showed stronger associations with retears at 6 months after surgery than did measures of tissue quality and concomitant shoulder injuries. [35] (10.1177/0363546514525336)
  • [L5] Small- and medium-sized rotator cuff tears can be treated with open or arthroscopic repair with a high rate of success (>90%), while large or massive tears in older patients are less likely to be repaired successfully and are best treated with reconstructive options such as revision repair, superior capsular reconstruction, subacromial balloon spacers, tendon transfers, and reverse total shoulder arthroplasty. [38] (10.1016/j.jhsa.2021.02.005)
  • [L3] There were no differences in repair integrity or clinical outcomes between workers' compensation patients who underwent revision arthroscopic rotator cuff repair with an onlay bioinductive implant compared to those who underwent standard revision rotator cuff repair. [39] (10.1177/23259671231175883)
  • [L3] Performing concurrent SAD conferred a 26% relative risk reduction (NNT≈4 patients) for revision rotator cuff repair when compared to ARCR alone. [40] (10.1177/2325967123s00187)
  • [L3] A single shoulder injection within a year prior to arthroscopic RCR is not associated with any increased risk of revision surgery. [41] (10.1177/2325967118s00081)
  • [L3] Successful outcomes were observed at long-term follow-up for revision rotator cuff repair with and without bioaugmentation. [49] (10.1016/j.jseint.2024.04.009)
  • [L3] Revision patients should not expect to see the improvements in ROM that may occur after primary repair. [50] (10.1016/j.jse.2024.05.011)
  • [L3] The application of BMAC at the time of rotator cuff repair was associated with a significant decrease in the incidence of revision surgery. [55] (10.1177/23259671221127004)
  • [L5] [87] (10.5435/jaaos-d-17-00086)
  • [L3] [119] (10.1016/j.jse.2023.06.028)
  • [L3] MRI and US provide similar assessments of postoperative rotator cuff healing, although US is less sensitive. [122] (10.1016/j.otsr.2015.06.006)
  • [L3] The results of this study indicate that there is substantial variability when evaluating MRI scans after rotator cuff repair. [128] (10.1177/0363546512449424)
  • [L3] Tendinosis severity assessed by preoperative MRI was the only factor associated with failure to heal in patients with partial-thickness and small full-thickness rotator cuff tears. [132] (10.1177/0363546514561004)
  • [Paper] A 2-stage arthroscopic approach using compaction bone grafting is a reliable method for addressing rotator cuff retears associated with large uncontained defects of the greater tuberosity, restoring the bony scaffold to allow stable suture anchor fixation and sufficient tendon-to-bone contact. [136] (10.1016/j.eats.2021.04.030)
  • [L4] Clinical results showed improvements in scores and decreased pain, especially in patients treated with a new repair. [137] (10.1016/j.jse.2021.03.121)
  • [L3] Magnetic resonance imaging is useful for the evaluation of patients who have pain and loss of function after a repair of the rotator cuff, particularly for identifying full-thickness tears, intact cuffs, ruptures of the biceps tendon, and detachments of the origin of the deltoid muscle, though it is less effective for partial-thickness tears. [141] (10.2106/00004623-199609000-00015)
  • [Paper] In our study, we found that the AI radiological measurement is not a predictor for RC recurrent tears after primary arthroscopic repair. [142] (10.1007/s00264-013-1963-9)
  • [L3] However, performing selective MRI to assess rotator cuff integrity to indicate RSA or TSA is cost-effective if surgical preparedness, patient expectations, and implant availability preclude the ability to switch implants intraoperatively. [143] (10.1097/corr.0000000000002110)
  • [L4] Latissimus transfer, as a salvage procedure for failed rotator cuff repair with loss of elevation, allows for significant return of active elevation and function with minimal post-operative pain. [149] (10.1016/j.jse.2008.04.007)
  • [L1] DLD should be considered among other risk factors when counseling patients regarding expected rotator cuff repair outcomes. [152] (10.1016/j.xrrt.2022.02.003)
  • [L3] Early use of fluoroquinolones following rotator cuff repair was independently associated with significantly increased rates of failure requiring revision rotator cuff repair. [153] (10.1007/s00167-016-4354-0)

See Also

References

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[2] Arthroscopic Revision Rotator Cuff Repair. Video Atlas of Arthroscopic Rotator Cuff Repair. 2021. DOI: 10.1055/b-0041-179892

[3] Arthroscopic Revision Rotator Cuff Repair. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201111000-00002

[4] Revision Rotator Cuff Repair: Tips and Tricks to Get it Repaired and to Get it to Heal. Techniques in Shoulder & Elbow Surgery. 2016. DOI: 10.1097/bte.0000000000000113

[5] Healing and Functional Results of Dermal Allograft Augmentation of Complex and Revision Rotator Cuff Repairs. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211015194

[6] Medium-term outcomes of a cohort of revision rotator cuff repairs. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.12.011

[7] Outcomes after Arthroscopic Revision Rotator Cuff Repair. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509346401

[8] Clinical and radiographic factors influencing the results of revision rotator cuff repair. 2013.

[9] Results of Arthroscopic Revision Rotator Cuff Repair for Failed Open or Arthroscopic Repair: A Prospective Multicenter Study on 100 Cases. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221097410

[10] Current concepts review: revision rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.029

[11] Management of failed rotator cuff repair: a systematic review. Journal of ISAKOS. 2016. DOI: 10.1136/jisakos-2015-000027

[13] Long-term results of revision rotator cuff repair for failed cuff repair: a minimum 10-year follow-up study. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.06.009

[14] Predicting good clinical outcomes after revision rotator cuff repair: the revision cuff repair prediction score. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.034

[15] Complications After Arthroscopic Revision Rotator Cuff Repair. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.06.015

[16] Subacromial Decompression is Associated with a Number Needed to Treat of 4 for Reduced Revision Rotator Cuff Repair: A Large Matched Cohort Insurance Database Analysis. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.378

[17] Clinical Outcomes, Tendon Integrity, and Shoulder Strength After Revision Rotator Cuff Reconstruction: A Minimum 2 Years’ Follow-up. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518786006

[18] Failed rotator cuff repair. Orthopaedics & Traumatology: Surgery & Research. 2019. DOI: 10.1016/j.otsr.2018.06.012

[19] Preoperative Shoulder Injections are Associated with Increased Risk of Subsequent Revision Rotator Cuff Repair. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118s00006

[20] Arthroscopic Repair of Massive Rotator Cuff Tears. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513485719

[21] Preoperative Shoulder Injections Are Associated With Increased Risk of Revision Rotator Cuff Repair. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.10.107

[22] Arthroscopic Revision Rotator Cuff Repair: The Role of Previously Neglected Subscapularis Tears. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211047485

[25] Advantages of Arthroscopic Rotator Cuff Repair With a Transosseous Suture Technique: A Prospective Randomized Controlled Trial. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517695789

[26] Associations of preoperative patient mental health status, sociodemographic and clinical characteristics with baseline pain, function and satisfaction in patients undergoing revision rotator cuff repairs. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.05.007

[27] Rotator Cuff Retears. JBJS Reviews. 2020. DOI: 10.2106/jbjs.rvw.19.00039

[28] Increasing Numbers of Shoulder Corticosteroid Injections Within a Year Preoperatively May Be Associated With a Higher Rate of Subsequent Revision Rotator Cuff Surgery. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019. DOI: 10.1016/j.arthro.2018.07.043

[29] The effectiveness of arthroscopically inserted onlay bioinductive implant on revision rotator cuff repair in workers’ compensation patients: a case-controlled cohort study with minimum 2-year follow-up. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.11.021

[30] Clinical outcome and prognostic factors of revision arthroscopic rotator cuff tear repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4392-7

[32] A High Rate of Bacteriologic Culture‐Positive Findings Is Seen After Revision Rotator Cuff Surgery. Arthroscopy, Sports Medicine, and Rehabilitation. 2023. DOI: 10.1016/j.asmr.2023.100792

[33] Podium Presentation Title: The Incidence of Subclinical Infection in Revision Rotator Cuff Surgery. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2024.11.038

[34] Revision Rotator Cuff Repair: A Comprehensive Approach and Stepwise Technique. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2021.03.028

[35] Factors Predicting Rotator Cuff Retears. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514525336

[38] Rotator Cuff Repair and Reconstruction. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.02.005

[39] Revision Rotator Cuff Repair With Versus Without an Arthroscopically Inserted Onlay Bioinductive Implant in Workers’ Compensation Patients. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/23259671231175883

[40] Poster 202: Subacromial Decompression is Associated with a Number Needed to Treat of 4 for Reduced Revision Rotator Cuff Repair: A Large Matched Cohort Insurance Database Analysis. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00187

[41] Increasing Numbers of Pre-operative Shoulder Injections are Associated with a Higher Rate of Subsequent Revision Rotator Cuff Surgery. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118s00081

[49] Bioaugmentation demonstrates similar outcomes and failure rates for arthroscopic revision rotator cuff repair compared to revision without bioaugmentation. JSES International. 2024. DOI: 10.1016/j.jseint.2024.04.009

[50] Revision rotator cuff repair versus primary repair: an assessment of longitudinal outcomes in revision rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.05.011

[55] Effect of Bone Marrow Aspirate Concentrate and Platelet-Rich Plasma Augmentation on the Rate of Revision Rotator Cuff Repair. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221127004

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[73] Campbell S Operative Orthopaedics 4 Volume Set. ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH BONE-PATELLAR TENDON-BONE GRAFT > SHOULDER INJURIES > ANATOMY AND BIOMECHANICS.

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[119] Revision rotator cuff repair: can a Sugaya III tendon considered to be healed or not. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.06.028

[122] Evaluating postoperative rotator cuff healing: Prospective comparison of MRI and ultrasound. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2015.06.006

[128] Magnetic Resonance Imaging Identification of Rotator Cuff Retears After Repair. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512449424

[132] Arthroscopic Repair of Partial-Thickness and Small Full-Thickness Rotator Cuff Tears. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514561004

[136] Arthroscopic Compaction Bone Grafting for Uncontained Bone Defects of the Greater Tuberosity Associated With a Rotator Cuff Retear. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2021.04.030

[137] Arthroscopic Surgery of Rotator Cuff Retear: New Repair Versus Tendon Transfer. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.121

[141] Magnetic Resonance Imaging for Evaluation of Failed Repairs of the Rotator Cuff. Relationship to Operative Findings. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199609000-00015

[142] The acromial index is not predictive for failed rotator cuff repair. International Orthopaedics. 2013. DOI: 10.1007/s00264-013-1963-9

[143] Is Advanced Imaging to Assess Rotator Cuff Integrity Before Shoulder Arthroplasty Cost-effective? A Decision Modeling Study. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002110

[149] Outcome of latissimus dorsi transfer as a salvage procedure for failed rotator cuff repair with loss of elevation. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2008.04.007

[152] Dyslipidemia is associated with risk for rotator cuff repair failure: a systematic review and meta-analysis. JSES Reviews, Reports, and Techniques. 2022. DOI: 10.1016/j.xrrt.2022.02.003

[153] Early postoperative fluoroquinolone use is associated with an increased revision rate after arthroscopic rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4354-0

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d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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