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Cuff Pathology

Rotator cuff tendinopathy and tears — natural history of progression, symptomatic presentation, and the spectrum from partial tears to cuff tear arthropathy.

Overview

Rotator cuff repair is the primary surgical intervention for symptomatic tears, with arthroscopy established as the gold standard due to reduced invasiveness and fewer complications, despite persistent recurrence rates [73]. The presence of a cuff tear does not necessitate surgical repair [1]. When surgery is indicated, the AAOS Appropriate Use Criteria (AUC) provide guidance for full-thickness tears by synthesizing evidence and expert opinion across 432 patient scenarios [83]. Indications for massive and irreparable tears are determined by expert consensus and best available evidence to guide technique selection [23]. Surgeons must consider repair size and patient factors to maximize outcomes [66].

Concomitant procedures do not universally alter outcomes. Addressing biceps pathology during rotator cuff repair yields similar failure, revision, and complication rates, as well as comparable patient-reported outcomes at 2 years, compared to isolated repair [6]. In chronic calcific tendinitis, concomitant cuff repairs or the degree of calcification removal do not affect clinical outcome [5]. Routine acromioplasty lacks evidence-based support for all cases [77]. Differences in complication rates between open and arthroscopic approaches may reflect selection bias and narrowing indications for open repair [21].

Revision repair is primarily indicated for persistent symptoms despite nonsurgical management without substantial failure risk factors [17]. Augmentation scaffolds require human studies to confirm clinical effectiveness and appropriate indications [83]. Current clinical outcome studies often fail to describe patient characteristics and surgical indications [14].

Anatomy & Pathophysiology

Scapular Mechanics and Kinematics

Optimal scapular function is a key component of all shoulder function [36], and alterations in scapular motion are associated with most types of shoulder pathology [36]. Patients who reached at least 85° of motion compensated for the loss of glenohumeral motion by increased scapulothoracic contribution, suggesting that structural damage interferes with motion mechanics [71]. Three-dimensional glenohumeral kinematics at the early phase of arm elevation may affect shoulder function in patients with massive rotator cuff tears [55]. Dynamic elongation of repair tissue during scapular-plane abduction exhibited one of two distinct patterns, which may suggest different patterns of supraspinatus mechanical and neuromuscular function [63].

Rotator Cuff Biomechanics and Tears

Tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics in a cadaveric model of the throwing shoulder [41]. Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increased glenohumeral translation and changed kinematics in a cadaveric biomechanical model [60]. Increased glenohumeral joint loads due to a full-thickness supraspinatus (SSP) tear can be reversed with rotator cuff repair (RCR) in a dynamic biomechanical cadaveric model [65]. The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in the functional planes of motion [56].

Surgical Reconstruction and Repair Outcomes

The goal of tendon transfers is to achieve stable kinematics by restoring rotational strength and force coupling of the shoulder joint [52]. Performing a superior capsule reconstruction (SCR) only partially restored native glenohumeral joint loads in a dynamic shoulder model [46], although biomechanical studies suggest that the humeral head–stabilizing effect of superior capsule reconstruction (SCR) appears to translate into improved clinical outcomes [58]. Surgical techniques should be tailored to optimize residual cuff activation to restore balanced shoulder mechanics [72]. Recent modifications of suture configurations for rotator cuff repair offer no biomechanical advantage in tendon-grasping strength [76], and biomechanical data does not translate to clinical re-rupture rates after shoulder rotator cuff repair using different suture techniques stratified by method of repair and tear size [92].

Joint Stability and Long-Term Changes

Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect and the physiologic load required remains unknown [86]. Shoulder strength and patient-reported outcomes improved significantly over 24 months, but the glenohumeral joint contact center gradually shifted superiorly, potentially reflecting altered loading patterns or loss of dynamic stability despite functional improvements [75]. Findings from an animal model of rotator cuff tears are consistent with alterations in shoulder function observed with rotator cuff and other shoulder injuries in humans [89, 90].

Classification

Rotator cuff disease represents a continuum progressing from tendinitis to cuff arthropathy, with prevalence increasing significantly with age [13]. Pain in painful rotator cuff tears associates more strongly with histopathological changes in the bursa than in the rotator cuff itself [11]. While different tear morphologies do not influence clinical outcomes post-arthroscopic repair at mid-term follow-up [7], a comprehensive classification system integrating historical and newer descriptions may help guide treatment [8]. One such scheme encompassing 97% of all tears was described to facilitate anatomic repair [29].

ISAKOS: The ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communication among surgeons and for pooling data from clinical studies [61].

Snyder: The Snyder classification system is reproducible and can be used in future research studies to analyze treatment options for partial rotator cuff tears [51]. However, neither the Snyder nor the Ellman classification reproduces the extension of partial-thickness tears in the transverse and coronal planes related to their etiology and pathomorphology [64].

Hamada: Understanding the Hamada classification helps predict appropriate care and outcomes in patients with massive rotator cuff pathology [53].

Patte (Modified): The diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability [59].

Coracoid Morphology: A classification system was created to divide coracoids according to their morphology and relative risk of associated subscapularis tears [54].

Other Considerations: 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 (articular vs bursal) of involvement with partial-thickness tears [42]. Acromial morphology classification is an unreliable method to assess the acromion, and the acromial index shows no association with the presence of rotator cuff disease [10]. Patients exhibiting higher classification of fatty infiltration in the rotator cuff muscles, as well as those with more extensive tears, may be associated with increased levels of hidden blood loss during arthroscopic rotator cuff repair [62].

Clinical Presentation

Rotator cuff disease represents a continuum progressing from tendinitis to cuff arthropathy [13]. The prevalence of both rotator cuff tears and tendinopathy increases significantly with age [13, 33]. This degenerative pathophysiology weakens the enthesis in rotator cuff defects [33]. Consequently, management decisions for rotator cuff defects should be based on the likelihood of a newly symptomatic chronic, degenerative defect rather than an acute traumatic injury [33].

Patients with suspected rotator cuff pathology commonly report subjective mechanical symptoms in the affected shoulder [30]. Pain in painful rotator cuff tears is associated with histopathological changes in the bursa [11]. This pain has a greater association with histopathological changes in the bursa compared with those in the rotator cuff itself [11]. In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear, resulting in a measurable decline in function within 3 years [3].

The clinical syndrome of 'impingement' should be termed 'rotator cuff disease' or 'anterolateral shoulder pain syndrome' due to the wide variety of etiologies and the difficulty in reliably establishing the exact structure causing pain [38]. Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses [34].

Clinical examination is useful in the diagnosis of rotator cuff tears, impingement syndrome, and biceps pathology [12]. Rotator cuff injuries are most accurately diagnosed with a combination of cuff- and impingement-specific clinical tests [9]. Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear [40].

Subscapularis tendon pathology can present as isolated tears, partial-thickness tears, or complete rotator cuff avulsion [31]. Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology [32].

Investigations

Rotator cuff disease represents a continuum [2]. Imaging is integral to the workup of suspected rotator cuff abnormality [16].

Plain radiography: When humeral cysts are detected in a patient with a painful shoulder, maintain a high index of suspicion for rotator cuff tear, particularly in patients aged over 60 years [87]. MR imaging is suggested for patients with radiographic greater tuberosity sclerosis or spurs to detect advanced rotator cuff lesions [67]. Focal diminished bone mineral density of the greater tuberosity is present in rotator cuff disease with and without full-thickness tears; this finding in the absence of tears warrants further investigation [103]. The incidence of rotator cuff tears in calcific tendonitis is higher than previously reported [91].

MRI: MRI is the test of choice for rotator cuff pathology due to its versatility and availability [78]. Among patients with symptomatic rotator cuff tendinopathy remaining symptomatic at ≥1 year with follow-up MRI, 39% progressed to a partial or full-thickness tear [97]. Radiologic severity of supraspinatus pathology correlates with dynamic clinical function across the full range of pathology [99]. However, radiological evaluation of supraspinatus muscle alterations underestimates abnormalities seen at histology [98]. Clinically significant disagreements in rotator cuff tendon and muscle MRI parameters indicate the need for improved imaging tools for precise evaluation [95]. There is substantial variability when evaluating MRI scans after rotator cuff repair [107]. A 3 T MRI protocol can evaluate morphological tendon outcomes after different treatment modalities for supraspinatus tendonosis and partial thickness tears [106].

Ultrasound: Ultrasound can be performed if an unrecognized partial subscapularis tendon injury is suspected after MRI [78]. Artificial intelligence models are equally adept as musculoskeletal radiologists in using ultrasound to diagnose rotator cuff pathology [100].

Other Considerations: Diagnosis of long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology is challenging due to limitations in MRI and arthroscopic visualization [80]. Surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing these pathologies [80]. Magnetic resonance arthrography is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair [82]. Neither MRI nor clinical tests are sufficiently reliable to diagnose biceps lesions prior to rotator cuff repair [82]. Preoperative MRI scans do not reliably predict which rotator cuff injury patients have subscapularis tendon tears [93]. MRI might not provide adequate preoperative information for subscapularis tears [94]. Arthroscopy remains the gold standard for diagnosing subscapularis tears [94]. 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 [85]. Traumatic and degenerative rotator cuff repairs lead to comparable clinical and radiologic results [101].

Treatment

Non-Operative

Nonoperative management is an effective and lasting option for many patients with chronic, full-thickness rotator cuff tears [47, 48]. It is also efficacious for patients with chronic, massive, irreparable rotator cuff tears [68]. For partial-thickness tears, nonoperative treatment serves as appropriate initial therapy, with operative management considered only if conservative measures fail [81]. Conservative treatment remains the mainstay for spontaneous resorption of calcification at the long head of the biceps tendon, reserving arthroscopic debridement for cases where symptoms are not controlled by non-operative therapy [84]. At one-year follow-up, operative treatment offers no advantage over conservative treatment for non-traumatic supraspinatus tears, supporting conservative care as the primary method [104]. In situ-forming fibrin gel encapsulation of MSC-exosomes may serve as a candidate for the nonoperative management of partial-thickness rotator cuff tears [105]. However, there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease [50].

Operative

Indications: The major indication for revision rotator cuff repair is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure [17]. Cuff tears can be left unrepaired in selected patients [79]. Operative management of cuff tears is increasingly cost-effective over time, given that nonrepaired cuff tears are unlikely to heal and portend worse symptomatology [57]. The indications for operative treatment of massive and irreparable rotator cuff tears were determined based on expert consensus and the best available evidence to guide the appropriateness of various surgical techniques for different clinical scenarios [23].

Surgical Approach / Technique: Addressing biceps pathology when performing rotator cuff repair resulted in similar rates of cuff failure, revision rotator cuff repair, and complications, as well as similar improvement in patient-reported outcomes compared with isolated rotator cuff repair at 2 years postoperatively [6]. Concomitant cuff repairs or the degree of removal of calcification does not affect the clinical outcome in the functional recovery of the shoulder after arthroscopic treatment for chronic calcific tendinitis [5]. Arthroscopic removal of as much symptomatic calcium deposits as possible is a safe and effective treatment when nonoperative methods fail, provided the cuff is not markedly degenerative [108]. Debridement and balloon spacers offer reliable outcomes with documented improvements in pain and function for subacromial surgery for irreparable posterosuperior rotator cuff tears, though disease progression to rotator cuff arthropathy is possible [39]. Shoulder function is significantly lower if the teres minor is atrophic or fatty infiltrated; pseudoparalysis or severe cuff arthropathy are contraindications for arthroscopic biceps tenotomy and tenodesis for massive irreparable rotator cuff tears [102]. Simultaneous surgical treatment of rotator cuff and long head of biceps tendon lesions in smokers allowed for functional outcomes approximating non-smokers in long-term follow-up, though smoking is a significant negative factor associated with massive rotator cuff tears and higher pain levels [96].

Implant Selection: Graft augmentation provides promising clinical outcomes, with initial reports demonstrating clinical improvements that could significantly change treatment approaches despite little evidence of drastic outcome improvements in arthroscopic rotator cuff repair over the last 30 years [37]. Surgical advances including patch augmentation have improved the treatment of massive rotator cuff tears, although long-term studies are needed to identify prognostic factors and ideal techniques and to optimize selection of patients [44]. Augmentation with an autograft biceps patch ("Biceps Smash") results in low retear rates at 6 months and promising clinical outcomes at 12 months, with the potential to be safe and effective for improving rotator cuff repair healing rates [49].

Other Considerations: Healed rotator cuff repairs show improved patient-reported and functional outcomes compared to physical therapy and unhealed rotator cuff repairs [45]. 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 [4]. 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 [21]. The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [14]. Rotator cuff disease is widespread with prevalence increasing with age; both surgical and nonsurgical treatments can be effective, and while untreated chronic tears can lead to arthrosis, salvage options exist [26]. The best treatment for rotator cuff disease continues to be controversial and is currently based on the individual surgeon's clinical experience rather than firm scientific data [43].

Complications

Disease Progression: Untreated chronic rotator cuff tears can lead to arthrosis [26]. Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time [28]. In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear, resulting in a measurable decline in function within 3 years [3].

Outcomes and Integrity: Greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes at mid-term follow-up [4]. Although improvement in supraspinatus atrophy was affected by 10-year postoperative cuff integrity, this improvement did not affect long-term postoperative outcomes [19]. A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up [20]. All intact rotator cuff tendons at 1 year remained intact at 2 years [22]. Different types of cuff tear morphology do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up [7].

Concomitant Procedures: Addressing biceps pathology when performing rotator cuff repair resulted in similar rates of cuff failure, revision rotator cuff repair, and complications compared with isolated rotator cuff repair at 2 years postoperatively [6]. The short-term clinical influence of biceps complications on shoulder outcome is very limited [24]. Concomitant cuff repairs or the degree of removal of calcification does not affect the clinical outcome in the treatment of chronic calcific tendinitis [5].

Other Considerations: A complete history and physical, careful attention to auxiliary tests, and treatment of multiple diagnoses in the same shoulder avoids missed pathologic features and the necessity for revision operations [15].

Recovery

Light activity (weeks): Clinical evidence does not specify a week range for light activity, desk work, or driving. However, patients should expect similar improvement in pain and validated outcome measures for each side at a minimum of 1-year follow-up after rotator cuff repair [70]. Patients may experience more pain during the middle portion of recovery on the contralateral side after bilateral rotator cuff repair [70].

Full activity (months): The evidence does not define a specific month range for full activity, manual work, or strength return. Arthroscopic rotator cuff repair has evolved into one of the most common orthopedic surgical procedures worldwide, yet there is still much work to be carried out to improve healing rates, outcomes, and long-term durability [25].

Complete recovery / outcome plateau (months): 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 [69]. At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes [4]. Different types of cuff tear morphology do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up [7]. Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome [18]. Improvement in supraspinatus atrophy did not affect long-term postoperative outcomes, although it was affected by 10-year postoperative cuff integrity [19]. A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up [20]. All intact rotator cuff tendons at 1 year remained intact at 2 years [22].

Rehabilitation protocol: The evidence does not specify rehabilitation protocols, PT phasing, immobilisation duration, or sling removal timing. The short-term clinical influence of biceps complications on shoulder outcome is very limited [24].

Functional milestones: In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear, resulting in a measurable decline in function within 3 years [3]. Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time [28]. Tear progression was observed in approximately 50% of patients with symptomatic small to medium full-thickness rotator cuff tears [117]. The tear size of symptomatic rotator cuff tears progressed by 55% in 1.5 years, with a degree of progression of 6.0 mm in length and 3.6 mm in width per year [114]. 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 [111]. The presence of a rotator cuff tear influences progression in Hamada grade, but the magnitude of radiographic progression is not influenced by tear severity or enlargement at midterm time points [113]. There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease [115]. This study demonstrates the progressive nature of degenerative rotator cuff disease [116]. The article represents the highest-quality research efforts, a prospective randomized trial with long-term outcomes and minimal attrition, highlighting the need for more studies to understand the ability of interventions to interrupt the natural history of rotator cuff tears [27].

Other Considerations: The evidence does not provide specific data on return-to-work failure predictors or patient-selection caveats for early ROM beyond the general observations on tear progression and outcome predictors listed above.

Key Evidence

  • [L1] The presence of a cuff tear does not necessitate surgical repair. (10.1177/1758573215620571)
  • [Paper] This issue reinforces the concept that rotator cuff disease is a continuum and brings readers up to date on rotator cuff disease, covering epidemiology, imaging, techniques, and outcomes. (10.1016/j.csm.2012.08.001)
  • [L2] In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years. (10.1016/j.jse.2023.09.008)
  • [L4] At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes. (10.1016/j.arthro.2023.06.031)
  • [L4] Concomitant cuff repairs or the degree of removal of calcification does not affect the clinical outcome. (10.5397/cise.2018.21.2.75)
  • [L3] Addressing biceps pathology when performing rotator cuff repair resulted in similar rates of cuff failure, revision rotator cuff repair, and complications, as well as a similar improvement in patient-reported outcomes when compared with isolated rotator cuff repair at 2 years postoperatively. (10.1177/03635465221085661)
  • [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. (10.1016/j.jisako.2023.10.014)
  • [L4] A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further. (10.1302/2058-5241.1.160005)
  • [L5] Current consensus suggests rotator cuff injuries are most accurately diagnosed with a combination of cuff- and impingement-specific clinical tests. (10.1016/j.arthro.2013.07.265)
  • [L3] The acromial morphology classification system is an unreliable method to assess the acromion, and the acromial index shows no association with the presence of rotator cuff disease. (10.1016/j.jse.2011.09.028)
  • [L4] This study defines the main clinical and histopathological features of painful rotator cuff tear, observing a greater association of pain with histopathological changes in the bursa compared with those in the rotator cuff. (10.1007/s00167-015-3650-4)
  • [L5] It is useful in the diagnosis of rotator cuff tears, impingement syndrome, and biceps pathology. (10.1016/j.pmrj.2012.08.019)
  • [L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. (10.1007/s11999-008-0585-9)
  • [L4] A complete history and physical, careful attention to auxiliary tests, and treatment of multiple diagnoses in the same shoulder avoids missed pathologic features and necessity for revision operations. (10.1097/01.blo.0000063791.32430.59)
  • [Paper] Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality. (10.1016/j.csm.2012.07.010)
  • [L5] The major indication for revision rotator cuff repair is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure. (10.5435/00124635-201111000-00002)
  • [L3] Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. (10.2106/00004623-199907000-00012)
  • [Abstract] Although improvement in supraspinatus atrophy was affected by the 10-year postoperative cuff integrity, this improvement did not affect long-term postoperative outcomes. (10.1016/j.jse.2024.01.011)
  • [L2] A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up. (10.1016/j.jse.2020.01.083)
  • [L5] Shoulder surgeons must carefully interpret literature comparing open and arthroscopic rotator cuff repair outcomes, as differences in complications may be influenced by selection bias and narrowing indications for open repair. (10.1016/j.arthro.2017.11.026)
  • [L3] All intact rotator cuff tendons at 1 year remained intact at 2 years. (10.1177/0363546509335764)
  • [L5] The indications for the operative treatment of massive and irreparable rotator cuff tears were determined based on expert consensus and the best available evidence, seeking to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios. (10.1016/j.jisako.2024.01.001)
  • [L3] Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited. (10.1177/2325967121s00362)
  • [L4] Arthroscopic rotator cuff repair has evolved into one of the most common orthopedic surgical procedures worldwide, yet there is still much work to be carried out to improve healing rates, outcomes, and long-term durability. (10.1016/j.xrrt.2021.01.004)
  • [L5] The article represents the highest-quality research efforts, a prospective randomized trial with long-term outcomes and minimal attrition, highlighting the need for more studies to understand the ability of interventions to interrupt the natural history of rotator cuff tears. (10.2106/jbjs.19.00325)
  • [L4] Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time. (10.1016/j.arthro.2018.07.031)
  • [L4] A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair. (10.1016/j.arthro.2007.05.002)
  • [L2] Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. (10.1016/j.jse.2024.02.024)
  • [L5] Subscapularis tendon pathology is infrequently identified but can present as isolated tears, partial-thickness tears, or complete rotator cuff avulsion. (10.5435/00124635-200509000-00009)
  • [L5] Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology. (10.5435/jaaos-d-15-00258)
  • [L4] Rotator cuff tendinopathy and defects are increasingly common with age and are related, with degenerate pathophysiology weakening the enthesis; management decisions should be based on the likelihood of a newly symptomatic chronic, degenerative defect rather than an acute traumatic injury. (10.1016/j.jhsa.2010.11.027)
  • [L3] Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses. (10.1177/23259671251332942)
  • [L5] Optimal scapular function is a key component of all shoulder function, and alterations in scapular motion are associated with most types of shoulder pathology. (10.5435/jaaos-20-06-364)
  • [L5] Despite little evidence of drastic outcome improvements in arthroscopic rotator cuff repair over the last 30 years, initial reports of graft augmentation demonstrate clinical improvements that could significantly change treatment approaches. (10.1016/j.arthro.2021.11.035)
  • [L5] Debridement and balloon spacers offer reliable outcomes with documented improvements in pain and function, though disease progression to rotator cuff arthropathy is possible. (10.1016/j.arthro.2024.02.003)
  • [L1] Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. (10.1186/s13018-014-0070-y)
  • [L5] In this cadaveric shoulder model of the throwing shoulder, tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics. (10.1177/2325967117s00373)
  • [L2] With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. (10.1177/0363546506298108)
  • [L4] The best treatment for rotator cuff disease continues to be controversial and is currently based on the individual surgeon's clinical experience rather than firm scientific data. (10.5435/00124635-199807000-00007)
  • [L5] Surgical advances including patch augmentation have improved the treatment of massive rotator cuff tears; however, long-term studies are needed to identify prognostic factors and ideal techniques and to optimize selection of patients. (10.1016/j.jse.2015.04.005)
  • [L5] In this dynamic shoulder model, performing an SCR only partially restored native glenohumeral joint loads. (10.1016/j.jisako.2023.03.405)
  • [L2] Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. (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. (10.1016/j.jse.2017.10.009)
  • [L4] This augmentation option has the potential to be safe and effective for improving rotator cuff repair healing rates. (10.1002/arj.70379)
  • [L1] This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease. (10.5435/00124635-200701000-00002)
  • [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. (10.1177/2325967116667058)
  • [L4] The goal of tendon transfers is to achieve stable kinematics by restoring rotational strength and force coupling of the shoulder joint. (10.1530/eor-22-0023)
  • [L5] Early surgical intervention can reliably treat significant shoulder impairment in acute traumatic tears, and understanding the Hamada classification helps predict appropriate care and outcomes in patients with massive rotator cuff pathology. (10.1016/j.arthro.2018.11.006)
  • [L3] This study was the first to create a classification system to divide coracoids according to their morphology and relative risk of associated subscapularis tears. (10.1016/j.jse.2020.01.074)
  • [Abstract] The 3D glenohumeral kinematics at the early phase of arm elevation may affect the shoulder function in patients with massive rotator cuff tears. (10.1016/j.jse.2020.01.004)
  • [L4] The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in the functional planes of motion. (10.2106/00004623-198668030-00013)
  • [L3] Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology. (10.1016/j.jseint.2025.04.038)
  • [L4] Biomechanical studies suggest that the humeral head–stabilizing effect of SCR appears to translate into improved clinical outcomes. (10.1016/j.jse.2019.07.005)
  • [L3] Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. (10.1002/ksa.12162)
  • [L5] Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increased glenohumeral translation and changed kinematics in our cadaveric biomechanical model. (10.1016/j.jse.2016.12.063)
  • [L2] The ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communicating among surgeons and for pooling of data from clinical studies. (10.1016/j.jisako.2021.12.004)
  • [L3] Patients exhibiting higher classification of fatty infiltration in the rotator cuff muscles, as well as those with more extensive rotator cuff tears, may be associated with increased levels of hidden blood loss (HBL) during arthroscopic rotator cuff repair. (10.1186/s12891-025-09310-7)
  • [L4] Dynamic elongation of repair tissue during scapular-plane abduction exhibited 1 of 2 distinct patterns, which may suggest different patterns of supraspinatus mechanical and neuromuscular function. (10.1177/23259671221084294)
  • [L4] Neither the classification of Snyder nor that of Ellman reproduces the extension of the partial-thickness rotator cuff tear in the transverse and coronal planes related to its etiology and pathomorphology. (10.1016/j.jse.2008.06.007)
  • [L5] In a dynamic biomechanical cadaveric model, increased glenohumeral joint loads due to a full-thickness SSP tear can be reversed with RCR. (10.1016/j.arthro.2021.10.036)
  • [L3] Surgeons should consider the size of a cuff repair and corresponding surgical and patient factors to help maximize patient outcomes. (10.1177/2325967124s00130)
  • [L3] MR imaging is suggested for patients with radiographic greater tuberosity sclerosis or spurs to detect advanced rotator cuff lesions. (10.1016/j.jse.2019.03.010)
  • [L1] Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. (10.1016/j.jse.2020.11.002)
  • [L1] Shoulder scores may decline at mid- to long-term follow-up. (10.1186/s13018-022-03411-y)
  • [L5] At a minimum of 1-year follow-up after rotator cuff repair, patients should expect similar improvement in pain and validated outcome measures for each side, though they may experience more pain during the middle portion of recovery on the contralateral side. (10.1016/j.arthro.2018.07.025)
  • [L4] Patients who reached at least 85° compensated for the loss of glenohumeral motion by increased scapulothoracic contribution, suggesting that structural damage interferes with motion mechanics. (10.1016/j.jse.2016.02.031)
  • [L5] The authors suggest that surgical techniques should be tailored to optimize residual cuff activation to restore balanced shoulder mechanics. (10.2106/jbjs.25.01543)
  • [L5] Arthroscopy has become the gold standard for rotator cuff repair due to reduced invasiveness and fewer complications, though results still include a large number of recurrences. (10.1007/s00167-015-3515-x)
  • [L3] Shoulder strength and patient-reported outcomes improved significantly over 24 months, but the glenohumeral joint contact center gradually shifted superiorly, potentially reflecting altered loading patterns or loss of dynamic stability despite functional improvements. (10.1016/j.jseint.2025.101421)
  • [L5] Recent modifications of the configurations offer no biomechanical advantage. (10.1007/s00167-010-1322-y)
  • [L5] Evidenced-based data is currently lacking to support routine use of acromioplasty in all cases of rotator cuff repair. (10.1016/j.arthro.2019.04.008)
  • [L5] In the author's practice, MRI is the test of choice for rotator cuff pathology due to its versatility and availability, though ultrasound can be performed if an unrecognized partial subscapularis tendon injury is suspected after MRI. (10.1016/j.arthro.2021.08.029)
  • [L3] Comparison of the 'tear' and 'non-tear' patient groups suggest that cuff tears can be left unrepaired in selected patients. (10.1111/j.1758-5740.2009.00015.x)
  • [L5] Diagnosis of long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology can be challenging due to limitations in MRI and arthroscopic visualization; surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing pathology. (10.1016/j.arthro.2017.09.005)
  • [L5] Nonoperative treatment is appropriate as initial therapy, while operative management including arthroscopic subacromial decompression, debridement, or repair is considered when nonoperative treatment fails. (10.5435/00124635-199901000-00004)
  • [L5] The authors maintain that magnetic resonance arthrography is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair, regardless of the gold standard used, and that neither MRI nor clinical tests are sufficiently reliable in this context. (10.1007/s00167-019-05775-x)
  • [L5] The AAOS developed Appropriate Use Criteria (AUC) using the RAND/UCLA Appropriateness Method to guide treatment decisions for full-thickness rotator cuff tears by synthesizing evidence and expert opinion across 432 patient scenarios. (10.5435/00124635-201312000-00008)
  • [L4] Conservative treatment remains the mainstay, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy. (10.1177/1758573214567559)
  • [L4] The integration of 3D imaging and volumetric analysis offers novel advancement in diagnosing and classifying rotator cuff injuries, challenging the conventional reliance on 2D MRI. (10.1016/j.jse.2024.08.030)
  • [L5] Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect and the physiologic load required remains unknown. (10.1016/j.arthro.2010.10.014)
  • [L3] When humeral cysts are detected on plain radiographs in a patient with a painful shoulder, the index of suspicion for rotator cuff tear should be high, particularly in those patients aged over 60 years. (10.1111/j.1758-5740.2011.00143.x)
  • [L5] Human studies are necessary to confirm the appropriate indications and effectiveness of augmentation scaffolds for rotator cuff repair healing in the clinical setting. (10.1016/j.jse.2017.12.016)
  • [L1] The findings in this study are consistent with the alterations in shoulder function observed with rotator cuff and other shoulder injuries in the human. (10.1016/j.jse.2008.10.008)
  • [L4] The incidence of rotator cuff tears in cases of calcific tendonitis in this cohort of patients who underwent MRI is higher than previously reported. (10.1016/j.arthro.2019.11.127)
  • [L5] Biomechanical data does not translate to clinical re-rupture rates after shoulder rotator cuff repair using different suture techniques stratified by method of repair and tear size. (10.1016/j.arthro.2015.05.018)
  • [L3] Preoperative MRI scans of the shoulder do not reliably predict which rotator cuff injury patients have subscapularis tendon tears. (10.1016/j.arthro.2010.02.028)
  • [L5] MRI might not provide adequate preoperative information, and arthroscopy remains the gold standard for diagnosing subscapularis tears. (10.1016/j.arthro.2015.12.011)
  • [L4] However, the presence of clinically significant disagreements, even in such favorable circumstances, indicates the need for improved imaging tools for precise rotator cuff evaluation. (10.1016/j.jse.2021.04.021)
  • [L3] Simultaneous surgical treatment of rotator cuff and long head of biceps tendon lesions in smokers allowed for functional outcomes approximating non-smokers in long-term follow-up, though smoking is a significant negative factor associated with massive rotator cuff tears and higher pain levels. (10.3390/jcm10040599)
  • [L3] Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year and obtained a follow-up MRI, 39% progressed to a partial or full-thickness tear. (10.1016/j.asmr.2022.05.004)
  • [L3] Radiological evaluation of the supraspinatus muscle alterations seemed to underestimate the degree of the same abnormalities evaluated at histology. (10.1186/s12891-023-06237-9)
  • [L3] Radiologic severity of supraspinatus pathology was correlated with dynamic clinical function across the full range of pathology. (10.1177/2325967121s00337)
  • [L3] In particular, these models are equally adept as musculoskeletal radiologists in using ultrasound to diagnose rotator cuff pathology and exhibit statistically superior levels of accuracy and specificity when using MRI compared to orthopaedic surgeons. (10.1016/j.arthro.2023.06.018)
  • [L3] Traumatic and degenerative rotator cuff repairs lead to comparable clinical and radiologic results. (10.1016/j.asmr.2023.100867)
  • [L3] Shoulder function is significantly lower if the teres minor is atrophic or fatty infiltrated, and pseudoparalysis or severe cuff arthropathy are contraindications. (10.1016/j.arthro.2007.03.039)
  • [L4] The finding of focal diminished bone mineral density of the greater tuberosity in the absence of rotator cuff tears warrants further investigation. (10.1016/j.jse.2010.12.009)
  • [L1] At one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition. (10.1302/0301-620x.96b1.32168)
  • [L5] This approach may be a candidate for the nonoperative management of partial-thickness rotator cuff tears. (10.2106/jbjs.21.01157)
  • [L4] This rotator cuff MRI protocol can be applied to evaluate morphological tendon outcomes after different treatment modalities. (10.1186/s13018-014-0128-x)
  • [L3] The results of this study indicate that there is substantial variability when evaluating MRI scans after rotator cuff repair. (10.1177/0363546512449424)
  • [L4] The results of this study indicate that arthroscopic removal of as much as possible of symptomatic calcium deposits of the rotator cuff is a safe and effective treatment when nonoperative methods fail, as long as the cuff is not markedly degenerative. (10.1177/0363546510396320)
  • [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. (10.1016/j.arthro.2007.01.023)
  • [L2] Whereas the presence of a rotator cuff tear influences progression in Hamada grade, the magnitude of radiographic progression is not influenced by tear severity or enlargement at midterm time points. (10.1016/j.jse.2016.07.022)
  • [Abstract] The tear size of symptomatic rotator cuff tears progressed by 55% in 1.5 years and the degree of progression was 6.0 mm in length and 3.6 mm in width per year. (10.1016/j.jse.2015.08.022)
  • [L3] There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease. (10.1016/j.jse.2013.10.001)
  • [L2] This study demonstrates the progressive nature of degenerative rotator cuff disease. (10.2106/jbjs.n.00099)
  • [L3] Tear progression was observed in approximately 50% of patients with symptomatic small to medium full-thickness rotator cuff tears. (10.1016/j.jse.2022.09.012)

See Also

References

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

[96] The Impact of Smoking on Clinical Results Following the Rotator Cuff and Biceps Tendon Complex Arthroscopic Surgery. Journal of Clinical Medicine. 2021. DOI: 10.3390/jcm10040599

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[101] Traumatic and Atraumatic Rotator Cuff Tears Have the Same Rates of Healing. Arthroscopy, Sports Medicine, and Rehabilitation. 2024. DOI: 10.1016/j.asmr.2023.100867

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[103] Bone density of the greater tuberosity is decreased in rotator cuff disease with and without full-thickness tears. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.12.009

[104] Treatment of non-traumatic rotator cuff tears. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b1.32168

[105] In Situ-Forming Fibrin Gel Encapsulation of MSC-Exosomes for Partial-Thickness Rotator Cuff Tears in a Rabbit Model. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.21.01157

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