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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.

214 citationsUpdated Sep 2026

Overview¶

Clinical decision-making for rotator cuff tears remains complex and lacks consensus among orthopaedic surgeons, as neither American Academy of Orthopaedic Surgeons clinical practice guidelines nor Cochrane systematic reviews provide specific management guidance [1]. Patients are generally stratified into three categories based on the risk of nonoperative treatment and the benefits of surgical intervention: 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 developed Appropriate Use Criteria using the RAND/UCLA Appropriateness Method to guide treatment decisions for full-thickness tears by synthesizing evidence and expert opinion across 432 patient scenarios [56]. Treatment options for large and massive tears must be based on individual patient indications [57], while indications for operative treatment of massive and irreparable tears were determined based on expert consensus and the best available evidence [47].

Arthroscopic rotator cuff repair is favored for improving shoulder function, whereas other procedures or intraarticular treatments offer no significant benefits [216]. Complications after rotator cuff repair are not common and are equivalent between arthroscopic and open techniques [255], with open surgery remaining a valid option in specific indications and settings where arthroscopic resources are limited [51]. Routine distal clavicle resection is not recommended with arthroscopic repair [53], and new studies show no significant benefit from the utility of acromioplasty at the time of repair [18]. Proper indications for shoulder subacromial decompression result in excellent outcomes [222], and prevention of complications and successful primary repair results in better functional outcomes than revision strategies [226]. 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, 37].

Rotator cuff repair is cost-effective for all populations [236]. Appropriately selected patients aged 65 years or over with a massive full-thickness tear can be expected to have a good functional outcome and pain relief after repair [261]. One-year follow-up does not determine the long-term outcome of rotator cuff repair [12], although the 2-year benchmark may be arbitrary as 1-year follow-up appears clinically sufficient [60]. Authors are obliged to evaluate the long-term outcomes of rotator cuff repair procedures [12]. Bridging reconstruction performs best for irreparable tears of the superior-posterior rotator cuff with an intact or reparable subscapularis [57]. A paucity of rigorous clinical evaluation regarding effectiveness and safety prevents firm recommendations for augmented rotator cuff repair with implantable meshes [43].

Anatomy & Pathophysiology¶

Anatomy¶

The rotator cuff comprises four muscles arising from the scapula, with tendons that blend into the subjacent capsule to attach to the humeral tuberosities [119]. The subscapularis originates from the anterior scapula and inserts on the lesser tuberosity [119]. 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 [119]. The infraspinatus originates from the fossa below the scapular spine and inserts on the posterolateral greater tuberosity [119]. The teres minor arises from the lower lateral scapula and attaches to the lower portion of the greater tuberosity [119]. Innervation follows distinct pathways: the supraspinatus receives supply from the suprascapular nerve after it passes through the suprascapular notch [119], while the infraspinatus is innervated by the suprascapular nerve after it traverses the spinoglenoid notch [119]. The subscapularis is supplied by the upper and lower subscapular nerves [119], and the teres minor by a branch of the axillary nerve [119].

The rotator cuff tendons consist of five distinct histologic layers [119]. The most superficial layer contains coracohumeral ligament fibers oriented obliquely to the muscle axis [119]. The second layer comprises large bundles extending from the supraspinatus tendon over the biceps tendon groove [119]. The third layer contains smaller, less tightly packed fascicles with less uniform orientation [119]. The fourth layer consists of loose connective tissue with thick collagen bands that merge with the coracohumeral ligament at the anterior edge of the supraspinatus [119]. The fifth and deepest layer is a continuous sheet of collagen fibrils composing the superior joint capsule [119]. Significant interdigitation of supraspinatus and infraspinatus tendons occurs near the footprint [119], where the infraspinatus insertion occupies the preponderance of the greater tuberosity footprint [119]. The supraspinatus insertion occupies a smaller portion of the greater tuberosity than previously believed [119].

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 [119]. The coracohumeral ligament and transverse humeral ligament keep the biceps tendon aligned in the groove [119]. Functionally, the rotator cuff stabilizes the humeral head into the glenoid when the deltoid lifts the arm forwards or sideways [6]. The coracoacromial arch, a fibro-osseous canopy formed by the acromion process, coracoid process, and coracoacromial ligament, is separated from the rotator cuff tendons by the subacromial bursa to allow gliding [6].

Specific footprint dimensions are defined for surgical planning. The supraspinatus footprint measures 13 mm in width medial-laterally and 20 mm anteroposteriorly [38]. The infraspinatus footprint measures 14 mm wide and 20 mm superoinferiorly [38]. A 7 mm medial-lateral tear corresponds to a 50% partial thickness tear of the supraspinatus [38]. The rotator cable is a thick bundle of fibers running perpendicular to the supraspinatus tendon fibers, connecting the supraspinatus and infraspinatus tendons [38]. This cable is divided into anterior, middle, and posterior segments [130]. The anterior segment forms the lateral part of the rotator interval [130]. The middle portion lies 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 coracohumeral ligament contributes fibers that envelope the supraspinatus tendon in the rotator interval [130].

The rotator interval capsule, superior glenohumeral ligament, and coracohumeral ligament come under tension with glenohumeral flexion, extension, external rotation, and adduction [136]. The superior glenohumeral ligament crosses the rotator interval capsule 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]. The glenohumeral joint capsule exhibits variable thickness: it is thickest in the inferior pouch at 2.8 mm [136], with the anterior portion measuring 2.4 mm [136] and the posterior portion measuring 2.2 mm [136]. The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in functional planes of motion [153].

Pathophysiology¶

Rotator cuff disease represents a continuum progressing from mild impingement to partial tear, full-thickness tear, massive tear, and rotator cuff tear arthropathy [305]. The prevalence of full-thickness rotator cuff tears is approximately 25% in patients over 60 years of age [2], increasing to 50% in patients over 80 years of age [2]. 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 overall prevalence of asymptomatic partial-thickness rotator cuff tears is 20% [4], rising to 26% in patients older than 60 years [4]. 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], and a portion will progress to full-thickness rotator cuff tears [4].

Pathogenesis involves both intrinsic and extrinsic factors. Intrinsic degeneration involves age-related changes in collagen, proteoglycan, water content, and vascularity [38]. This degeneration usually involves the supraspinatus and infraspinatus, starting on the articular side [38]. Extrinsic injury mechanisms involve chronic impingement on the coracoacromial arch [38], with tears from extrinsic impingement usually starting on the bursal side of the tendon [38]. Acute traumatic rotator cuff tears typically occur after a fall and/or dislocation in patients under 40 years of age [38]. Risk factors for rotator cuff tear development include age, smoking, female sex, family history, diabetes, and high cholesterol [38].

Degenerative rotator cuff tears initiate approximately 13 to 17 mm posterior to the long head of the biceps tendon [67]. These tears propagate anteriorly and posteriorly from the initiation site [67], which correlates with the posterior supraspinatus and anterior infraspinatus region [67]. The "rotator crescent" tissue is thinner and more avascular than the "rotator cable" [67]. Tears involving the anterior cable of the rotator cuff have a significant impact on the rate of irreversible muscle degeneration [67]. Loss of integrity of the anterior supraspinatus tissue may lead to accelerated retraction and degeneration of muscle tissue [67].

Morphological risk factors include specific bony indices. The critical shoulder angle is formed by lines drawn from the inferior glenoid to the superior glenoid and from the inferior glenoid to the inferolateral acromion [264]. A critical shoulder angle above 35° to 38° has been shown to correlate with rotator cuff tears and postoperative retears [264]. The acromial index is the ratio of the medial/lateral length from the glenoid to the lateral acromion divided by the length from the glenoid to the lateral aspect of the greater tuberosity [264]. An acromial index above 0.7 has been associated with full-thickness rotator cuff tears and higher retear rates [264]. Rotator cuff disease may involve a genetic predisposition to intrinsic degenerative tendinopathic changes [264]. Studies have shown familial hereditary patterns of rotator cuff disease [264], and genes associated with significant rotator cuff pathology have been identified [264]. Two correlated single nucleotide polymorphisms are associated with full-thickness rotator cuff tears [5].

The supraspinatus tendon is most often initially involved in rotator cuff tendinosis [17]. Rotator cuff impingement is thought to arise 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 for impingement include spurs growing down the coracoacromial ligament and osteoarthritic thickening of the acromioclavicular joint [154]. The "impingement position" is defined as abduction, slight flexion, and internal rotation [154].

Cuff tear arthropathy is the final stage of the shoulder impingement syndrome spectrum [16]. 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 [16]. Cuff tear arthropathy affects women at a 3:1 female to male ratio [16], more commonly affects patients over 70 years of age [16], and more commonly affects the dominant shoulder [16]. Risk factors for cuff tear arthropathy include chronic rotator cuff tears, hemorrhagic shoulder, rheumatic disease, and crystal-induced arthropathy [16]. Mechanical factors in cuff tear arthropathy include insufficient cuff, superior migration of the humeral head, instability, eccentric wear of the glenoid, and humeral head deformity [16]. Nutritional factors in cuff tear arthropathy include hypomobility-induced cartilage atrophy, poor nutrition, dehydration, and subchondral osteoporosis [16]. Crystalline-induced arthropathy involves synovial-based matrix protein degradation destroying rotator cuff tendons and cartilage [16].

Calcific tendinitis presents with a prevalence of 2.7% in a working population [211], though reported prevalence varies between 2% and 20% [296]. 35% of shoulders with calcific tendinitis are symptomatic [211]. The condition typically affects patients aged 30 to 60 years [211] and affects women more commonly than men [211]. The supraspinatus tendon is most often involved in calcific tendinitis [211], specifically the "critical zone" of relative hypovascularity [296]. Calcific tendinitis involves a cyclical progression of reactive calcium hydroxyapatite crystal intratendinous deposition followed by spontaneous resorption and healing [296]. It is the result of a metaplastic cell-mediated transformation of tenocytes into chondrocytes which induce calcification [296]. Foci of metaplasia in calcific tendinitis are phagocytized by giant cells and the tendon remodels to reform normal tendon [296].

The precalcific stage of calcific tendinitis consists of predominantly fibrocartilaginous metaplasia within less vascular areas of the tendon [211]. In the formative phase of the calcific stage, matrix vesicles unite to form calcium hydroxyapatite deposits separated by fibrocollagenous tissue [211]. The resorption phase of calcific tendinitis involves an inflammatory response and is exquisitely painful [211]. Pain during the proliferative phase of calcific tendinitis is correlated with macrophage activity during the resorptive phase [211].

Biologic changes contributing to rotator cuff tear pathogenesis include extracellular matrix remodeling, angiogenesis, changes in metabolism, apoptosis, and stress-related genes [342]. Metaplasia of rotator cuff cells is contributed to by changes in gene expression [342]. The rotator cuff serves multiple functions including initiating/assisting active shoulder motion and providing dynamic stability via force-couple moment [264]. Most rotator cuff tears occur in the anterior portion of the supraspinatus tendon [264]. Tears involving the rotator cable result in increased tear gap distance and strain compared with those in the crescent area [264]. Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increase glenohumeral translation and change kinematics [166].

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]. The critical tear size leading to loss of normal shoulder biomechanics is identified as a half tear of the infraspinatus accompanied by a complete tear of the supraspinatus tendon [158]. Dynamic superior migration of the humeral head during abduction occurs in patients with rotator cuff tears [178]. Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes [161]. The rotator interval is central to normal glenohumeral kinematics, and any insult to its integrity alters shoulder motion throughout abduction [97]. Tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics in a cadaveric model of the throwing shoulder [105].

The pathophysiological basis of PAINT lesions includes internal impingement, intrinsic tendon degeneration, local tissue hypovascularity, and anterior-inferior glenohumeral instability [156]. The articular side of the rotator cuff is less vascular and has a higher modulus of elasticity compared with the bursal surface [156]. Eccentric forces tend to be concentrated more along the articular surface fibers of the rotator cuff [156].

Classification¶

General Principles and Reliability¶

Rotator cuff disease is described as a continuum of pathology [27], with models providing a framework to stage the continuity of the disease [189]. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes [163]. Currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons, with the exception of distinguishing partial-thickness from full-thickness tears and identifying the side of involvement in partial-thickness tears [133]. The ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communicating among surgeons and for pooling of data from clinical studies [141]. A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further [73]. 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].

Partial-Thickness Tears¶

Ellman: Ellman described a classification of partial-thickness rotator cuff tears based on location and depth of tearing noted at the time of shoulder arthroscopy [4]. Partial-thickness rotator cuff tears are classified as articular-sided (A), bursal-sided (B), or intratendinous (C) [4]. In the Ellman classification, partial-thickness tears are grade 1 if involving 3 mm or less of tendon depth [4]. In the Ellman classification, partial-thickness tears are grade 2 if involving 3 to 6 mm of tendon depth [4]. In the Ellman classification, partial-thickness tears are grade 3 if involving more than 6 mm of tendon depth [4]. Grade 3 partial-thickness tears represent tears of more than 50% of tendon width [4]. Ellman proposed a classification scheme that included specific consideration of the site and extent of partial cuff tears, recording location as articular surface, bursal surface, or intratendinous [63]. In Ellman’s classification, grade I partial tears have a depth of less than 3 mm [63]. In Ellman’s classification, grade II partial tears have a depth of 3 to 6 mm [63]. In Ellman’s classification, grade III partial tears involve more than half of the cuff thickness [63]. The average cuff thickness is 9 to 12 mm [63]. In Ellman’s subclassification of stage-III rotator cuff tears, partial-thickness tears are designated by location (A: Articular, B: Bursal, C: Interstitial) and grade (1: <3 mm, 2: 3–6 mm, 3: >6 mm) [343]. The area of defect for partial-thickness tears is defined as the base of the tear multiplied by maximum retraction in square millimeters [343].

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) [63]. In Neer’s classification, partial tears were not categorized separately and have been considered advanced stage II lesions by some authors and early stage III lesions by others [63].

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 [112].

Other Considerations: Classification of partial-thickness rotator cuff tears should be descriptive in terms of location (tendon involved and surface affected), size (depth) of the tear, and cause [63]. The presence of a grade III partial-thickness rotator cuff tear is often considered a relative indication for surgical repair in the symptomatic patient [63]. A proposed classification system may assist decision making in the treatment of partial thickness rotator cuff tears [116]. A novel classification for partial subscapularis tendon tears has been presented to enable more detailed and reproducible description [241].

Full-Thickness Tears¶

Ellman: Full-thickness rotator cuff tears are designated by location (A: Supraspinatus, B: Infraspinatus, C: Teres minor, D: Subscapularis) and grade (1: Small <2 cm, 2: Large 2–4 cm, 3: Massive >5 cm) in Ellman’s subclassification [343]. A fourth grade is added to Ellman’s full-thickness classification to include cuff arthropathy, defined as a massive tear with articular irregularity, collapse of the humeral head, chronic synovitis, and capsular laxity [343]. The area of defect for full-thickness tears is defined as the base of the tear multiplied by maximum retraction in square centimeters [343].

Patte: A modified Patte classification system for rotator cuff tendon retraction has excellent diagnostic performance for reparability and acceptable performance for rotator cuff healing [184]. In the Patte classification, segment 1 corresponds to a subscapularis tear [49]. In the Patte classification, segment 2 corresponds to a coracohumeral ligament tear [49]. In the Patte classification, segment 3 corresponds to an isolated supraspinatus tear [49]. In the Patte classification, segment 4 corresponds to a tear of the entire supraspinatus and one-half of the infraspinatus [49]. In the Patte classification, segment 5 corresponds to a tear of the supraspinatus and infraspinatus [49]. In the Patte classification, segment 6 corresponds to a tear of the subscapularis, supraspinatus, and infraspinatus [49]. Anteriorly situated rotator cuff defects are more painful, whereas posterior lesions interfere more with function [49]. 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 [49]. Isolated coracohumeral ligament tears (Patte segment 2) are traumatic in nature and do not contribute to the pathology of the cuff [49]. Patte segments 4 and 5 tears merit special attention given the inherent difficulties of repair [49]. Secondary osteoarthritis was most common among patients with total-cuff tears (Patte segment 6) [49].

Other Considerations: A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair [83]. 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 [168]. Different types of cuff tear morphology do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up [213]. 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 [174].

Fatty Infiltration and Muscle Degeneration¶

Goutallier: 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 classification, grade 0 is normal muscle [2]. In the Goutallier classification, grade 1 has some fatty streaks [2]. In the Goutallier classification, grade 2 has more muscle than fat [2]. In the Goutallier classification, grade 3 has equal amounts of muscle and fat [2]. In the Goutallier classification, grade 4 has more fat than muscle [2]. Goutallier grades 3 and 4 are indications of a long-term chronic rotator cuff tear [2]. Goutallier grades 3 and 4 have a higher potential for failure when surgery is undertaken and are likely deemed irreparable [2].

Other Considerations: Fatty degeneration has been shown to correlate with chronicity of rotator cuff tears and is a negative prognostic factor [325]. A three-stage classification based on the occupation ratio has been proposed to improve indications for rotator cuff tear treatment regarding supraspinatus atrophy [221].

Massive Tears and Arthropathy¶

Hamada: 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 [142]. The Hamada classification highlights the progressive nature of massive rotator cuff tears leading to cuff tear arthropathy [142]. The Hamada classification system divides massive rotator cuff tears into five radiographic stages based on structural changes within the coracoacromial arch and changes in the acromiohumeral interval [308]. Consecutive stages in the Hamada classification indicate disease progression [308]. 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 [308]. The Seebauer classification 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 [308].

Other Considerations: A radiographic classification of massive rotator cuff tear arthropathy has been developed to define bone changes associated with the disorder [231].

Associated Pathology and Imaging Reliability¶

Other Considerations: A new arthroscopic classification for anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears was created based on arthroscopic observations [217]. Long head of the biceps instability was associated with long head of the biceps lesions and rotator cuff tear size [217]. A morphologic classification system has been defined for the appearance of the teres minor in isolated and multiple rotator cuff tendon tears [146]. Multiple classification systems exist for calcifying tendinitis of the rotator cuff, including Uhthoff's stages, Gärtner and Heyer's radiologic staging, Bosworth's size classification, and Molé et al.'s morphological classification [225]. A CT-based scoring system has been developed to estimate the likelihood of a degenerative posterosuperior rotator cuff tear in patients for whom MRI is unavailable or contraindicated [240]. A classification system has been created to divide coracoids according to their morphology and relative risk of associated subscapularis tears [139]. Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair [78]. Using the Sugaya classification to assess post-operative rotator cuff healing was associated with substantial intra-observer and fair inter-observer agreement [232]. All other outcomes and classifications, excluding those with acceptable reliability, did not show acceptable reliability for preoperative evaluation of a rotator cuff tear [209]. In experienced hands, sonography has a low level of interobserver variability for the detection, classification, and localization of rotator cuff tears [214].

Clinical Presentation¶

History and Symptoms¶

Patients with symptomatic full-thickness rotator cuff tears typically report anterolateral shoulder pain radiating to the subdeltoid region, often exacerbated by overhead activity and lifting objects with an outstretched arm [2]. Frequent night pain and sleep disturbance are common complaints in this population [2]. In chronic rotator cuff disease, the onset is often insidious, characterized by lateral or anterior shoulder pain associated with overhead activities and night pain [205]. A clear history of trauma resulting in acute pain and weakness strongly suggests an acute rotator cuff tear [205]. A family or personal history of rotator cuff disease increases the likelihood of diagnosis [205]. The combination of age over 65 years, night pain, and weakness demonstrates 95% specificity for rotator cuff tears [38]. Subjective mechanical symptoms are a frequent complaint in suspected rotator cuff pathology [87].

In subacromial bursitis and rotator cuff tendinosis, pain is present with overhead motion but usually absent or mild with the arm at the side [17]. Patients may occasionally be awakened by night pain [17]. Calcified deposits within rotator cuff tendons are most probably not the main cause of clinical symptoms in patients with shoulder pain and dysfunction [121]. The status of the rotator cuff is not the primary variable determining symptom severity or decline in shoulder-specific health-related quality of life [113]. There is only a weak relationship between symptom duration and features associated with rotator cuff disease [31]. Data from the Multicenter Orthopaedic Outcomes Network group indicate that pain and symptom duration are not associated with rotator cuff tear severity [20]. Similarly, pain does not correlate with tear severity in a cross-sectional study of 393 patients with symptomatic atraumatic full-thickness tears [5]. Delay in care for female patients with rotator cuff pathology is multifaceted, involving delays in presentation to any provider and orthopedics, later diagnostic imaging, and later offering of surgery [80].

Physical Examination: Inspection and General Findings¶

Inspection of the shoulder in the upright position at rest and in motion may reveal rotator cuff muscle atrophy, signs of dysfunction, and anterosuperior escape [281]. Inspection for muscular atrophy of the deltoid and the supraspinatus and infraspinatus fossa is part of the physical examination for chronic rotator cuff tears [38]. In a full-thickness rotator cuff tear, wasting of the supraspinatus and infraspinatus is usually present [289]. In subacromial bursitis and rotator cuff tendinosis, no atrophy of the shoulder muscles is present [17]. In cuff tear arthropathy, inspection reveals supraspinatus and infraspinatus atrophy, anterior prominence of the humeral head with arm elevation (anterosuperior escape), and subcutaneous effusion [16].

Physical Examination: Range of Motion and Strength¶

Active range of shoulder motion may be limited by pain in subacromial bursitis and rotator cuff tendinosis, where manual muscle testing demonstrates mild weakness [17]. In a full-thickness rotator cuff tear, the patient is initially unable to abduct the arm; with time, there may be some recovery of active abduction, though power in both abduction and external rotation remains weaker than normal [289]. In partial rotator cuff tears, remaining cuff fibres permit active abduction with a painful arc [289]. In cuff tear arthropathy, range of motion is very limited for elevation, external, and internal rotation [16]. Pseudoparalysis in cuff tear arthropathy is defined as less than 60º elevation, lack of active external rotation, and incompetent subscapularis [16]. Chronic long head of biceps rupture is usually present in cuff tear arthropathy [16]. Subacromial/glenohumeral crepitus with movement is observed in cuff tear arthropathy [16]. The external rotation lag sign and hornblower sign indicate teres minor insufficiency in cuff tear arthropathy [16]. The hornblower sign is the inability to keep external rotation when the shoulder is 90º flexed and 90º abducted [16].

Physical Examination: Specific 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 [281]. The external rotation strength test assesses the infraspinatus with the arm in adduction and the elbow at 90° of flexion [281]. The lift-off and belly press tests assess the subscapularis [281]. The external rotation lag sign and hornblower’s sign both assess for massive failure of the infraspinatus and teres minor [281]. The drop arm test examines failure of the superior rotator cuff [281]. No one test for rotator cuff disease has reliably high diagnostic value, and a combination of tests increases diagnosis specificity [281].

The empty can test has a sensitivity of 71.7% and a specificity of 64.6% for full-thickness supraspinatus tears [205]. The lift-off and belly-press tests have high specificity but low sensitivity for full-thickness subscapularis tears [205]. Patients with an external rotation lag sign at the side likely have a large posterosuperior tear involving the infraspinatus [205]. A positive hornblower sign suggests a massive posterosuperior cuff tear that prohibits the active positioning of the hand in space [205]. The Neer impingement sign involves discomfort when the internally rotated shoulder is moved into forward flexion, which resolves with a subacromial lidocaine injection [17]. 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 [90]. The sensitivity and specificity for full-thickness or high-grade partial tears using the crepitus test is 82% and 73%, respectively [90]. The presence of crepitus in patients older than 55 years has a sensitivity of 76%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 38% [90].

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 [79]. Tests for subscapularis tears were all highly specific [79]. No optimal combination of tests improved the ability to correctly diagnose rotator cuff tears [79]. Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear [91]. 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 [96]. 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 [29]. 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 [89]. 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 [99]. The Neer sign is the only test to reliably predict subacromial impingement or rotator cuff tear among the common impingement tests [99]. Clinical tests including the O’Brien, Yergason, Speed, and direct palpation tests have limited specificity for biceps tendon pathology [324].

Diagnostic Imaging¶

MRI is the benchmark for diagnosing rotator cuff tears with 94% sensitivity and 93% specificity [38]. T2-weighted images best visualize rotator cuff tears [38]. T1 sagittal oblique cuts reveal muscle/tendon retraction and muscle atrophy to determine chronicity, reparability, and outcome of surgical rotator cuff repairs [38]. Intra-articular contrast-enhanced magnetic resonance arthrography (MRA) is best for detecting partial-thickness rotator cuff tears with 95% sensitivity and 95% specificity [38]. Ultrasonography has good accuracy with 92% sensitivity and 93% specificity for rotator cuff tears [38]. Ultrasonography allows for dynamic assessment of the cuff insertion [38]. Ultrasonography is operator dependent and has limited assessment of chondral lesions [38]. Ultrasonography has poor sensitivity to diagnose partial-thickness rotator cuff tears [38]. 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 [205]. MRI accurately assesses muscle, bone, and cartilage, which has advantages for surgical planning [205]. CT arthrography is useful in postoperative assessment, retear evaluation in patients with retained metallic anchors causing artifact on MRI, and when MRI is contraindicated [38].

Radiographs are used to rule out glenohumeral and acromioclavicular arthritis [38]. The true AP view evaluates the acromiohumeral interval, the critical shoulder angle, and acromion index [38]. Greater tuberosity excrescences on AP view in external and internal rotation are pathognomonic for cuff disease [38]. The supraspinatus outlet view evaluates acromial morphology according to Bigliani classification [38]. The axillary view assesses glenohumeral joint morphology and joint space and rules out dislocations [38]. 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 [22]. 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 [30]. A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders [26]. 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 [24]. 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 [28]. The presence of clinically significant disagreements in MRI parameters indicates the need for improved imaging tools for precise rotator cuff evaluation [36]. Effective management of rotator cuff pathology critically relies on initial identification of all cuff tears, including nonobvious, partial and/or obscured full tears [23]. The arthroscopic “Bellows” sign identifies hidden rotator cuff tears [23].

Investigations¶

Clinical Presentation and History: In patients with subacromial bursitis or rotator cuff tendinosis, pain is present with activity involving overhead motion, and there is usually no pain or only mild pain with the arm at the side [17]. Patients with cuff tear arthropathy present with chronic shoulder pain, night pain, weakness, and stiffness [16]. Inspection of the shoulder in cuff tear arthropathy may reveal supraspinatus and infraspinatus atrophy, anterior prominence of the humeral head with arm elevation (anterosuperior escape), and subcutaneous effusion [16]. Range of motion in cuff tear arthropathy is characterized by subacromial/glenohumeral crepitus with movement and very limited ROM for elevation, external, and internal rotation [16]. The external rotation lag sign and hornblower sign indicate teres minor insufficiency in the setting of cuff tear arthropathy [16]. Chronic long head of biceps rupture is usually present in patients with cuff tear arthropathy [16].

Physical Examination: The Neer impingement sign is defined as discomfort experienced when the internally rotated shoulder is moved into forward flexion, which resolves with a dramatic increase in strength and range of motion following subacromial lidocaine injection [17]. In patients with subacromial bursitis or rotator cuff tendinosis, active range of shoulder motion may be limited by pain, and manual muscle testing demonstrates mild weakness without muscle atrophy [17]. The tangent sign predicts the repairability of rotator cuff tears [21]. It 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 [223]. The presence of the tangent sign correlates with muscle atrophy and fatty infiltration of the supraspinatus [223]. Patients with the presence of the tangent sign are more likely to have an irreparable rotator cuff tear [223].

Plain radiography: Secondary radiographic findings on conventional views are useful for initial screening of patients with shoulder pain [318]. Radiographs may demonstrate classic changes within the acromion or coracoacromial ligament, including spurring and calcification, in addition to cystic changes within the greater tuberosity [223]. With chronic rotator cuff disease, superior migration of the humeral head with extensive degenerative change may be present on radiographs [223]. Radiographic greater tuberosity spurs and narrow acromiohumeral intervals are associated with advanced retraction of the supraspinatus tendon in patients with symptomatic rotator cuff tears [22]. Irreparable rotator cuff tears are more likely to occur when the acromiohumeral distance appears shorter than 7 mm on AP radiograph [223]. In cuff tear arthropathy, radiographs may show acetabularization of the acromion and femoralization of the humeral head [16]. Radiographs may also show eccentric superior glenoid wear [16], the absence of typical peripheral osteophytes around the humeral head as seen on osteoarthritis [16], osteopenia and subarticular sclerosis (snowcap sign) [16], and loss of the coracoacromial arch, indicating anterosuperior escape [16]. A deep learning-based algorithm improved the role of shoulder radiography as an initial imaging modality to rule out rotator cuff tears [311]. Radiographs combined with active tasks offer new possibilities in diagnosing early-stage rotator cuff tears [323]. MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions [257].

MRI: MRI is obtained in the evaluation of a potential rotator cuff tear if the patient has no contraindications [2]. It allows the surgeon to characterize the location, size, and amount of retraction of the rotator cuff tear [2], as well as the degree of atrophy and fatty infiltration of the rotator cuff musculature [2]. MRI is used to define the extent of tear, degree of tear retraction, and presence of muscular atrophy [223]. The major role of MR imaging in the investigation of rotator cuff disorders is in the detection of full-thickness rotator cuff tears [314]. Diagnostic imaging of the rotator cuff performed by MRI provides valuable information about the nature of the injury [230]. Analysis of data supports the reliability of MRI assessment by shoulder specialists for rotator cuff disorders [299]. MRI and MRA are both sensitive and specific for full-thickness rotator cuff tears [242]. A full-thickness rotator cuff tear is identified on MRI if fiber discontinuity spans the entire thickness of the tendon, with the defect filled with fluid signal intensity on T2-weighted sequences [242]. 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 measured on the sagittal view, and the extent of retraction measured on the coronal sequence for supraspinatus and infraspinatus and on the axial sequence for the subscapularis [242]. A partial-thickness rotator cuff tear spans only a portion of the tendon thickness [242]. The description of a partial-thickness tear should include the tendon(s) involved, the location within the tendon, the percentage of tendon thickness that is affected (greater or less than 50%), and the side of the tendon that is torn [242]. 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 [242]. MRI is key for evaluating fatty infiltration, although the Goutallier classification was originally based on CT [223]. 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]. 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]. 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]. 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]. Three-dimensional MRI seems to be useful in assessing the rotator cuff muscles [312]. Three-dimensional magnetic resonance imaging appears to be useful to assess the rotator cuff muscles [316]. 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 [328]. 3D-MRI can serve as an important instrument for better categorizing and understanding rotator cuff tears to aid in pre-surgical planning [339]. 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 [331]. 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 [321].

Magnetic Resonance Arthrography (MRA): 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 [242]. The rotator cable can be reliably identified with the shoulder in ABER position, even in the absence of a rotator cuff tear [242]. Magnetic resonance arthrography was more accurate in evaluating rotator cuff tear size and morphologic features than conventional magnetic resonance imaging [258]. MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears [315]. Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears [283].

Ultrasonography: Ultrasonography is increasing in popularity as a tool both for diagnosis of rotator cuff disease and for confirmation of intraarticular or subacromial location of injections [223]. Ultrasonography is more accurate for full-thickness rotator cuff tears, comparable to MRI [22]. Full-thickness rotator cuff tears can be identified using ultrasound and MRI with comparable accuracy [313]. 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 [330]. MRI and US provide similar assessments of postoperative rotator cuff healing, although US is less sensitive [317]. Both MRI and ultrasound can be used to evaluate the repaired rotator cuff and potential complications [293]. 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 [302]. In the author's practice, MRI is the test of choice for rotator cuff pathology due to its versatility and availability, though ultrasound can be performed if an unrecognized partial subscapularis tendon injury is suspected after MRI [338].

Postoperative Imaging: 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 [334]. Radiologists should approach the postoperative shoulder comprehensively to recognize normal expected findings and discern common complications such as recurrent tears, muscle degeneration, infection, and osteoarthritis [340]. 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% [286]. One should use caution in the interpretation of magnetic resonance imaging scans of the shoulder soon after the injection of corticosteroids [336]. 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 [36].

Other Considerations: CT is helpful to quantify glenoid bone stock when reverse shoulder replacement is considered in cases of advanced arthropathy [16]. MRI/CT scan is not routinely necessary for cuff tear arthropathy, especially if radiographs show anterosuperior escape [16]. MRI/CT scan establishes the extent of RCT, retraction, and fatty infiltration in cuff tear arthropathy [16]. Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality [32].

Treatment¶

Non-Operative¶

Conservative management of rotator cuff pathology typically consists of 6 to 12 weeks of rest and activity modification, symptom management often with NSAIDs, and physical therapy [245]. Physical therapy with a home exercise regimen focuses on passive and active range of motion plus strengthening of scapular stabilizing muscles and of the rotator cuff itself [245]. Systemic pharmacotherapy for patients with shoulder pain in conservative management consists of non-steroidal anti-inflammatory drugs [251], with cyclooxygenase-2-selective inhibitors introduced for management of shoulder pain in conservative treatment [251]. Surgeons may use occasional subacromial injections for the painful shoulder but should consider the effects on tissue quality and infection risk attributed to steroid injections associated with rotator cuff repair, especially when given preoperatively within 1 month of surgery and up to 3 months postoperatively [245]. Bursal injection can be accomplished through anterior, lateral, or posterior routes, with the anterior and lateral access points possibly demonstrating increased accuracy [245]. Steroid injection with physical therapy, extracorporeal shockwave therapy, ultrasound-guided needle lavage, and arthroscopic débridement are all valid options for treatment of rotator cuff calcific tendinitis [59].

Operative¶

Indications: Neither the American Academy of Orthopaedic Surgeons clinical practice guidelines nor Cochrane systematic reviews provide guidance on the management of rotator cuff tears [1]. Patients with rotator cuff tears are generally divided into three categories: those needing urgent or early operative repair, those who can benefit from a trial of conservative treatment, and those best suited for nonoperative treatment [1]. 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 [56]. The indications for the operative treatment of massive and irreparable rotator cuff tears were determined based on expert consensus and the best available evidence [47]. Patients are indicated for single medial-row anchor with biceps tenodesis in a transosseous double-row construct if they have a rotator cuff tear and have not responded to nonoperative management [252]. Contraindications to single medial-row anchor with biceps tenodesis in a transosseous double-row construct include a concurrent subscapularis tear or an irreparable rotator cuff tear [252]. The general indications for augmentation include patients with large (>3 cm), multitendon rotator cuff tears or chronic tears with poor tissue quality [218]. The ideal indication for tendon transfer is a patient with an irreparable supraspinatus and infraspinatus tear, intact teres minor and subscapularis, forward elevation >90 degrees, and no prior surgery [196]. Rotator cuff repair may be suggested after failed non-surgical treatment [228]. Non-surgical treatment is recommended as the preferred approach for patients with non-traumatic rotator cuff injuries [287]. 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 [248]. Following nonoperative treatment for at least 6 weeks, subacromial decompression is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff [290].

Surgical Approach / Technique: The current standard of care for rotator cuff repair is arthroscopic repair [45]. Arthroscopic repair has been shown to have similar outcomes and failure rates compared to open or mini-open repair, with decreased short-term pain and more rapid return to activity [45]. There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears [137]. Open rotator cuff repair surgery remains a valid option and has some appeal in specific indications and in settings where arthroscopic resources are limited [51]. The goal of rotator cuff repair is to restore the tendon to its anatomic footprint to encourage healing [45]. Arthroscopic repair is performed with suture anchors in various configurations, including single-row, double-row, and transosseous-equivalent repair technique [45]. Controlled laboratory studies have generally shown superiority of double-row techniques over single-row in terms of initial and ultimate failure strength, decreased gap formation, decreased strain and suture cut-through, and improved vascularity in transosseous-equivalent double-row repair [45]. Arthroscopic surgery offers more thorough visualization, diagnosis, and treatment of lesions within the joint compared to traditional open repair techniques [274]. Arthroscopy allows a more comprehensive assessment of intra-articular pathology and rotator cuff tear configuration by viewing from multiple angles [274]. Tendon mobilization is facilitated by precise releases of adhesions that limit tendon excursion during arthroscopic repair, leading to an improved ability to anatomically reduce the edge and create a tension-free repair [274]. Injury to the deltoid muscle is minimized during arthroscopic repair [274]. The acromial deltoid origin is preserved during arthroscopic repair, eliminating the risk of deltoid dehiscence [274]. A key theoretical benefit of arthroscopic repair is decreased postoperative pain secondary to less soft tissue trauma [274]. Decreased postoperative pain from arthroscopic repair aids in postoperative rehabilitation, leading to earlier resumption of range of motion and possibly less pain-induced muscle inhibition [274]. Anatomic footprint restoration is possible with arthroscopic repair, with fixation at both the suture-tendon interface and the anchor-bone interface that approximates traditional open transosseous repairs [274]. The double-row technique has been advocated as a better biomechanical construct and a more anatomic repair strategy [274]. While in biomechanical studies, the double-row repair outperforms single-row repair in failure strength, superior clinical results with double-row fixation over single-row fixation is still controversial [274]. The SpeedBridge Knotless Double-Pulley Rotator Cuff Repair maintains clinically significant patient-reported and functional outcomes and rotator cuff repair survivorship [15]. 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]. 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]. 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]. Rotator cuff repairs provide sustained clinical improvement out past 5 years, with most functional improvement and pain relief occurring within the first 6 months but continuing to 24 months [185]. Both patient-reported outcomes and achievement of clinically significant outcomes show small differences at 1 and 2 years after rotator cuff repair [169]. The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair [11]. Patients receiving single-stage or staged bilateral arthroscopic rotator cuff repair showed similarly good clinical outcomes at follow-ups longer than 6 months [201]. Despite advances in surgical options and rehabilitation, failure rates for large-to-massive rotator cuff tears remain high [202]. At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes after massive rotator cuff repair [13]. Healed rotator cuff repairs show improved patient-reported and functional outcomes compared to physical therapy and unhealed rotator cuff repairs [159]. Postoperative strength is better in individuals with healed rotator cuffs versus those with defects after repair [59]. Patient-reported outcomes and pain are not correlated with rotator cuff healing on ultrasonography or MRI [59]. The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [8]. This progress in rotator cuff surgery can be questioned, since there are not convincing data of the superiority of the operative treatment over non-operative management in all rotator cuff tears [203]. Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology [247]. A rotator cuff repair procedure could save up to $78,000 compared with nonsurgical management, depending on patient age [19]. 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 [301]. The results of a 10-year follow-up study showed differences of greater magnitude and significance favoring surgical management of small and medium degenerative rotator cuff tears [309]. Significantly greater improvements of 9.6 points on the Constant and 15.7 points on the American Shoulder and Elbow Surgeons rating score were reported in favor of surgical management of small and medium degenerative rotator cuff tears at 10-year follow-up [309]. Patients with rotator cuff tears who undergo surgical treatment tend to improve to a greater degree than those undergoing nonsurgical treatment [268, 278]. Rotator cuff repair in patients aged >75 years could achieve high clinical success rates with good outcomes and pain relief [191]. Carefully selected patients older than 70 years did well after rotator cuff repair and functionally improved as much as younger patients [2]. The best potential for healing after rotator cuff repair was in patients younger than 70 years with acute, small tears (<3 cm) and a healthy tendon-bone interface who are compliant with sling wear and are able to undergo an extended rehabilitation program of 6 to 9 months [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]. 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]. Intraoperative prognostic healing factors for rotator cuff repairs include tendon and bone quality and the ability to anatomically reduce and repair the tendon to its normal footprint on the tuberosity without undue tension [2]. If anatomic repair cannot be achieved without significant tension, medialised repair can be performed [2]. Strong fixation of the repair is essential to prevent gapping of the tendon [2]. When tears are irreparable, or the patient has concomitant advanced glenohumeral arthrosis, alternative options such as arthroplasty can be recommended [45]. Salvage options for irreparable cuff tears include superior capsular reconstruction (SCR), tendon transfers, and reverse total shoulder arthroplasty (RTSA) in properly selected and appropriately counseled patients [244]. The review aims to aid shoulder surgeons in patient selection for surgery, including the indications and contra-indications to tendon transfer [207]. Comparison of the 'tear' and 'non-tear' patient groups suggest that cuff tears can be left unrepaired in selected patients [303]. The efficacy of determination of rotator cuff tears will also increase after the introduction of shoulder ultrasonography [177]. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients [24].

Other Considerations: Partial-thickness rotator cuff tears are classified as articular-sided, bursal-sided, or intratendinous tears [4]. In the Ellman classification, tears are classified as articular-sided (A), bursal-sided (B), or intratendinous (C) and are grade 1 if involving 3 mm or less, grade 2 if 3 to 6 mm, and grade 3 if more than 6 mm of tendon is torn [4].

Complications¶

Surgical Outcomes and Structural Integrity¶

Re-tear rates following rotator cuff repair average 20%, with higher incidence observed in larger tears [66]. Most repair failures manifest within the first 3 months postoperatively [54]. Long-term structural integrity shows an overall survivorship of 94% at 5 years and 83% at 10 years after open surgery [44]. Specific anatomical and clinical predictors significantly elevate 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]. In patients undergoing simultaneous rotator cuff and Bankart repair after shoulder dislocation, the persistent or recurrent rotator cuff tear rate was 31% [50]. Patient-specific factors also influence outcomes, as a history of bariatric surgery is associated with increased failure rates after arthroscopic repair [298], and individuals with a family history of rotator cuff tearing are more likely to experience repair failures [265].

Short-Term Complications and Risk Factors¶

The incidence of short-term complications following rotator cuff repair is low [101] and generally rare [125]. Preoperative testosterone replacement therapy use was not linked to increased short-term complications after arthroscopic rotator cuff repair [194].

The short-term clinical influence of biceps complications on shoulder outcome is very limited [195].

Adjunctive Procedures and Long-Term Outcomes¶

Subacromial decompression did not significantly affect the outcome of arthroscopic rotator cuff repair at short-term follow-up [48]. The utility of acromioplasty at the time of rotator cuff repair has come into question, with new studies showing no significant benefit [18]. Steroid injections performed within 6 months of the index surgical procedure are correlated with a greater likelihood of revision rotator cuff surgery [337].

Recovery¶

Rehabilitation protocol: Successful management of rotator cuff disease depends on appropriate rehabilitation based on an evaluation of underlying tissue quality and structural integrity, rather than solely on empirical clinical experience or fixed healing timelines [356].

Other Considerations: 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 [54]. All intact rotator cuff tendons at 1 year remained intact at 2 years [355]. Overall survivorship was 94% at 5 years after open rotator cuff surgery and 83% at 10 years [44]. 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 [151]. 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 [179]. The persistent or recurrent rotator cuff tear rate of 31% did not appear to significantly impact functional outcomes in patients undergoing simultaneous rotator cuff and Bankart repair [50].

Revision rotator cuff repair provides significant pain relief and improvement in functional scores at long-term follow-up [220]. Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome [208]. 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]. At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes [13]. 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 [187]. Patients who undergo staged bilateral rotator cuff repair can expect to have similarly good clinical outcomes regardless of hand dominance or chronologic incidence with excellent healing rates in both shoulders [358].

The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively [55]. 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 [357]. Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time [351]. 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 [353]. There was no evidence of progression of intrinsic rotator cuff pathologic conditions at a mean follow-up of 4.5 years for partial-thickness rotator cuff tears treated with acromioplasty without repair [70].

Rotator cuff repair may not alter natural history [42]. 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 [62]. 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 [12]. The existing literature on long-term follow-up after massive rotator cuff repair is scarce and not of high level of evidence [34].

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)
[L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. [8] (10.1007/s11999-008-0585-9)
[L3] The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair. [11] (10.1177/0363546514560729)
[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. [12] (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. [13] (10.1016/j.arthro.2023.06.031)
[L5] It maintains clinically significant patient-reported and functional outcomes and rotator cuff repair survivorship. [15] (10.1016/j.eats.2021.12.039)
[Paper] The utility of acromioplasty at the time of rotator cuff repair has come into question, with new studies showing no significant benefit. [18] (10.1016/j.ocl.2013.12.003)
[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. [22] (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. [23] (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. [24] (10.1007/s10067-013-2260-0)
[L5] A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders. [26] (10.1016/j.pmrj.2012.08.019)
[Paper] This issue reinforces the concept that rotator cuff disease is a continuum and brings readers up to date on rotator cuff disease, covering epidemiology, imaging, techniques, and outcomes. [27] (10.1016/j.csm.2012.08.001)
[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. [28] (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. [29] (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. [30] (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. [31] (10.1016/j.jse.2013.10.001)
[Paper] Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality. [32] (10.1016/j.csm.2012.07.010)
[Paper] The existing literature on long-term follow-up after massive rotator cuff repair is scarce and not of high level of evidence. [34] (10.1177/15563316211008137)
[L4] The major indication for revision rotator cuff repair is the persistence of clinical symptoms, despite nonsurgical management, in the absence of substantial risk factors for failure. [35] (10.1055/b-0041-179892)
[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. [36] (10.1016/j.jse.2021.04.021)
[L5] The major indication for revision rotator cuff repair is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure. [37] (10.5435/00124635-201111000-00002)
[L4] Thus, rotator cuff repair may not alter natural history. [42] (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. [43] (10.1136/bmjopen-2020-039552)
[L4] Overall survivorship was 94% at 5 years after open rotator cuff surgery and 83% at 10 years. [44] (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)
[L1] At short-term follow-up, subacromial decompression did not seem to significantly affect the outcome of arthroscopic rotator cuff repair. [48] (10.1016/j.arthro.2006.10.011)
[L4] The persistent or recurrent rotator cuff tear rate of 31% did not appear to significantly impact functional outcomes in this patient population. [50] (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. [51] (10.1007/s43465-020-00345-7)
[L1] We do not recommend doing routine DCR with arthroscopic rotator cuff repair. [53] (10.1016/j.otsr.2020.08.006)
[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. [54] (10.1177/0363546511424268)
[L1] The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively. [55] (10.1177/0363546518780694)
[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. [56] (10.5435/00124635-201312000-00008)
[L5] Treatment options for large and massive rotator cuff tears must be based on individual patient indications, with bridging reconstruction performing best for irreparable tears of the superior-posterior rotator cuff with an intact or reparable subscapularis. [57] (10.1016/j.arthro.2024.08.034)
[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. [60] (10.1016/j.arthro.2023.11.002)
[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. [62] (10.1016/j.jse.2024.05.056)
[L5] [63] (10.5435/00124635-199901000-00004)
[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. [68] (10.1016/j.jse.2023.11.012)
[L4] There was no evidence of progression of intrinsic rotator cuff pathologic conditions at a mean follow-up of 4.5 years. [70] (10.1177/03635465020300021801)
[L4] A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further. [73] (10.1302/2058-5241.1.160005)
[L4] Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. [78] (10.1007/s00167-014-3486-3)
[L1] [79] (10.1177/0363546514538390)
[L2] Delay in care in female patients with rotator cuff pathology is multifaceted, including delay in presentation to any provider and to orthopedics, later diagnostic imaging, and later offering of surgery. [80] (10.1016/j.jse.2025.06.008)
[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)
[L2] Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. [87] (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. [89] (10.2519/jospt.2020.0606)
[L2] [90] (10.1016/j.jse.2013.12.037)
[L1] Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. [91] (10.1186/s13018-014-0070-y)
[L2] As no single clinical test is sufficiently reliable to diagnose posterosuperior rotator cuff tears, clinicians should consider various combinations of patient characteristics and clinical tests, as well as imaging modalities, to confirm diagnosis and select the appropriate treatment option. [96] (10.1007/s00167-020-06136-9)
[L5] The rotator interval is central to normal glenohumeral kinematics, and any insult to its integrity alters shoulder motion throughout abduction. [97] (10.1186/s12891-016-0898-x)
[L4] [99] (10.5435/jaaos-d-17-00090)
[L4] Rotator cuff repair has a low incidence of short-term complications. [101] (10.1016/j.arthro.2017.10.040)
[L5] In this cadaveric shoulder model of the throwing shoulder, tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics. [105] (10.1177/2325967117s00373)
[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)
[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. [112] (10.1177/2325967116667058)
[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. [113] (10.2106/jbjs.o.01085)
[L4] The proposed classification system may assist decision making in the treatment of partial thickness rotator cuff tears. [116] (10.4103/0019-5413.136249)
[L3] For patients with shoulder pain, shoulder dysfunction, and calcified deposits within the rotator cuff tendons, these calcified deposits are most probably not the main cause of the clinical symptoms. [121] (10.1007/s004020000255)
[L3] Short-term complications after rotator cuff repair are rare. [125] (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)
[L4] The appearance of the teres minor in isolated and multiple rotator cuff tendon tears is defined in this study using a morphologic classification system. [146] (10.1007/s00256-011-1178-3)
[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. [151] (10.1016/j.jse.2021.03.073)
[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)
[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. [158] (10.1109/access.2019.2895997)
[L3] Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes. [161] (10.1016/j.jse.2025.03.038)
[Paper] Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes. [163] (10.1016/j.clinbiomech.2010.08.001)
[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. [165] (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. [166] (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. [168] (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. [169] (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. [174] (10.1016/j.arthro.2012.04.054)
[L4] The efficacy of determination of rotator cuff tears will also increase after the introduction of shoulder ultrasonography. [177] (10.1186/s13018-017-0565-4)
[L3] This study confirms dynamic superior migration of the humeral head during abduction in patients with rotator cuff tears using in vivo 3D kinematic analysis. [178] (10.1016/j.arthro.2015.08.031)
[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. [179] (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. [181] (10.1002/14651858.cd012224)
[L3] Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. [184] (10.1002/ksa.12162)
[L2] Rotator cuff repairs provide sustained clinical improvement out past 5 years, with most functional improvement and pain relief occurring within the first 6 months but continuing to 24 months. [185] (10.1177/23259671221119222)
[L1] Shoulder scores may decline at mid- to long-term follow-up. [187] (10.1186/s13018-022-03411-y)
[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)
[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)
[L3] Patients receiving single-stage or staged bilateral arthroscopic rotator cuff repair showed similarly good clinical outcomes at follow-ups longer than 6 months. [201] (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. [202] (10.2106/jbjs.20.00177)
[L3] This progress can be questioned, since there are not convincing data of the superiority of the operative treatment over non-operative management in all rotator cuff tears. [203] (10.1186/s12891-015-0639-6)
[L4] The review aims to aid shoulder surgeons in patient selection for surgery, including the indications and contra-indications to tendon transfer. [207] (10.1111/j.1758-5740.2012.00224.x)
[L3] Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. [208] (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. [209] (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. [212] (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. [213] (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. [214] (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. [216] (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. [217] (10.1016/j.arthro.2006.08.025)
[L5] The general indications for augmentation include patients with large (>3 cm), multitendon rotator cuff tears or chronic tears with poor tissue quality. [218] (10.1016/j.eats.2024.103287)
[L4] Revision rotator cuff repair provides significant pain relief and improvement in functional scores at long-term follow-up. [220] (10.1016/j.jse.2023.06.009)
[L3] The study proposes a three-stage classification based on the occupation ratio to improve indications for rotator cuff tear treatment. [221] (10.3109/17453679608994685)
[L5] Proper indications for shoulder subacromial decompression result in excellent outcomes. [222] (10.1016/j.arthro.2021.04.023)
[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. [226] (10.2106/jbjs.rvw.17.00052)
[L1] Therefore, rotator cuff repair may be suggested after failed non-surgical treatment. [228] (10.1136/annrheumdis-2020-219099)
[L5] Diagnostic imaging of the rotator cuff, performed by MRI, provides valuable information about the nature of the injury. [230] (10.1016/j.ejrad.2008.02.018)
[L3] [231] (10.1007/s11999-011-1896-9)
[L4] Using the Sugaya classification to assess post-operative rotator cuff healing was associated with substantial intra-observer and fair inter-observer agreement. [232] (10.1016/j.otsr.2017.06.006)
[L1] There is a need for well-designed level I and level II trials to elucidate the optimal rotator cuff repair rehabilitation protocol. [233] (10.1177/1941738108331200)
[L4] Rotator cuff repair is cost-effective for all populations. [236] (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. [237] (10.1007/s00167-015-3700-y)
[L3] The primary objective was to develop and validate a scoring system to estimate the likelihood of a degenerative posterosuperior rotator cuff tear in patients for whom MRI is unavailable or contraindicated. [240] (10.1186/s12891-026-09874-y)
[L3] The study presents a novel classification for partial subscapularis tendon tears to enable more detailed and reproducible description. [241] (10.1007/s00167-020-05989-4)
[L3] Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology. [247] (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. [248] (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. [249] (10.1177/0363546517717947)
[L4] Use of these higher values should be considered when evaluating improvements of individual patients after rotator cuff repair, to determine comparative effectiveness of various rotator cuff repair techniques and to determine sample sizes for prospective comparative trials of rotator cuff repair methods. [250] (10.1016/j.jse.2019.11.018)
[L4] [251] (10.1159/000328910)
[L5] [252] (10.1016/j.eats.2022.03.035)
[L5] Complications after rotator cuff repair are not common and are equivalent between arthroscopic and open techniques. [255] (10.1007/s12178-014-9247-6)
[L3] Retrospective and prospective evaluations of the outcome of rotator cuff repair are different. [256] (10.1016/j.jse.2008.04.003)
[L2] MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions. [257] (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. [258] (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. [259] (10.1080/09638288.2016.1198431)
[L4] Appropriately selected patients aged 65 years or over with a massive full-thickness rotator cuff tear can be expected to have a good functional outcome and pain relief after repair. [261] (10.1016/j.jse.2004.02.016)
[L2] Individuals with a family history of rotator cuff tearing were more likely to have repair failures. [265] (10.1016/j.jse.2016.02.019)
[L1] [267] (10.1177/17585732251374282)
[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. [268] (10.1177/2325967113s00100)
[L4] Patients undergoing rotator cuff repair had fewer comorbidities than those undergoing nonoperative treatments. [269] (10.1016/j.jse.2016.05.001)
[L3] Patients with rotator cuff tears who undergo surgical or nonsurgical treatment tend to improve, with surgical patients improving to a greater degree. [278] (10.1177/2325967114s00059)
[L2] Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears. [283] (10.1148/radiol.12112062)
[L3] 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%. [286] (10.1067/mse.2002.120139)
[L3] Additionally, non-surgical treatment is recommended as the preferred approach for patients with non-traumatic rotator cuff injuries. [287] (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. [290] (10.1016/j.arthro.2019.06.012)
[L5] Both MRI and ultrasound can be used to evaluate the repaired rotator cuff and potential complications. [293] (10.2214/ajr.18.19648)
[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. [298] (10.1177/23259671261447216)
[L4] Analysis of our data supports the reliability of MRI assessment by shoulder specialists for rotator cuff disorders. [299] (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. [301] (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. [302] (10.1007/s12178-018-9463-6)
[L3] Comparison of the 'tear' and 'non-tear' patient groups suggest that cuff tears can be left unrepaired in selected patients. [303] (10.1111/j.1758-5740.2009.00015.x)
[L5] [308] (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. [311] (10.1016/j.jse.2023.02.066)
[Abstract] Three-dimensional MRI seems to be useful in assessing the rotator cuff muscles. [312] (10.1016/j.jse.2020.01.010)
[L4] Full-thickness rotator cuff tears can be identified using ultrasound and MRI with comparable accuracy. [313] (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. [314] (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. [315] (10.2214/ajr.08.1241)
[Abstract] Three-dimensional magnetic resonance imaging appears to be useful to assess the rotator cuff muscles. [316] (10.1016/j.jse.2016.11.032)
[L3] MRI and US provide similar assessments of postoperative rotator cuff healing, although US is less sensitive. [317] (10.1016/j.otsr.2015.06.006)
[L3] These secondary radiographic findings on conventional views are useful for initial screening of patients with shoulder pain. [318] (10.1067/mse.2001.117123)
[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. [321] (10.1016/j.jse.2019.04.003)
[L4] Possibly, radiographs combined with active tasks offer new possibilities in diagnosing early-stage rotator cuff tears. [323] (10.1007/s11517-013-1057-2)
[L5] [325] (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. [328] (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. [330] (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. [331] (10.1016/j.arthro.2012.04.142)
[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. [334] (10.1259/bjr.20130630)
[L4] One should use caution in the interpretation of magnetic resonance imaging scans of the shoulder soon after the injection of corticosteroids. [336] (10.1016/j.arthro.2007.01.024)
[L5] The historical treatment paradigm of steroid injections for painful rotator cuff conditions warrants reconsideration as they are correlated with a greater likelihood of revision rotator cuff surgery when performed within 6 months of the index surgical procedure. [337] (10.1016/j.arthro.2018.12.017)
[L5] In the author's practice, MRI is the test of choice for rotator cuff pathology due to its versatility and availability, though ultrasound can be performed if an unrecognized partial subscapularis tendon injury is suspected after MRI. [338] (10.1016/j.arthro.2021.08.029)
[L4] The findings suggest that 3D-MRI can serve as an important instrument for better categorizing and understanding rotator cuff tears to aid in pre-surgical planning. [339] (10.1177/2325967117s00367)
[Paper] Radiologists should approach the postoperative shoulder comprehensively to recognize normal expected findings and discern common complications such as recurrent tears, muscle degeneration, infection, and osteoarthritis. [340] (10.1148/rg.2016160023)
[L5] [342] (10.1016/j.jse.2011.10.022)
[L4] Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time. [351] (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. [353] (10.1016/j.arthro.2007.01.023)
[L3] All intact rotator cuff tendons at 1 year remained intact at 2 years. [355] (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. [356] (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. [357] (10.1016/j.jse.2011.10.012)
[L4] Patients who undergo staged bilateral rotator cuff repair can expect to have similarly good clinical outcomes regardless of hand dominance or chronologic incidence with excellent healing rates in both shoulders. [358] (10.1016/j.jse.2016.01.027)

References¶

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[2] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC REPAIR OF POSTERIOR HUMERAL AVULSION OF THE GLENOHUMERAL LIGAMENT > FULL-THICKNESS ROTATOR CUFF TEARS.

[4] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC REPAIR OF POSTERIOR HUMERAL AVULSION OF THE GLENOHUMERAL LIGAMENT > PARTIAL-THICKNESS ROTATOR CUFF TEARS.

[5] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Shoulder Instability, Rotator Cuff Disorders, Muscular Ruptures, Adhesive Capsulitis, Calcific Tendinitis > Annotated References.

[6] Apley And Solomon S Concise System Of Orthopaedics And Trauma. DISORDERS OF THE ROTATOR CUFF.

[7] Minimum 15-year follow-up for clinical outcomes of arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.116

[8] Indications for Surgery in Clinical Outcome Studies of Rotator Cuff Repair. Clinical Orthopaedics & Related Research. 2009. DOI: 10.1007/s11999-008-0585-9

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