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Rotator Cuff

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

218 citationsUpdated Oct 2026

Overview

Management of rotator cuff tears remains complex due to a lack of consensus among orthopaedic surgeons and the absence of specific guidance from American Academy of Orthopaedic Surgeons clinical practice guidelines or Cochrane systematic reviews [1]. Patients are generally categorised into three groups based on the risk of nonoperative treatment and the potential benefit of surgery: those requiring urgent or early operative repair, those who may benefit from a trial of conservative treatment, and those best suited for nonoperative management [1]. The AAOS Appropriate Use Criteria, developed via the RAND/UCLA Appropriateness Method, synthesises evidence and expert opinion across 432 patient scenarios to guide treatment decisions for full-thickness tears [236]. Indications for operative treatment of massive and irreparable tears are determined by expert consensus and the best available evidence to assess the appropriateness of various surgical techniques [47]. Treatment options for large and massive tears must be based on individual patient indications [255].

Arthroscopic rotator cuff repair is favoured for improving shoulder function, as other procedures or intraarticular treatments offer no significant benefits [219]. Proper indications for shoulder subacromial decompression result in excellent outcomes [223], although the utility of acromioplasty at the time of repair has come into question with new studies showing no significant benefit [54]. Critical Shoulder Angle and Acromial Index do not appear to influence 24-month functional outcomes postoperatively and are not contraindications to arthroscopic repair [252]. Open rotator cuff repair remains a valid option in specific indications or where arthroscopic resources are limited [52], though surgeons must carefully interpret literature comparing open and arthroscopic outcomes, as differences in complications may be influenced by selection bias and narrowing indications for open repair [168]. Reverse total shoulder arthroplasty provides comparable clinical outcomes across indications of irreparable rotator cuff tear, rotator cuff tear arthropathy, and primary osteoarthritis at 2 years [49], and reverse shoulder arthroplasty with preservation of the rotator cuff demonstrates excellent outcomes without increased risk of complications [239].

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 [35, 36]. 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 [42]. Rotator cuff repair is cost-effective for all populations [241]. One-year follow-up appears clinically sufficient, as the widely accepted 2-year benchmark may be arbitrary and does not add clinical relevance, although patients must live with long-term outcomes and authors are obliged to evaluate them [10, 235]. Despite the availability of revision strategies, prevention of complications and successful primary repair results in better functional outcomes [228]. There is a need for well-designed level I and level II trials to elucidate the optimal rehabilitation protocol [237]. Patient characteristics and indications for surgery were not described in a majority of clinical outcome studies [26], and it was not possible to reach any definitive conclusion regarding the most relevant predictors of outcome due to low methodological quality of included studies [242].

Anatomy & Pathophysiology

Anatomy

The rotator cuff comprises four muscles: subscapularis, supraspinatus, infraspinatus, and teres minor [6]. The subscapularis originates from the anterior scapula and inserts on the lesser tuberosity [122]. The supraspinatus arises from the fossa superior to the scapular spine, passes beneath the acromion and acromioclavicular joint, and attaches to the superior aspect of the greater tuberosity [122]. The infraspinatus originates from the fossa below the scapular spine and inserts on the posterolateral greater tuberosity [122]. The teres minor arises from the lower lateral scapula and attaches to the lower portion of the greater tuberosity [122]. These tendons blend to form a continuous cuff around the humeral head [122].

Innervation follows specific pathways: the supraspinatus is supplied by the suprascapular nerve after it passes through the suprascapular notch [122]; the infraspinatus is innervated by the suprascapular nerve after it passes through the spinoglenoid notch [122]; the subscapularis receives innervation from the upper and lower subscapular nerves [122]; and the teres minor is supplied by a branch of the axillary nerve [122].

Histologic analysis reveals five distinct layers in the rotator cuff tendons [122]. The most superficial layer consists of coracohumeral ligament fibers oriented obliquely to the muscle axis [122]. The second layer contains fibers grouped into large bundles extending from the supraspinatus tendon over the biceps tendon [122]. The third layer comprises smaller, less tightly packed tendon fascicles with less uniform orientation [122]. The fourth layer is composed of loose connective tissue with thick collagen bands that merge with the coracohumeral ligament at the anterior edge of the supraspinatus [122]. The fifth and deepest layer is a sheet of collagen fibrils composing the superior joint capsule [122].

Significant interdigitation exists between the supraspinatus and infraspinatus tendons near the footprint [122]. The supraspinatus insertion occupies a smaller portion of the greater tuberosity than previously believed, with the infraspinatus insertion occupying the preponderance of the footprint [122]. The supraspinatus footprint measures 13 mm in width medial-lateral and 20 mm anteroposterior [37]. The infraspinatus footprint measures 14 mm wide and 20 mm superoinferior [37]. A 7 mm medial-lateral tear corresponds to a 50% partial thickness tear of the supraspinatus [37].

The long head of the biceps tendon attaches to the supraglenoid tubercle, runs between the subscapularis and supraspinatus, and exits through the bicipital groove under the transverse humeral ligament [122]. The coracohumeral ligament and transverse humeral ligament keep the biceps tendon aligned in the groove [122]. The rotator cable is a thick bundle of fibers running perpendicular to the supraspinatus tendon fibers, connecting the supraspinatus and infraspinatus tendons [37]. It is divided into anterior, middle, and posterior segments [130]. The anterior segment forms the lateral part of the rotator interval [130]. The middle portion forms under the supraspinatus tendon [130]. The posterior part is covered by the infraspinatus tendon and ends at the insertion region between the infraspinatus and teres minor tendons [130].

The coracoacromial arch is formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [6]. The subacromial bursa separates the rotator cuff tendons from this arch [6]. The glenohumeral joint capsule is thickest in the inferior pouch at 2.8 mm, 2.4 mm in the anterior portion, and 2.2 mm in the posterior portion [136]. The superior glenohumeral ligament crosses the rotator interval capsule and lies between the supraspinatus and subscapularis tendons [136]. The coracohumeral ligament originates at the base of the coracoid, blends into the cuff tendons, and inserts into the greater and lesser tuberosities [136].

Pathophysiology

Rotator cuff disease is a continuum beginning with mild impingement and progressing through partial tear, full-thickness tear, massive tear, to rotator cuff tear arthropathy [310]. 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 [2]. The prevalence of rotator cuff tears ranges from 13% for patients in their fifties to 50% for patients aged 80 years or older [17]. The prevalence of full-thickness rotator cuff tears is 7% to 40%, while partial-thickness rotator cuff tears have a 50% higher prevalence [37]. Small full-thickness rotator cuff tears and painful partial-thickness tears become 25% to 50% larger within 3 to 4 years [37].

Intrinsic degeneration involves age-related changes in collagen, proteoglycan, water content, and vascularity, usually involving the supraspinatus and infraspinatus starting on the articular side [37]. Extrinsic factors include chronic impingement on the coracoacromial arch, with tears usually starting on the bursal side of the tendon [37]. Acute traumatic tears typically occur after a fall and/or dislocation of the shoulder in patients under 40 years of age [37]. Risk factors for rotator cuff tear development include male sex, manual labor, and history of trauma [17]. Additional risk factors include age, smoking, female sex, family history, diabetes, and high cholesterol [37].

Degenerative rotator cuff tears initiate approximately 13 to 17 mm posterior to the long head of the biceps tendon [65]. Ultrasound data suggest that degenerative rotator cuff tears initiate at the middle of the rotator crescent tissue and propagate in both directions [65]. The rotator crescent is thinner and more avascular than the rotator cable [65]. Loss of integrity of the anterior supraspinatus tissue may lead to accelerated retraction and degeneration of muscle tissue [65].

Partial-thickness rotator cuff tears have a limited ability to spontaneously heal [4]. As many as 53% of partial-thickness rotator cuff tears will progress in tear size [4]. A portion of partial-thickness rotator cuff tears will progress to full-thickness rotator cuff tears [4]. The prevalence of asymptomatic partial-thickness rotator cuff tears is 20%, increasing to 26% in patients older than 60 years [4].

Cuff tear arthropathy is the final stage of the shoulder impingement syndrome spectrum [14]. It affects patients with long-term insufficient massive rotator cuff tears, superior migration of the humeral head, subchondral osteoporosis, humeral head collapse, and painful debilitating shoulder arthritis [14]. Cuff tear arthropathy affects women at a 3:1 female to male ratio, more commonly in patients over 70 years old and on the dominant shoulder [14]. Mechanical factors include insufficient cuff, superior migration of the humeral head, instability, eccentric wear of the glenoid, and humeral head deformity [14]. Nutritional factors include hypomobility-induced cartilage atrophy, poor nutrition, dehydration, and subchondral osteoporosis [14]. Crystalline-induced arthropathy involves synovial-based matrix protein degradation destroying rotator cuff tendons and cartilage, with end-stage calcium-phosphate crystal deposition [14].

The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in the functional planes of motion [153]. The presence of a rotator cuff tear is associated with superior migration of the humeral head in the scapular plane [115]. Patients with rotator cuff tearing demonstrate abnormal glenohumeral kinematics with superior translation of the humeral head in the scapular plane [151]. Simulated anterosuperior rotator cuff tears involving the superior half of the subscapularis lead to increased anterosuperior and superior glenohumeral translation under higher loads [143]. Tears of the subscapularis have greater biomechanical consequences than tears of the infraspinatus [135]. Partial-thickness articular-sided rotator cuff tears with a thickness greater than 50% involving the rotator cable increase glenohumeral translation and change kinematics [169]. The critical tear size leading to the loss of normal shoulder biomechanics is identified as a half tear of the infraspinatus accompanied by a complete tear of the supraspinatus tendon [160].

Rotator cuff pathology constitutes up to 60% of all shoulder conditions [166]. Primary impingement results from encroachment of the rotator cuff in the subacromial space due to swelling or scarring, acromial morphologies, or selective hypomobility of noncontractile tissues [166]. Secondary impingement results from microinstability of the glenohumeral joint due to acquired ligamentous laxity, inadequate dynamic muscular stabilization, and scapular dysfunction [166]. Internal impingement is commonly involved in overhead athletes or when the arm is used in an abducted, externally rotated, and horizontally extended position [166].

The critical shoulder angle above 35° to 38° has been shown to correlate with rotator cuff tears and postoperative retears [269]. The acromial index above 0.7 has been associated with full-thickness rotator cuff tears and higher retear rates [269]. Increased lateralization of the acromion and increased superior glenoid inclination may increase the shear forces of deltoid contraction [269]. Genetic predisposition contributes to intrinsic degenerative tendinopathic changes in molecular composition and vascularity, resulting in tendinosis and tearing [269].

Calcific tendinitis is characterized by a cyclical progression of reactive calcium hydroxyapatite crystal intratendinous deposition followed by spontaneous resorption and healing [303]. It most commonly affects the critical zone of relative hypovascularity of the supraspinatus tendon [303]. The pathogenesis involves a metaplastic cell-mediated transformation of tenocytes into chondrocytes, which induce calcification [303]. The precalcific stage consists of predominantly fibrocartilaginous metaplasia within less vascular areas of the tendon [214]. In the formative phase of the calcific stage, matrix vesicles unite to form calcium hydroxyapatite deposits separated by fibrocollagenous tissue [214]. The resorption phase involves an inflammatory response and is generally the most painful phase [214].

Rotator cuff impingement arises from repetitive compression or rubbing of the tendons under the coracoacromial arch [154]. Intrinsic factors for impingement include tendon degeneration, changes in highly sulphated glycosaminoglycans, changes in collagen composition with loading, and changes in vascularity [154]. Extrinsic factors include spurs growing down the coracoacromial ligament and osteoarthritic thickening of the acromioclavicular joint [154]. 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 [158]. Eccentric forces tend to be concentrated more along the articular surface fibers of the rotator cuff [158]. Biologic changes contributing to rotator cuff tear pathogenesis include extracellular matrix remodeling, angiogenesis, changes in metabolism, apoptosis, and stress-related genes [345]. Metaplasia of rotator cuff cells is contributed to by changes in gene expression [345].

The rotator cuff serves multiple functions including initiating/assisting active shoulder motion and providing dynamic stability via force-couple moments [269]. Most rotator cuff tears occur in the anterior portion of the supraspinatus tendon [269]. Tears involving the rotator cable result in increased tear gap distance and strain compared with those in the crescent area [269].

Classification

Full-Thickness Rotator Cuff Tears

Goutallier: This classification grades fatty infiltration of rotator cuff musculature from grade 0 (normal muscle) to grade 4 (more fat than muscle) [2]. Grades 3 and 4 indicate a long-term chronic rotator cuff tear with a higher potential for surgical failure and are likely deemed irreparable [2]. Specifically, Goutallier stages III and IV tears accompanied by a tendinous stump of less than 15 mm and a positive tangent sign have a 90% failure rate [2]. Tears with Goutallier grades III and IV are usually deemed irreparable and are treated with alternative strategies such as debridement, tendon transfer, superior capsular reconstruction, or reverse shoulder arthroplasty [2]. The Goutallier staging system defines Level 0 as normal muscle with no fatty streak, Level 1 as some fatty streaks, Level 2 as important fatty infiltration but more muscle than fat, Level 3 as equal amounts of fat and muscle, and Level 4 as more fat than muscle [333].

Patte: The Patte classification system assesses rotator cuff tears based on extent, topography in the sagittal plane, topography in the frontal plane, trophic quality of the muscle, and state of the long head of the biceps [50]. In the sagittal plane, Segment 1 represents a subscapularis tear [50]. Segment 2 represents a coracohumeral ligament tear [50]. Segment 3 represents an isolated supraspinatus tear [50]. Segment 4 represents a tear of the entire supraspinatus and one-half of the infraspinatus [50]. Segment 5 represents a tear of the supraspinatus and infraspinatus [50]. Segment 6 represents a tear of the subscapularis, supraspinatus, and infraspinatus [50]. Anteriorly situated rotator cuff defects are more painful, whereas posterior lesions interfere more with function [50]. Isolated subscapularis tears (Patte Segment 1) are seldom exclusively involved in degenerative tears and are generally due to traumatic avulsions often associated with a medial dislocation of the long head of the biceps [50]. Isolated coracohumeral ligament tears (Patte Segment 2) are traumatic in nature and do not contribute to the pathology of the cuff [50]. Patte Segments 4 and 5 tears merit special attention given the inherent difficulties of repair [50]. Secondary osteoarthritis was most common among patients with total-cuff tears (Patte Segment 6) [50].

Hamada: The Hamada classification is a commonly used scheme that uses a mechanistic approach to explain radiographic changes seen with chronic massive rotator cuff tears, highlighting the progressive nature of massive rotator cuff tears leading to cuff tear arthropathy [142]. The system describes structural changes within the coracoacromial arch and changes in the acromiohumeral interval on anteroposterior radiographs as the bases for classification [313]. It divides massive rotator cuff tears into five radiographic stages, with consecutive stages indicating disease progression [313]. Understanding the Hamada classification helps predict appropriate care and outcomes in patients with massive rotator cuff pathology [199].

Seebauer: The Seebauer classification system separates rotator cuff tear arthropathy into four distinct types: IA, IB, IIA, and IIB [313]. It is a biomechanical description of rotator cuff tear arthropathy distinguished by the degree of superior migration of the humeral head and the amount of instability [313].

ISAKOS: The ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communicating among surgeons and for pooling of data from clinical studies [141].

Massive Tear Morphology: Massive rotator cuff tears can be divided into three types: anterosuperior, posterosuperior, and anteroposterior [171]. Each type of massive rotator cuff tear (anterosuperior, posterosuperior, and anteroposterior) shows distinctive characteristics and different results in preoperative and postoperative metrics [171]. Massive rotator cuff tears are classified based on their size, with several definitions proposed in the literature [333].

Other Considerations: Patients with a symptomatic full-thickness rotator cuff tear in one shoulder have a 50% chance of an asymptomatic full-thickness rotator cuff tear in the contralateral shoulder [2]. The presence of a tendon stump attached to the greater tuberosity decreases the length of tendon available for repair [2]. Factors associated with failure after rotator cuff repair include larger tears, greater retraction, advanced Goutallier grade, older age, smoking status, osteoporosis, diabetes mellitus, hypercholesterolemia, and more aggressive rehabilitation protocols [2]. A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair [83]. The geometric classification and 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 [177]. The size of the rotator cuff tear could be categorized into one of four groups with accuracy in only 56% of the cases using shoulder arthrography [183]. The diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability [185]. Different types of cuff tear morphology do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up, despite affecting surgical repair technique [216].

Partial-Thickness Rotator Cuff 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 [4]. Partial-thickness tears are classified as articular-sided (A), bursal-sided (B), or intratendinous (C) [4]. Grade 1 partial-thickness tears involve 3 mm or less of tendon [4]. Grade 2 partial-thickness tears involve 3 to 6 mm of tendon [4]. Grade 3 partial-thickness tears involve more than 6 mm of tendon [4]. Grade 3 partial-thickness tears represent tears of more than 50% of tendon width based on the width of the supraspinatus footprint [4]. In Ellman’s classification, grade I partial-thickness tears have a depth of less than 3 mm [62]. Grade II partial-thickness tears have a depth of 3 to 6 mm [62]. Grade III partial-thickness tears involve more than half of the cuff thickness, with an average cuff thickness of 9 to 12 mm [62]. In the Ellman classification, a grade 1 partial tear is less than 3-mm deep and involves definite disruption of tendinous fibres [346]. Grade 2 lesions are 3–6-mm deep and extend well into the substance of the cuff but do not exceed one-half of the thickness of the tendon [346]. Grade 3 lesions are more than 6 mm in depth and represent significant disruptions of more than one-half the substance of the cuff [346]. The normal rotator cuff is considered to be 10–12-mm thick in the context of the Ellman classification [346]. The Ellman classification includes a subclassification of stage-III rotator cuff tears that covers both partial- and full-thickness tears [346]. In the Ellman classification, full-thickness tears are designated by location (supraspinatus, infraspinatus, teres minor, subscapularis) and size (small <2 cm, large 2–4 cm, massive >5 cm) or cuff arthropathy [346]. The area of defect in the Ellman classification is estimated by multiplying the length of the base of the tear by the distance of maximum retraction [346]. Ellman proposed a classification scheme for partial-thickness rotator cuff tears that includes specific consideration of the site and extent of the tear [62].

Neer: Neer’s classification described three stages of rotator cuff disease: stage I (hemorrhage and cuff edema), stage II (cuff fibrosis), and stage III (cuff tear) [62]. Partial tears were not categorized separately in Neer’s classification and have been considered advanced stage II lesions by some authors and early stage III lesions by others [62].

Snyder: The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears [114].

Other Considerations: The overall prevalence of asymptomatic partial-thickness rotator cuff tears is 20%, increasing to 26% in patients older than 60 years [4]. MRI evaluation classifies partial-thickness tears as low grade or high grade depending on whether they involve less than or more than 50% of the tendon width [4]. 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 [133]. The proposed classification system in the Indian Journal of Orthopaedics study may assist decision making in the treatment of partial thickness rotator cuff tears [119].

Fatty Infiltration and Muscle Atrophy

Other Considerations: Fatty infiltration of the supraspinatus increased with the size of the rupture and the number of tendons ruptured [281]. Fatty infiltration was greater in partial lesions of the supraspinatus and greater in massive lesions involving the three tendons (supraspinatus, infraspinatus, and subscapularis) [281]. Fatty infiltration of the infraspinatus increased with the size of the tear [281]. Fatty infiltration of the subscapularis muscle was statistically more frequent and more severe when the tendon was ruptured [281]. Fatty infiltration was greater in isolated ruptures of the subscapularis tendon than in more extensive ruptures involving the supraspinatus and infraspinatus tendons without involving the subscapularis tendon [281]. The study proposes a three-stage classification based on the occupation ratio to improve indications for rotator cuff tear treatment regarding supraspinatus belly atrophy [222].

Other Classifications and Reliability

Other Considerations: A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further [72]. Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair [77]. A morphologic classification system allowed the appearance of the teres minor to be defined in isolated and multiple rotator cuff tears in CT and MRI images [106]. 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 [28]. This study was the first to create a classification system to divide coracoids according to their morphology and relative risk of associated subscapularis tears [139]. Classification of rotator cuff tears should take into account the site of the tear since it may help physicians predict the outcome of the disease more precisely [145]. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes [165]. The model described in the British Journal of Sports Medicine is relevant for the rotator cuff and provides a framework to stage the continuity of rotator cuff pathology [189]. All other outcomes and classifications did not show acceptable reliability for preoperative evaluation of a rotator cuff tear, therefore caution is needed when using them [212]. In experienced hands, sonography has a low level of interobserver variability for the detection, classification, and localization of rotator cuff tears [217]. Long head of the biceps instability was associated with long head of the biceps lesions and rotator cuff tear size, leading to the creation of a new arthroscopic classification [220]. The text describes multiple classification systems for calcifying tendinitis of the rotator cuff, including Uhthoff's stages of disease evolution, Gärtner and Heyer's radiologic staging, Bosworth's size classification, and Molé et al.'s morphological classification [227]. The purpose of the article is to propose a comprehensive review and classification of all different subtypes of anterior impingement in the shoulder, including newly described entities [232]. The unclassified types of the mechanoreceptors were thought to be related to the dysfunction and painful condition in the rotator cuff tear [224].

Clinical Presentation

History and Symptoms

Shoulder pain is the most common and consistent presenting symptom of rotator cuff pathology, with weakness of the shoulder and arm as a common secondary complaint [87]. Patients with symptomatic full-thickness tears typically report anterolateral shoulder pain radiating into the subdeltoid location [2]. Complaints of pain with overhead activity and lifting objects with an outstretched arm are frequent, as are night pain and sleep disturbance [2]. In chronic rotator cuff disease, patients often describe an insidious onset of lateral and/or anterior shoulder pain associated with overhead activities, with night pain being a common presenting symptom [209]. A clear history of trauma resulting in acute pain and weakness strongly suggests an acute rotator cuff tear [209]. A family or personal history of rotator cuff disease increases the likelihood of diagnosis [209]. Subjective mechanical symptoms are also a common complaint in patients with suspected rotator cuff pathology [88].

For subacromial bursitis and rotator cuff tendinosis, pain is present with activity involving overhead motion, while there is usually no pain or only mild pain with the arm at the side [15]. Patients may occasionally be awakened by pain at night [15]. In rotator cuff syndrome, pain is located over the front and lateral aspect of the shoulder for supraspinatus involvement, tears of the cuff, and tendinitis, and over the front for biceps pathology [6]. If the rotator cuff or biceps has ruptured, weakness is also present [6]. A patient with a full-thickness rotator cuff tear may experience sudden pain and be unable to abduct the arm [293]. In long-standing cases of partial or complete rotator cuff rupture, secondary osteoarthritis of the shoulder may supervene, resulting in severely restricted movements [293]. Chronic shoulder pain, night pain, weakness, and stiffness are characteristic of cuff tear arthropathy [14]. The combination of age over 65 years, night pain, and weakness has 95% specificity for rotator cuff tears [37]. Symptoms of rotator cuff disease usually wax and wane periodically while a physiological decline occurs over time, resulting in eventual cuff tear arthropathy [17].

Data from the Multicenter Orthopaedic Outcomes Network Shoulder Group indicate that pain and duration of symptoms are not associated with the severity of rotator cuff tears [18]. There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease [30]. The status of the rotator cuff is not the primary variable that results in patient symptom severity or decline in shoulder-specific health-related quality of life [116].

Physical Examination

Inspection of the shoulder may reveal rotator cuff muscle atrophy, signs of rotator cuff dysfunction, and anterosuperior escape [285]. Inspection for muscular atrophy of the deltoid and supraspinatus and infraspinatus fossa is part of the physical examination for chronic rotator cuff tears [37]. In a full-thickness rotator cuff tear, there is usually wasting of the supraspinatus and infraspinatus [293]. In cuff tear arthropathy, inspection reveals supraspinatus and infraspinatus atrophy, anterior prominence of the humeral head with arm elevation (anterosuperior escape), and subcutaneous effusion [14]. No atrophy of the shoulder muscles is present in subacromial bursitis and rotator cuff tendinosis [15].

Palpation of the greater tuberosity, acromioclavicular joint, bicipital groove, and coracoid process is part of the physical examination for rotator cuff tears [37]. Cervical spine palpation, range of motion, and Spurling test are performed to rule out cervical spine pathologies as a cause of shoulder pain [37]. There is often tenderness of the acromioclavicular joint in full-thickness rotator cuff tears [293].

Active and passive range of motion of the shoulder is assessed during the physical examination for rotator cuff tears [37]. Passive range of motion assessment can rule out adhesive capsulitis, which is ideally treated before rotator cuff repair [285]. It is important to assess for concomitant symptomatic pathologies such as biceps tendon disease, acromioclavicular joint arthrosis, or impingement syndrome during the physical examination [285]. Active range of shoulder motion may be limited by pain in subacromial bursitis and rotator cuff tendinosis [15]. In cuff tear arthropathy, very limited range of motion for elevation, external, and internal rotation is observed [14]. Subacromial/glenohumeral crepitus with movement is observed in cuff tear arthropathy [14].

Special Tests: The Jobe or empty can test isolates the supraspinatus with resistance testing of the arm at 90° of abduction, 30° of flexion in the scapular plane, and thumb pointed down [285]. The external rotation strength test assesses the infraspinatus with the arm in adduction and the elbow at 90° of flexion [285]. The lift-off and belly press tests assess the subscapularis [285]. The external rotation lag sign and hornblower’s sign both assess for massive failure of the infraspinatus and teres minor [285]. The drop arm test examines failure of the superior rotator cuff [285]. The Neer impingement sign is characterized by discomfort when the internally rotated shoulder is moved into forward flexion, which resolves with a dramatic increase in strength and range of motion after subacromial lidocaine injection [15].

Diagnostic Performance: No one test for rotator cuff disease has reliably high diagnostic value, and a combination of tests increases diagnosis specificity [285]. The empty can test has a sensitivity of 71.7% and a specificity of 64.6% for full-thickness supraspinatus tears [209]. The lift-off and belly-press tests have high specificity but low sensitivity for full-thickness subscapularis tears [209]. Patients with an external rotation lag sign at the side likely have a large posterosuperior tear involving the infraspinatus [209]. A positive hornblower sign suggests a massive posterosuperior cuff tear that prohibits the active positioning of the hand in space [209]. The crepitus test has a sensitivity of 67%, specificity of 80%, positive predictive value of 91%, and negative predictive value of 43% for all types of rotator cuff tears [92]. The sensitivity and specificity for full-thickness or high-grade partial tears using the crepitus test is 82% and 73%, respectively [92]. The positive predictive value and negative predictive value for full-thickness or high-grade partial tears using the crepitus test are 77% and 79%, respectively [92]. In patients older than 55 years, the presence of crepitus has a sensitivity of 76%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 38% [92].

Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear [93]. The findings of an investigation suggest that a clinical diagnosis of a full-thickness tear of the rotator cuff cannot be conclusively reached using one or more of the lag signs [108]. None of the physical examination tests were highly sensitive for diagnosing rotator cuff tears or tendinosis [78]. Tests for subscapularis tears were all highly specific [78]. No optimal combination of tests improved the ability to correctly diagnose rotator cuff tears [78]. The internal rotation and lateral rotation lag sign did not improve the diagnostic ability for rotator cuff tears [78]. When evaluating for either subacromial bursitis or rotator cuff tears, the Neer, Hawkins, and painful arc tests have greater sensitivity than specificity and are useful screening tests in ruling out these conditions if they are negative [100]. The Neer sign is the only test to reliably predict rotator cuff pathology among the subacromial impingement tests [100]. Current consensus suggests rotator cuff injuries are most accurately diagnosed with a combination of cuff- and impingement-specific clinical tests [86]. 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 [98]. A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders [23]. Clinical assessment followed by specific imaging may help define the pathology in order to direct appropriate management in patients with shoulder symptoms severe enough to consider surgery [21]. When combined with a careful history and clinical examination, plain radiographs help guide the use of further radiological investigations, obviating unnecessary waiting times and tests for many without cuff tears [24]. A diagnosis of a rotator cuff tear requires a full clinical examination, combined with imaging studies [75]. Advanced practice providers should be acquainted with physical examination findings and special testing consistent with rotator cuff pathology to prompt appropriate advanced imaging [105]. The authors argue that shoulder 'special tests' for rotator cuff-related shoulder pain should be discontinued as they lack validity for isolating specific structures or identifying the cause of symptoms [90].

Imaging and Diagnostic Studies

An MRI is obtained in the evaluation of a potential rotator cuff tear if the patient has no contraindications [2]. 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 [2]. 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 [2]. 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 [2]. 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 [2]. 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 [2]. 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 [2].

Radiographs are used to rule out glenohumeral and acromioclavicular arthritis [37]. The true AP view is used to evaluate the acromiohumeral interval, the critical shoulder angle, and acromion index [37]. The normal acromiohumeral interval is 7 to 14 mm [37]. Greater tuberosity excrescences on AP view in external and internal rotation are pathognomonic for cuff disease [37]. The supraspinatus outlet view is used to evaluate acromial morphology according to Bigliani classification [37]. The axillary view is used to assess glenohumeral joint morphology and joint space and rule out dislocations [37].

MRI is the benchmark for diagnosing rotator cuff tears with 94% sensitivity and 93% specificity [37]. T2-weighted images best visualize rotator cuff tears [37]. T1 sagittal oblique cuts reveal muscle/tendon retraction and muscle atrophy to determine chronicity, reparability, and outcome of surgical rotator cuff repairs [37]. Intra-articular contrast-enhanced magnetic resonance arthrography is best for detecting partial-thickness rotator cuff tears with 95% sensitivity and 95% specificity [37]. Ultrasonography has good accuracy with 92% sensitivity and 93% specificity for rotator cuff tears [37]. Ultrasonography allows for dynamic assessment of the cuff insertion [37]. Ultrasonography is operator dependent and has limited assessment of chondral lesions [37]. Ultrasonography has poor sensitivity to diagnose partial-thickness rotator cuff tears [37]. 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 [37].

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 [209]. Ultrasonography is relatively inexpensive, allowing for dynamic testing, guided injections, and immediate feedback [209]. MRI accurately assesses muscle, bone, and cartilage, which has advantages for surgical planning [209]. MRI continues to be the imaging modality of choice for most providers, with ultrasonography becoming common in certain centers [209]. The goal of diagnostic imaging is to 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 [209]. Imaging findings of rotator cuff disease must be considered in a clinical context and should never be used as the only basis for operative intervention [29]. When patients with clinical suspicion of rotator cuff tear present with combinations of radiographic signs including greater tuberosity spurs and narrow acromiohumeral intervals, a prompt MRI examination and a referral to a shoulder specialist are recommended [19]. The SLAM sign is a simple and easily identifiable radiological predictor of rotator cuff disease [109]. Effective management of rotator cuff pathology critically relies on initial identification of all cuff tears, including nonobvious, partial and/or obscured full tears [20]. A rotator cuff tear is a clinical syndrome, and a case definition simply based on imaging findings is incomplete and clinically inaccurate [96]. The sensitivity of MRI in partial-thickness rotator cuff tears is 64% [96]. Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality [31]. The Society of Radiologists in Ultrasound convened a panel of specialists to reach a consensus about the recommended imaging evaluation of painful shoulders with clinically suspected rotator cuff disease [27]. A thorough understanding of the anatomy and function of the rotator cuff and of the consequences of rotator cuff disorders is essential for optimal treatment planning and prognostic accuracy [111].

In cuff tear arthropathy, radiographs show acetabularization of the acromion and femoralization of the humeral head [14]. Radiographs in cuff tear arthropathy show eccentric superior glenoid wear [14]. Radiographs in cuff tear arthropathy show absence of typical peripheral osteophytes around the humeral head as seen on osteoarthritis [14]. Radiographs in cuff tear arthropathy show osteopenia and subarticular sclerosis (snowcap sign) [14]. Radiographs in cuff tear arthropathy show loss of the coracoacromial arch, indicating anterosuperior escape [14]. MRI or CT scan is not routinely necessary for cuff tear arthropathy, especially if radiographs show anterosuperior escape [14]. MRI or CT scan establishes the extent of rotator cuff tear, retraction, and fatty infiltration in cuff tear arthropathy [14]. CT is helpful to quantify glenoid bone stock when reverse shoulder replacement is considered in cases of advanced arthropathy [14].

Investigations

Clinical Presentation and History

Symptomatic full-thickness rotator cuff tears frequently present with night pain and sleep disturbance [2]. Across all conditions comprising rotator cuff syndrome, patients report pain over the front and lateral aspect of the shoulder [6]. Weakness on abduction is characteristic of supraspinatus involvement, cuff tears, and tendinitis [6], while weakness is present if the rotator cuff or biceps has ruptured [6]. For subacromial bursitis and rotator cuff tendinosis, key diagnostic features include mild or moderate pain with overhead shoulder motion and a history of repetitive overhead activity [15]. Notably, no muscle atrophy is present in these conditions [15]. Pain relief following a subacromial lidocaine injection is a defining feature of subacromial bursitis and rotator cuff tendinosis [15]. The Neer impingement sign involves discomfort when the internally rotated shoulder is moved into forward flexion, which resolves with a dramatic increase in strength and range of motion after subacromial lidocaine injection [15].

It is critical to recognize that symptoms of pain do not correlate with rotator cuff tear severity in patients with symptomatic atraumatic full-thickness rotator cuff tears [5]. Furthermore, patient-reported outcomes and pain are not correlated with rotator cuff healing on ultrasonography or MRI [58], and PROMIS upper extremity and pain interference scores do not significantly predict rotator cuff tear dimensions [326].

Physical Examination

In cuff tear arthropathy, inspection may reveal supraspinatus and infraspinatus atrophy [14]. Anterior prominence of the humeral head with arm elevation, known as anterosuperior escape, is observed in this condition [14]. Subcutaneous effusion may also be observed on inspection [14]. Range of motion findings include subacromial or glenohumeral crepitus with movement [14] and very limited range of motion for elevation, external, and internal rotation [14]. Clinical assessment followed by specific imaging may help define the pathology to direct appropriate management in patients with shoulder symptoms severe enough to consider surgery [21].

Plain Radiography

Radiographs may demonstrate classic changes within the acromion or coracoacromial ligament, including spurring and calcification, in addition to cystic changes within the greater tuberosity [225]. With chronic rotator cuff disease, superior migration of the humeral head with extensive degenerative change may be present [225]. Radiographs of subjects with a documented rotator cuff tear have greater tuberosity radiographic abnormalities that are not noted in asymptomatic subjects without a rotator cuff tear [300]. Radiographic greater tuberosity spurs and narrow acromiohumeral intervals are associated with advanced retraction of the supraspinatus tendon in patients with symptomatic rotator cuff tears [19]. When patients with clinical suspicion of rotator cuff tear present with combinations of radiographic signs such as greater tuberosity spurs and narrow acromiohumeral intervals, a prompt MRI examination and a referral to a shoulder specialist are recommended [19].

Specific radiographic findings in cuff tear arthropathy include eccentric superior glenoid wear [14], absence of typical peripheral osteophytes around the humeral head (distinguishing it from osteoarthritis) [14], osteopenia and subarticular sclerosis (snowcap sign) [14], and loss of the coracoacromial arch indicating anterosuperior escape [14]. An acromiohumeral distance appearing shorter than 7 mm on AP radiograph suggests irreparable rotator cuff tears are more likely to occur [225]. Conversely, a radiologic acromiohumeral distance (AHD) equal to or greater than 6 mm is of no diagnostic relevance for determining if the rotator cuff is continuous or showing a full-thickness tear [295]. Secondary radiographic findings on conventional views are useful for initial screening of patients with shoulder pain [324]. Radiographs combined with active tasks offer new possibilities in diagnosing early-stage rotator cuff tears [331], and a deep learning-based algorithm has improved the role of shoulder radiography as an initial imaging modality to rule out rotator cuff tears [316]. MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions [261].

Ultrasonography

Ultrasonography is increasing in popularity as a tool for diagnosis of rotator cuff disease and for confirmation of intraarticular or subacromial location of injections [225]. It is more accurate for full-thickness rotator cuff tears, comparable to MRI [3]. Full-thickness rotator cuff tears can be identified using ultrasound and MRI with comparable accuracy [318]. The diagnostic accuracy of ultrasonography, MRI, and MR arthrography in the characterisation of full-thickness rotator cuff tears is high, with overall estimates of sensitivity and specificity over 0.90 [338]. Both MRI and ultrasound can be used to evaluate the repaired rotator cuff and potential complications [298]. While MRI and ultrasound provide similar assessments of postoperative rotator cuff healing, ultrasound is less sensitive [322]. Both modalities are useful in the postoperative assessment of the rotator cuff for evaluating integrity, detecting hardware complications, and identifying other etiologies of shoulder pain [308].

MRI

MRI is obtained in the evaluation of a potential rotator cuff tear if the patient has no contraindications [2]. It 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 [2]. MRI is used to define the extent of tear, degree of tear retraction, and presence of muscular atrophy [225]. It is key for evaluating fatty infiltration, although the Goutallier classification was originally based on CT [225]. MRI is an effective tool for evaluating rotator cuff tears and determining tear severity [326], and diagnostic imaging of the rotator cuff performed by MRI provides valuable information about the nature of the injury [233]. The major role of MR imaging in the investigation of rotator cuff disorders is in the detection of full-thickness rotator cuff tears [319], and MRI seems to be the most sensitive procedure in diagnosing cuff tears [323]. Analysis of data supports the reliability of MRI assessment by shoulder specialists for rotator cuff disorders [306].

The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits, and suspected cuff tendinopathy other than full-thickness tears provides negative value in management [329]. This is because rotator cuff tears are frequently asymptomatic [22]. 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 [2]. 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 [2]. The overall prevalence of asymptomatic partial-thickness rotator cuff tears is 20%, which increased to 26% in patients older than 60 years [4]. 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 [4]. Progression of symptomatic full-thickness and partial-thickness rotator cuff tears correlates with presenting tear size [5].

In cuff tear arthropathy, MRI or CT scan is not routinely necessary, especially if radiographs show anterosuperior escape [14]. Three-dimensional MRI seems to be useful in assessing the rotator cuff muscles [317], and three-dimensional magnetic resonance imaging appears to be useful to assess the rotator cuff muscles [321]. 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 [336]. Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with a described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies [339]. The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term [340]. The presence of clinically significant disagreements in inter-rater agreement of rotator cuff tendon and muscle MRI parameters indicates the need for improved imaging tools for precise rotator cuff evaluation [341].

Magnetic Resonance Arthrography (MRA)

MRI and MRA are both sensitive and specific for full-thickness rotator cuff tears [244]. The sensitivity of MRI for full-thickness rotator cuff tears is 92.1% and specificity is 92.9% [244]. The sensitivity of MRA for full-thickness rotator cuff tears is 95.4% and specificity is 98.9% [244]. For partial-thickness rotator cuff tears, the sensitivity of MRI is 63.6% and specificity is 91.7% [244], whereas the sensitivity of MRA is 85.9% and specificity is 96.0% [244]. MRA is more sensitive for the detection of partial-thickness, particularly articular-sided tears, which can be filled with contrast when the cuff relaxes with the arm in ABER position [244]. Magnetic resonance arthrography was more accurate in evaluating rotator cuff tear size and morphologic features than conventional magnetic resonance imaging [262]. MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears [320]. Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears [287].

Specific Imaging Signs and Findings

In the Goutallier 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 [2]. 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 [225]. The tangent sign correlates with muscle atrophy and fatty infiltration of the supraspinatus [225]. Patients with the presence of the tangent sign are more likely to have an irreparable rotator cuff tear [225], and a positive tangent sign predicts the repairability of rotator cuff tears [3]. Goutallier stages III and IV tears, if accompanied by a tendinous stump of less than 15 mm and a positive tangent sign, have a 90% failure rate [2]. Tears with Goutallier grades III and IV usually are deemed irreparable and are treated with alternative strategies such as debridement, tendon transfer, superior capsular reconstruction, or reverse shoulder arthroplasty [2]. Another important consideration on MRI evaluation is whether any tendon stump remains attached to the greater tuberosity, which decreases the length of tendon for repair [2].

A full-thickness rotator cuff tear is identified if fiber discontinuity spans the entire thickness of the tendon, with the defect filled with fluid signal intensity on T2-weighted sequences or with gadolinium on T1-weighted sequences of an MRA [244]. If a tear is chronic and retracted, the humeral head migrates superiorly, contacting the undersurface of the acromion and resulting in osseous remodeling of the humeral head and acromion (acetabularization), and eventually rotator cuff associated–arthropathy [244]. The description of a full-thickness tear should include the tendon(s) involved, the location within the tendon (footprint, critical zone, or myotendinous junction), the AP dimension best measured on the sagittal view, and the extent of retraction best measured on the coronal sequence for supraspinatus and infraspinatus and on the axial sequence for the subscapularis [244]. A partial-thickness rotator cuff tear spans only a portion of the tendon thickness [244]. The description of a partial-thickness tear should include the tendon(s) involved, the location within the tendon (footprint, critical zone, or myotendinous junction), the percentage of tendon thickness that is affected (greater or less than 50%), and the side of the tendon that is torn (bursal surface and/or articular surface) [244]. Articular-side thickening of the supraspinatus and infraspinatus on images obtained in the neutral position suggests the presence of a partial-thickness articular-side rotator cuff tear [244]. The rotator cable can be reliably identified with the shoulder in ABER position, even in the absence of a rotator cuff tear [244]. Partial-thickness articular-surface tears are more common than bursal-surface tears [244]. Larger, more retracted tears (>40 mm length/width) are characterized by fatty atrophy and supraspinatus width of less than 5 mm at glenoid margin [225].

MRI appears to be accurate in detecting the presence of a recurrent rotator cuff tear in shoulders with suspected failed cuff repairs, with a sensitivity of 91% [290]. A useful approach to image the shoulder after surgery is standard radiography, followed by MRI or MR arthrography for patients with low metal presence and CT for patients with higher metal presence [342]. The association between acromial type as determined on magnetic resonance imaging and the presence of rotator cuff tearing was less significant [299].

Treatment

Non-Operative

Nonoperative treatment is the preferred initial approach for non-traumatic rotator cuff injuries [291] and most partial-thickness tears [4]. Conservative management typically involves 6 to 12 weeks of rest, activity modification, symptom management with NSAIDs, and physical therapy [247]. For chronic full-thickness tears, nonoperative treatment is generally initiated, particularly in patients over 65 years of age [2]. This approach yields successful outcomes in 60% of patients with symptomatic full-thickness tears [2] and is effective for chronic, massive, irreparable tears despite low-quality evidence [215]. In a cohort of 452 patients with asymptomatic full-thickness tears, 75% did not require surgery at 2-year follow-up [247]. Patient expectations regarding physical therapy are more predictive of success than tear structural factors [247]. However, the risk of tear progression with nonoperative treatment is approximately 50% at 2 years [2]. Long-standing tears may increase in size, retraction, and fatty infiltration, compromising future structural integrity and functional outcomes [2]. Risk factors for conservative management failure in partial-thickness tears include bursal-sided location, involvement of the dominant upper extremity, and tears involving greater than 50% of tendon thickness [247].

Operative

Indications: Rotator cuff repair is indicated for acute full-thickness tears or chronic full-thickness tears after failed nonoperative treatment [2]. The optimal strategy for symptomatic full-thickness tears remains debated [2]. For acute tears, repair is generally attempted within 3 months, as outcomes are inferior when performed more than 4 months post-injury [2]. Relative indications for revision surgery include symptomatic recurrence in active, nonsmoking patients [201]. Tendon transfer is ideally indicated for patients with irreparable supraspinatus and infraspinatus tears, intact teres minor and subscapularis, forward elevation greater than 90 degrees, and no prior surgery [196]. Indications for operative treatment of massive and irreparable tears are based on expert consensus and available evidence to guide surgical technique selection [47]. Arthroscopic subacromial decompression is a viable option for shoulder impingement with an intact rotator cuff following at least 6 weeks of nonoperative treatment [294].

Surgical Approach / Technique: Arthroscopic repair is the current standard of care, offering similar outcomes and failure rates to open or mini-open repair, with decreased short-term pain and more rapid return to activity [44]. There is no evidence of difference in effectiveness between open and arthroscopic repair [137]. Arthroscopy allows comprehensive assessment of intra-articular pathology and tear configuration from multiple angles [280]. It facilitates tendon mobilization through precise adhesion releases, enabling anatomical reduction and tension-free repair [280]. Deltoid injury is minimized, and the acromial deltoid origin is preserved, eliminating the risk of deltoid dehiscence [280]. Historically, arthroscopic repair used a single row of bone anchors [280]. The double-row technique uses two rows of suture anchors, tied separately, and is advocated as a more anatomic repair strategy [280]. Newer techniques use a medial row with suture strands passed to a lateral row to compress the tendon to bone [280]. Biomechanical studies show double-row repair outperforms single-row in failure strength, decreased gap formation, and strain, though superior clinical results remain controversial [280, 44]. Arthroscopic transosseous (TO) repair is a safe alternative to anchor-based methods, providing comparable improvements in pain and function at one year [156]. The SpeedBridge Knotless Double-Pulley technique maintains clinically significant outcomes and repair survivorship [13].

Implant Selection: Anatomic footprint restoration is achievable in arthroscopic repair, with fixation at the suture-tendon and anchor-bone interfaces approximating traditional open transosseous repairs [280]. While historical concerns regarding fixation options have eased with improved implants and suture materials [280], specific implant design choices are not detailed in the provided evidence beyond the general use of suture anchors and transosseous techniques.

Adjuncts: Routine distal clavicle resection is not recommended with arthroscopic rotator cuff repair [202]. Augmented rotator cuff repair may decrease failure rates and improve function, but rigorous clinical evaluation is lacking [42]. There are no differences in clinical outcomes between repair with or without mesenchymal stem cell augmentation [188], though further investigation is needed as it shows promise for healing rates [198]. Bioinductive collagen scaffolds may improve pain, function, and structural outcomes in selected tears, but evidence is limited and heterogeneous [278].

Other Considerations: For partial-thickness tears, repair is best for tears involving more than 50% of tendon width, while debridement and potential decompression are preferred for those less than 50% [4]. Debridement has a higher failure rate for bursal-sided tears compared to articular-sided tears [4]. For deep partial tears, transtendon repair or completion to full-thickness repair shows no difference in functional outcomes or re-tear rates at 2 years [21, 4]. In situ repair or completion to full-thickness repair yields similar functional outcomes and re-tear rates [4]. Debridement is favored for partial-thickness tears with poor-quality tendon remaining and involving more than 80% of tendon thickness [4]. Transtendinous repair is indicated for delamination-type articular-side tears [4]. Intratendinous tears must be localized preoperatively, identified with a spinal needle, opened with an arthroscopic knife, and repaired side-to-side; extensive debridement is unnecessary [4]. Bilateral arthroscopic repair, whether single-stage or staged, yields similarly good clinical outcomes at follow-ups longer than 6 months [204]. Long-term follow-up (≥15 years) demonstrates durable improvement in patient-reported outcomes for all-arthroscopic repair [7]. ARCR is an effective and safe option with durable clinical results [140]. Patient-reported outcomes show small differences at 1 and 2 years post-repair [172]. Repair is effective in older populations, with good or excellent results in 87% of shoulders in one study [167], and high clinical success rates in patients aged >75 years [191]. Healed repairs show improved outcomes compared to physical therapy and unhealed repairs [161]. Greater preoperative disease severity is associated with failure to achieve clinically significant outcomes after massive repair [11]. Failure rates for large-to-massive tears remain high [205], and treatment usually results in pain relief but poor function [187]. Reverse total shoulder arthroplasty (rTSA) provides comparable clinical outcomes across indications of irreparable tear, tear arthropathy, and primary osteoarthritis at 2 years [49].

Rehabilitation: Surgical technique and postoperative rehabilitation protocol are two surgeon-controlled factors affecting outcomes [64]. With re-tear rates around 20% or greater for larger tears, the rehabilitation protocol is a critical modifiable factor [64]. Protocols vary between immobilization and early mobilization [64]. A large majority (93.9%) of protocols recommend sling use, typically discontinued between 4-6 weeks [276]. Sling discontinuation is delayed by 1.2 weeks for large/massive tears compared to small/medium tears [276]. A recent RCT found no significant differences in mobility or functional scores regardless of sling use for small/medium repairs, with slight increases in pain scores [276]. Rehabilitation begins with early passive range of motion to protect the repair and prevent stiffness, followed by scapular stabilization and rotator cuff strengthening [292]. Scapular stabilization is a foundational requirement for both nonsurgical and postoperative rehabilitation [292]. Weakness or dyskinesis of the scapula is common, and early emphasis on the serratus anterior and lower trapezius force couple is recommended [292]. Exercises must activate the rotator cuff and scapular musculature without promoting impingement or instability [292]. In a study of biceps tenodesis or tenotomy, patients used a sling for 6 weeks, began active-assisted range of motion after immobilization, and initiated strengthening at 12 weeks, with the goal of no restrictions by 24 weeks [279]. The best healing potential is in patients younger than 70 years with acute, small tears (<3 cm), a healthy tendon-bone interface, compliance with sling wear, and the ability to undergo an extended 6 to 9-month rehabilitation program [2].

Complications

General Complication Rates: Rotator cuff repair is associated with a low incidence of short-term complications [102], which are generally considered rare [126]. In cases of partial repair for irreparable supraspinatus tendon tears, complications remain rare and align with the usual sequelae observed in standard rotator cuff repairs [203].

Re-tear and Structural Failure: Re-tear rates following rotator cuff repair are approximately 20%, with higher rates reported for larger tears [64]. Symptomatic retear rates vary widely, ranging from 20% to 94% [284]. Specific anatomical and clinical factors significantly influence failure risk. Goutallier stages III and IV tears accompanied by a tendinous stump of less than 15 mm and a positive tangient sign carry a 90% failure rate [2]. Patients with a family history of rotator cuff tearing are more likely to experience repair failures [270], as are those with a history of bariatric surgery [305]. In patients undergoing simultaneous rotator cuff and Bankart repair, a persistent or recurrent rotator cuff tear rate of 31% did not appear to significantly impact functional outcomes [51].

Biceps-Related Complications: The short-term clinical influence of biceps complications on overall shoulder outcome is very limited [195].

Risk Factors and Modifiable Variables: Preoperative testosterone replacement therapy use is not linked to increased short-term complications after arthroscopic rotator cuff repair [194]. Conversely, steroid injections performed within 6 months of the index surgical procedure are correlated with a greater likelihood of revision rotator cuff surgery [343]. Neither trauma history nor preoperative symptom duration affected cuff integrity 6 months after arthroscopic rotator cuff repair [71].

Recovery

Natural History and Progression: In patients with full-thickness supraspinatus tears who refused operative treatment, there was no increase in the average size of the rotator cuff tears on MRI at 3.5 years after the initial MR arthrogram [18]. However, of 24 patients with full-thickness supraspinatus tears treated nonoperatively, 8 (33%) had an increase in tear size and 4 (17%) had no change in tear size [18]. In a cohort of 59 full and partial-thickness tears followed for at least 18 months, 48% were found to have progression of tear size [18]. In the same cohort of 59 tears, only 19% of tears followed for less than 18 months showed progression of tear size [18]. Full-thickness rotator cuff tears are more likely to progress than partial-thickness tears [18]. Tear progression occurred in 54% of patients over the age of 60 years compared with 17% in patients under 60 years [18]. 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 [18]. Approximately 50% of asymptomatic rotator cuff tears have a significant increase in size at a median time of 2.8 years [18]. Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time [354]. Fatty infiltration of the rotator cuff appears as early as 6 weeks after surgical detachment, starts near the musculotendinous junction, and progresses medially over time, worsening over the course of 1 year in the unrepaired rotator cuff [357]. The natural history of patients with rotator cuff tears included in randomized controlled trials is to improve over time, whether treated operatively or nonoperatively [56]. In cases of rotator cuff tears treated conservatively, at 13 years after diagnosis, about 90% of patients had no or only slight pain and about 70% had no disturbance in activities of daily life [361].

Surgical Outcomes and Survivorship: Overall survivorship was 94% at 5 years after open rotator cuff surgery and 83% at 10 years [43]. Long-term functional outcomes and structural integrity are maintained after arthroscopic double-row transosseous equivalent repair of medium to large rotator cuff tears at a minimum follow-up of 10 years [150]. Although long term rotator cuff integrity following repair is maintained in only 2/3 of operated shoulders, function is equivalent to the contralateral shoulder [155]. 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 [181]. Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome [211]. All intact rotator cuff tendons at 1 year remained intact at 2 years [359]. 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 [207]. 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 [200]. The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair [33, 38, 39]. Shoulder scores may decline at mid- to long-term follow-up for large and massive irreparable rotator cuff tears treated with superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers [186]. 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 [61]. Rotator cuff repair may not alter natural history [41].

Rehabilitation and Management: Successful management of rotator cuff disease is dependent on appropriate rehabilitation, which should be based on an evaluation of underlying tissue quality and structural integrity rather than solely on empirical clinical experience or fixed healing timelines [360].

Key Evidence

• [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. [7] (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] (10.1016/j.arthro.2024.12.040)
• [L4] At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes. [11] (10.1016/j.arthro.2023.06.031)
• [L5] It maintains clinically significant patient-reported and functional outcomes and rotator cuff repair survivorship. [13] (10.1016/j.eats.2021.12.039)
• [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] When patients with clinical suspicion of rotator cuff tear present with combinations of these radiographic signs, a prompt MRI examination and a referral to a shoulder specialist are recommended. [19] (10.1016/j.jseint.2020.09.015)
• [L4] Effective management of rotator cuff pathology critically relies on initial identification of all cuff tears, including nonobvious, partial and/or obscured full tears. [20] (10.1016/j.eats.2022.01.003)
• [L2] In patients with shoulder symptoms severe enough to consider surgery, clinical assessment followed by specific imaging may help define the pathology in order to direct appropriate management. [21] (10.1007/s10067-013-2260-0)
• [L4] Rotator cuff tears are frequently asymptomatic. [22] (10.1308/003588406x94968)
• [L5] A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders. [23] (10.1016/j.pmrj.2012.08.019)
• [L4] When combined with a careful history and clinical examination, it will help guide the use of further radiological investigations, obviating unnecessary waiting times and tests for many without cuff tears. [24] (10.1177/1758573217743942)
• [L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. [26] (10.1007/s11999-008-0585-9)
• [L5] The Society of Radiologists in Ultrasound convened a panel of specialists to reach a consensus about the recommended imaging evaluation of painful shoulders with clinically suspected rotator cuff disease. [27] (10.1148/radiol.13121947)
• [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. [28] (10.1016/j.jse.2011.09.028)
• [L4] Imaging findings of rotator cuff disease must be considered in a clinical context and should never be used as the only basis for operative intervention. [29] (10.1016/s0720-048x(03)00159-1)
• [L3] There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease. [30] (10.1016/j.jse.2013.10.001)
• [Paper] Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality. [31] (10.1016/j.csm.2012.07.010)
• [L3] The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair. [33] (10.1177/0363546514560729)
• [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. [35] (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. [36] (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. [38] (10.1177/2325967114s00016)
• [L3] Short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair. [39] (10.1016/j.jse.2015.05.015)
• [L4] Thus, rotator cuff repair may not alter natural history. [41] (10.2106/jbjs.oa.17.00043)
• [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. [42] (10.1136/bmjopen-2020-039552)
• [L4] Overall survivorship was 94% at 5 years after open rotator cuff surgery and 83% at 10 years. [43] (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. [47] (10.1016/j.jisako.2024.01.001)
• [L3] rTSA provides comparable clinical outcomes across indications of irreparable rotator cuff tear, rotator cuff tear arthropathy, and primary osteoarthritis at 2 years, supporting its broad applicability. [49] (10.1016/j.jsea.2026.100080)
• [L4] The persistent or recurrent rotator cuff tear rate of 31% did not appear to significantly impact functional outcomes in this patient population. [51] (10.1016/j.arthro.2014.04.041)
• [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. [52] (10.1007/s43465-020-00345-7)
• [Paper] The utility of acromioplasty at the time of rotator cuff repair has come into question, with new studies showing no significant benefit. [54] (10.1016/j.ocl.2013.12.003)
• [L1] The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively. [56] (10.1177/0363546518780694)
• [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. [61] (10.1016/j.jse.2024.05.056)
• [L5] [62] (10.5435/00124635-199901000-00004)
• [L3] Trauma history and preoperative symptom duration did not affect cuff integrity 6 months after arthroscopic RCR. [71] (10.1177/23259671251355125)
• [L4] A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further. [72] (10.1302/2058-5241.1.160005)
• [L5] [75] (10.1016/j.eats.2024.103145)
• [L4] Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. [77] (10.1007/s00167-014-3486-3)
• [L1] [78] (10.1177/0363546514538390)
• [L4] A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair. [83] (10.1016/j.arthro.2007.05.002)
• [L5] Current consensus suggests rotator cuff injuries are most accurately diagnosed with a combination of cuff- and impingement-specific clinical tests. [86] (10.1016/j.arthro.2013.07.265)
• [L4] The most common and consistent presenting symptom is shoulder pain, with weakness of the shoulder and arm as a common secondary complaint. [87] (10.1016/s1058-2746(95)80145-6)
• [L2] Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. [88] (10.1016/j.jse.2024.02.024)
• [L5] The authors argue that shoulder 'special tests' for rotator cuff-related shoulder pain should be discontinued as they lack validity for isolating specific structures or identifying the cause of symptoms, and recommend evolving the diagnostic approach to focus on functional assessment, psychosocial factors, and evidence-informed management. [90] (10.2519/jospt.2020.0606)
• [L2] [92] (10.1016/j.jse.2013.12.037)
• [L1] Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. [93] (10.1186/s13018-014-0070-y)
• [L2] [96] (10.1177/2325967118784897)
• [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. [98] (10.1007/s00167-020-06136-9)
• [L4] [100] (10.5435/jaaos-d-17-00090)
• [L4] Rotator cuff repair has a low incidence of short-term complications. [102] (10.1016/j.arthro.2017.10.040)
• [L5] Advanced practice providers should be acquainted with physical examination findings and special testing consistent with rotator cuff pathology to prompt appropriate advanced imaging. [105] (10.1097/nor.0000000000000441)
• [L4] A morphologic classification system allowed the appearance of the teres minor to be defined in isolated and multiple rotator cuff tears in CT and MRI images. [106] (10.1007/s00256-011-1178-3)
• [L4] The findings of this investigation suggest that a clinical diagnosis of a full-thickness tear of the rotator cuff cannot be conclusively reached using one or more of the lag signs. [108] (10.1016/j.apmr.2007.10.046)
• [L4] The SLAM sign is a simple and easily identifiable radiological predictor of rotator cuff disease. [109] (10.1016/j.jseint.2021.05.013)
• [L5] A thorough understanding of the anatomy and function of the rotator cuff and of the consequences of rotator cuff disorders is essential for optimal treatment planning and prognostic accuracy. [111] (10.1148/rg.264055087)
• [L2] The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears. [114] (10.1177/2325967116667058)
• [L4] The presence of a rotator cuff tear was associated with a disruption of normal glenohumeral kinematics in the scapular plane, characterized by superior migration of the humeral head. [115] (10.1016/s1058-2746(00)90002-8)
• [L5] The status of the rotator cuff is not the primary variable that results in patient symptom severity or decline in shoulder-specific health-related quality of life. [116] (10.2106/jbjs.o.01085)
• [L4] The proposed classification system may assist decision making in the treatment of partial thickness rotator cuff tears. [119] (10.4103/0019-5413.136249)
• [L3] Short-term complications after rotator cuff repair are rare. [126] (10.1016/j.arthro.2017.10.027)
• [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. [133] (10.1177/0363546506298108)
• [L5] Tears of the subscapularis have greater biomechanical consequences than do tears of the infraspinatus. [135] (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. [137] (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. [139] (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. [140] (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. [141] (10.1016/j.jisako.2021.12.004)
• [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. [142] (10.1007/s11999-017-5340-7)
• [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. [143] (10.1016/j.arthro.2008.10.005)
• [L3] The classification of rotator cuff tears should take into account the site of the tear since it may help physicians predict the outcome of the disease more precisely. [145] (10.1080/000164702317281387)
• [L3] Long-term functional outcomes and structural integrity are maintained after arthroscopic DR-TOE repair of medium to large rotator cuff tears at a minimum follow-up of 10 years. [150] (10.1016/j.jse.2021.03.073)
• [L3] Patients with rotator cuff tearing demonstrate abnormal glenohumeral kinematics with superior translation of the humeral head in the scapular plane and a strong trend toward abnormal glenohumeral-scapulothoracic motion relationships before surgery. [151] (10.1016/s1058-2746(97)90084-7)
• [L4] The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in the functional planes of motion. [153] (10.2106/00004623-198668030-00013)
• [L4] Although long term rotator cuff integrity following repair is maintained in only 2/3 of operated shoulders, function is equivalent to the contralateral shoulder. [155] (10.1016/s1058-2746(98)90082-9)
• [L3] Arthroscopic TO rotator cuff repair is a safe and effective alternative to AB methods, providing comparable improvements in pain, shoulder function, and range of motion at one year. [156] (10.1177/17585732251408837)
• [L5] The critical tear size which leads to the loss of normal shoulder biomechanics was identified as half tear of the infraspinatus accompanied by a complete tear of the supraspinatus tendon. [160] (10.1109/access.2019.2895997)
• [Paper] Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes. [165] (10.1016/j.clinbiomech.2010.08.001)
• [L4] This study demonstrates the effectiveness of rotator cuff repair in an older population, with good or excellent results in 84 (87%) of 97 shoulders. [167] (10.1067/mse.2001.110513)
• [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. [168] (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. [169] (10.1016/j.jse.2016.12.063)
• [L2] Massive rotator cuff tears can be divided into 3 types (anterosuperior, posterosuperior, and anteroposterior), each showing distinctive characteristics and different results in preoperative and postoperative metrics, providing a reasonable basis for subclassification. [171] (10.1177/0363546516667498)
• [L4] Both patient-reported outcomes and achievement of clinically significant outcomes show small differences at 1 and 2 years after rotator cuff repair. [172] (10.1016/j.arthro.2023.09.024)
• [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. [177] (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. [181] (10.1016/j.arthro.2018.09.026)
• [L1] One trial compared manual therapy and exercise with placebo in 120 participants with chronic rotator cuff disease and found high quality evidence of small improvements in overall pain and function, and a higher proportion of participants reporting treatment success. [182] (10.1002/14651858.cd012224)
• [L4] The size of the rotator cuff tear could be categorized into one of four groups with accuracy in only 56% of the cases. [183] (10.1016/s1058-2746(09)80127-4)
• [L3] Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. [185] (10.1002/ksa.12162)
• [L1] Shoulder scores may decline at mid- to long-term follow-up. [186] (10.1186/s13018-022-03411-y)
• [L4] Treatment of massive rotator cuff tears usually results in pain relief but poor function. [187] (10.1016/s1058-2746(96)80431-9)
• [L4] There are no differences in clinical and functional outcomes between rotator cuff repair with or without augmentation with MSCs. [188] (10.1016/j.xrrt.2024.12.003)
• [L5] This model is relevant for the rotator cuff and provides a framework to stage the continuity of rotator cuff pathology. [189] (10.1136/bjsm.2008.054817)
• [L4] Rotator cuff repair in patients aged >75 years could achieve high clinical success rates with good outcomes and pain relief. [191] (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. [192] (10.1016/j.jseint.2024.11.018)
• [L2] Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. [193] (10.1016/j.jse.2017.10.009)
• [L2] Preoperative TRT use was not linked to increased short-term complications after arthroscopic rotator cuff repair. [194] (10.1016/j.jse.2025.12.013)
• [L3] Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited. [195] (10.1177/2325967121s00362)
• [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. [197] (10.1186/s13018-025-06643-w)
• [L1] Further investigation is needed into this new and evolving treatment; however, it shows promise for improving the rate of rotator cuff repair healing and overall functional outcome. [198] (10.1177/2325967119s00275)
• [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. [199] (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. [200] (10.2106/jbjs.24.00065)
• [L5] Relative indications for revision rotator cuff surgery include the symptomatic recurrence of a rotator cuff tear in an active, nonsmoking patient. [201] (10.1097/bte.0b013e31824c2574)
• [L1] We do not recommend doing routine DCR with arthroscopic rotator cuff repair. [202] (10.1016/j.otsr.2020.08.006)
• [L4] Complications were rare and in line with the usual sequelae of a rotator cuff repair. [203] (10.1016/j.jse.2010.11.002)
• [L3] Patients receiving single-stage or staged bilateral arthroscopic rotator cuff repair showed similarly good clinical outcomes at follow-ups longer than 6 months. [204] (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. [205] (10.2106/jbjs.20.00177)
• [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. [207] (10.1177/0363546511424268)
• [L3] Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. [211] (10.2106/00004623-199907000-00012)
• [L4] All other outcomes and classifications did not show acceptable reliability; therefore, caution is needed when using them for preoperative evaluation of a rotator cuff tear. [212] (10.1177/03635465231166077)
• [L1] Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. [215] (10.1016/j.jse.2020.11.002)
• [L3] Different types of cuff tear morphology, despite affecting surgical repair technique, do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up. [216] (10.1016/j.jisako.2023.10.014)
• [L3] In experienced hands, sonography has a low level of interobserver variability for the detection, classification, and localization of rotator cuff tears. [217] (10.2214/ajr.183.5.1831465)
• [L1] Arthroscopic rotator cuff repair is favored for improving shoulder function, while other procedures or intraarticular treatments offer no significant benefits. [219] (10.1186/s13018-024-05129-5)
• [L4] LHB instability was associated with LHB lesions and rotator cuff tear size, leading to the creation of a new arthroscopic classification. [220] (10.1016/j.arthro.2006.08.025)
• [L3] The study proposes a three-stage classification based on the occupation ratio to improve indications for rotator cuff tear treatment. [222] (10.3109/17453679608994685)
• [L5] Proper indications for shoulder subacromial decompression result in excellent outcomes. [223] (10.1016/j.arthro.2021.04.023)
• [L5] The unclassified types of the mechanoreceptors were thought to be related to the dysfunction and painful condition in the rotator cuff tear. [224] (10.1016/s1058-2746(96)80452-6)
• [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. [228] (10.2106/jbjs.rvw.17.00052)
• [L1] Therefore, rotator cuff repair may be suggested after failed non-surgical treatment. [230] (10.1136/annrheumdis-2020-219099)
• [L4] The purpose of this article is to propose a comprehensive review and classification of all different subtypes of anterior impingement in the shoulder, including newly described entities. [232] (10.1007/s00264-017-3515-1)
• [L5] Diagnostic imaging of the rotator cuff, performed by MRI, provides valuable information about the nature of the injury. [233] (10.1016/j.ejrad.2008.02.018)
• [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. [235] (10.1016/j.arthro.2023.11.002)
• [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. [236] (10.5435/00124635-201312000-00008)
• [L1] There is a need for well-designed level I and level II trials to elucidate the optimal rotator cuff repair rehabilitation protocol. [237] (10.1177/1941738108331200)
• [L3] While indications have expanded for RSA beyond rotator cuff arthropathy, our study demonstrates that RSA with preservation of the rotator cuff demonstrates excellent outcomes without increased risk of complications. [239] (10.1016/j.jisako.2023.03.330)
• [L4] Rotator cuff repair is cost-effective for all populations. [241] (10.2106/jbjs.l.01495)
• [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. [242] (10.1007/s00167-015-3700-y)
• [L3] Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology. [249] (10.1016/j.jseint.2025.04.038)
• [L4] The non-surgical route with an appropriate physiotherapy programme has a role in the management of degenerative rotator cuff tears, especially in patients with significant risk factors for surgery, those who do not wish to go through a surgical treatment and those with small, partial and irreparable tears. [250] (10.1308/rcsann.2019.0173)
• [L3] CSA and AI do not appear to influence 24-month functional outcomes postoperatively and hence are not contraindications to arthroscopic rotator cuff repair. [252] (10.1177/0363546517717947)
• [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. [255] (10.1016/j.arthro.2024.08.034)
• [L2] MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions. [261] (10.1016/j.jse.2015.06.005)
• [L2] Magnetic resonance arthrography was more accurate in evaluating rotator cuff tear size and morphologic features than conventional magnetic resonance imaging. [262] (10.1097/01.blo.0000176142.01262.35)
• [L1] There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. [263] (10.1080/09638288.2016.1198431)
• [L2] Individuals with a family history of rotator cuff tearing were more likely to have repair failures. [270] (10.1016/j.jse.2016.02.019)
• [L3] Patients with rotator cuff tears who undergo surgical or nonsurgical treatment tend to improve, with patients allocated to surgery improving to a greater degree across three years of follow-up. [273] (10.1177/2325967113s00100)
• [L4] [276] (10.1016/j.jse.2020.11.016)
• [L4] BCS may improve pain, function, and structural outcomes in selected rotator cuff tears; however, evidence remains limited, heterogeneous, and predominantly non-randomized. [278] (10.5397/cise.2025.01326)
• [L3] [279] (10.1016/j.arthro.2019.02.017)
• [L4] [281] (10.1016/j.otsr.2009.05.001)
• [L3] Patients with rotator cuff tears who undergo surgical or nonsurgical treatment tend to improve, with surgical patients improving to a greater degree. [283] (10.1177/2325967114s00059)
• [L2] [284] (10.1016/j.arthro.2021.04.041)
• [L2] Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears. [287] (10.1148/radiol.12112062)
• [L4] MRI appears to be accurate in detecting the presence of a recurrent rotator cuff tear in shoulders with suspected failed cuff repairs, with a sensitivity of 91%. [290] (10.1067/mse.2002.120139)
• [L3] Additionally, non-surgical treatment is recommended as the preferred approach for patients with non-traumatic rotator cuff injuries. [291] (10.1186/s13018-024-04858-x)
• [L5] Following nonoperative treatment for at least 6 weeks, SAD is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff. [294] (10.1016/j.arthro.2019.06.012)
• [L4] In practice, radiologic AHD equal to or greater than 6 mm is of no diagnostic relevance: the rotator cuff may be continuous, or showing full-thickness tear. [295] (10.1016/j.otsr.2011.01.010)
• [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. [297] (10.1016/j.jse.2023.11.012)
• [L5] Both MRI and ultrasound can be used to evaluate the repaired rotator cuff and potential complications. [298] (10.2214/ajr.18.19648)
• [L4] The association between acromial type as determined on magnetic resonance imaging and the presence of rotator cuff tearing was less significant. [299] (10.1016/s1058-2746(95)80022-0)
• [L4] These results indicate that shoulder radiographs of subjects with a documented rotator cuff tear have greater tuberosity radiographic abnormalities that are not noted in asymptomatic subjects without a rotator cuff tear. [300] (10.1067/mse.2003.19)
• [L3] A history of bariatric surgery is associated with increased failure rates, worse postoperative pain, and worse patient-reported outcomes after arthroscopic rotator cuff repair. [305] (10.1177/23259671261447216)
• [L4] Analysis of our data supports the reliability of MRI assessment by shoulder specialists for rotator cuff disorders. [306] (10.1016/j.pmrj.2014.08.949)
• [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. [307] (10.2106/jbjs.20.00400)
• [L4] MRI and US are useful in the postoperative assessment of the rotator cuff, not only for evaluation of the integrity of the rotator cuff, but also for detecting hardware complications and other etiologies of shoulder pain. [308] (10.1007/s12178-018-9463-6)
• [L5] [313] (10.2214/ajr.14.13815)
• [L2] Thus, the algorithm improved the role of shoulder radiography as an initial imaging modality to rule out rotator cuff tears. [316] (10.1016/j.jse.2023.02.066)
• [Abstract] Three-dimensional MRI seems to be useful in assessing the rotator cuff muscles. [317] (10.1016/j.jse.2020.01.010)
• [L4] Full-thickness rotator cuff tears can be identified using ultrasound and MRI with comparable accuracy. [318] (10.4103/0973-6042.63218)
• [L4] The major role of MR imaging in the investigation of rotator cuff disorders is in the detection of full-thickness rotator cuff tears. [319] (10.1148/radiology.194.3.7862988)
• [L1] MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears. [320] (10.2214/ajr.08.1241)
• [Abstract] Three-dimensional magnetic resonance imaging appears to be useful to assess the rotator cuff muscles. [321] (10.1016/j.jse.2016.11.032)
• [L3] MRI and US provide similar assessments of postoperative rotator cuff healing, although US is less sensitive. [322] (10.1016/j.otsr.2015.06.006)
• [L3] MRI seems to be the most sensitive procedure in diagnosing cuff tears. [323] (10.1016/s1058-2746(96)80177-7)
• [L3] These secondary radiographic findings on conventional views are useful for initial screening of patients with shoulder pain. [324] (10.1067/mse.2001.117123)
• [L4] MRI is an effective tool for evaluating rotator cuff tears and determining tear severity. [326] (10.1016/j.jseint.2021.10.003)
• [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. [329] (10.1016/j.jse.2019.04.003)
• [L4] Possibly, radiographs combined with active tasks offer new possibilities in diagnosing early-stage rotator cuff tears. [331] (10.1007/s11517-013-1057-2)
• [L5] [333] (10.5435/jaaos-21-08-492)
• [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. [336] (10.1016/j.jse.2024.08.030)
• [L1] The diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness rotator cuff tears is high with overall estimates of sensitivity and specificity over 0.90. [338] (10.1136/bjsports-2014-094148)
• [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. [339] (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. [340] (10.1016/j.jse.2020.07.037)
• [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. [341] (10.1016/j.jse.2021.04.021)
• [L4] A useful approach to image the shoulder after surgery is standard radiography, followed by MRI or MR arthrography for patients with low metal presence and CT for patients with higher metal presence. [342] (10.1259/bjr.20130630)
• [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. [343] (10.1016/j.arthro.2018.12.017)
• [L5] [345] (10.1016/j.jse.2011.10.022)
• [L4] Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time. [354] (10.1016/j.arthro.2018.07.031)
• [L5] Fatty infiltration of the rotator cuff appears as early as 6 weeks after surgical detachment, starts near the musculotendinous junction, and progresses medially over time, worsening over the course of 1 year in the unrepaired rotator cuff. [357] (10.1016/j.arthro.2007.01.023)
• [L3] All intact rotator cuff tendons at 1 year remained intact at 2 years. [359] (10.1177/0363546509335764)
• [L5] Successful management of rotator cuff disease is dependent on appropriate rehabilitation, which should be based on an evaluation of underlying tissue quality and structural integrity rather than solely on empirical clinical experience or fixed healing timelines. [360] (10.5435/00124635-200610000-00002)
• [L2] In cases of rotator cuff tears treated conservatively, at 13 years after diagnosis, about 90% of patients had no or only slight pain and about 70% had no disturbance in activities of daily life. [361] (10.1016/j.jse.2011.10.012)

See Also

• Rotator Cuff Repair
• Subacromial Decompression
• Total shoulder arthroplasty
• Reverse Shoulder Arthroplasty
• Revision rotator cuff repair
• Shoulder Arthritis
• Calcific Tendinitis
• Shoulder Arthroscopy
• Cuff Arthropathy
• Rotator Cuff Disorders
• Biceps Tenodesis

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