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Rotator cuff repair

Surgeon-side topic for rotator cuff repair. Backed by 410 articles from the corpus, retrieved via combined MeSH + title-text matching.

183 citationsUpdated Oct 2026

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Overview

Rotator cuff repair has evolved into one of the most common orthopaedic procedures worldwide, yet significant work remains to improve healing rates, outcomes, and long-term durability [23]. The primary indication for revision surgery is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure [3, 4]. While short-term clinical outcomes of revision repair are similar to those after primary repair [6, 8, 9], successful primary repair and prevention of complications yield better functional outcomes [7]. 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 [72].

Long-term follow-up of at least 15 years demonstrates that patient-reported outcomes of all-arthroscopic rotator cuff repair show significant improvement from baseline and remain durable [21]. Although one-year follow-up appears clinically sufficient and the widely accepted 2-year benchmark may be arbitrary [191], patients must live with long-term outcomes, obliging authors to evaluate them [71]. Retrospective and prospective evaluations of outcome differ [74]. Higher values for the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores should be considered when evaluating individual improvements, determining comparative effectiveness, and setting sample sizes for prospective trials [58].

Open rotator cuff repair remains a valid option in specific indications or where arthroscopic resources are limited [59]. There is no evidence of difference in effectiveness between open and arthroscopic repair [212], though surgeons must carefully interpret literature comparing these approaches, as differences in complications may be influenced by selection bias and narrowing indications for open repair [65]. Routine distal clavicle resection is not recommended with arthroscopic repair [63]. Critical Shoulder Angle and Acromial Index do not appear to influence 24-month functional outcomes and are not contraindications to arthroscopic repair [211]. Rotator cuff repair is cost-effective for all populations [199]. While augmented repair suggests decreased failure rates and small improvements in function and pain, a paucity of rigorous clinical evaluation prevents firm recommendations [201]. Definitive conclusions regarding outcome predictors are limited by low methodological quality of included studies [22], and well-designed level I and II trials are needed to elucidate optimal rehabilitation protocols [24]. Patient characteristics and indications were not described in a majority of clinical outcome studies [1].

Anatomy & Pathophysiology

Anatomy

The rotator cuff comprises a sheet of conjoined tendons closely applied over the shoulder capsule, inserting primarily into the greater tuberosity of the humerus, with the subscapularis inserting into the lesser tuberosity [11]. Anatomically, the cuff consists of the subscapularis anteriorly, supraspinatus superiorly, and infraspinatus and teres minor posteriorly [11]. These muscles stabilize the humeral head by pulling it firmly into the glenoid whenever the deltoid lifts the arm forwards or sideways [11]. The coracoacromial arch forms a fibro-osseous canopy comprising the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [11]. The subacromial bursa separates the rotator cuff tendons from this arch, allowing them to glide [11].

Muscle Origins and Innervation: * Subscapularis: Arises from the anterior aspect of the scapula, attaches over much of the lesser tuberosity, and is innervated by the upper and lower subscapular nerves [90]. * Supraspinatus: Arises from the fossa superior to the scapular spine, passes beneath the acromion and acromioclavicular joint, attaches to the superior aspect of the greater tuberosity, and is innervated by the suprascapular nerve after it passes through the suprascapular notch [90]. * Infraspinatus: Arises from the fossa below the scapular spine, attaches to the posterolateral aspect of the greater tuberosity, and is innervated by the suprascapular nerve after it passes through the spinoglenoid notch [90]. * Teres Minor: Arises from the lower lateral aspect of the scapula, attaches to the lower portion of the greater tuberosity, and is innervated by a branch of the axillary nerve [90].

Histologic studies describe the rotator cuff tendons as having five distinct layers, with the most superficial layer being coracohumeral ligament fibers and the fifth layer being the continued sheet of collagen fibrils composing the superior joint capsule [90]. Significant interdigitation and overlap of the supraspinatus and infraspinatus tendons occur near the footprint on the greater tuberosity [90]. The supraspinatus footprint measures 13 mm width medial-lateral and 20 mm anteroposterior, with 7 mm medial-lateral tears corresponding to 50% partial thickness [27]. The infraspinatus footprint measures 14 mm wide and 20 mm superoinferior [27].

The rotator cable is a thick bundle of fibers running perpendicular to the supraspinatus tendon fibers, connecting the supraspinatus and infraspinatus tendons [27]. It is divided into anterior, middle, and posterior segments, with the middle segment running perpendicular to the longitudinal axes of the supraspinatus and infraspinatus tendons under the supraspinatus tendon [93]. Fascicles of the supraspinatus destined for the subscapularis insertion cross over the bicipital groove to create a roof, while fascicles of the subscapularis headed for the supraspinatus insertion create a floor for the groove [93]. The coracohumeral ligament contributes fibers that envelope the supraspinatus tendon, forming a laterally based arch or suspension bridge visible on the deep surface [93]. The long head of the biceps tendon attaches to the supraglenoid tubercle, runs between the subscapularis and supraspinatus, exits through the bicipital groove under the transverse humeral ligament, and may serve as a passive restraint contributing to anterior stability in abduction and external rotation [90].

Pathophysiology

Partial-thickness rotator cuff tears have an overall prevalence of 20% in the general population, increasing to 26% in patients older than 60 years [2]. The prevalence of full-thickness rotator cuff tears is approximately 25% in patients over 60 years of age and increases to 50% in patients over 80 years of age [19]. Rotator cuff tear prevalence ranges from 13% for patients in their fifties to 50% for patients aged 80 years or older [207]. Partial-thickness rotator cuff tears have a limited ability to spontaneously heal, with as many as 53% progressing in tear size and a portion progressing to full-thickness tears [2].

Etiology and Risk Factors: * Intrinsic Degeneration: Involves age-related changes in collagen, proteoglycan, water content, and vascularity (tendinosis), usually involving the supraspinatus and infraspinatus starting on the articular side [27]. * Extrinsic Factors: Include chronic impingement on the coracoacromial arch, with tears usually starting on the bursal side of the tendon [27]. * Acute Trauma: Typically occurs after a fall and/or dislocation of the shoulder in patients younger than 40 years [27]. * Risk Factors: Include age, smoking, female sex, family history, diabetes, and high cholesterol [27].

Biopsy specimens of retrieved tendon from rotator cuff tears show disorganized collagen, scar tissue, and minimal attempts at a healing process [12]. The confluence of age-related tendinosis and apoptosis leads to rotator cuff tendon failure [12]. The articular side of the rotator cuff is less vascular and has a higher modulus of elasticity, greater stiffness, and a less favorable stress-strain curve compared with the bursal surface [117]. Eccentric forces tend to be concentrated more along the articular surface fibers of the rotator cuff [117]. The progression of rotator cuff disease from tendinitis to degenerated full-thickness tear is a failure of biology, resulting in deposition of disorganized connective, fatty, and fibrous tissue in chronic tears [244]. Muscle degeneration following rotator cuff injury is mediated by fibroadipogenic progenitor cells that differentiate into adipocytes and fibroblasts in the chronic setting, leading to fatty infiltration and intramuscular fibrosis [297].

A normal tendon-bone insertion site is not regenerated after tendon-to-bone repair; healing occurs by reactive scar formation rather than regeneration of a histologically normal insertion site [299]. The zone of calcified cartilage does not re-form after rotator cuff repair [299]. The critical shoulder angle, formed from lines drawn from the inferior glenoid to the superior glenoid and from the inferior glenoid to the inferolateral acromion, has been shown to correlate with rotator cuff tears and postoperative retears when above 35° to 38° [238]. The acromial index, a ratio of the medial/lateral length from the glenoid to the lateral acromion divided by the length from the glenoid to the lateral aspect of the greater tuberosity, is associated with full-thickness rotator cuff tears and higher retear rates when above 0.7 [238]. Increased lateralization of the acromion and increased superior glenoid inclination may increase the shear forces of deltoid contraction [238].

Rotator cuff disease may involve a genetic predisposition to intrinsic degenerative tendinopathic changes in molecular composition and vascularity [238]. Studies have shown familial hereditary patterns of rotator cuff disease and genes associated with significant pathology [238]. The rotator cuff serves multiple functions for the glenohumeral joint, including initiating/assisting active shoulder motion and providing dynamic stability through force-couple moments [238]. Most rotator cuff tears occur in the anterior portion of the supraspinatus tendon and tend to be larger and associated with fatty muscle degeneration [238]. Biomechanical testing has shown that tears involving the rotator cable result in increased tear gap distance and strain compared with those in the crescent area [238]. Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes [123]. In a dynamic biomechanical cadaveric model, increased glenohumeral joint loads due to a full-thickness supraspinatus tear can be reversed with rotator cuff repair [137]. Isolated supraspinatus tears did not perturb glenohumeral kinematics in a cadaveric model of the throwing shoulder, in contrast to a transosseous-equivalent repair [139].

Classification

Partial-Thickness Tears

Ellman: The Ellman classification grades partial-thickness rotator cuff tears based on location and depth of tearing noted at the time of shoulder arthroscopy [2]. Tears are designated as articular-sided (A), bursal-sided (B), or intratendinous (C) [2]. Depth is graded as follows: Grade 1 involves 3 mm or less of tendon; Grade 2 involves 3 to 6 mm of tendon; and Grade 3 involves more than 6 mm of tendon [2]. Grade 3 tears represent tears of more than 50% of tendon width [2]. MRI evaluation classifies partial-thickness rotator cuff tears as low grade or high grade depending on whether they involve less than or more than 50% of the tendon width [2].

Full-Thickness and Massive Tears

Hamada: The Hamada classification is a commonly used scheme that uses a mechanistic approach to explain the radiographic changes seen with chronic massive rotator cuff tears [161]. It highlights the progressive nature of massive rotator cuff tears leading to CTA [161].

Snyder: Snyder’s classification describes the extent, location, and size of rotator cuff tears [271]. Tear location is classified as articular (type A), bursal (type B), and complete (type C) [271]. Full-thickness tear dimensions are defined as: 1 = small tear; 2 = moderate tear, less than 2 cm of only 1 tendon without retraction; 3 = large complete tear, usually 3 to 4 cm, with minimal retraction; and 4 = massive rotator cuff tear involving 2 or more rotator cuff tendons with retraction associated [271].

Modified Patte: A modified Patte classification system for rotator cuff tendon retraction has excellent diagnostic performance for reparability and acceptable diagnostic performance for rotator cuff healing [152]. The system has high measurement reliability [152].

Cofield: The Cofield classification is used to categorize massive rotator cuff tears [247].

Structural Integrity and Healing Assessment

Sugaya: The Sugaya classification is used to assess the structural integrity of repaired rotator cuffs [269]. It includes types I through V [271].

Boileau et al.: The Boileau et al. grading system using computed tomography arthrography classifies structural integrity as 'intact,' 'incomplete leakage,' or 'complete leakage' [266]. 'Intact' indicates no leakage at the insertion or in the tendon [266]. 'Incomplete leakage' indicates a small slit of contrast medium leakage into the tendon limited to one oblique coronal section [266]. 'Complete leakage' indicates apparent discontinuity with contrast medium into the subacromial space [266]. Healing is defined as occurring when structural integrity is intact at both the insertion and in the tendon [266]. Incomplete healing is defined as incomplete leakage at either the insertion or in the tendon [266]. Retears are defined by the presence of complete leakage at the insertion [266]. New tears are defined by the presence of complete leakage in the tendon [266].

Other Classifications

Bigliani-Morrison: The Bigliani-Morrison classification is used to assess acromial type [271].

Goutallier: The Goutallier stage is used to assess fatty degeneration of the supraspinatus muscle [274].

Clinical Presentation

Symptoms and History

Patients with symptomatic full-thickness rotator cuff tears typically report anterolateral shoulder pain radiating into the subdeltoid location [19]. Common complaints include pain during overhead activity and lifting objects with an outstretched arm [19]. Frequent night pain and sleep disturbance are also characteristic features [19]. In chronic rotator cuff disease, patients often describe an insidious onset of lateral and/or anterior shoulder pain associated with overhead activities [213]. Night pain remains a common presenting symptom in these chronic cases [213]. A clear history of trauma resulting in acute pain and weakness strongly suggests an acute rotator cuff tear [213]. A family or personal history of rotator cuff disease increases the likelihood of diagnosis [213].

In pediatric rotator cuff tears, pain is the most common presenting complaint, reported in 21 out of 23 patients with available initial presentation data [95]. Other presenting complaints include weakness (n=6), functional impairment (n=3), decreased range of motion (n=2), dislocation (n=2), and numbness (n=2) [95]. The time from injury to diagnosis in this pediatric cohort ranged from 1 day to 24 months [95]. Specifically, 45 patients were diagnosed within 6 months of injury, with 11 diagnosed within 1 month [95]. Five patients were diagnosed at least one year after injury [95].

The commonest causes of pain around the shoulder are disorders of the rotator cuff, chiefly rotator cuff syndrome, calcific tendinitis, and adhesive capsulitis [11]. In rotator cuff syndrome, pain is located over the front and lateral aspect of the shoulder with weakness on abduction for supraspinatus involvement, tears of the cuff, and tendinitis [11]. Pain located over the front indicates biceps pathology [11]. If the rotator cuff or biceps has ruptured, weakness is also present [11]. A patient with a full-thickness rotator cuff tear gives a history of refractory shoulder pain with increasing stiffness and weakness [223]. Such a tear may occur spontaneously after a sprain or jerking injury, resulting in sudden pain and inability to abduct the arm [223]. With time, there may be some recovery of active abduction, though power in both abduction and external rotation remains weaker than normal [223]. There is usually wasting of the supraspinatus and infraspinatus in long-standing cases of partial or complete rotator cuff rupture [223]. On testing the biceps in these long-standing cases, there may be an old tear of the long head of biceps tendon [223]. Tenderness of the acromioclavicular joint is often present [223]. Secondary osteoarthritis of the shoulder may supervene, resulting in severely restricted movements [223]. Partial rotator cuff tears may occur within the substance or on the deep surface of the cuff, permitting active abduction with a painful arc [223]. It is difficult to distinguish chronic tendinitis complicated by a partial tear because the remaining cuff fibres permit active abduction with a painful arc [223]. The patient with a rotator cuff tear is usually aged over 45 [223]. Symptoms of depression and anxiety related to the shoulder improved dramatically after rotator cuff repair, with or without a preexisting clinical diagnosis of depression or anxiety [102].

Physical Examination

Physical examination is critical in the workup of rotator cuff tears and consists of assessment of range of motion in the adducted and abducted positions, assessment of strength, and examination of associated structures such as the biceps and acromioclavicular joint [213]. Inspection for muscular atrophy of the deltoid and supraspinatus and infraspinatus fossa is performed to identify chronic rotator cuff tears [27]. Palpation of the greater tuberosity, acromioclavicular joint, bicipital groove, and coracoid process is part of the physical examination [27]. Cervical spine palpation, range of motion, and Spurling test are used to rule out cervical spine pathologies as a cause of shoulder pain [27].

Active and passive range of motion of the shoulder is assessed during physical examination [27]. Provocative tests such as Neer, Hawkins-Kennedy, Yocum, and painful arc are impingement signs with low specificity for rotator cuff tears [27]. Resisted elevation tests including Jobe, empty can, and drop arm sign assess supraspinatus function [27]. The empty can test has a sensitivity of 71.7% and a specificity of 64.6% for full-thickness supraspinatus tears [213]. External rotation tests including lag sign, Patte, and hornblower sign assess infraspinatus and teres minor function [27]. Patients with an external rotation lag sign at the side likely have a large posterosuperior tear involving the infraspinatus [213]. A positive hornblower sign suggests a massive posterosuperior cuff tear that prohibits the active positioning of the hand in space [213]. A positive lag sign indicates a massive rotator cuff tear [27]. Internal rotation tests including belly press, lift-off (Gerber), modified lift-off, and bear hug assess subscapularis function [27]. The lift-off and belly-press tests have high specificity but low sensitivity for full-thickness subscapularis tears [213]. Deltoid strength and axillary nerve function are assessed during physical examination [27]. The combination of age >65 years, night pain, and weakness has 95% specificity for rotator cuff tears [27].

If the diagnosis of a full-thickness rotator cuff tear is in doubt, pain can be eliminated by injecting a local anaesthetic into the subacromial space [223]. If active abduction is possible after subacromial local anaesthetic injection, the tear must be only partial [223]. If active abduction remains impossible after subacromial local anaesthetic injection, then a complete tear is likely [223]. Special tests for specific rotator cuff muscle function were reported in 17 total patients in a pediatric rotator cuff tear cohort [95]. Sixteen of 17 patients in the pediatric cohort had at least one positive special test that indicated rotator cuff pathology [95]. In two pediatric patients, testing was limited due to pain [95]. Clinical tests including the O’Brien, Yergason, Speed, and direct palpation tests have limited specificity for long head of biceps tendon pathology [260]. Along with a history of radiating anterior shoulder pain, clinical tests may inform the examiner of pain generation from the long head of biceps tendon [260].

Imaging

An MRI is obtained in the evaluation of a potential rotator cuff tear if the patient has no contraindications [19]. MRI allows the surgeon to characterize the location, size, and amount of retraction of the rotator cuff tear, as well as the degree of atrophy and fatty infiltration of the rotator cuff musculature [19]. The quality of the rotator cuff musculature is classified according to the degree of fatty infiltration originally described by Goutallier et al. for CT evaluation and modified by Fuchs et al. for MRI evaluation [19]. In the Goutallier-Fuchs classification, grade 0 is normal muscle, grade 1 has some fatty streaks, grade 2 has more muscle than fat, grade 3 has equal amounts of muscle and fat, and grade 4 has more fat than muscle [19]. Goutallier grades 3 and 4 are indications of a long-term chronic rotator cuff tear, which has a higher potential for failure when surgery is undertaken and likely is deemed irreparable [19]. An important consideration on MRI evaluation is whether any tendon stump remains attached to the greater tuberosity, which decreases the length of tendon for repair [19]. An MRI is indicated in younger, active patients with acute rotator cuff tears and in patients with chronic rotator cuff tears in whom a trial of nonoperative treatment has failed [19].

Radiographs are used to rule out glenohumeral and acromioclavicular arthritis [27]. A true AP view radiograph is used to evaluate the acromiohumeral interval, the critical shoulder angle, and acromion index [27]. The normal acromiohumeral interval is 7 to 14 mm [27]. AP views in external and internal rotation are used to identify greater tuberosity excrescences, which are pathognomonic for cuff disease [27]. The supraspinatus outlet view is used to evaluate acromial morphology according to Bigliani classification (type 1 = flat; type 2 = curved; type 3 = hooked) [27]. The axillary view is used to assess glenohumeral joint morphology and joint space and rule out dislocations [27].

MRI is the benchmark for diagnosing rotator cuff tears with 94% sensitivity and 93% specificity [27]. T2-weighted MRI images best visualize rotator cuff tears [27]. T1 sagittal oblique MRI cuts reveal muscle and tendon retraction and muscle atrophy to determine chronicity, reparability, and outcome of surgical rotator cuff repairs [27]. Intra-articular contrast-enhanced magnetic resonance arthrography (MRA) is best for detecting partial-thickness rotator cuff tears with 95% sensitivity and 95% specificity [27]. Ultrasonography has good accuracy with 92% sensitivity and 93% specificity for rotator cuff tears [27]. Ultrasonography allows for dynamic assessment of the cuff insertion [27]. Ultrasonography is operator dependent and has limited assessment of chondral lesions [27]. Ultrasonography has poor sensitivity to diagnose partial-thickness rotator cuff tears [27]. CT arthrography is uncommon in the United States but useful in postoperative assessment, retear evaluation in patients with retained metallic anchors causing artifact on MRI, and when MRI is contraindicated [27]. For full-thickness rotator cuff tears, ultrasonography approaches the sensitivity and specificity of MRI for detecting the presence of a tear with an experienced practitioner [213]. Ultrasonography is relatively inexpensive, allowing for dynamic testing, guided injections, and immediate feedback [213]. MRI accurately assesses muscle, bone, and cartilage, which has advantages for surgical planning [213]. MRI continues to be the imaging modality of choice for most providers, with ultrasonography becoming common in certain centers [213]. The goal of diagnostic imaging is threefold: determine the presence, size, and orientation of the rotator cuff tear; evaluate the healing capacity of the tendon; and assess associated pathology such as long head biceps tendinitis, acromioclavicular joint pathology, and arthrosis [213].

Radiograph results were reported for 17 patients in a pediatric rotator cuff tear cohort, of which 12 were reported as negative and 5 showed signs of pathology [95]. Of the 5 pediatric patients with positive radiographs, only two were specific to the rotator cuff [95]. In one pediatric patient, an arthrogram demonstrated signs of partial rotator cuff tendon tear [95]. In another pediatric patient, a halo of calcification superior to the humeral head in the subacromial space indicated long-standing supraspinatus injury [95]. MRI or MRA results were reported for 51 patients in a pediatric rotator cuff tear cohort, of which 50 demonstrated some indication of rotator cuff pathology and only one was negative [95]. Only 3 studies comprising 3 total patients in the pediatric cohort reported ultrasound examinations, all of which were positive for signs of rotator cuff damage [95]. Diagnosis of a rotator cuff tear requires a full clinical examination combined with imaging studies including ultrasound, arthrocomputed tomography, and magnetic resonance imaging or arthroemagnetic resonance imaging [87]. If pain or loss of function is present, and there are no clinical or radiologic contraindications, the patient is offered arthroscopic repair [87]. Other tools to evaluate biceps pathology include MRI, ultrasonography, and arthroscopic examination of the long head of biceps tendon and its pulley [260]. Arthroscopic examination is limited to the intra-articular long head of biceps tendon as well as the proximal groove, missing less common distal biceps groove lesions [260].

Natural History and Prevalence

The overall prevalence of full-thickness rotator cuff tears is approximately 25% in patients over 60 years of age and increases to 50% in patients over 80 years of age [19]. If a patient has a symptomatic full-thickness rotator cuff tear in one shoulder, they have a 50% chance of an asymptomatic full-thickness rotator cuff tear in the contralateral shoulder [19]. The prevalence of rotator cuff tears is 28% in patients under 50 years and 65% in patients over 70 years [27]. The prevalence of full-thickness rotator cuff tears is 7% to 40%, while partial-thickness rotator cuff tears are more common with a 50% higher prevalence [27]. Small full-thickness rotator cuff tears and painful partial-thickness tears become 25% to 50% larger within 3 to 4 years, with larger lesions progressing faster [27]. In a study using bilateral shoulder ultrasound in patients with bilateral shoulder pain, the average age of patients with bilaterally intact cuffs, unilateral cuff tears, and bilateral cuff tears was 48.7, 58.7, and 67.8 years, respectively [44]. Population-based studies have shown that one-quarter of patients above 60 years of age and half of patients above 80 years will have a rotator cuff tear [44]. The overall prevalence of asymptomatic partial-thickness rotator cuff tears is 20%, which increased to 26% in patients older than 60 years [2].

Partial-thickness rotator cuff tears have a limited ability to spontaneously heal as shown by histological and radiographic studies [2]. As many as 53% of partial-thickness rotator cuff tears will progress in tear size [2]. A portion of partial-thickness rotator cuff tears will progress to full-thickness rotator cuff tears [2]. Nonoperative treatment of full-thickness rotator cuff tears is effective in 75% of patients after 2 years [230]. A patient’s perception of whether physical therapy would be beneficial was a strong predictor of whether conservative treatment would be successful for full-thickness rotator cuff tears [230]. Pain and duration of symptoms are not associated with the severity of rotator cuff tears in a longitudinal cohort of more than 400 patients with atraumatic, full-thickness rotator cuff tears [230]. In a study of 24 patients who refused operative treatment for full-thickness supraspinatus tears, there was no increase in the average size of the rotator cuff tears on MRI at 3.5 years after the initial MR arthrogram [230]. Of the 24 patients treated nonoperatively for full-thickness supraspinatus tears, 8 (33%) had an increase in tear size and 4 (17%) had no change in tear size [230]. This group of patients treated nonoperatively for full-thickness supraspinatus tears had a high level of satisfaction [230].

In a study of 59 full and partial-thickness tears followed with MRI for a minimum of 6 months, 48% were found to have progression of tear size in those followed for at least 18 months, compared with only 19% in those tears followed for less than 18 months [230]. Full-thickness tears were more likely to progress than partial-thickness tears [230]. Age was an important factor in tear progression, with progression in 54% of tears in patients over the age of 60 years versus 17% in patients under 60 years [230]. In a cohort of patients under the age of 60 years treated nonoperatively for full-thickness rotator cuff tears, 49% of the tears increased in size [230]. Approximately 50% of asymptomatic tears have a significant increase in size at a median time of 2.8 years [230]. Full-thickness tears are more likely to enlarge, become painful, and progress to muscle degeneration compared with partial-thickness tears [230]. In a longitudinal study of asymptomatic shoulders, 18 of 50 tears (36%) developed symptoms and an increase in tear size was associated with symptoms [230]. Tears that became symptomatic over time also significantly increased in size, while tears that did not become symptomatic did not increase in size [230].

Investigations

Plain radiography: Radiographs are the first imaging study obtained for rotator cuff evaluation [215]. They may demonstrate classic changes within the acromion or coracoacromial ligament, including spurring and calcification, as well as cystic changes within the greater tuberosity [154]. With chronic rotator cuff disease, superior migration of the humeral head with extensive degenerative change may be present [154]. An acromiohumeral distance appearing shorter than 7 mm on AP radiograph is associated with a higher likelihood of irreparable tears [154].

MRI: Magnetic resonance imaging provides the best overall evaluation of the rotator cuff [215]. It is used to define the extent of the tear, degree of tear retraction, and presence of muscular atrophy [154]. MRI is key for evaluating fatty infiltration, although the Goutallier classification was originally based on CT [154]. The sensitivity of MRI for detecting full-thickness rotator cuff tears is 92.1%, with a specificity of 92.9% [160]. For partial-thickness tears, MRI sensitivity is 63.6% and specificity is 91.7% [160]. MRI often fails to diagnose the presence of subscapularis and infraspinatus tears, while concordance with MRI results is good for the supraspinatus [83]. The shift angle and medial retraction of the deep layer on MRI are associated with intraoperative reparability in large-to-massive rotator cuff tears [345].

Magnetic Resonance Arthrography: MRA is both sensitive and specific for full-thickness rotator cuff tears [160]. The sensitivity of MRA for detecting full-thickness tears is 95.4%, with a specificity of 98.9% [160]. For partial-thickness tears, MRA sensitivity is 85.9% and specificity is 96.0% [160]. MRA is more sensitive than MRI for the detection of partial-thickness, particularly articular-sided tears [160]. However, MRA is not suitable for the diagnosis of long head of biceps lesions prior to arthroscopic rotator cuff repair [346], and is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair [294].

Ultrasonography: Ultrasonography is increasing in popularity as a tool for the diagnosis of rotator cuff disease [154]. It is also used for confirmation of intraarticular or subacromial location of injections [154]. Ultrasonography is more accurate for full-thickness rotator cuff tears, comparable to MRI [15]. In the community setting, ultrasound may be used to evaluate the integrity of a repaired rotator cuff tendon and constitutes a comparable alternative to MRI [334]. It is an adequate imaging modality to classify rotator cuff repair integrity [324].

Specific Findings and Signs: The tangent sign is defined as failure of the supraspinatus muscle belly to cross a line from the superior border of the coracoid to the superior border of the scapular spine [154]. This sign correlates with muscle atrophy and fatty infiltration of the supraspinatus [154]. Patients with the presence of the tangent sign are more likely to have an irreparable rotator cuff tear [154], and a positive tangent sign predicts the repairability of rotator cuff tears [15].

Postoperative Imaging: Radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair [78]. Most deformities after rotator cuff repair remodel over time and do not affect the radiologic outcome of repair after 6 months of follow-up [315]. The MRI appearance of the repaired tendon changes over time but does not correlate with function or predict clinical outcomes at 1 year after surgery [296]. Immediate changes in the appearance of fatty infiltration and muscle atrophy on MRI should be considered when assessing rotator cuff muscle changes by comparing preoperative and postoperative MRI [295]. After successful arthroscopic rotator cuff repair, there was a slight increase in muscle volume from preoperatively to final follow-up, as seen on serial MRI [270].

Other Considerations: Metal artefacts from titanium suture anchors prevented accurate diagnosis from MRI scans of rotator cuff retear in 36% of patients studied [335]. Biocomposite suture anchors are frequently still visible on MRI 2 years after rotator cuff reconstruction [84]. Poor interobserver agreement regarding postoperative graft and rotator cuff integrity by MRI was found in superior capsular reconstruction augmentation [322]. Clinically significant disagreements in the evaluation of rotator cuff tendon and muscle MRI parameters indicate the need for improved imaging tools for precise rotator cuff evaluation [310].

Treatment

Non-Operative

Non-surgical treatment is recommended as the preferred approach for patients with non-traumatic rotator cuff injuries [229]. Most partial-thickness rotator cuff tears are best initially managed with nonoperative treatment [2]. Surgical repair provides significantly better long-term outcomes and a higher probability of substantial improvement for symptomatic rotator cuff tears compared to nonoperative treatment [217]. However, there are not convincing data of the superiority of the operative treatment over non-operative management in all rotator cuff tears [153].

Operative

Indications: Clinical decision-making for the management of rotator cuff tears can be complex and lacks consensus among orthopedic surgeons, as neither the American Academy of Orthopaedic Surgeons guidelines nor Cochrane systematic reviews provide specific guidance [10]. Patients are generally divided into three categories: those needing urgent or early operative repair, those that can benefit from a trial of conservative treatment, and those best suited for nonoperative treatment [10]. Repair of symptomatic single-tendon rotator cuff tears in patients aged older than 65 years who do not respond to conservative treatment appears justified [242]. Severely obese patients achieve overall excellent outcomes after repair and noninferior clinical differences when compared to healthy weight patients [51]. Operative management is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology [185]. The author considers arthroscopic examination and attempted repair of large and massive rotator cuff tears to be the gold standard of treatment for nonarthritic shoulders, cautioning against the high complication and reoperation rates associated with reverse total shoulder replacements in younger patients [281].

Surgical Approach / Technique: The current standard of care is arthroscopic repair, although the superiority of arthroscopic versus open or mini-open repair is still somewhat controversial [69]. Arthroscopic repair has been shown to have similar outcomes and failure rates, with decreased short-term pain and more rapid return to activity compared to other approaches [69]. Advances in arthroscopic equipment and increased surgeon familiarity have made arthroscopic surgery the preferred method for many shoulder surgeons [234]. Arthroscopy allows a more comprehensive assessment of intra-articular pathology and rotator cuff tear configuration by viewing from multiple angles [234]. Tendon mobilization is facilitated by precise releases of adhesions that limit tendon excursion, leading to an improved ability to anatomically reduce the edge and create a tension-free repair [234]. Injury to the deltoid muscle is minimized in arthroscopic repair, and the acromial deltoid origin is preserved, eliminating the risk of deltoid dehiscence [234]. A key theoretical benefit of arthroscopic repair is decreased postoperative pain secondary to less soft tissue trauma, which aids in postoperative rehabilitation and leads to earlier resumption of range of motion [234].

Mini-open rotator cuff repair has the advantages of allowing direct assessment of the nature of the cuff tear, the quality of the remaining tissue, and the ease with which the tendon edge can be restored to the normal insertion site with the arm in an adducted position [53]. The transosseous technique for attachment of the tendon to the tuberosity is simple, expeditious, avoids issues related to suture anchors, and enables the surgeon to find sufficiently strong bone to hold the sutures [53]. The creation of a trough into which the tendon is inserted increases the surface area of the repair, stimulates local stem cells and growth factors, excludes joint fluid from the repair site, and places sutures laterally so that they do not rub beneath the coracoacromial arch [53]. The goal of repair is strong fixation of the tendon to the humerus under normal tension with the arm at the side while leaving a smooth surface on the proximal humeral concavity to articulate with the undersurface of the coracoacromial arch [53]. The desired attachment site is at the sulcus near the base of the tuberosity [53]. Three stages of sequential release are required because the cuff is usually retracted and tissue is lost in chronic cuff disease [53]. Unless these releases are carried out, increased tension in the repaired tendon will predispose to tightness of the glenohumeral joint and will additionally challenge the repair site [53].

Anatomic footprint restoration is now possible with arthroscopic repair, with fixation at both the suture-tendon interface and the anchor-bone interface that approximates traditional open transosseous repairs [234]. The rotator cuff tends to fail at or near the tendon-bone junction, and the goal of repair is to restore the tendon to its anatomic footprint to encourage healing [69]. Controlled laboratory studies have generally shown superiority of double-row techniques over single-row in terms of initial and ultimate failure strength, decreased gap formation, decreased strain and suture cut-through, and improved vascularity in transosseous-equivalent double-row repair [69]. The double-row technique has been advocated as a better biomechanical construct and a more anatomic repair strategy [234]. While in biomechanical studies, the double-row repair outperforms single-row repair in failure strength, superior clinical results with double-row fixation over single-row fixation is still controversial [234]. The healing of the rotator cuff using an anatomic technique was superior to that in the single row repair group [148].

Rotator cuff repair techniques evolve at a fast pace, with new solutions often being used without solid clinical evidence of superiority [50]. The authors describe the rationale, current indications, and technical strategies for different types of rotator cuff repair constructs [16]. The authors emphasize that the type of rotator cuff tear affects the approach to these tears [77]. This report reviews current clinical treatments and preclinical approaches for rotator cuff tear repair, focusing on surgical techniques, new repair strategies under development, and animal models available for research [57]. This approach aims to minimize complications, optimize rotator cuff healing, and maximize postoperative results and patient satisfaction [119]. Arthroscopic repair of rotator cuff tears is an effective and straightforward technique when performed in an organized, well-considered manner [138]. The novel all-inside arthroscopic rotator cuff repair technique was safe and significantly faster and provided better healing rates than other repair techniques [143]. Both knotless and knot-tying anchor techniques may be used successfully to repair full-thickness rotator cuff tears with very good functional outcome [142]. The technique of rotator cuff repair in large to massive rotator cuff tears matters [116]. The banana suture lasso double-row fixation technique has simplified massive rotator cuff tear repairs and offered an easier approach that is simple, reproducible, and does not cost more [118].

Implant Selection: Arthroscopic transosseous rotator cuff repair achieves similar clinical outcomes, patient-reported outcomes, and healing rates with 30-80% reduction in implant costs, compared to traditional anchored techniques [353]. Despite using more anchors and incurring higher implant costs, the knotless technique for rotator cuff repair required less surgical procedure time and cost less overall than the knotted technique and resulted in equivalent clinical results [357]. Shoulder function was improved after complete rotator cuff repair and similar clinical outcomes were achieved regardless of suture anchor material and shape [73]. At a short-term follow-up, differences between arthroscopic repair of full-thickness rotator cuff tears with metal and biodegradable suture anchors were not significant [305]. Every patient presenting with shoulder pain after usage of a biodegradable fixation material should be evaluated closely [338]. Every tested anchor presented different problems that may lead to premature failure of the rotator cuff reconstruction [339]. Gap formation between the bone and the soft tissue fixation jeopardizes the repair, and the anchor is not appropriate for rotator cuff repair if used on its own [321]. Initial fixation strength is an essential consideration in optimizing rotator cuff repair [330]. The ideal rotator cuff repair technique should have high initial fixation strength to allow minimal gap formation between the tendon and bone [348]. This finding may have implications for the type of cuff fixation device used and for rehabilitation after fixation [342]. Both anchor insertion techniques resulted in acceptable shoulder clinical outcomes for patients with osteoporosis undergoing rotator cuff repair [356]. Solid fixation of the rotator cuff tear was obtained in all cases of rotator cuff repair associated with large greater tuberosity bone cysts [312].

Other Considerations: Partial-thickness rotator cuff tears are common in the general population, with an increased incidence with increasing age [2]. Sher et al. showed an overall prevalence of asymptomatic partial-thickness rotator cuff tears of 20%, which increased to 26% in patients older than 60 years [2]. Partial-thickness rotator cuff tears can be classified as articular-sided, bursal-sided, or intratendinous tears [2]. Ellman described a classification of partial-thickness rotator cuff tears based on location and depth of tearing noted at the time of shoulder arthroscopy [2]. Tears are classified as articular-sided (A), bursal-sided (B), or intratendinous (C) and are grade 1 if involving 3 mm or less, grade 2 if 3 to 6 mm, and grade 3 if more than 6 mm of tendon is torn [2]. Grade 3 tears represent tears of more than 50% of tendon width based on previous studies noting the width of the supraspinatus footprint [2]. With MRI evaluation, these tears are classified as low grade or high grade depending on whether they involve less than or more than 50% of the tendon width [2]. Partial-thickness tears have a limited ability to spontaneously heal as shown by histological and radiographic studies [2]. A substantial portion of partial-thickness rotator cuff tears will progress in tear size, as many as 53% in one study, and a portion of these will progress to full-thickness rotator cuff tears [2]. Surgical treatment with either rotator cuff repair or debridement is indicated for patients in whom nonoperative treatment fails [2]. Most surgeons agree that tears involving more than 50% of tendon width are best treated with repair and those involving less than 50% with debridement and potential decompression [2]. A higher failure rate of debridement has been suggested for partial-thickness bursal-sided rotator cuff tears compared to articular-sided rotator cuff tears, leading some surgeons to favor repair in even low-grade bursal-sided tears [2]. There is no difference in functional outcome scores or re-tear rates between in situ rotator cuff repair and completion to a full-thickness rotator cuff tear with subsequent repair [2]. For tears with poor-quality tendon remaining and involving more than 80% of tendon thickness, debridement is favored [2]. If delamination of the tear is present in delamination-type tears of the articular side, a transtendinous repair is indicated [2]. Intratendinous tears that can be identified on MRI must be localized through preoperative planning and use of a spinal needle to identify the tear site [2]. The tear can be opened using an arthroscopic knife and the edge debrided back slightly to promote local healing [2]. Goodmurphy et al. showed that extensive debridement is unnecessary for intratendinous tears [2]. Intratendinous tears are repaired side-to-side using arthroscopic technique [2].

The need for concomitant procedures with cuff repair did not jeopardize the result, and they should be performed when indicated [47]. Every attempt should be made at the time of the arthroplasty to balance the soft tissues and securely repair the rotator cuff because subsequent attempts to repair the rotator cuff are prone to failure [41]. We do not recommend doing routine DCR with arthroscopic rotator cuff repair [63]. Acromioplasty cannot be recommended as a routine technique in every rotator cuff repair [210]. Despite Clinical Practice Guidelines recommending the nonroutine use of acromioplasty, surgeons continue to perform acromioplasty with rotator cuff repair in most of the cases throughout all subcategorizations analyzed [243]. Perform an anterior acromioplasty as described in Technique 46.1, as this is an important part of rotator cuff surgery, and the results of repair without decompression are not as good as the results using the combined procedure [32]. After standard acromioplasty, evaluate the rotator cuff tear carefully [32]. Perform a subacromial bursectomy [32]. Protect the biceps tendon unless biceps pathology is present; if so, a proximal biceps tendon release or tenodesis is indicated [32]. Tears usually begin at the supraspinatus insertion, and the end retracts into its fossa under the acromioclavicular joint [32]. Most tears not only are transverse but also have a longitudinal component, making them oval or triangular [32]. All but the smallest tears need to be advanced anteriorly and laterally, not just laterally, to restore anatomic position and correct muscle-tendon unit length [32]. In tears of more than 2 to 3 cm, the infraspinatus tendon is involved as well [32]. When the defect has been identified and its size approximated, attention is turned to the repair itself, and typically some degree of mobilization is necessary [32]. Begin mobilization posteriorly with the infraspinatus, using a blunt probe or a finger to release adhesions inside and outside the joint [32]. Do not dissect below the level of the teres minor to avoid injury to the axillary nerve in the quadrangular space or the suprascapular nerve in the area of the spinoglenoid notch near the inferior border [32].

Revision: Revision rotator cuff repair is technically more difficult than primary repair due to poor tissue quality, adhesions, and retained hardware [85]. Optimization of surgical techniques and the use of appropriate biologic or tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair [140]. This technique represents a reasonable, low-morbidity salvage option for the patient with a rotator cuff tear that is not primarily repairable [61, 62, 151]. The general indications for augmentation include patients with large (>3 cm), multitendon rotator cuff tears or chronic tears with poor tissue quality [196]. The purpose of this technique is to show a simple and reproducible method for rotator cuff augmentation that can be easily adopted by arthroscopic shoulder surgeons to decrease surgical time [133]. This surgical technique is a straightforward, reproducible, and effective approach to enhancing rotator cuff repair [99]. This technique of concomitant superior capsular reconstruction with rotator cuff repair has been a reproducible method for achieving successful surgical management of patients with massive rotator cuff tears and superior capsular insufficiency [150]. Superior capsular reconstruction with incorporation of the native rotator cuff may provide surgeons the opportunity to perform a robust repair in situations where arthroplasty or other more invasive procedures were once the only options [340]. Patch augmentation can be technically challenging and requires the surgeon to be patient and organized [311]. The procedure described for patch augmentation is specifically used to augment posterosuperior rotator cuff tears that are completely reparable [311]. This technique is not recommended to address either completely irreparable or partially reparable tears [311]. Extracellular matrix augmentation of large and massive rotator cuff tears may decrease repair failure rates [318]. Arthroscopic augmentation is technically challenging [318]. The "pull-over" technique offers additional advantages over previously described techniques by facilitating the passage of the patch into the bursa as well as providing a more robust medial stabilization of the augment and therefore possibly a stronger construct [318]. Despite the growing clinical use of scaffold devices for rotator cuff repair, numerous questions related to their indication, surgical application, safety, mechanism of action, and efficacy remain to be clarified or addressed [192]. BCS may improve pain, function, and structural outcomes in selected rotator cuff tears; however, evidence remains limited, heterogeneous, and predominantly non-randomized [219]. These results indicate that a synthetic interposition graft with screw fixation could not prevent cuff tear arthropathy and preserve cuff integrity in a long-term perspective [331].

Complications

General Complication Rates: Short-term complications following rotator cuff repair are generally rare [45], with a low incidence reported in the literature [82]. However, clinical registries indicate that adverse events may occur in almost 1 of 5 cases [363]. A literature review of 2,890 patients undergoing arthroscopic rotator cuff repair identified a total of 414 complications [241]. In a consecutive series of 263 patients undergoing primary arthroscopic repair, 28 patients (10.6%) sustained a complication [256]. The complication rate after arthroscopic revision rotator cuff repair is approximately twice the published rate for primary repair [232]. Specific cohorts report varying rates: in 45 patients undergoing linked tape bridging knotless double-row repair, follow-up was obtained for 46 shoulders (85.3% of patients) [108]; in 51 patients undergoing open repair, there were no intraoperative complications and three postoperative complications [113]; in patients younger than 45 years undergoing arthroscopic primary repair, no intraoperative, perioperative, or postoperative complications were reported [129]; in a randomized controlled trial of 60 patients undergoing arthroscopic repair with or without synovectomy, no side effects were reported [127]; and in 1,000 consecutive cases of undersurface repair for partial-thickness tears, no patients required reoperation for infection or post-operative stiffness [393].

Re-tear and Structural Failure: Re-rupture is the most frequently encountered complication in arthroscopic rotator cuff repair, with re-tear rates ranging between 11.4 and 94% in a literature review [241]. Recurrent tears are not uncommon after arthroscopic repair of large and massive tears [26]. In a single-center case series of patients aged 30 years and under, 3 patients (9.4%) had repair failures, including 2 complete re-tears and 1 partial re-tear [264]. In a cohort of 2,010 patients, 3% (61/2,010) reported a worsened shoulder at 6 months post-repair [111]. Among patients with diabetes mellitus, 20 patients (5.0%) underwent revision arthroscopic surgery for repair failure at a mean 17.6±14.9 months, and 7 patients (1.7%) underwent revision to reverse shoulder arthroplasty for failure at a mean 23.7±24.1 months [279]. In 1,000 consecutive cases of undersurface repair, seven patients (0.7%) underwent revision rotator cuff repair [393]. In a study of 51 patients undergoing open repair, one patient had reoperation for arthrographically proven cuff rerupture 9 months after primary surgery [113].

A study of 50 patients undergoing reoperation for failed rotator cuff repair provides detailed demographic and clinical context. The average age at final reoperation was 54.5 years (range 34 to 79 years), with 39 men and 11 women [292]. All patients had significant pain at rest and with use, and the usual history involved feeling a sudden snap or tearing in the shoulder, followed by an inability to raise the arm and recurrence of pain [292]. The average number of previous operations was 1.6 (range 1 to 4), with 30 patients having one unsuccessful surgery, 13 having two, four having three, and three having four [292]. The interval between the last failed surgery and the final operation averaged 16.9 months (range 3 to 60 months) [292]. Detailed information about previous repairs was unavailable in many cases, and no conclusions could be drawn concerning factors implicated in contributing to failure [292].

In this same cohort of 50 patients, specific intraoperative and postoperative findings included early start on resistive exercises with weights within the first 3 months in 28 patients [292]. Six patients had deltoid dysfunction [292]. One patient had a permanent axillary nerve palsy from a concomitant dislocation and rotator cuff rupture [292]. One patient had severe deltoid scarring from an earlier postoperative infection [292]. Four patients had deltoid origin detachment with fixed distal retraction [292]. No patient had had a lateral or complete acromionectomy [292]. The persistence of a cuff defect was confirmed by single-contrast arthrography in all cases [292]. Additionally, 48 patients had been referred by other physicians for the final operation [292].

Stiffness and Range of Motion: Stiffness was observed in 74 patients in a literature review of 2,890 patients undergoing arthroscopic rotator cuff repair [241]. In a consecutive series of 263 patients undergoing primary arthroscopic repair, shoulder stiffness was the most common complication, and persistent stiffness usually responded to extensive physical therapy [256]. In a single-center case series of patients aged 30 years and under, 5 patients (15.6%) had postoperative shoulder stiffness [264]. In a cohort of patients with diabetes mellitus, 6 patients (1.5%) underwent capsular release and lysis of adhesions for postoperative stiffness at a mean 8.4±6.3 months [279].

In a study of 51 patients undergoing open rotator cuff repair, one patient developed a huge subacromial ossification, requiring subacromial decompression 11 months after primary large cuff reconstruction [113]. At revision surgery for this patient, the cuff was healed, and the final result was good [113]. Another patient in this cohort had recurrence of pain 3 months after surgery when starting strengthening exercises, leading to reoperation for arthrographically proven cuff rerupture 9 months after primary surgery, with a fair end result [113]. The third postoperative complication in this series involved a female patient [113]. The overall postoperative Constant functional score averaged 82.7 of 100 points for the surgically treated shoulder and 92.4 points for the control shoulder, a difference that was significant (p = 0.0021) [113].

Recovery

Light activity (weeks): Patients demonstrate no clinically important negative impact on driving fitness as early as 2 weeks postoperatively [228].

Full activity (months): The majority of injured workers return to previous work at approximately 8 months after surgery [147], and a vast majority of patients can expect to return to work within 8 months [167]. In manual laborers, 89.6% of patients were able to return to work following arthroscopic repair [182]. For general activities, 88.5% of patients returned with a mean duration of 6.59 months [249]. In geriatric workers' compensation patients, return to full-duty work takes about 5 months regardless of surgical approach [246].

Complete recovery / outcome plateau (months): The plateau of maximum recovery occurs at 1 year, with high satisfaction rates maintained at all time points [165, 176]. Functional recovery based on clinical outcomes shows approximately 60% of ultimate recovery at 3 months and approximately 75% recovery at 6 months [183]. Arthroscopic repair yields very good functional results with recovery as early as 3 months, further improvement over the first year, and subsequent stabilization [337]. Although the ability to sleep comfortably plateaus at 6 months, these improvements are maintained more than 4 years without re-emergence of sleep disturbance [359].

Rehabilitation protocol: Current literature identifies no significant differences in functional outcomes or re-tear risks between delayed and early motion protocols [66]. Early passive motion is not mandatory for small to medium-sized full-thickness tears [179], though early rehabilitation is associated with initial improvements in range of motion and function [180]. Water therapy provides better early results compared to traditional dry rehabilitation or self-exercise [177]. Delayed postoperative physical therapy is associated with improved outcome measures and shoulder function compared to the preoperative state, with healing demonstrated by MRI [145]. While long-term healing rates are not clearly affected by rehabilitation type, early passive motion protocols might result in lower tendon healing rates in large-sized tears [187]. Further studies are needed to determine effective dosing of physical therapy [164]. A healed repair results in superior outcomes compared with a non-healed repair; surgeons maximize healing chances by adhering to core principles of tear pattern recognition, repair construct selection, biological healing optimization, and avoiding aggressive early rehabilitation [68].

Functional milestones: On average, patients achieve milestones measured by the five most commonly asked questions on the PROMIS-UE CAT by 1-4 months postoperatively [328]. At 10 years, differences in outcome between primary tendon repair and physiotherapy for small and medium-sized tears have increased, with better results for primary tendon repair [149].

Other Considerations: Long-term follow-up (≥15 years) shows that patient-reported outcomes for all-arthroscopic repair remain durable and significantly improved from baseline [21]. Functional results remain stable at intermediate follow-up of 5 years [76]. However, early high functional scores after primary repair or reconstruction did not persist in some cohorts, with function lost as range of motion and strength decreased to less than preoperative values [351]. Satisfactory long-term outcomes can be achieved after repair of large and massive tears [358]. Arthroscopic in situ repair of partial-thickness tears produces excellent functional outcomes in more than 80% of patients with low revision rates during long-term follow-up [381]. Only 5% of patients underwent subsequent surgery at an average of more than 4 years' follow-up, suggesting partial repair of massive tears provides a durable, joint-preserving intervention [81].

Specific populations and procedures show varied recovery profiles. Patients undergoing staged bilateral repair expect similarly good clinical outcomes regardless of hand dominance or chronologic incidence, with excellent healing rates in both shoulders [48]. At a minimum of 1-year follow-up, patients should expect similar improvement in pain and validated outcome measures for each side, though they may experience more pain during the middle portion of recovery on the contralateral side [352]. Upper extremity ambulators demonstrate clinically significant improvements following surgery despite apparent risks [70]. Favorable outcomes are reported for repairs in spinal cord injury patients, with pain reduced and transfers performed with greater ease in 7 of 8 shoulders [254]. Short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary repair [6, 8, 9]. Specific procedures maintain clinically significant patient-reported and functional outcomes and rotator cuff repair survivorship [29], with no impairment in tendon healing or function following arthroscopic repair at 2 years postoperative [56]. Despite a high rate of healing failures, arthroscopic repair can be recommended in patients with massive tears because of the functional gain at midterm follow-up [373]. Previous rotator cuff repair does not appear to adversely affect the early outcome after reverse shoulder arthroplasty [355]. Patients requiring rotator cuff repair with simultaneous biceps tenodesis have lower baseline ASES scores and earlier post-operative plateaus in pain relief and motion improvement [365]. Rotator cuff repair and subsequent rehabilitation markedly improved shoulder strength [184]. Arthroscopic rotator cuff repair demonstrates significant improvement in clinical outcomes and a good rate of healing by postoperative ultrasound [382].

Predictors of return-to-work failure include pre-injury work status; six months after repair, patients who continued to work after injury but presurgery were the most likely to return to work at any level, and those with less strenuous preinjury work levels were most likely to return to their preinjury levels [231]. Workers' compensation recipients who underwent arthroscopic rotator cuff repair had worse outcomes while receiving workers' compensation benefits [214]. Return to full-duty work in geriatric workers' compensation patients costs significantly more in patients aged 65 [246].

Key Evidence

• [L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. [1] (10.1007/s11999-008-0585-9)
• [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] (10.1055/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. [4] (10.5435/00124635-201111000-00002)
• [L3] The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair. [6] (10.1177/0363546514560729)
• [L4] Despite the availability of revision strategies and treatment options, the prevention of complications and successful primary rotator cuff repair results in better functional outcomes. [7] (10.2106/jbjs.rvw.17.00052)
• [L3] Short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair. [8] (10.1016/j.jse.2015.05.015)
• [L3] The short term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair. [9] (10.1177/2325967114s00016)
• [L5] [12] (10.1016/j.arthro.2013.07.265)
• [L5] The authors describe the rationale, current indications, and technical strategies for different types of rotator cuff repair constructs. [16] (10.1097/bte.0b013e31824aeae1)
• [L4] At long-term follow-up (≥15 years), the patient-reported outcomes of all-arthroscopic rotator cuff repair show significant improvement from baseline preoperative function and remain durable over a period of 15 years. [21] (10.1016/j.jse.2022.01.116)
• [L4] Despite the large number of outcomes and prognostic factors evaluated, it was not possible to reach any definitive conclusion regarding the most relevant predictors of outcome of rotator cuff repair due to low methodological quality of included studies. [22] (10.1007/s00167-015-3700-y)
• [L4] Arthroscopic rotator cuff repair has evolved into one of the most common orthopedic surgical procedures worldwide, yet there is still much work to be carried out to improve healing rates, outcomes, and long-term durability. [23] (10.1016/j.xrrt.2021.01.004)
• [L1] There is a need for well-designed level I and level II trials to elucidate the optimal rotator cuff repair rehabilitation protocol. [24] (10.1177/1941738108331200)
• [L3] Recurrent rotator cuff tears are not uncommon after arthroscopic repair of large and massive tears. [26] (10.1177/0363546511413372)
• [L5] It maintains clinically significant patient-reported and functional outcomes and rotator cuff repair survivorship. [29] (10.1016/j.eats.2021.12.039)
• [L5] Although the open surgical technique has long been considered the gold standard of rotator cuff repair, surgeons are becoming more adept at decreasing patient morbidity through decreased surgical trauma from an all-arthroscopic approach. [36] (10.2519/jospt.2009.2918)
• [L4] Every attempt should be made at the time of the arthroplasty to balance the soft tissues and securely repair the rotator cuff because subsequent attempts to repair the rotator cuff are prone to failure. [41] (10.1016/j.jse.2005.06.002)
• [L3] Short-term complications after rotator cuff repair are rare. [45] (10.1016/j.arthro.2017.10.027)
• [L3] The need for concomitant procedures with cuff repair did not jeopardize the result, and they should be performed when indicated. [47] (10.1067/mse.2001.113963)
• [L4] Patients who undergo staged bilateral rotator cuff repair can expect to have similarly good clinical outcomes regardless of hand dominance or chronologic incidence with excellent healing rates in both shoulders. [48] (10.1016/j.jse.2016.01.027)
• [L4] Rotator cuff repair techniques evolve at a fast pace, with new solutions often being used without solid clinical evidence of superiority. [50] (10.1007/s00167-014-3445-z)
• [L3] Severely obese patients and their associated comorbid conditions pose unique challenges in rotator cuff tear management, but they still achieve overall excellent outcomes after repair and noninferior clinical differences when compared to healthy weight patients. [51] (10.1016/j.arthro.2022.02.026)
• [L2] It demonstrated no impairment in tendon healing or function following arthroscopic rotator cuff repair at 2 years postoperative. [56] (10.1016/j.jisako.2025.100806)
• [L5] This report reviews current clinical treatments and preclinical approaches for rotator cuff tear repair, focusing on surgical techniques, new repair strategies under development, and animal models available for research. [57] (10.1016/j.jse.2016.06.009)
• [L4] Use of these higher values should be considered when evaluating improvements of individual patients after rotator cuff repair, to determine comparative effectiveness of various rotator cuff repair techniques and to determine sample sizes for prospective comparative trials of rotator cuff repair methods. [58] (10.1016/j.jse.2019.11.018)
• [L4] Open rotator cuff repair surgery remains a valid option and has some appeal in specific indications and in settings where arthroscopic resources are limited. [59] (10.1007/s43465-020-00345-7)
• [L4] This technique represents a reasonable, low-morbidity salvage option for the patient with a rotator cuff tear that is not primarily repairable. [61] (10.1016/j.jse.2016.12.056)
• [L4] This technique represents a reasonable, low-morbidity salvage option for the patient with a rotator cuff tear that is not primarily repairable. [62] (10.1016/j.arthro.2016.03.037)
• [L1] We do not recommend doing routine DCR with arthroscopic rotator cuff repair. [63] (10.1016/j.otsr.2020.08.006)
• [L5] Shoulder surgeons must carefully interpret literature comparing open and arthroscopic rotator cuff repair outcomes, as differences in complications may be influenced by selection bias and narrowing indications for open repair. [65] (10.1016/j.arthro.2017.11.026)
• [L4] The currently available literature did not identify any significant differences in functional outcomes and relative risks of re-tears between delayed and early motion in patients undergoing arthroscopic rotator cuff repairs. [66] (10.2174/1874325001711010154)
• [L5] A healed rotator cuff repair results in a superior outcome for the patient compared with a non-healed repair, and the surgeon can maximize the chance of a healed repair by adhering to core principles regarding tear pattern recognition, repair construct selection, biological healing optimization, and avoiding aggressive early rehabilitation. [68] (10.1016/j.arthro.2018.11.002)
• [L4] Despite the apparent risks associated in rotator cuff repair in upper extremity ambulators, these patients demonstrate clinically significant improvements following surgery. [70] (10.1016/j.jseint.2022.08.015)
• [L5] One-year follow-up is not the last word for rotator cuff repair outcomes; patients must live with the long-term outcomes of surgical procedures, and authors are obliged to evaluate these long-term outcomes. [71] (10.1016/j.arthro.2024.12.040)
• [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. [72] (10.1016/j.otsr.2018.06.012)
• [L1] Shoulder function was improved after complete rotator cuff repair and similar clinical outcomes were achieved regardless of suture anchor material and shape. [73] (10.1016/j.arthro.2019.08.049)
• [L3] Retrospective and prospective evaluations of the outcome of rotator cuff repair are different. [74] (10.1016/j.jse.2008.04.003)
• [L2] The data support the hypothesis that the functional results of all-arthroscopic rotator cuff repairs remain stable at an intermediate follow-up of 5 years. [76] (10.1016/j.jse.2011.03.029)
• [L5] The authors emphasize that the type of rotator cuff tear affects the approach to these tears. [77] (10.1097/bte.0000000000000117)
• [L3] Radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair. [78] (10.1177/23259671221126095)
• [L4] Only 5% of patients underwent subsequent surgery at an average of more than 4 years' follow-up, suggesting that partial repair of massive rotator cuff tears can provide a durable, joint-preserving intervention. [81] (10.1016/j.asmr.2020.08.017)
• [L4] Rotator cuff repair has a low incidence of short-term complications. [82] (10.1016/j.arthro.2017.10.040)
• [L4] While concordance with MRI results are good for the supraspinatus, MRI often fails to diagnose the presence of subscapularis tears and infraspinatus tears. [83] (10.4103/0973-6042.91000)
• [L4] Biocomposite suture anchors are frequently still visible on MRI 2 years after rotator cuff reconstruction. [84] (10.1177/2325967117s00368)
• [L5] Revision rotator cuff repair is technically more difficult than primary repair due to poor tissue quality, adhesions, and retained hardware. [85] (10.1016/j.jse.2011.11.029)
• [L5] [87] (10.1016/j.eats.2024.103145)
• [L4] [95] (10.1016/j.asmr.2021.11.010)
• [L5] This surgical technique is a straightforward, reproducible, and effective approach to enhancing rotator cuff repair. [99] (10.1016/j.eats.2025.103581)
• [L3] After rotator cuff repair, symptoms of depression/anxiety related to the shoulder improved dramatically with or without preexisting clinical diagnosis of depression or anxiety. [102] (10.1016/j.jse.2020.03.046)
• [L4] [108] (10.1177/03635465261450185)
• [L3] [111] (10.5435/jaaos-d-24-00646)
• [L4] [113] (10.1097/01.000093903.12372.3f)
• [L5] The technique of rotator cuff repair in large to massive rotator cuff tears matters. [116] (10.1016/j.arthro.2018.03.041)
• [Paper] The technique has simplified massive rotator cuff tear repairs and offered an easier approach that is simple, reproducible, and does not cost more. [118] (10.1016/j.eats.2020.10.048)
• [L5] This approach aims to minimize complications, optimize rotator cuff healing, and maximize postoperative results and patient satisfaction. [119] (10.1097/bte.0b013e3181558b2a)
• [L3] Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes. [123] (10.1016/j.jse.2025.03.038)
• [L1] [127] (10.1177/23259671261474635)
• [L4] [129] (10.1016/j.arthro.2013.01.015)
• [L5] The purpose of this technique is to show a simple and reproducible method for rotator cuff augmentation that can be easily adopted by arthroscopic shoulder surgeons to decrease surgical time. [133] (10.1016/j.eats.2025.103878)
• [L5] In a dynamic biomechanical cadaveric model, increased glenohumeral joint loads due to a full-thickness SSP tear can be reversed with RCR. [137] (10.1016/j.arthro.2021.10.036)
• [L5] Arthroscopic repair of rotator cuff tears is an effective and straightforward technique when performed in an organized, well-considered manner. [138] (10.5435/00124635-200707000-00008)
• [L5] In contrast to a TOE repair of the supraspinatus tendon, isolated supraspinatus tears did not perturb glenohumeral kinematics in this cadaveric model of the throwing shoulder. [139] (10.1177/0363546514547348)
• [L5] Optimization of surgical techniques and the use of appropriate biologic or tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair. [140] (10.5435/jaaos-d-17-00086)
• [L4] Both techniques may be used successfully to repair full-thickness rotator cuff tears with very good functional outcome. [142] (10.1007/s00402-020-03584-3)
• [L4] The novel all-inside arthroscopic rotator cuff repair technique was safe and significantly faster and provided better healing rates than other repair techniques. [143] (10.1177/2325967119864088)
• [L4] The delayed postoperative physical therapy protocol was associated with improvements in the outcome measures and shoulder function compared to the preoperatory state and rotator cuff healing demonstrated by MRI. [145] (10.3390/osteology1010003)
• [L4] The majority of injured workers undergoing rotator cuff repair return to previous work at approximately 8 months after surgery. [147] (10.1177/0363546520975426)
• [L3] The healing of the rotator cuff using an anatomic technique was superior to that in the single row repair group. [148] (10.1016/j.arthro.2012.04.078)
• [L1] At 10 years, the differences in outcome between primary tendon repair and physiotherapy for small and medium-sized rotator cuff tears had increased, with better results for primary tendon repair. [149] (10.2106/jbjs.18.01373)
• [Paper] This technique of concomitant superior capsular reconstruction with rotator cuff repair has been a reproducible method for achieving successful surgical management of patients with massive rotator cuff tears and superior capsular insufficiency. [150] (10.1016/j.eats.2019.01.004)
• [L4] This technique represents a reasonable, low-morbidity salvage option for the patient with a rotator cuff tear that is not primarily repairable. [151] (10.1016/j.arthro.2011.03.020)
• [L3] Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. [152] (10.1002/ksa.12162)
• [L3] This progress can be questioned, since there are not convincing data of the superiority of the operative treatment over non-operative management in all rotator cuff tears. [153] (10.1186/s12891-015-0639-6)
• [L5] The Hamada classification is a commonly used classification scheme that uses a mechanistic approach to explain the radiographic changes seen with chronic massive rotator cuff tears, highlighting the progressive nature of massive rotator cuff tears leading to CTA. [161] (10.1007/s11999-017-5340-7)
• [L2] Further studies are needed to determine effective dosing of physical therapy after rotator cuff repair. [164] (10.1016/j.jse.2017.02.009)
• [L4] The plateau of maximum recovery following rotator cuff repair occurred at 1 year with high satisfaction rates at all time points. [165] (10.1016/j.arthro.2017.04.033)
• [L3] A vast majority of patients undergoing rotator cuff repair can expect to return to work within 8 months of surgery. [167] (10.1177/2325967119878415)
• [L4] The plateau of maximum recovery after rotator cuff repair occurred at 1 year with high satisfaction rates at all time points. [176] (10.1016/j.jse.2016.11.002)
• [L1] Water therapy after rotator cuff repair provides better early results compared to traditional dry rehabilitation or self-exercise therapy. [177] (10.1177/2325967121s00007)
• [L1] Early passive motion exercise is not mandatory after arthroscopic repair of small to medium-sized full-thickness rotator cuff tears. [179] (10.1177/0363546511434287)
• [L1] Early rehabilitation after arthroscopic cuff repair is associated with some initial improvements in ROM and function. [180] (10.1080/00913847.2015.1025683)
• [L4] Arthroscopic rotator cuff repair portended favorable outcomes and high rates of return to work in this cohort of manual laborers, with 89.6% of patients able to return to work. [182] (10.1177/03635465221097102)
• [L3] Functional recovery based on clinical outcomes showed approximately 60% of ultimate recovery at 3 months and approximately 75% recovery at 6 months after rotator cuff repair. [183] (10.1007/s00167-020-06019-z)
• [L1] Rotator cuff repair, and subsequent rehabilitation, markedly improved shoulder strength. [184] (10.1177/2325967115s00155)
• [L3] Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology. [185] (10.1016/j.jseint.2025.04.038)
• [L1] The healing rate at long-term follow-up is not clearly affected by the type of rehabilitation, but the EPM protocol might result in lower rates of tendon healing in the shoulder with large-sized tendon tears. [187] (10.1097/md.0000000000009625)
• [L5] The widely accepted 2-year benchmark for rotator cuff repair outcomes may be arbitrary and does not add clinical relevance, as 1-year follow-up appears clinically sufficient. [191] (10.1016/j.arthro.2023.11.002)
• [L4] Despite the growing clinical use of scaffold devices for rotator cuff repair, numerous questions related to their indication, surgical application, safety, mechanism of action, and efficacy remain to be clarified or addressed. [192] (10.1016/j.jse.2011.10.003)
• [L5] The general indications for augmentation include patients with large (>3 cm), multitendon rotator cuff tears or chronic tears with poor tissue quality. [196] (10.1016/j.eats.2024.103287)
• [L4] Rotator cuff repair is cost-effective for all populations. [199] (10.2106/jbjs.l.01495)
• [L1] While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented rotator cuff repair, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations. [201] (10.1136/bmjopen-2020-039552)
• [L3] Thus, acromioplasty cannot be recommended as a routine technique in every rotator cuff repair. [210] (10.1080/00913847.2016.1216717)
• [L3] CSA and AI do not appear to influence 24-month functional outcomes postoperatively and hence are not contraindications to arthroscopic rotator cuff repair. [211] (10.1177/0363546517717947)
• [L1] There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. [212] (10.1302/0301-620x.99b1.bjj-2016-0424.r1)
• [L3] Workers' compensation recipients who underwent arthroscopic rotator cuff repair had worse outcomes while receiving workers' compensation benefits. [214] (10.1177/2309499018802507)
• [Paper] Radiographs should be the first imaging study obtained, and magnetic resonance imaging provides the best overall evaluation of the cuff. [215] (10.1016/j.csm.2012.07.010)
• [L5] This commentary highlights that while nonoperative treatment may yield better short-term outcomes, surgical repair provides significantly better long-term outcomes and a higher probability of substantial improvement for symptomatic rotator cuff tears, supporting its use in shared decision-making. [217] (10.2106/jbjs.20.00400)
• [L4] BCS may improve pain, function, and structural outcomes in selected rotator cuff tears; however, evidence remains limited, heterogeneous, and predominantly non-randomized. [219] (10.5397/cise.2025.01326)
• [L2] Patients showed no clinically important negative impact on driving fitness as early as 2 weeks after rotator cuff repair. [228] (10.2106/jbjs.21.01436)
• [L3] Additionally, non-surgical treatment is recommended as the preferred approach for patients with non-traumatic rotator cuff injuries. [229] (10.1186/s13018-024-04858-x)
• [L3] Six months after rotator cuff repair, patients who continued to work after injury but presurgery were the most likely to return to work at any level, and patients who had less strenuous preinjury levels of work were the most likely to return to their preinjury levels of work. [231] (10.1177/03635465231152479)
• [L4] The complication rate after arthroscopic revision rotator cuff repair is about twice the published rate for primary rotator cuff repair. [232] (10.1016/j.arthro.2013.06.015)
• [Paper] [241] (10.1007/s12306-011-0175-y)
• [L4] Repair of symptomatic single-tendon rotator cuff tears in patients aged older than 65 years who do not respond to conservative treatment appears justified. [242] (10.1016/j.jse.2012.03.012)
• [L4] Despite Clinical Practice Guidelines recommending the nonroutine use of acromioplasty, surgeons continue to perform acromioplasty with rotator cuff repair in most of the cases throughout all subcategorizations analyzed. [243] (10.5435/jaaosglobal-d-22-00075)
• [L3] Return to full-duty work in geriatric workers' compensation patients after rotator cuff repair takes about 5 months regardless of surgical approach and costs significantly more in patients aged 65. [246] (10.1177/2151458517732209)
• [L3] [247] (10.1016/j.asmr.2022.03.004)
• [L1] As much as 88.5% of patients were able to return to activities after arthroscopic rotator cuff repair with a mean duration of 6.59 months. [249] (10.1177/2325967121s00867)
• [L4] We report a favorable outcome for rotator cuff repairs in SCI patients, with pain reduced and transfers performed with greater ease in 7 of 8 shoulders. [254] (10.1016/s1058-2746(03)00035-1)
• [L4] [256] (10.1016/j.arthro.2006.09.001)
• [L4] [264] (10.1177/17585732241312192)
• [L3] [266] (10.1007/s00167-011-1520-2)
• [L3] [269] (10.1016/j.jseint.2022.12.019)
• [L4] After successful arthroscopic rotator cuff repair, there was a slight (11.3%-13.9%) increase in muscle volume from preoperatively to final follow-up, as seen on serial MRI. [270] (10.1177/0363546515625211)
• [L1] [271] (10.1177/0363546517695789)
• [L3] [274] (10.1016/j.jse.2021.10.004)
• [L3] [279] (10.1016/j.jse.2023.06.034)
• [L5] The author considers arthroscopic examination and attempted repair of large and massive rotator cuff tears to be the gold standard of treatment for nonarthritic shoulders, cautioning against the high complication and reoperation rates associated with reverse total shoulder replacements in younger patients. [281] (10.1016/j.arthro.2017.10.036)
• [L4] [292] (10.1016/s1058-2746(09)80054-2)
• [L5] The authors maintain that magnetic resonance arthrography is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair, regardless of the gold standard used, and that neither MRI nor clinical tests are sufficiently reliable in this context. [294] (10.1007/s00167-019-05775-x)
• [L4] These immediate changes should be considered when assessing rotator cuff muscle changes by comparing preoperative MRI with postoperative MRI. [295] (10.1016/j.arthro.2012.10.006)
• [L2] MRI appearance of the repaired tendon changes over time but does not correlate with function or predict clinical outcomes at 1 year after surgery. [296] (10.2214/ajr.10.4436)
• [L5] [297] (10.5435/jaaos-d-25-00069)
• [L5] [299] (10.1016/j.jse.2007.03.012)
• [L1] At a short-term follow-up, differences between arthroscopic repair of full-thickness rotator cuff tears with metal and biodegradable suture anchors were not significant. [305] (10.1016/j.arthro.2010.01.030)
• [L4] However, the presence of clinically significant disagreements, even in such favorable circumstances, indicates the need for improved imaging tools for precise rotator cuff evaluation. [310] (10.1016/j.jse.2021.04.021)
• [L4] [311] (10.1007/s12178-020-09658-4)
• [L4] Solid fixation of the rotator cuff tear was obtained in all cases. [312] (10.1097/bte.0b013e3181e2989c)
• [L3] Most deformities after rotator cuff repair remodel over time and do not affect the radiologic outcome of repair after 6 months of follow-up. [315] (10.1016/j.arthro.2013.07.023)
• [Paper] [318] (10.1016/j.eats.2016.11.007)
• [L5] Therefore, gap formation between the bone and the soft tissue fixation jeopardizes the repair, and the anchor is not appropriate for rotator cuff repair if used on its own. [321] (10.1016/j.jse.2007.11.017)
• [L4] Poor interobserver agreement regarding postoperative graft and rotator cuff integrity by MRI was found. [322] (10.1016/j.arthro.2021.11.008)
• [L4] Ultrasonography is an adequate imaging modality to classify rotator cuff repair integrity, which could reduce economic and practical burdens of CTA, MRI or MRA. [324] (10.1007/s00167-015-3505-z)
• [L3] On average, patients undergoing rotator cuff repair achieved milestones measured by the five most commonly asked questions on the PROMIS-UE CAT by 1-4 months postoperatively. [328] (10.1177/2325967121s00341)
• [L5] It highlights that initial fixation strength is an essential consideration in optimizing rotator cuff repair. [330] (10.4055/cios.2013.5.2.89)
• [L4] These results indicate that a synthetic interposition graft with screw fixation could not prevent cuff tear arthropathy and preserve cuff integrity in a long-term perspective. [331] (10.1016/j.jse.2018.03.011)
• [L3] In the community setting, ultrasound may be used to evaluate the integrity of a repaired rotator cuff tendon and constitutes a comparable alternative to MRI when evaluating the integrity of a rotator cuff repair. [334] (10.1016/j.jse.2014.01.045)
• [L4] Metal artefacts prevented accurate diagnosis from MRI scans of rotator cuff retear in 36% of the patients studied. [335] (10.1177/1758573217710833)
• [L4] Arthroscopic repair of rotator cuff lesions gives very good results in terms of functional recovery, with recovery as early as 3 months, further improvement over the first year, and subsequent stabilization. [337] (10.1016/j.arthro.2007.07.023)
• [L4] Every patient presenting with shoulder pain after usage of a biodegradable fixation material should be evaluated closely. [338] (10.1007/s00402-010-1125-0)
• [L5] Every tested anchor presented different problems that may lead to premature failure of the rotator cuff reconstruction. [339] (10.1016/j.arthro.2009.12.023)
• [Paper] Superior capsular reconstruction with incorporation of the native rotator cuff may provide surgeons the opportunity to perform a robust repair in situations where arthroplasty or other more invasive procedures were once the only options. [340] (10.1016/j.eats.2018.04.005)
• [L5] This finding may have implications for the type of cuff fixation device used and for rehabilitation after fixation. [342] (10.1016/j.jse.2009.05.002)
• [L3] The shift angle and medial retraction of the deep layer on magnetic resonance imaging are associated with intraoperative reparability in large-to-massive rotator cuff tears. [345] (10.1002/ars2.70058)
• [L1] MRA is not suitable for the diagnosis of LHB lesions prior to arthroscopic rotator cuff repair. [346] (10.1007/s00167-019-05633-w)
• [L5] The ideal rotator cuff repair technique should have high initial fixation strength to allow minimal gap formation between the tendon and bone. [348] (10.1177/23259671211006040)
• [L4] The early high functional scores after primary rotator cuff repair or reconstruction did not persist; function was lost as ROM and strength decreased to less than preoperative values. [351] (10.1007/s11999-010-1403-8)
• [L5] At a minimum of 1-year follow-up after rotator cuff repair, patients should expect similar improvement in pain and validated outcome measures for each side, though they may experience more pain during the middle portion of recovery on the contralateral side. [352] (10.1016/j.arthro.2018.07.025)
• [L3] Arthroscopic transosseous rotator cuff repair achieves similar clinical outcomes, patient-reported outcomes, and healing rates with 30-80% reduction in implant costs, compared to traditional anchored techniques. [353] (10.1016/j.arthro.2016.03.084)
• [L3] Previous rotator cuff repair does not appear to affect the early outcome after RSA adversely. [355] (10.1302/0301-620x.101b1.bjj-2018-0874.r1)
• [L3] Both anchor insertion techniques resulted in acceptable shoulder clinical outcomes for patients with osteoporosis undergoing rotator cuff repair. [356] (10.1177/23259671251408497)
• [L4] Despite using more anchors and incurring higher implant costs, the knotless technique for rotator cuff repair required less surgical procedure time and cost less overall than the knotted technique and resulted in equivalent clinical results. [357] (10.1016/j.asmr.2019.09.005)
• [L4] A satisfactory long-term outcome can be achieved after repair of large and massive rotator cuff tears. [358] (10.1016/s1058-2746(98)90081-7)
• [L4] Although recovery of the ability to sleep comfortably plateaued at 6 months, the achieved improvements in sleep are maintained more than 4 years after rotator cuff repair without evidence for the re-emergence of sleep disturbance. [359] (10.1016/j.jse.2024.05.043)
• [L5] Clinical registries are a highly beneficial source of information showing that adverse events after rotator cuff repair may occur in almost 1 of 5 cases, but retrospective review of registry data has limitations including inconsistent reporting, lack of control of confounding variables, and loss to follow-up. [363] (10.1016/j.arthro.2020.10.045)
• [L4] Patients requiring rotator cuff repair with simultaneous biceps tenodesis have lower baseline ASES, and earlier post-operative plateaus in pain relief and motion improvement following surgery. [365] (10.1016/j.arthro.2018.10.075)
• [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. [373] (10.1177/0363546513485719)
• [L4] During long-term follow-up, arthroscopic in situ repair of partial-thickness rotator cuff tears produces excellent functional outcomes in more than 80% of patients, and revision rates are low. [381] (10.1016/j.arthro.2018.09.026)
• [L4] Arthroscopic rotator cuff repair demonstrates significant improvement in clinical outcomes and good rate of healing by postoperative ultrasound. [382] (10.1016/j.jse.2008.11.018)
• [L4] Seven patients (0.7%) underwent revision rotator cuff repair, and no patients required reoperation for infection or post-operative stiffness. [393] (10.1016/j.jseint.2026.101778)

See Also

• Rotator Cuff
• Shoulder Arthroscopy
• Calcific Tendinitis
• Revision rotator cuff repair
• Reverse Shoulder Arthroplasty
• Capsular Release for Frozen Shoulder
• Subacromial Decompression
• Biceps Tenodesis

References

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[74] A comparison of prospective and retrospective assessment of functional outcome after rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2008.04.003

[76] Prospective evaluation of arthroscopic rotator cuff repairs at 5 years: part I - Functional outcomes and radiographic healing rates. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.03.029

[77] The Evolution of Arthroscopic Rotator Cuff Repair Techniques: What Repair Construct to Use and How to Do It Well. Techniques in Shoulder & Elbow Surgery. 2017. DOI: 10.1097/bte.0000000000000117

[78] Evaluation of Radiographic Changes 5 Years After Arthroscopic Rotator Cuff Repair. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221126095

[81] Partial Rotator Cuff Repair for Massive Tears Rarely Require Revision Surgery. Arthroscopy, Sports Medicine, and Rehabilitation. 2020. DOI: 10.1016/j.asmr.2020.08.017

[82] Risk Factors for Short‐term Complications After Rotator Cuff Repair in the United States. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.10.040

[83] The frequency of subscapularis tears in arthroscopic rotator cuff repairs: A retrospective study comparing magnetic resonance imaging and arthroscopic findings. International Journal of Shoulder Surgery. 2011. DOI: 10.4103/0973-6042.91000

[84] Biodegradation of Biocomposite Suture Anchor Implants 2,2 years after Rotator Cuff Repair. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00368

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

[87] The Mason‐Loop for Single‐Row Full‐Thickness Rotator Cuff Repair. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103145

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[95] Rotator Cuff Repair in the Pediatric Population Displays Favorable Outcomes: A Systematic Review. Arthroscopy, Sports Medicine, and Rehabilitation. 2022. DOI: 10.1016/j.asmr.2021.11.010

[99] Partial‐Thickness Bursal‐Site Rotator Cuff Repair With Autologous Bursa Augmentation. Arthroscopy Techniques. 2025. DOI: 10.1016/j.eats.2025.103581

[102] Patients with depression and anxiety symptoms from adjustment disorder related to their shoulder may be ideal patients for arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.03.046

[108] Minimum 15-Year Outcomes and Return to Activity After Linked Tape Bridging Knotless Double-Row Rotator Cuff Repair. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261450185

[111] Determinants of Patient-Rated Benefit 6 Months Post Arthroscopic Rotator Cuff Repair: An Analysis of 2010 Patients. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00646

[113] Functional and Electromyographic Results After Open Rotator Cuff Repair. Clinical Orthopaedics and Related Research. 2003. DOI: 10.1097/01.000093903.12372.3f

[116] Editorial Commentary: What's in a Name: Is There a Difference Between Incomplete and Partial Rotator Cuff Repairs?. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.03.041

[117] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > Rotator Cuff Tears > Surgical Findings.

[118] Massive Rotator Cuff Repair: Banana SutureLasso Double‐Row Fixation. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2020.10.048

[119] Basics of Arthroscopic Rotator Cuff Repair. Techniques in Shoulder & Elbow Surgery. 2007. DOI: 10.1097/bte.0b013e3181558b2a

[123] Glenohumeral decentering in rotator cuff deficiency: relationship to rotator cuff muscle, scapula morphology, and shoulder function. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.03.038

[127] The Efficacy of Synovectomy in Rotator Cuff Repair: A Randomized Controlled Trial. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261474635

[129] Arthroscopic Primary Rotator Cuff Repairs in Patients Aged Younger Than 45 Years. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.01.015

[133] Acellular Dermal Graft Augmentation Technique for Arthroscopic Rotator Cuff Repair. Arthroscopy Techniques. 2025. DOI: 10.1016/j.eats.2025.103878

[137] Increased Glenohumeral Joint Loads Due to a Supraspinatus Tear Can Be Reversed With Rotator Cuff Repair: A Biomechanical Investigation. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2022. DOI: 10.1016/j.arthro.2021.10.036

[138] Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200707000-00008

[139] The Effect of Supraspinatus Tears on Glenohumeral Translations in Passive Pitching Motion. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514547348

[140] Management of Failed Rotator Cuff Repair in Young Patients. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-17-00086

[142] The functional outcome of arthroscopic rotator cuff repair with double-row knotless vs knot-tying anchors. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03584-3

[143] A Novel, Fast, Safe, and Effective All-Inside Arthroscopic Rotator Cuff Repair Technique: Results of 1000 Consecutive Cases. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119864088

[145] Delayed Rehabilitation Protocol after Rotator Cuff Repair. Osteology. 2020. DOI: 10.3390/osteology1010003

[147] Return to Work After Primary Rotator Cuff Repair: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2021. DOI: 10.1177/0363546520975426

[148] Serial Ultrasound Evaluation of Tendon Healing of Anatomic Rotator Cuff Repair Compared to Single Row Repair in Patients Over 65 (SS‐18). Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.04.078

[149] At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.18.01373

[150] Superior Capsular Reconstruction With Arthroscopic Rotator Cuff Repair in a “Functional Biologic Augmentation” Technique to Treat Massive Atrophic Rotator Cuff Tears. Arthroscopy Techniques. 2019. DOI: 10.1016/j.eats.2019.01.004

[151] Partial Rotator Cuff Repair in Massive Rotator Cuff Tears: Long‐Term Follow‐Up (SS‐17). Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.03.020

[152] A modified Patte classification system for rotator cuff tendon retraction to predict reparability and tendon healing in arthroscopic rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12162

[153] Increasing incidence of rotator cuff repairs—A nationwide registry study in Finland. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0639-6

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[161] Classifications in Brief: Hamada Classification of Massive Rotator Cuff Tears. Clinical Orthopaedics & Related Research. 2017. DOI: 10.1007/s11999-017-5340-7

[164] A systematic review of cost-effective treatment of postoperative rotator cuff repairs. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.02.009

[165] Speed of Recovery After Arthroscopic Rotator Cuff Repair. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.04.033

[167] Preoperative Mental Health Scores and Achieving Patient Acceptable Symptom State Are Predictive of Return to Work After Arthroscopic Rotator Cuff Repair. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119878415

[176] Speed of recovery after arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.11.002

[177] Evaluation of 3 different rehabilitation protocols after rotator cuff repair, and the effectiveness of pool therapy: a randomized control study. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00007

[179] Is Early Passive Motion Exercise Necessary After Arthroscopic Rotator Cuff Repair?. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546511434287

[180] Early versus delayed rehabilitation following arthroscopic rotator cuff repair: A systematic review. The Physician and Sportsmedicine. 2015. DOI: 10.1080/00913847.2015.1025683

[182] Rates of Return to Manual Labor After Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221097102

[183] Patients who have undergone rotator cuff repair experience around 75% functional recovery at 6 months after surgery. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06019-z

[184] Functional Outcomes after Double Row Versus Single Row Rotator Cuff Repair. Orthopaedic Journal of Sports Medicine. 2015. DOI: 10.1177/2325967115s00155

[185] Cost-effectiveness of rotator cuff repair based on modern constructs, tear size, and implant cost at 1, 5, and 10 years. JSES International. 2025. DOI: 10.1016/j.jseint.2025.04.038

[187] The clinical effect of rehabilitation following arthroscopic rotator cuff repair. Medicine. 2018. DOI: 10.1097/md.0000000000009625

[191] Editorial Commentary: One‐ and 2‐Year Outcomes Are Clinically Similar After Rotator Cuff Repair: What Are We Waiting For?. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.11.002

[192] Scaffold devices for rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.10.003

[196] A Technique for Arthroscopic Double‐Row Rotator Cuff Repair With Acellular Dermal Matrix Augmentation. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103287

[199] The Societal and Economic Value of Rotator Cuff Repair. Journal of Bone and Joint Surgery. 2013. DOI: 10.2106/jbjs.l.01495

[201] Use of implantable meshes for augmented rotator cuff repair: a systematic review and meta-analysis. BMJ Open. 2020. DOI: 10.1136/bmjopen-2020-039552

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[210] Rotator Cuff Repair: Is there any role for acromioplasty?. The Physician and Sportsmedicine. 2016. DOI: 10.1080/00913847.2016.1216717

[211] Critical Shoulder Angle and Acromial Index Do Not Influence 24-Month Functional Outcome After Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517717947

[212] Effectiveness of open and arthroscopic rotator cuff repair (UKUFF). The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b1.bjj-2016-0424.r1

[213] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Shoulder Instability, Rotator Cuff Disorders, Muscular Ruptures, Adhesive Capsulitis, Calcific Tendinitis > Rotator Cuff Tears > Evaluation.

[214] Do patients receiving workers’ compensation who undergo arthroscopic rotator cuff repair have worse outcomes than non-recipients? Retrospective case–control study. Journal of Orthopaedic Surgery. 2018. DOI: 10.1177/2309499018802507

[215] Imaging Evaluation of the Rotator Cuff. Clinics in Sports Medicine. 2012. DOI: 10.1016/j.csm.2012.07.010

[217] Rotator Cuff Repair Over Nonoperative Management: The Prudent Choice for Symptomatic Rotator Cuff Tears in the Shared Decision-Making Model. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.20.00400

[219] Bioinductive collagen scaffolds for partial- and full-thickness rotator cuff repair: a systematic review. Clinics in Shoulder and Elbow. 2026. DOI: 10.5397/cise.2025.01326

[223] Apley And Solomon S Concise System Of Orthopaedics And Trauma. SECONDARY ARTHROPATHY > TEARS OF THE ROTATOR CUFF.

[228] Patients Who Undergo Rotator Cuff Repair Can Safely Return to Driving at 2 Weeks Postoperatively. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.21.01436

[229] Comparison of functional outcomes following early and delayed arthroscopic repair for traumatic and non-traumatic rotator cuff injuries. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04858-x

[230] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > Natural History of Symptomatic Rotator Cuff Tears.

[231] Predictors of Return to Work Following Primary Arthroscopic Rotator Cuff Repair: An Analysis of 1502 Cases. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231152479

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

[234] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > ARTHROSCOPIC ROTATOR CUFF REPAIR.

[238] Orthopaedic Knowledge Update Sports Medicine 6. Rotator Cuff Disease > Biomechanics, Anatomy, and Genetics.

[241] Complications associated with arthroscopic rotator cuff repair: a literature review. MUSCULOSKELETAL SURGERY. 2011. DOI: 10.1007/s12306-011-0175-y

[242] Outcome of single-tendon rotator cuff repair in patients aged older than 65 years. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.03.012

[243] Trends in Acromioplasty Utilization During Arthroscopic Rotator Cuff Repair: An Epidemiological Study of 139,586 Patients. JAAOS: Global Research and Reviews. 2022. DOI: 10.5435/jaaosglobal-d-22-00075

[244] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Shoulder Instability, Rotator Cuff Disorders, Muscular Ruptures, Adhesive Capsulitis, Calcific Tendinitis > Rotator Cuff Tears > Natural History.

[246] A Review of a Workers’ Compensation Database 2003 to 2013: Patient Factors Influencing Return to Work and Cumulative Financial Claims After Rotator Cuff Repair in Geriatric Workers’ Compensation Cases. Geriatric Orthopaedic Surgery & Rehabilitation. 2017. DOI: 10.1177/2151458517732209

[247] Partial Rotator Cuff Repair Provides Improved Patient‐Reported Outcome Measures Following Superior Capsule Reconstruction (SCR). Arthroscopy, Sports Medicine, and Rehabilitation. 2022. DOI: 10.1016/j.asmr.2022.03.004

[249] Return to Activities after Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967121s00867

[254] Rotator cuff repair in spinal cord injury patients. Journal of Shoulder and Elbow Surgery. 2003. DOI: 10.1016/s1058-2746(03)00035-1

[256] Complications After Arthroscopic Rotator Cuff Repair. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.09.001

[260] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Shoulder Instability, Rotator Cuff Disorders, Muscular Ruptures, Adhesive Capsulitis, Calcific Tendinitis > Rotator Cuff Tears > Role of the Biceps Tendon.

[264] Full-thickness arthroscopic rotator cuff repair demonstrates low repair failure rates and high return to sport rates in patients aged 30 years and under at 9-year follow-up: A single-center case series. Shoulder & Elbow. 2025. DOI: 10.1177/17585732241312192

[266] The effect of multiple channeling on the structural integrity of repaired rotator cuff. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1520-2

[269] Relationship between hematoma-like tissue on the footprint and structural outcome of arthroscopic rotator cuff repair with a transosseous technique. JSES International. 2023. DOI: 10.1016/j.jseint.2022.12.019

[270] Reversibility of Supraspinatus Muscle Atrophy in Tendon-Bone Healing After Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546515625211

[271] 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

[274] Factors correlated with the optimal tension for arthroscopic rotator cuff repair using Grasper Tensioning Attachment. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.10.004

[279] Elevated HbA1c is not associated with reoperation following arthroscopic rotator cuff repair in patients with diabetes mellitus. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.06.034

[281] Editorial Commentary: Put Down Your Saw and Pick Up Your Scope! Or, Why Burn Down the Bridge When the Road Ahead Is Full of Potholes? Reverse Total Shoulder Replacement Versus Arthroscopic Rotator Cuff Repair. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2017.10.036

[292] Reoperation for failed rotator cuff repair: Analysis of fifty cases. Journal of Shoulder and Elbow Surgery. 1992. DOI: 10.1016/s1058-2746(09)80054-2

[294] Diagnostic accuracy of magnetic resonance arthrography to assess biceps pathologies prior to rotator cuff repair: response to the Letter to the Editor. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05775-x

[295] Changes in Appearance of Fatty Infiltration and Muscle Atrophy of Rotator Cuff Muscles on Magnetic Resonance Imaging After Rotator Cuff Repair: Establishing New Time‐Zero Traits. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2012.10.006

[296] Temporal Evolution of MRI Findings After Arthroscopic Rotator Cuff Repair. American Journal of Roentgenology. 2010. DOI: 10.2214/ajr.10.4436

[297] Orthobiologic Augmentation to Improve Rotator Cuff Repair Outcomes: Current and Future Strategies. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00069

[299] Biologic augmentation of rotator cuff tendon repair. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.03.012

[305] Arthroscopic Rotator Cuff Repair With Metal and Biodegradable Suture Anchors: A Prospective Randomized Study. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2010.01.030

[310] Inter-rater agreement of rotator cuff tendon and muscle magnetic resonance imaging parameters evaluated preoperatively and during the first postoperative year following rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.04.021

[311] Patch Augmentation in Rotator Cuff Repair. Current Reviews in Musculoskeletal Medicine. 2020. DOI: 10.1007/s12178-020-09658-4

[312] Rotator Cuff Repair Associated With Large Greater Tuberosity Bone Cysts: A Report of 3 Cases, Surgical Technique, and Review of the Literature. Techniques in Shoulder & Elbow Surgery. 2010. DOI: 10.1097/bte.0b013e3181e2989c

[315] Paper #19: Does The Deformity After Rotator Cuff Repair Remodel?. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.07.023

[318] The “Pull‐Over” Technique for All Arthroscopic Rotator Cuff Repair With Extracellular Matrix Augmentation. Arthroscopy Techniques. 2017. DOI: 10.1016/j.eats.2016.11.007

[321] Biomechanical testing of a new knotless suture anchor compared with established anchors for rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.11.017

[322] Prospective 1-Year Outcomes Are Maintained at Short-Term Final Follow-Up After Superior Capsular Reconstruction Augmentation of Complete Rotator Cuff Repair. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2022. DOI: 10.1016/j.arthro.2021.11.008

[324] Ultrasonic evaluation of the repair integrity can predict functional outcomes after arthroscopic double‐row rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3505-z

[328] PROMIS Milestones in Patients Undergoing Rotator Cuff Repair (233). Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00341

[330] Current Biomechanical Concepts for Rotator Cuff Repair. Clinics in Orthopedic Surgery. 2013. DOI: 10.4055/cios.2013.5.2.89

[331] Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.03.011

[334] Assessment of rotator cuff repair integrity using ultrasound and magnetic resonance imaging in a multicenter study. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.01.045

[335] Metal artefacts severely hamper magnetic resonance imaging of the rotator cuff tendons after rotator cuff repair with titanium suture anchors. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217710833

[337] The Time for Functional Recovery After Arthroscopic Rotator Cuff Repair: Correlation With Tendon Healing Controlled by Computed Tomography Arthrography. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.07.023

[338] Intraosseous foreign body granuloma in rotator cuff repair with bioabsorbable suture anchor. Archives of Orthopaedic and Trauma Surgery. 2010. DOI: 10.1007/s00402-010-1125-0

[339] Biomechanical Stability of Knotless Suture Anchors Used in Rotator Cuff Repair in Healthy and Osteopenic Bone. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2009.12.023

[340] Arthroscopic Superior Capsular Reconstruction and Over‐the‐Top Rotator Cuff Repair Incorporation for Treatment of Massive Rotator Cuff Tears. Arthroscopy Techniques. 2018. DOI: 10.1016/j.eats.2018.04.005

[342] Suture anchor loading after rotator cuff repair: Effects of an additional lateral row. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.05.002

[345] Shift Angle and Medial Retraction of the Deep Layer on Magnetic Resonance Imaging Are Associated With Intraoperative Reparability in Arthroscopic Rotator Cuff Repair. Arthroscopy, Sports Medicine, and Rehabilitation. 2026. DOI: 10.1002/ars2.70058

[346] Magnetic resonance arthrography is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05633-w

[348] Biomechanical Properties of Double-Row Transosseous Rotator Cuff Repair Combined With the Cinch Stitch in the Lateral Row. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/23259671211006040

[351] Pain Relief, Motion, and Function after Rotator Cuff Repair or Reconstruction May Not Persist after 16 Years. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-010-1403-8

[352] Editorial Commentary: The Second Side Is as Good as the First After Bilateral Rotator Cuff Repair: Preach Patience to the Patients. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.07.025

[353] Arthroscopic Transosseous Anchorless vs Anchored Rotator Cuff Repair: A Comparison of Clinical and Patient Reported Outcomes, Structural Integrity, and Costs. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.03.084

[355] Does having a rotator cuff repair prior to reverse total shoulder arthroplasty influence the outcome?. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b1.bjj-2018-0874.r1

[356] 20° Anchor Insertion Technique Toward the Subchondral Bone in Rotator Cuff Repairs for Patients With Osteoporosis Compared With the Traditional 45° Deadman Angle. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251408497

[357] Rotator Cuff Repair With Knotless Technique Is Quicker and More Cost‐Effective Than Knotted Technique. Arthroscopy, Sports Medicine, and Rehabilitation. 2019. DOI: 10.1016/j.asmr.2019.09.005

[358] 21 Long-term functional outcome following large and massive rotator cuff repair. Journal of Shoulder and Elbow Surgery. 1998. DOI: 10.1016/s1058-2746(98)90081-7

[359] Improvement in sleep disturbance following arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.05.043

[363] Editorial Commentary: Adverse Events After Rotator Cuff Repair Are Not Rare: Houston, We (May) Have a Problem. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2020.10.045

[365] Effect of Biceps Tenodesis on Speed of Recovery After Arthroscopic Rotator Cuff Repairs. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.10.075

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

[381] Long‐Term Outcomes After In Situ Arthroscopic Repair of Partial Rotator Cuff Tears. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.09.026

[382] Prospective analysis of arthroscopic rotator cuff repair: Subgroup analysis. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.11.018

[393] Undersurface rotator cuff repair for partial-thickness tears using the Opus knotless system: a prospective cohort of 1000 consecutive cases with a 1.4% retear rate. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101778