Rotator Cuff

Rotator cuff tears: management of symptomatic full-thickness tears, including conservative thresholds and surgical selection based on tear size and patient demographics.

Overview

Clinical decision-making for rotator cuff tears is complex and lacks consensus among orthopedic surgeons [1]. Neither the American Academy of Orthopaedic Surgeons clinical practice guidelines nor Cochrane systematic reviews provide specific guidance on management [1]. Patients are generally categorized into those needing urgent or early operative repair, those benefiting from a trial of conservative treatment, and those best suited for nonoperative treatment [1]. The American Academy of Orthopaedic Surgeons developed Appropriate Use Criteria using the RAND/UCLA Appropriateness Method to guide treatment decisions for full-thickness tears across 432 patient scenarios [30].

Most rotator cuff tears result from tendon degeneration rather than impingement by the acromion [2]. The amount of trauma required to produce a tear helps determine whether the injury is acute or chronic [2]. Many tears can be successfully managed without surgery [2]. There is only limited evidence that rotator cuff repair is an option for patients with chronic, symptomatic full-thickness tears [2], and only limited evidence that early surgical repair after acute tears is beneficial [2]. Evidence for or against a specific technique (arthroscopic, mini-open, or open repair) for full-thickness tears is inconclusive [2].

Tendon quality and patient characteristics are more dependent on the outcome of cuff surgery than the specific repair method used (single row, double row, TOE, or marginal convergence) [2]. Preponderance of re-tears in chronic degenerative tears result from suture pullout through worn tendon rather than failure at the anchor-bone or suture-anchor interfaces [2]. In patients older than 50 years with degenerative tears, there is no difference in clinical effectiveness or cost-effectiveness between open and arthroscopic repair at 2 years [2]. The rate of re-tear was not significantly different between arthroscopic (46.4%) and open (38.6%) surgery in this population [2]. For patients older than 55 years with degenerative supraspinatus tears, there were no significantly or clinically important differences in Constant score, VAS for pain, or patient satisfaction among physiotherapy only, acromioplasty plus physiotherapy, and arthroscopic rotator cuff repair with acromioplasty and physiotherapy groups at 2 years [2].

Acromioplasty is not a necessary part of surgical management [2]. There is moderate support for the recommendation that routine acromioplasty is not required at the time of rotator cuff repair [2]. Current evidence is lacking to support the routine use of acromioplasty in all cases [117], and it does not improve clinical outcomes of arthroscopic repair [117]. Rates of clinical improvement and anatomically durable repairs have not noticeably improved despite an exponential increase in publications on arthroscopic management methods [2]. The comfort and function of shoulders with failed anatomic repairs are not significantly different from those with successful repair attempts [2]. Arthroscopic repair and physiotherapy were significantly more expensive than physical therapy alone, resulting in less value for arthroscopic repair compared to physical therapy alone in patients older than 55 years [2].

One-year follow-up is not sufficient to determine long-term outcomes of rotator cuff repair; long-term outcomes must be evaluated [6]. The widely accepted 2-year benchmark for rotator cuff repair outcomes may be arbitrary as 1-year follow-up appears clinically sufficient [116]. 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 [17]. Indications for operative treatment of massive and irreparable tears were determined based on expert consensus and the best available evidence [26]. Treatment options for large and massive tears must be based on individual patient indications [31]. Bridging reconstruction performs best for irreparable tears of the superior-posterior rotator cuff with an intact or reparable subscapularis [31].

Proper indications for shoulder subacromial decompression result in excellent outcomes [110]. Differences in complications between open and arthroscopic repair may be influenced by selection bias and narrowing indications for open repair [86]. Critical Shoulder Angle (CSA) and Acromial Index (AI) do not appear to influence 24-month functional outcomes postoperatively and are not contraindications to arthroscopic rotator cuff repair [123]. Higher values for minimal clinically important differences in American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores should be considered when evaluating improvements after rotator cuff repair [124]. It was not possible to reach a definitive conclusion regarding the most relevant predictors of outcome of rotator cuff repair due to low methodological quality of included studies in a systematic review [118].

Anatomy & Pathophysiology

Gross Anatomy

The rotator cuff comprises four muscles arising from the scapula whose tendons blend with the subjacent capsule to attach to the humeral tuberosities [54]. The subscapularis arises from the anterior scapula and attaches to the lesser tuberosity [54]. The supraspinatus arises from the supraspinous fossa, passes beneath the acromion and acromioclavicular joint, and attaches to the superior aspect of the greater tuberosity [54]. The infraspinatus arises from the infraspinous fossa and attaches to the posterolateral aspect of the greater tuberosity [54]. The teres minor arises from the lower lateral scapula and attaches to the lower portion of the greater tuberosity [54].

The supraspinatus is innervated by the suprascapular nerve after it passes through the suprascapular notch [54]. The infraspinatus is innervated by the suprascapular nerve after it passes through the spinoglenoid notch [54]. The teres minor is innervated by a branch of the axillary nerve [54].

The rotator cuff tendons interdigitate significantly near their insertions, with the infraspinatus insertion occupying the preponderance of the greater tuberosity footprint [54]. The supraspinatus footprint measures 13 mm in medial-lateral width and 20 mm in anterior-posterior dimension [58]. The infraspinatus footprint measures 14 mm in width and 20 mm in superoinferior dimension [58]. The rotator cable is a thick bundle of fibers running perpendicular to the supraspinatus tendon fibers, connecting the supraspinatus and infraspinatus tendons [58]. The rotator cable is divided into anterior, middle, and posterior segments, with the anterior segment forming the lateral part of the rotator interval [62].

The long head of the biceps tendon attaches to the supraglenoid tubercle, runs between the subscapularis and supraspinatus tendons, and exits via the bicipital groove under the transverse humeral ligament [54]. The coracohumeral ligament and transverse humeral ligament align the biceps tendon in the groove [54]. The long head of the biceps tendon serves as a passive restraint during shoulder motion and contributes to anterior stability in abduction and external rotation [54]. The bicipital groove mechanism helps guide the humeral head during elevation and constrains rotation when the humerus is maximally abducted [54].

Microscopic Anatomy

Rotator cuff tendons consist of five distinct layers: superficial coracohumeral ligament fibers, large parallel tendon bundles, smaller obliquely oriented tendon fascicles, loose connective tissue with thick collagen bands, and the superior joint capsule [54]. The hypovascular critical zone is located on the articular side of the rotator cuff close to its insertion on the greater tuberosity [58].

Biomechanics and Kinematics

The rotator cuff stabilizes the humeral head in the glenoid during deltoid-mediated arm elevation [11]. The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in functional planes of motion [83]. The rotator interval is central to normal glenohumeral kinematics, and insults to its integrity alter shoulder motion throughout abduction [49].

The superior glenohumeral ligament crosses the rotator interval capsule between the supraspinatus and subscapularis tendons [72]. The coracohumeral ligament originates at the coracoid base, blends into cuff tendons, and inserts into the greater and lesser tuberosities [72]. The superior glenohumeral ligament and coracohumeral ligament come under tension with glenohumeral flexion, extension, external rotation, and adduction to resist posterior and inferior humeral head displacement [72]. The middle glenohumeral ligament originates anterosuperiorly on the glenoid and inserts midway along the anterior humeral articular surface adjacent to the lesser tuberosity [72]. The middle glenohumeral ligament is tensioned by external rotation when the humerus is abducted to 45 degrees [72].

Tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics [52]. Partial-thickness articular-sided rotator cuff tears involving the rotator cable with thickness greater than 50% increase glenohumeral translation and change kinematics [87]. Simulated anterosuperior rotator cuff tears involving the superior half of the subscapularis significantly alter shoulder biomechanics and lead to increased anterosuperior and superior glenohumeral translation under higher loads [77]. Tears of the subscapularis have greater biomechanical consequences than tears of the infraspinatus [71]. Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes [85].

Epidemiology and Natural History

Rotator cuff pathology prevalence increases with age, ranging from 13% in patients in their fifties to 50% in patients aged 80 years or older [33]. One-quarter of patients above 60 years of age and half of patients above 80 years will have a rotator cuff tear [18]. The prevalence of full-thickness rotator cuff tears is estimated to be as high as 30% among the aging population [24]. Full-thickness rotator cuff tear prevalence is 7% to 40%, while partial-thickness tears have a 50% higher prevalence [58]. Bilateral rotator cuff tears are common despite often unilateral symptoms [33].

Known risk factors for rotator cuff tear development include male sex, manual labor, and history of trauma [33]. Additional risk factors include age, smoking, female sex, family history, diabetes, and high cholesterol [58]. Symptoms in previously asymptomatic shoulders may emerge due to tear progression from partial to full thickness, worsening full-thickness tear size, muscle atrophy or fatty infiltration development, or new biceps pathology [33].

Small full-thickness and painful partial-thickness rotator cuff tears become 25% to 50% larger within 3 to 4 years, with larger lesions progressing faster [58]. Asymptomatic partial-thickness rotator cuff tears have an overall prevalence of 20%, increasing to 26% in patients older than 60 years [7]. As many as 53% of partial-thickness rotator cuff tears will progress in tear size, with a portion progressing to full-thickness tears [7]. Tear progression correlates with presenting tear size [8]. Symptoms of pain do not correlate with rotator cuff tear severity in patients with symptomatic atraumatic full-thickness tears [8]. Rotator cuff abnormalities are prevalent in both symptomatic and asymptomatic patients [33].

Pathophysiology of Tears

Most rotator cuff tears result from tendon degeneration rather than impingement by the acromion [2]. 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 [58]. Extrinsic factors include chronic impingement on the coracoacromial arch, with tears typically starting on the bursal side and potentially associated with a hook-shaped acromion [58]. Acute traumatic tears occur after a fall or shoulder dislocation, typically in patients younger than 40 years [58]. The rotator cuff tends to fail at or near the tendon-bone junction [24].

Factors associated with failure of rotator cuff repair include muscle degeneration (fatty infiltration and atrophy), tear size, chronicity, advanced age, and environmental factors [24]. The native fibrocartilaginous insertion to the greater tuberosity is not reconstituted after repair, and chronic tendinopathy impairs biological healing capacity on both the tendon and bone side [24]. The preponderance of re-tears in chronic degenerative tears result from suture pullout through worn tendon rather than failure at the anchor-bone or suture-anchor interfaces [2].

Pathophysiology of Cuff Tear Arthropathy

Cuff tear arthropathy is the final stage of the shoulder impingement syndrome spectrum, affecting patients with long-term insufficient massive rotator cuff tears [80]. Pathogenesis involves mechanical factors (superior migration of the humeral head, instability, eccentric glenoid wear), nutritional factors (hypomobility-induced cartilage atrophy, decreased glycosaminoglycans), and crystalline-induced arthropathy (calcium-phosphate crystal deposition) [80]. Cuff tear arthropathy affects women three times more often than men, typically over age 70, and more commonly on the dominant shoulder [80].

Risk factors include chronic rotator cuff tears, hemorrhagic shoulder conditions (oral anticoagulants, hematologic diseases), rheumatic disease, and crystal-induced arthropathy [80]. Clinical features include chronic shoulder pain, night pain, weakness, stiffness, supraspinatus and infraspinatus atrophy, anterosuperior escape of the humeral head, and subcutaneous effusion [80]. Radiographic findings include acetabularization of the acromion, femoralization of the humeral head, eccentric superior glenoid wear, absence of peripheral osteophytes, osteopenia, subarticular sclerosis (snowcap sign), and loss of the coracoacromial arch [80].

Pathophysiology of Calcific Tendinitis

Calcific tendinitis typically affects patients aged 30 to 60 years and women more commonly than men [107]. The supraspinatus tendon is the most often involved in calcific tendinitis [107]. The pathogenesis involves an active, cell-mediated process with three stages: precalcific, calcific, and postcalcific [107]. The precalcific stage consists of fibrocartilaginous metaplasia in less vascular areas of the tendon [107].

The formative phase of the calcific stage involves matrix vesicles uniting to form calcium hydroxyapatite deposits separated by fibrocollagenous tissue [107]. The resorption phase involves an inflammatory response and is exquisitely painful [107]. Calcific tendinitis is generally self-limited, with most cases resolving spontaneously [107].

Classification

Partial-Thickness Rotator Cuff Tears

Ellman: Classifies partial-thickness tears by depth and proportional thickness. Grade 1 involves ≤3 mm or <25% of tendon thickness, Grade 2 involves 3–6 mm or <50% thickness, and Grade 3 involves >6 mm or >50% thickness [7, 149]. Clinically, these are often categorized as low grade (<50% width) or high grade (>50% width) on MRI [7].

Subscapularis: A novel classification system enables more detailed and reproducible description of partial subscapularis tendon tears [119].

Full-Thickness Rotator Cuff Tears

General: Tears are defined by location (supraspinatus, infraspinatus, teres minor, subscapularis) and size: small (<2 cm), large (2–4 cm), or massive (>5 cm) [149]. Defect area is estimated by multiplying the tear base by maximum retraction [149]. A comprehensive scheme encompassing 97% of tears facilitates anatomic repair [44].

Patte: Assesses extent, sagittal/frontal topography, muscle trophic quality, and long head of biceps status [159]. Segment 1: isolated subscapularis; Segment 2: isolated coracohumeral ligament; Segment 3: isolated supraspinatus; Segment 4: entire supraspinatus + half infraspinatus; Segment 5: supraspinatus + infraspinatus; Segment 6: total-cuff (subscapularis, supraspinatus, infraspinatus) [159]. A modified system for tendon retraction shows excellent reliability for reparability and acceptable reliability for healing [93].

Goutallier: Grades fatty infiltration: Grade 0 (normal), Grade 1 (fatty streaks), Grade 2 (more muscle than fat), Grade 3 (equal muscle/fat), Grade 4 (more fat than muscle) [10]. Grades 3 and 4 indicate chronic tears with higher surgical failure potential [10]. Specifically, Goutallier stages III/IV with a tendinous stump <15 mm and positive tangential sign carry a 90% failure rate [10].

Hamada: Predicts appropriate care and outcomes in massive rotator cuff pathology [97].

Biceps Instability: A new arthroscopic classification describes anterior/posterior instability of the long head of the biceps tendon, linking instability to LHB lesions and rotator cuff tear size [109].

Imaging and Measurement Classifications

MR Assessment: Twenty-six criteria exist for post-repair MR assessment [42]. Geometric classification and 2D measurement via MR arthrography demonstrate good-to-excellent intraobserver and moderate-to-good interobserver agreement among experienced observers [90]. Stump classification reflects degeneration and fragility at the torn site [127].

Reliability and Agreement

Current classification systems exhibit little interobserver agreement among experienced surgeons, except for distinguishing partial- from full-thickness tears and identifying articular vs. bursal involvement in partial tears [69]. The ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for surgeon communication and clinical data pooling [76].

Other Morphological Classifications

Acromion: Acromial morphology classification is unreliable for acromion assessment, and the acromial index shows no association with rotator cuff disease presence [13].

Coracoid: A system divides coracoids by morphology and relative risk of associated subscapularis tears [74].

Clinical Presentation

Rotator cuff syndrome, comprising supraspinatus impingement and tendinitis, tears, acute calcific tendinitis, and biceps pathology, represents the commonest cause of shoulder pain [11]. Pain typically localizes to the front and lateral shoulder in rotator cuff disorders, whereas biceps pathology pain is anterior [11]. Chronic disease often presents with insidious lateral or anterior pain associated with overhead activities and occasional night pain that may awaken the patient [104]. A family or personal history of rotator cuff disease increases diagnostic likelihood [104]. Subacromial bursitis and rotator cuff tendinosis are characterized by mild-to-moderate pain with overhead motion, occasional night pain, and a history of repetitive overhead activity [25].

Acute full-thickness tears may follow trauma with sudden pain and inability to abduct, or occur spontaneously after sprain [134]. Over time, active abduction may partially recover, though power in abduction and external rotation remains weak [134]. Wasting of the supraspinatus and infraspinatus may occur, and tenderness of the acromioclavicular joint is common in long-standing tears [134]. Secondary osteoarthritis may supervene in chronic ruptures, severely restricting movement [134]. Patients with advanced disorder, refractory pain, stiffness, and weakness are usually aged over 45 [134]. Partial tears permit active abduction with a painful arc and may occur within the substance or deep surface of the cuff [134]. Subscapularis pathology presents as isolated, partial, or complete avulsion tears [63].

Asymptomatic tears are associated with clinically insignificant functional loss compared to intact cuffs [55]. Patient self-assessed comfort, function, and active motion do not correlate closely with surgically documented tear integrity [61]. Pain and symptom duration do not correlate with tear severity in multicenter cohorts or atraumatic full-thickness tears [36, 14]. Subjective mechanical symptoms are a common complaint in suspected pathology [45]. Delay in care for female patients includes later presentation, imaging, and surgical offering [12].

The most advanced stage involves progressive fibrosis and disruption resulting in partial or full-thickness tears [134]. Manual muscle testing shows mild weakness in subacromial bursitis and tendinosis, with no atrophy present [25]. Pain relief with subacromial lidocaine injection supports these diagnoses [25]. The Neer impingement sign involves discomfort during forward flexion of the internally rotated shoulder [25]. Strength and range of motion dramatically improve after subacromial lidocaine injection in these conditions [25].

Clinical tests for rotator cuff tears include: Empty can test: Sensitivity 71.7%, specificity 64.6% for full-thickness supraspinatus tears [104]. Lift-off and belly-press tests: High specificity but low sensitivity for full-thickness subscapularis tears [104]. External rotation lag sign: Sensitivity 47%, specificity 94% for full-thickness tears; indicates large posterosuperior infraspinatus tears [104]. Hornblower sign: Suggests massive posterosuperior tear prohibiting active hand positioning [104]. Internal rotation lag sign: Sensitivity 97%, specificity 83% for full-thickness tears [104]. Drop arm test: Sensitivity 24%, specificity 93% for rotator cuff disease [104]. Dropping sign: Sensitivity 73%, specificity 77% for full-thickness tears [104]. Gerber (lift-off) test: Sensitivity 34-68%, specificity 50-77% for rotator cuff disease [104]. Painful arc test: Sensitivity 71%, specificity 81% for rotator cuff disease [104]. Cross-body adduction test: Sensitivity 75%, specificity 61% for rotator cuff disease [104]. Hawkins test: Sensitivity 76%, specificity 48% for rotator cuff disease [104]. Neer test: Sensitivity 64-68%, specificity 30-61% for rotator cuff disease [104]. Yocum test: Sensitivity 79%, specificity 40% for rotator cuff disease [104]. Passive abduction: Sensitivity 74%, specificity 10% for rotator cuff disease [104]. External rotation resistance: Sensitivity 63%, specificity 75% for rotator cuff disease [104]. Full can test: Sensitivity 75%, specificity 68% for rotator cuff disease [104]. Patte test: Sensitivity 58%, specificity 60% for rotator cuff disease [104]. Resisted abduction: Sensitivity 58%, specificity 20% for rotator cuff disease [104]. Positive Hawkins and Neer combined: Sensitivity 78%, specificity 50% for rotator cuff disease [104].

Individual tests have moderate diagnostic value [46]. No single test is sufficiently reliable to diagnose posterosuperior tears [48], and no test in isolation is sufficient to diagnose damage [67]. Combining maneuvers increases diagnostic specificity [131]. The Jobe or empty can test isolates the supraspinatus with resistance at 90° abduction, 30° flexion in the scapular plane, thumb down [131]. External rotation strength tests the infraspinatus with arm adducted and elbow at 90° flexion [131]. Lift-off and belly press assess the subscapularis [131]. External rotation lag and hornblower signs assess massive infraspinatus and teres minor failure [131]. The drop arm test examines superior cuff failure [131]. The posterior sentinel sign of the biceps tendon is an arthroscopic indicator of supraspinatus tears, prompting search for occult anterosuperior tears [64].

Ultrasonography: Approaches MRI sensitivity and specificity for full-thickness tears with experienced practitioners; relatively inexpensive, allows dynamic testing, guided injections, and immediate feedback [104]. More accurate for full-thickness tears and comparable to MRI [22]. Diagnostic performance exists for fatty degeneration [23]. MRI: Accurately assesses muscle, bone, and cartilage for surgical planning; remains the imaging modality of choice for most providers [104].

Imaging plays an important role in workup [15]. Clinically significant disagreements in MRI parameters indicate a need for improved tools [16]. The acromial morphology classification system is unreliable for assessing the acromion [13]. The acromial index shows no association with rotator cuff disease presence [13]. The critical shoulder angle (CSA) is higher in patients with tears but is a static measure [12]. Patients with CSA >38° and AI >0.7 had higher retear rates but similar functional rates compared to controls [11]. CSA and AI do not influence 24-month functional outcomes after arthroscopic repair [13]. The tangent sign predicts tear repairability [21].

Investigations

Plain radiography: Radiography helps discriminate between traumatic and nontraumatic rotator cuff lesions [126]. Views of the subacromial space, such as the supraspinatus outlet view, may demonstrate an acromial undersurface spur causing subacromial space narrowing [25]. Classic changes include acromial or coracoacromial ligament spurring and calcification, along with cystic changes in the greater tuberosity [112]. Chronic disease presents with superior humeral head migration and extensive degenerative change [112]. An acromiohumeral distance <7 mm on AP radiograph indicates a higher likelihood of irreparable tears [112].

MRI: MRI is the test of choice for rotator cuff pathology due to its versatility and availability [148]. It is generally superior to ultrasound for evaluating rotator cuff pathology [148] and defines tear extent, retraction degree, and muscular atrophy [112]. MRI characterizes location, size, retraction amount, atrophy degree, and fatty infiltration [10]. The Goutallier classification grades fatty infiltration: grade 0 is normal; grade 1 has fatty streaks; grade 2 has more muscle than fat; grade 3 has equal muscle and fat; grade 4 has more fat than muscle [10]. Grades 3 and 4 indicate long-term chronic tears with higher surgical failure potential [10]. The tangent sign—failure of the supraspinatus muscle belly to cross a line from the coracoid superior border to the scapular spine superior border—correlates with supraspinatus atrophy and fatty infiltration [112]. A positive tangent sign predicts irreparability and poor repairability [112, 21]. MRI sensitivity for subscapularis tears correlates with tear size, unlike physical examination [153]. Systematic interpretation improves subscapularis tear diagnosis accuracy [143]. Post-repair, immediate fatty infiltration and atrophy changes establish new time-zero traits [151]. Successful arthroscopic repair yields an 11.3%-13.9% increase in supraspinatus muscle volume at final follow-up [160]. Cuff integrity on follow-up MRI positively affects clinical outcome [157]. Caution is required interpreting MRI soon after corticosteroid injection, as appearance may mimic a tear [146].

Magnetic Resonance Arthrography (MRA): MRA is sensitive and specific for full-thickness tears [152]. A full-thickness tear shows fiber discontinuity spanning the entire tendon thickness, with fluid signal on T2 or gadolinium on T1 sequences filling the defect [152]. MRA is more sensitive for partial-thickness, particularly articular-sided tears, which fill with contrast when the arm is in the ABER position [152]. MRA improves differentiation of degeneration from partial or complete tears [155]. However, MRA is insufficiently accurate for diagnosing biceps lesions prior to rotator cuff repair [150].

Ultrasound: Ultrasonography is more accurate for full-thickness tears and comparable to MRI [22]. It is increasingly popular for diagnosing rotator cuff disease and confirming intraarticular or subacromial injection location [112]. Ultrasound can detect unrecognized partial subscapularis tendon injuries after MRI [148]. Real-time sonoelastography assesses stiffness in tendinopathy, associated with MRI tendinosis grade [158]. Challenges exist in postoperative assessment [154]. Clinically significant disagreements in MRI parameters highlight the need for improved imaging tools [16].

Other Considerations: Symptoms of pain do not correlate with tear severity [11]. Patient-reported outcomes and pain are not correlated with healing on ultrasound or MRI [32]. Preoperative partial cuff tears on MRI do not significantly affect medium-term function after anatomic total shoulder replacement [144]. MRI before conservative management for atraumatic pain with minimal strength deficits and suspected tendinopathy (excluding full-thickness tears) provides negative value [37]. The incidence of tears in calcific tendonitis is higher than previously reported based on MRI [156]. Integration of 3D imaging and volumetric analysis offers novel advancement, challenging conventional 2D MRI reliance [142].

Treatment

Nonoperative Management

Nonoperative treatment is an effective and lasting option for many patients with chronic, full-thickness rotator cuff tears [95] and has been shown to be efficacious for patients with chronic, massive, irreparable tears [108]. Conservative management typically consists of 6 to 12 weeks of rest/activity modification, symptom management often with NSAIDs, and physical therapy [121]. Physical therapy with a home exercise regimen focuses on passive and active range of motion plus strengthening of scapular stabilizing muscles and of the rotator cuff itself [121]. Surgeons may use occasional subacromial injections for the painful shoulder, but should consider the effects on tissue quality and infection risk attributed to steroid injections associated with rotator cuff repair, especially when given preoperatively within 1 month of surgery and up to 3 months postoperatively [121]. Bursal injection can be accomplished through anterior, lateral, or posterior routes, with the anterior and lateral access points possibly demonstrating increased accuracy [121]. In a study of 452 patients with asymptomatic full-thickness rotator cuff tears initially treated nonsurgically, 75% did not require surgery at 2-year follow-up [121]. Patient expectations about physical therapy’s treatment ability were more important than tear structural factors regarding therapy success versus conversion to surgery [121].

For partial-thickness tears, risk factors for conservative management failure include bursal-sided tears, tears in the dominant upper extremity, and tears involving greater than 50% of the tendon thickness [121]. Most partial-thickness rotator cuff tears are best initially managed with nonoperative treatment [7]. Non-surgical treatment is recommended as the preferred approach for patients with non-traumatic rotator cuff injuries [133]. Nonoperative treatment remains a viable option for certain patients with traumatic rotator cuff tears, although results demonstrate a considerable early failure rate [138]. The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients [37].

Operative Indications and Decision Making

Clinical decision-making for the management of rotator cuff tears is complex and lacks consensus among orthopedic surgeons [1]. The AAOS current evidence-based guidelines for rotator cuff surgery are in a state of uncertainty, with only limited evidence that “rotator cuff repair is an option for patients with chronic, symptomatic full-thickness tears” and only limited evidence that “early surgical repair after acute rotator cuff tear” [2]. There is inconclusive evidence for or against a specific technique (arthroscopic, mini-open, or open repair) when surgery is indicated for full-thickness rotator cuff tears [2]. The only recommendation with moderate support in AAOS guidelines is that “routine acromioplasty is not required at the time of rotator cuff repair” [2]. The AAOS developed Appropriate Use Criteria (AUC) using the RAND/UCLA Appropriateness Method to guide treatment decisions for full-thickness rotator cuff tears by synthesizing evidence and expert opinion across 432 patient scenarios [30]. Treatment options for large and massive rotator cuff tears must be based on individual patient indications [31].

Surgical repair provides significantly better long-term outcomes and a higher probability of substantial improvement for symptomatic rotator cuff tears compared to nonoperative treatment, supporting its use in shared decision-making [139]. While nonoperative treatment may yield better short-term outcomes, surgical repair provides significantly better long-term outcomes [139]. A Norwegian randomized controlled trial comparing physical therapy with immediate repair for small- to medium-sized tears (<3 cm) confirmed that the surgery group had better Constant and American Shoulder and Elbow Surgeons scores that were statistically significant but likely not clinically significant at 5-year follow-up, with a greater clinical difference noted at 10-year follow-up [121]. Of note in the Norwegian trial, a third of the nonsurgically treated patients had poor outcomes with an associated tear size increase of >5 mm [121]. 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 [17]. Surgical treatment with either rotator cuff repair or debridement is indicated for partial-thickness rotator cuff tears in whom nonoperative treatment fails [7].

Surgical Techniques and Approaches

The current standard of care for rotator cuff repair is arthroscopic repair [24]. Arthroscopic repair has been shown to have similar outcomes and failure rates to open or mini-open repair, with decreased short-term pain and more rapid return to activity [24]. There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears [73]. Historically, transosseous tunnels were used in open rotator cuff repair, with sutures placed and tied through bone tunnels from the cuff footprint to the lateral aspect of the tuberosity [24]. Arthroscopically, repair is performed with suture anchors in various configurations—single-row, double-row, and transosseous-equivalent repair technique [24]. 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 [24].

For partial-thickness tears involving more than 50% of tendon width, repair is best treated with repair, while those involving less than 50% are best treated with debridement and potential decompression [7]. The decision for in situ rotator cuff repair or completion to a full-thickness rotator cuff tear with subsequent repair depends on the proportion and quality of the intact tendon [7]. For tears with poor-quality tendon remaining and involving more than 80% of tendon thickness, debridement is favored [7]. Delamination-type tears of the articular side should be recognized, and if delamination is present, a transtendinous repair is indicated [7]. 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 [7]. The tear can be opened using an arthroscopic knife and the edge debrided back slightly to promote local healing, as extensive debridement is unnecessary [7]. Intratendinous tears are repaired side-to-side using arthroscopic technique [7]. At a minimum of 2-year follow-up, there was no difference between treatment groups in a randomized control trial of 74 patients with PASTA tears treated with transtendon repair or completion and repair [21]. Arthroscopic rotator cuff repair is safe and effective for partial-thickness rotator cuff tears, showing postoperative improvement in shoulder function and patient quality of life [96].

Management of Massive and Irreparable Tears

Failure rates for large-to-massive rotator cuff tears remain high despite advances in surgical options and rehabilitation [100]. Bridging reconstruction performs best for irreparable tears of the superior-posterior rotator cuff with an intact or reparable subscapularis [31]. Tuberoplasty for the treatment of massive irreparable rotator cuff tears results in good clinical outcomes with significant pain relief in select populations [105]. Salvage surgeries including subscapularis release (SCR), tendon transfers, and reverse total shoulder arthroplasty (RTSA) have a role and should be considered on a case-by-case basis for irreparable cuff tears [120]. Reverse shoulder arthroplasty is indicated for cuff tear arthropathy [115]. Total shoulder arthroplasty is contraindicated in cuff tear arthropathy due to the risk of glenoid failure [115].

Outcomes and Prognostic Factors

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 [4]. Arthroscopic rotator cuff treatment appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time [75]. Rotator cuff repair in patients aged >75 years could achieve high clinical success rates with good outcomes and pain relief [94]. The rate of re-tear was not significantly different across randomized groups (46.4% for arthroscopic and 38.6% for open surgery) in a recent level I randomized controlled trial of degenerative supraspinatus rotator cuff tears in patients older than 55 years [2]. In the same level I trial, there were no significantly or clinically important differences in the Constant score, the VAS for pain, or patient satisfaction among physiotherapy only, acromioplasty plus physiotherapy, and arthroscopic rotator cuff repair groups at 2 years [2]. Because arthroscopic repair and physiotherapy were significantly more expensive than physical therapy alone, the value (clinical benefit/cost) of arthroscopic repair was less than physical therapy alone in the level I trial [2]. The comfort and function of shoulders with failure of the anatomic repair have results that are not significantly different from those in which the repair attempt was successful [2].

Mental health has a stronger association with patient-reported shoulder pain and function than tear size in patients with full-thickness rotator cuff tears [79]. Symptoms of pain do not correlate with rotator cuff tear severity in patients with a symptomatic atraumatic full-thickness rotator cuff tear [11]. Patient-reported outcomes and pain are not correlated with rotator cuff healing on ultrasonography or MRI [32]. Postoperative strength is better in individuals with healed rotator cuffs versus those with defects after repair [32]. Factors known to be associated with failure of rotator cuff repair include muscle degeneration (fatty infiltration and atrophy), tear size, chronicity, advanced age, and other environmental factors [24]. The effect of comorbidity on self-assessed function in patients with a chronic rotator cuff tear may ultimately influence the evaluation of the results of surgical treatment [103]. Patients undergoing rotator cuff repair had fewer comorbidities than those undergoing nonoperative treatments [130]. The preponderance of re-tears are from suture pullout through worn tendon, particularly in chronic degenerative tears where the tendon quality is weak [2]. The outcome of cuff surgery is much more dependent on the quality of the cuff tissue and the characteristics of the patient than whether the method used in the repair attempt is a single row, double row, TOE, or marginal convergence [2].

Other Considerations

Concomitant surgical treatment of nonmassive rotator cuff tears with moderate shoulder stiffness in a single stage may have comparable results to the surgical treatment of isolated rotator cuff tears [141]. Patients receiving single-stage or staged bilateral arthroscopic rotator cuff repair showed similarly good clinical outcomes at follow-ups longer than 6 months [99].

Complications

General Outcomes: Rotator cuff repair is associated with a low incidence of short-term complications [50], which are considered rare [56]. The overall survivorship of open rotator cuff surgery is 94% at 5 years and 83% at 10 years [23].

Re-tear and Failure: Re-tear rates are reported to be approximately 20%, increasing for larger tears [161]. In a randomized trial of patients older than 50 years, the re-tear rate was 46.4% for arthroscopic surgery and 38.6% for open surgery [2]. Most repair failures occur within the first 3 months post-surgery [29]. Specific high-risk morphological features—Goutallier stages III and IV tears accompanied by a tendinous stump of less than 15 mm and a positive tangential sign—carry a 90% failure rate [10].

Risk Factors for Failure: Factors associated with repair failure include larger tears, greater retraction, advanced Goutallier grade, older age, smoking status, osteoporosis, diabetes mellitus, hypercholesterolemia, and more aggressive rehabilitation protocols [10]. A family history of rotator cuff tearing correlates with higher likelihood of repair failure [128]. Additionally, steroid injections performed within 6 months of the index procedure are correlated with a greater likelihood of requiring revision surgery [147].

Nonoperative Management Risks: Nonoperative treatment carries a tear progression risk of approximately 50% at 2 years [10]. For full-thickness degenerative cuff tears, tear progression ranges from 30% to 40% at 3- to 4-year follow-up [145].

Recovery

Light activity (weeks): Evidence does not specify a precise week range for light activity or driving. However, most rotator cuff repair failures occur within the first 3 months after surgery, suggesting that relatively short follow-up is sufficient for evaluating primary structural integrity [29].

Full activity (months): One-year follow-up is not sufficient to determine rotator cuff repair long-term outcomes; long-term outcomes must be evaluated [6]. All intact rotator cuff tendons at 1 year remained intact at 2 years [162]. Overall survivorship was 94% at 5 years after open rotator cuff surgery and 83% at 10 years [23].

Complete recovery / outcome plateau (months): At long-term follow-up (≥15 years), patient-reported outcomes of all-arthroscopic rotator cuff repair show significant improvement from baseline preoperative function and remain durable [4]. Long-term outcomes from primary tendon repair remained superior to physiotherapy up to 15 years of follow-up for small-to-medium-sized rotator cuff tears [98].

Rehabilitation protocol: The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term [28]. Surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease, with patients demonstrating clinically relevant differences in pain and functional outcomes compared to nonoperative treatment [34]. Nonoperative treatment of full-thickness rotator cuff tears is effective in 75% of patients after 2 years [36]. A patient’s perception of whether physical therapy would be beneficial was a strong predictor of whether conservative treatment would be successful [36].

Functional milestones: Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome [106]. 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 [92]. There was no evidence of progression of intrinsic rotator cuff pathologic conditions at a mean follow-up of 4.5 years for partial-thickness tears treated with acromioplasty without repair [39]. Short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair [19, 21]. At short-term follow-up, subacromial decompression did not significantly affect the outcome of arthroscopic rotator cuff repair [27].

Key Evidence

• [Paper] This issue reinforces the concept that rotator cuff disease is a continuum and brings readers up to date on rotator cuff disease, covering epidemiology, imaging, techniques, and outcomes. (10.1016/j.csm.2012.08.001)
• [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. (10.1016/j.jse.2022.01.116)
• [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. (10.1016/j.arthro.2024.12.040)
• [L2] Delay in care in female patients with rotator cuff pathology is multifaceted, including delay in presentation to any provider and to orthopedics, later diagnostic imaging, and later offering of surgery. (10.1016/j.jse.2025.06.008)
• [L3] The acromial morphology classification system is an unreliable method to assess the acromion, and the acromial index shows no association with the presence of rotator cuff disease. (10.1016/j.jse.2011.09.028)
• [L3] There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease. (10.1016/j.jse.2013.10.001)
• [Paper] Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality. (10.1016/j.csm.2012.07.010)
• [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. (10.1016/j.jse.2021.04.021)
• [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. (10.5435/00124635-201111000-00002)
• [L3] The short term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair. (10.1177/2325967114s00016)
• [L3] Short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair. (10.1016/j.jse.2015.05.015)
• [L4] Overall survivorship was 94% at 5 years after open rotator cuff surgery and 83% at 10 years. (10.1016/j.jse.2010.11.019)
• [L5] The indications for the operative treatment of massive and irreparable rotator cuff tears were determined based on expert consensus and the best available evidence, seeking to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios. (10.1016/j.jisako.2024.01.001)
• [L1] At short-term follow-up, subacromial decompression did not seem to significantly affect the outcome of arthroscopic rotator cuff repair. (10.1016/j.arthro.2006.10.011)
• [L1] The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. (10.1302/0301-620x.99b6.bjj-2016-0569.r1)
• [L5] Most rotator cuff repair failures occur within the first 3 months after surgery, suggesting that relatively short follow-up is sufficient for evaluating primary structural integrity, though longer follow-up is beneficial for assessing symptomatic improvement. (10.1177/0363546511424268)
• [L5] The AAOS developed Appropriate Use Criteria (AUC) using the RAND/UCLA Appropriateness Method to guide treatment decisions for full-thickness rotator cuff tears by synthesizing evidence and expert opinion across 432 patient scenarios. (10.5435/00124635-201312000-00008)
• [L5] Treatment options for large and massive rotator cuff tears must be based on individual patient indications, with bridging reconstruction performing best for irreparable tears of the superior-posterior rotator cuff with an intact or reparable subscapularis. (10.1016/j.arthro.2024.08.034)
• [L2] Surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease, with patients demonstrating clinically relevant differences in pain and functional outcomes compared to nonoperative treatment. (10.1016/j.jse.2024.05.056)
• [L4] The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients, at both the individual and population level. (10.1016/j.jse.2019.04.003)
• [L4] There was no evidence of progression of intrinsic rotator cuff pathologic conditions at a mean follow-up of 4.5 years. (10.1177/03635465020300021801)
• [L4] Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. (10.1007/s00167-014-3486-3)
• [L4] A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair. (10.1016/j.arthro.2007.05.002)
• [L2] Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. (10.1016/j.jse.2024.02.024)
• [L1] Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. (10.1186/s13018-014-0070-y)
• [L2] As no single clinical test is sufficiently reliable to diagnose posterosuperior rotator cuff tears, clinicians should consider various combinations of patient characteristics and clinical tests, as well as imaging modalities, to confirm diagnosis and select the appropriate treatment option. (10.1007/s00167-020-06136-9)
• [L5] The rotator interval is central to normal glenohumeral kinematics, and any insult to its integrity alters shoulder motion throughout abduction. (10.1186/s12891-016-0898-x)
• [L4] Rotator cuff repair has a low incidence of short-term complications. (10.1016/j.arthro.2017.10.040)
• [L5] In this cadaveric shoulder model of the throwing shoulder, tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics. (10.1177/2325967117s00373)
• [L2] When asymptomatic, a rotator cuff tear is associated with a clinically insignificant loss of shoulder function compared with an intact rotator cuff. (10.1016/j.jse.2010.07.017)
• [L3] Short-term complications after rotator cuff repair are rare. (10.1016/j.arthro.2017.10.027)
• [L3] Management of patients with rotator cuff disorders needs to be informed by a better understanding of factors other than cuff integrity that influence comfort and functioning. (10.1016/j.jse.2017.05.011)
• [L5] Subscapularis tendon pathology is infrequently identified but can present as isolated tears, partial-thickness tears, or complete rotator cuff avulsion. (10.5435/00124635-200509000-00009)
• [L2] The presence of a sentinel sign should prompt the clinician to search for occult anterosuperior rotator cuff tears. (10.1016/j.jisako.2026.101065)
• [L1] No test in isolation is sufficient to diagnose a patient with rotator cuff damage. (10.1177/0363546514538390)
• [L2] With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. (10.1177/0363546506298108)
• [L5] Tears of the subscapularis have greater biomechanical consequences than do tears of the infraspinatus. (10.1016/j.arthro.2009.09.007)
• [L1] There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. (10.1302/0301-620x.99b1.bjj-2016-0424.r1)
• [L3] This study was the first to create a classification system to divide coracoids according to their morphology and relative risk of associated subscapularis tears. (10.1016/j.jse.2020.01.074)
• [L4] ARCR appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time. (10.1007/s00167-014-3234-8)
• [L2] The ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communicating among surgeons and for pooling of data from clinical studies. (10.1016/j.jisako.2021.12.004)
• [L5] Simulated anterosuperior rotator cuff tears involving the superior half of the subscapularis significantly alter shoulder biomechanics and lead to increased anterosuperior and superior glenohumeral translation under higher loads. (10.1016/j.arthro.2008.10.005)
• [L2] Further studies are needed to determine its effect on the outcome of the treatment of rotator cuff disease. (10.2106/jbjs.o.00444)
• [L4] The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in the functional planes of motion. (10.2106/00004623-198668030-00013)
• [L3] Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes. (10.1016/j.jse.2025.03.038)
• [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. (10.1016/j.arthro.2017.11.026)
• [L5] Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increased glenohumeral translation and changed kinematics in our cadaveric biomechanical model. (10.1016/j.jse.2016.12.063)
• [L3] The geometric classification and the 2-dimensional measurement of rotator cuff tears using MR arthrography have good to excellent intraobserver agreement and moderate to good interobserver agreement among experienced observers. (10.1016/j.arthro.2012.04.054)
• [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. (10.1016/j.arthro.2018.09.026)
• [L3] Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. (10.1002/ksa.12162)
• [L4] Rotator cuff repair in patients aged >75 years could achieve high clinical success rates with good outcomes and pain relief. (10.3389/fpubh.2022.1060700)
• [L2] Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. (10.1016/j.jse.2017.10.009)
• [L2] Arthroscopic rotator cuff repair is safe and effective for partial-thickness rotator cuff tears, showing postoperative improvement in shoulder function and patient quality of life. (10.1186/s13018-025-06643-w)
• [L5] Early surgical intervention can reliably treat significant shoulder impairment in acute traumatic tears, and understanding the Hamada classification helps predict appropriate care and outcomes in patients with massive rotator cuff pathology. (10.1016/j.arthro.2018.11.006)
• [L1] Long-term outcomes from primary tendon repair remained superior to physiotherapy up to 15 years of follow-up, supporting its use as the primary treatment for small-to-medium-sized rotator cuff tears. (10.2106/jbjs.24.00065)
• [L3] Patients receiving single-stage or staged bilateral arthroscopic rotator cuff repair showed similarly good clinical outcomes at follow-ups longer than 6 months. (10.1186/s12891-021-04304-7)
• [L5] Despite advances in surgical options and rehabilitation, failure rates for large-to-massive rotator cuff tears remain high. (10.2106/jbjs.20.00177)
• [L1] This effect may ultimately influence the evaluation of the results of surgical treatment of rotator cuff tears and should be considered when treating patients and analyzing outcomes. (10.2106/00004623-200402000-00020)
• [L1] Tuberoplasty for the treatment of massive irreparable rotator cuff tears results in good clinical outcomes with significant pain relief in select populations. (10.1016/j.arthro.2023.11.032)
• [L3] Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. (10.2106/00004623-199907000-00012)
• [L1] Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. (10.1016/j.jse.2020.11.002)
• [L4] LHB instability was associated with LHB lesions and rotator cuff tear size, leading to the creation of a new arthroscopic classification. (10.1016/j.arthro.2006.08.025)
• [L5] Proper indications for shoulder subacromial decompression result in excellent outcomes. (10.1016/j.arthro.2021.04.023)
• [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. (10.1016/j.arthro.2023.11.002)
• [Commentary] Current evidence is lacking to support routine use of acromioplasty in all cases of rotator cuff repair; the acromioplasty does not improve clinical outcomes of arthroscopic rotator cuff repair. (10.1016/j.arthro.2021.07.012)
• [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. (10.1007/s00167-015-3700-y)
• [L3] The study presents a novel classification for partial subscapularis tendon tears to enable more detailed and reproducible description. (10.1007/s00167-020-05989-4)
• [L3] CSA and AI do not appear to influence 24-month functional outcomes postoperatively and hence are not contraindications to arthroscopic rotator cuff repair. (10.1177/0363546517717947)
• [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. (10.1016/j.jse.2019.11.018)
• [L2] MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions. (10.1016/j.jse.2015.06.005)
• [L4] Imaging based on stump classification reflects the degeneration and fragility of the torn rotator cuff site. (10.1177/03635465221090649)
• [L2] Individuals with a family history of rotator cuff tearing were more likely to have repair failures. (10.1016/j.jse.2016.02.019)
• [L4] Patients undergoing rotator cuff repair had fewer comorbidities than those undergoing nonoperative treatments. (10.1016/j.jse.2016.05.001)
• [L3] Additionally, non-surgical treatment is recommended as the preferred approach for patients with non-traumatic rotator cuff injuries. (10.1186/s13018-024-04858-x)
• [L4] Nonoperative treatment remains a viable option for certain patients with traumatic rotator cuff tears; however, the results of our study demonstrate a considerable early failure rate. (10.1016/j.jse.2023.11.012)
• [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. (10.2106/jbjs.20.00400)
• [L2] Concomitant surgical treatment of nonmassive rotator cuff tears with moderate shoulder stiffness in a single stage may have comparable results to the surgical treatment of isolated rotator cuff tears. (10.1016/j.jse.2017.03.005)
• [L4] The integration of 3D imaging and volumetric analysis offers novel advancement in diagnosing and classifying rotator cuff injuries, challenging the conventional reliance on 2D MRI. (10.1016/j.jse.2024.08.030)
• [L3] Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with the described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies. (10.1016/j.arthro.2012.04.142)
• [L4] The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term. (10.1016/j.jse.2020.07.037)
• [Commentary] The article is a commentary on a systematic review, concluding that while tear progression for full-thickness degenerative cuff tears ranges from 30% to 40% at 3- to 4-year follow-up, further research is needed to define natural history in relation to tear size and location to refine surgical intervention. (10.1016/j.arthro.2018.09.010)
• [L4] One should use caution in the interpretation of magnetic resonance imaging scans of the shoulder soon after the injection of corticosteroids. (10.1016/j.arthro.2007.01.024)
• [L5] The historical treatment paradigm of steroid injections for painful rotator cuff conditions warrants reconsideration as they are correlated with a greater likelihood of revision rotator cuff surgery when performed within 6 months of the index surgical procedure. (10.1016/j.arthro.2018.12.017)
• [L5] In the author's practice, MRI is the test of choice for rotator cuff pathology due to its versatility and availability, though ultrasound can be performed if an unrecognized partial subscapularis tendon injury is suspected after MRI. (10.1016/j.arthro.2021.08.029)
• [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. (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. (10.1016/j.arthro.2012.10.006)
• [L3] The diagnostic sensitivity of MRI is associated with subscapularis tear size, whereas physical examination is independent of tear size. (10.1016/j.arthro.2015.11.019)
• [L5] Challenges exist for both ultrasound and MR imaging in the assessment of the postoperative rotator cuff. (10.1016/j.jse.2007.02.114)
• [L2] Magnetic resonance arthrography can improve the differentiation of rotator cuff degeneration from partial or complete rotator cuff tears. (10.2106/jbjs.e.00509)
• [L4] The incidence of rotator cuff tears in cases of calcific tendonitis in this cohort of patients who underwent MRI is higher than previously reported. (10.1016/j.arthro.2019.11.127)
• [L4] Cuff integrity on follow-up MRI scans had a positive effect on the clinical outcome. (10.1016/j.jse.2018.09.003)
• [L3] The MRI tendinosis grade is associated with stiffness assessed using sonoelastography in patients with rotator cuff tendinopathy. (10.1016/j.jse.2015.10.019)
• [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. (10.1177/0363546515625211)
• [L3] All intact rotator cuff tendons at 1 year remained intact at 2 years. (10.1177/0363546509335764)

See Also

• Rotator Cuff Repair
• Revision rotator cuff repair
• Subacromial Decompression
• Cuff Pathology
• Calcific Tendinitis
• Rotator Cuff Disorders
• Total shoulder arthroplasty
• Reverse Shoulder Arthroplasty
• Arthroscopic Surgery

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[34] Does surgical intervention alter the natural history of degenerative rotator cuff tears? Comparative analysis from a prospective longitudinal study. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.05.056

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

[37] A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.04.003

[39] The Partial-Thickness Rotator Cuff Tear: Is Acromioplasty without Repair Sufficient?. The American Journal of Sports Medicine. 2002. DOI: 10.1177/03635465020300021801

[42] Magnetic resonance imaging criteria for the assessment of the rotator cuff after repair: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-014-3486-3

[44] Frequency of Various Tear Patterns in Full‐Thickness Tears of the Rotator Cuff. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.05.002

[45] The significance of subjective mechanical symptoms in rotator cuff pathology. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.02.024

[46] The diagnostic value of the combination of patient characteristics, history, and clinical shoulder tests for the diagnosis of rotator cuff tear. Journal of Orthopaedic Surgery and Research. 2014. DOI: 10.1186/s13018-014-0070-y

[48] Reliable diagnosis of posterosuperior rotator cuff tears requires a combination of clinical tests. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06136-9

[49] The effect of the rotator interval on glenohumeral kinematics during abduction. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0898-x

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

[52] The Effects of Posterior Rotator Cuff Cable Tears on Glenohumeral Biomechanics in a Cadaveric Model of the Throwing Shoulder. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00373

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[55] Asymptomatic rotator cuff tears: Patient demographics and baseline shoulder function. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.07.017

[56] Comparison of Short‐term Complications After Rotator Cuff Repair: Open Versus Arthroscopic. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2017.10.027

[58] Aaos Comprehensive Orthopaedic Review 3. Rotator Cuff Tears and Cuff Tear Arthropathy > I. Rotator Cuff Tears.

[61] Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.05.011

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[63] Subscapularis Tendon Tears. Journal of the American Academy of Orthopaedic Surgeons. 2005. DOI: 10.5435/00124635-200509000-00009

[64] Posterior sentinel sign of the biceps tendon as an arthroscopic indicator of supraspinatus tears. Journal of ISAKOS. 2026. DOI: 10.1016/j.jisako.2026.101065

[67] Clinical Assessment of Physical Examination Maneuvers for Rotator Cuff Lesions. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514538390

[69] Interobserver Agreement in the Classification of Rotator Cuff Tears. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506298108

[71] The Effect of Posterosuperior Rotator Cuff Tears and Biceps Loading on Glenohumeral Translation. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2009.09.007

[72] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > Rotator Cuff > Scapulohumeral Ligaments.

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

[74] Coracoid morphology and humeral version as risk factors for subscapularis tears. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.01.074

[75] Long‐term outcome after arthroscopic rotator cuff treatment. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3234-8

[76] Reliable interobserver and intraobserver agreement of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification system of rotator cuff tears. Journal of ISAKOS. 2022. DOI: 10.1016/j.jisako.2021.12.004

[77] The Effect of Anterosuperior Rotator Cuff Tears on Glenohumeral Translation. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.10.005

[79] Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.o.00444

[80] Aaos Comprehensive Orthopaedic Review 3. Rotator Cuff Tears and Cuff Tear Arthropathy > II. Cuff Tear Arthropathy.

[83] Clarification of the role of the supraspinatus muscle in shoulder function.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668030-00013

[85] 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

[86] Editorial Commentary: Don't Throw Away the Retractors: Complications of Open Versus Arthroscopic Rotator Cuff Repair Could Be Influenced by Indications. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2017.11.026

[87] Partial-thickness tears involving the rotator cable lead to abnormal glenohumeral kinematics. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.12.063

[90] Preoperative Agreement on the Geometric Classification and 2‐Dimensional Measurement of Rotator Cuff Tears Based on Magnetic Resonance Arthrography. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.04.054

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

[93] 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

[94] Repair of rotator cuff tears in patients aged 75 years and older: Does it make sense? A systematic review. Frontiers in Public Health. 2023. DOI: 10.3389/fpubh.2022.1060700

[95] What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.10.009

[96] Comparison of articular-sided, bursal-sided, and intratendinous partial rotator cuff tears: outcomes of surgical repair from a multicenter cohort study. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-025-06643-w

[97] Editorial Commentary: What's Hamada With Partial Rotator Cuff Repair?. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.11.006

[98] Fifteen-Year Results of a Comparative Analysis of Tendon Repair Versus Physiotherapy for Small-to-Medium-Sized Rotator Cuff Tears. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.24.00065

[99] Bilateral single-staged arthroscopic rotator cuff repair is comparable to staged procedures: a retrospective follow up study of 2 years. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04304-7

[100] An Update on Surgical Management of the Repairable Large-to-Massive Rotator Cuff Tear. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.20.00177

[103] The Effect of Comorbidity on Self-Assessed Function in Patients with a Chronic Rotator Cuff Tear. The Journal of Bone & Joint Surgery. 2004. DOI: 10.2106/00004623-200402000-00020

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[105] Massive Irreparable Rotator Cuff Tears Treated With a Tuberoplasty Yield Favorable Clinical Outcomes With Variable Rates of Complications: A Systematic Review. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.11.032

[106] Long-Term Functional Outcome of Repair of Large and Massive Chronic Tears of the Rotator Cuff. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199907000-00012

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[108] Nonoperative treatment of chronic, massive irreparable rotator cuff tears: a systematic review with synthesis of a standardized rehabilitation protocol. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.11.002

[109] Anterior and Posterior Instability of the Long Head of the Biceps Tendon in Rotator Cuff Tears: A New Classification Based on Arthroscopic Observations. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.08.025

[110] Proper Indications for Shoulder Subacromial Decompression Result in Excellent Outcomes. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.04.023

[112] Miller S Review Of Orthopaedics. ROTATOR CUFF DISEASE > 4. Imaging.

[115] Chapter 72 Rotator Cuff Tears and Cuff Tear Arthropathy. 2019.

[116] 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

[117] Editorial Commentary: Acromioplasty Does Not Improve Clinical Outcome of Arthroscopic Rotator Cuff Repair: The Game Is Over!. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.07.012

[118] Prognostic factors influencing the outcome of rotator cuff repair: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3700-y

[119] A classification for partial subscapularis tendon tears. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-05989-4

[120] Orthopaedic Knowledge Update Sports Medicine 6. Rotator Cuff Disease > Summary.

[121] Orthopaedic Knowledge Update Sports Medicine 6. Rotator Cuff Disease > Nonsurgical Management.

[123] 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

[124] Minimal clinically important differences in the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores after arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.11.018

[126] How to discriminate between acute traumatic and chronic degenerative rotator cuff lesions: an analysis of specific criteria on radiography and magnetic resonance imaging. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.06.005

[127] Biochemical Markers of Aging (Advanced Glycation End Products) and Degeneration Are Increased in Type 3 Rotator Cuff Tendon Stumps With Increased Signal Intensity Changes on MRI. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221090649

[128] Identification of a genetic variant associated with rotator cuff repair healing. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.02.019

[130] Initial medical management of rotator cuff tears: a demographic analysis of surgical and nonsurgical treatment in the United States Medicare population. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.05.001

[131] Orthopaedic Knowledge Update Sports Medicine 6. Rotator Cuff Disease > Physical Examination.

[133] 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

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[138] Outcomes of initial nonoperative treatment of traumatic full-thickness rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.11.012

[139] 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

[141] One-stage surgical treatment for concomitant rotator cuff tears with shoulder stiffness has comparable results with isolated rotator cuff tears: a systematic review. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.03.005

[142] Volumetric classification: unveiling the true extent of rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.08.030

[143] A Systematic Approach for Diagnosing Subscapularis Tendon Tears With Preoperative Magnetic Resonance Imaging Scans. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.04.142

[144] Preoperative partial-thickness rotator cuff tears do not compromise anatomic total shoulder replacement outcomes: medium-term follow-up. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.07.037

[145] Editorial Commentary: Progression of Degenerative Full-Thickness Rotator Cuff Tears: Are We Finally Using Natural History Data to Define At-Risk Tears?. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019. DOI: 10.1016/j.arthro.2018.09.010

[146] Magnetic Resonance Imaging Appearance of the Shoulder After Subacromial Injection With Corticosteroids Can Mimic a Rotator Cuff Tear. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.01.024

[147] Editorial Commentary: Steroid Injections Prior to Arthroscopic Rotator Cuff Repair—Is It Time to Rethink a Conservative Treatment Paradigm?. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.12.017

[148] Editorial Commentary: Magnetic Resonance Imaging Is Generally Superior to Ultrasound for Evaluation of Rotator Cuff Pathology: If Unrecognized Subscapularis Pathology Is Suspected After Magnetic Resonance Imaging, Ultrasound Can Then Be Performed. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2021.08.029

[149] Classifications And Scores Of The Shoulder. 5.3 Arthroscopic classification of partial-thickness rotator cuff tears according to Ellman [32].

[150] 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

[151] 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

[152] Orthopaedic Knowledge Update Sports Medicine 6. Magnetic Resonance Imaging of the Glenohumeral Joint > The Rotator Cuff.

[153] Clinical, Radiographic, and Surgical Presentation of Subscapularis Tendon Tears: A Retrospective Analysis of 139 Patients. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2015.11.019

[154] Imaging of the rotator cuff following repair: Human and animal models. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.114

[155] The Use of Magnetic Resonance Arthrography to Detect Partial-Thickness Rotator Cuff Tears. Journal of Bone and Joint Surgery. 2005. DOI: 10.2106/jbjs.e.00509

[156] Calcific Tendonitis of the Shoulder: Protector or Predictor of Cuff Pathology? A Magnetic Resonance Imaging–Based Study. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.11.127

[157] Long-term results after arthroscopic transosseous rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.09.003

[158] Real-time sonoelastography in the diagnosis of rotator cuff tendinopathy. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.10.019

[159] Classifications And Scores Of The Shoulder. Classifications of rotator cuff.

[160] 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

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[162] Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509335764