Skip to content

Clinicians › Shoulder

Cuff Pathology

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

112 citationsUpdated Aug 2026

Overview

The presence of a cuff tear does not necessitate surgical repair [1]. 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 [73]. Evidenced-based data is currently lacking to support routine use of acromioplasty in all cases of rotator cuff repair [77]. Surgeons should consider the size of a cuff repair and corresponding surgical and patient factors to help maximize patient outcomes [66].

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]. 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 [6]. Concomitant cuff repairs or the degree of removal of calcification does not affect the clinical outcome in the treatment of chronic calcific tendinitis [5].

The indications for the operative treatment of massive and irreparable rotator cuff tears were determined based on expert consensus and the best available evidence to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios [23]. 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 [83]. Differences in complications between open and arthroscopic rotator cuff repair outcomes 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]. Human studies are necessary to confirm the appropriate indications and effectiveness of augmentation scaffolds for rotator cuff repair healing in the clinical setting [88].

Anatomy & Pathophysiology

Scapular Kinematics and Global Function

Optimal scapular function is a key component of all shoulder function [36]. Alterations in scapular motion are associated with most types of shoulder pathology [36]. 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 [71].

Glenohumeral Biomechanics and Kinematics

Three-dimensional glenohumeral kinematics at the early phase of arm elevation may affect shoulder function in patients with massive rotator cuff tears [55]. 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]. 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 [63].

Rotator Cuff Muscle Dynamics and Force Coupling

The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in the functional planes of motion [56]. The goal of tendon transfers is to achieve stable kinematics by restoring rotational strength and force coupling of the shoulder joint [52]. Surgical techniques should be tailored to optimize residual cuff activation to restore balanced shoulder mechanics [72].

Joint Loads and Stability

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]. Performing a superior capsule reconstruction (SCR) only partially restores native glenohumeral joint loads in a dynamic shoulder model [46]. Biomechanical studies suggest that the humeral head–stabilizing effect of superior capsule reconstruction (SCR) appears to translate into improved clinical outcomes [58]. 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].

Clinical Outcomes and Tissue Behavior

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]. Recent modifications of suture configurations for rotator cuff repair offer no biomechanical advantage in tendon-grasping strength [76]. 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].

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 is more strongly associated with histopathological changes in the subacromial bursa than with those in the rotator cuff tendon [11]. Different types of rotator cuff tear morphology do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up [7].

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 [51]. However, neither the Snyder nor the Ellman classification reproduces the extension of partial-thickness rotator cuff 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 modified Patte classification system has excellent diagnostic performance for reparability and acceptable performance for rotator cuff healing, with high measurement reliability [59].

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

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]. A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair [29]. A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment [8].

Acromial morphology classification systems are unreliable methods to assess the acromion [10]. 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 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 tears and defects increases significantly with age, driven by degenerative pathophysiology that weakens the enthesis [13, 33]. Management decisions for defects should prioritize the likelihood of a newly symptomatic chronic, degenerative defect over acute traumatic injury [33].

Patients with subacromial pain syndrome frequently present with conflicting and concomitant diagnoses [34]. Subjective mechanical symptoms are common complaints in suspected pathology [30]. Pain may develop in a contralateral asymptomatic tear in one-quarter of patients, causing measurable functional decline within 3 years [3].

Clinical examination aids in diagnosing tears, impingement syndrome, and biceps pathology [12]. Individual shoulder tests hold moderate diagnostic value for rotator cuff tears [40]. Current consensus recommends a combination of cuff- and impingement-specific clinical tests for accurate diagnosis [9].

The term 'impingement' is discouraged due to varied etiologies and difficulty isolating the pain source; the syndrome is better termed 'rotator cuff disease' or 'anterolateral shoulder pain syndrome' [38]. Imaging plays an important role in the workup of suspected abnormalities [16]. In painful tears, pain associates more strongly with histopathological changes in the bursa than in the rotator cuff [11].

Comprehensive management requires understanding subscapularis pathology, which infrequently presents as isolated tears, partial-thickness tears, or complete avulsion [31]. Knowledge of teres minor function and pathology is paramount for comprehensive shoulder management [32]. A complete history and physical, careful attention to auxiliary tests, and treatment of multiple diagnoses in the same shoulder avoid missed pathologic features and the need for revision operations [15].

Investigations

Plain radiography: 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 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 found in rotator cuff disease with and without full-thickness tears; this finding in the absence of rotator cuff tears warrants further investigation [103]. The incidence of rotator cuff tears in cases of 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]. Ultrasound can be performed if an unrecognized partial subscapularis tendon injury is suspected after MRI [78]. Neither MRI nor clinical tests are sufficiently reliable to diagnose biceps lesions prior to rotator cuff repair [82]. Magnetic resonance arthrography is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair [82]. Preoperative MRI scans of the shoulder do not reliably predict which rotator cuff injury patients have subscapularis tendon tears [93], and MRI might not provide adequate preoperative information for subscapularis tears [94]. 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 [97]. Radiological evaluation of the supraspinatus muscle alterations seemed to underestimate the degree of the same abnormalities evaluated at histology [98]. Radiologic severity of supraspinatus pathology was correlated with dynamic clinical function across the full range of pathology [99]. A 3 T MRI protocol can be applied to evaluate morphological tendon outcomes after different treatment modalities for supraspinatus tendonosis and partial thickness tears [106]. There is substantial variability when evaluating MRI scans after rotator cuff repair [107].

Ultrasound: 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 can be 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 long head biceps tendon and subscapularis pathology [80]. 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 [85]. Volumetric analysis challenges the conventional reliance on 2D MRI for rotator cuff injury classification [85]. The presence of clinically significant disagreements in rotator cuff tendon and muscle MRI parameters indicates the need for improved imaging tools for precise rotator cuff evaluation [95]. Artificial intelligence models exhibit statistically superior levels of accuracy and specificity when using MRI compared to orthopaedic surgeons [100]. Traumatic and degenerative rotator cuff repairs lead to comparable clinical and radiologic results [101].

Treatment

Nonoperative Management

Nonoperative treatment is an effective and lasting option for many patients with chronic, full-thickness rotator cuff tears [47] and has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears [68]. Conservative treatment remains the mainstay for spontaneous resorption of calcification at the long head of the biceps tendon, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy [84]. At one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and conservative treatment should be considered as the primary method of treatment for this condition [104]. Nonoperative treatment is appropriate as initial therapy for partial-thickness tears of the rotator cuff, while operative management including arthroscopic subacromial decompression, debridement, or repair is considered when nonoperative treatment fails [81]. In situ-forming fibrin gel encapsulation of MSC-exosomes may be a candidate for the nonoperative management of partial-thickness rotator cuff tears [105]. There is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease [50].

Operative Indications and Selection

Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology [57]. Cuff tears can be left unrepaired in selected patients [79]. 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 [23]. 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]. Shoulder function is significantly lower if the teres minor is atrophic or fatty infiltrated, and pseudoparalysis or severe cuff arthropathy are contraindications for arthroscopic biceps tenotomy and tenodesis for massive irreparable rotator cuff tears [102].

Surgical Techniques and Outcomes

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]. 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 [108]. 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]. 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]. 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]. Initial reports of graft augmentation demonstrate clinical improvements that could significantly change treatment approaches for rotator cuff repair [37]. Augmentation with an autograft biceps patch 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]. 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]. 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

Other Considerations: Untreated chronic cuff tears can lead to arthrosis [26]. 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]. 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]. Biceps-related complications after tenotomy associated with arthroscopic rotator cuff repair have a very limited short-term clinical influence on shoulder outcome [24]. 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): Evidence does not specify a precise week range for light activity or desk work return. However, patients undergoing bilateral rotator cuff repair may experience increased pain during the middle portion of recovery on the contralateral side [70].

Full activity (months): At a minimum of 1-year follow-up, patients should expect similar improvement in pain and validated outcome measures for each side [70].

Complete recovery / outcome plateau (months): Clinical outcomes stabilize at mid-term follow-up, where greater preoperative rotator cuff disease severity is associated with failure to achieve clinically significant outcomes [4]. 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].

Rehabilitation protocol: The evidence does not specify immobilisation duration, sling removal timing, or specific PT phasing protocols.

Functional milestones: 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]. 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]. Improvement in supraspinatus atrophy did not affect long-term postoperative outcomes, although it was affected by 10-year postoperative cuff integrity [19]. All intact rotator cuff tendons at 1 year remained intact at 2 years [22]. The short-term clinical influence of biceps complications on shoulder outcome is very limited [24].

Other Considerations: 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]. The highest-quality research efforts, including prospective randomized trials with long-term outcomes and minimal attrition, highlight the need for more studies to understand the ability of interventions to interrupt the natural history of rotator cuff tears [27]. Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time [28]. 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]. 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]. There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease [115]. Degenerative rotator cuff disease demonstrates a progressive nature [116]. Tear progression was observed in approximately 50% of patients with symptomatic small to medium full-thickness rotator cuff tears [117].

Key Evidence

  • [L1] The presence of a cuff tear does not necessitate surgical repair. [1] (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. [2] (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. [3] (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. [4] (10.1016/j.arthro.2023.06.031)
  • [L4] Concomitant cuff repairs or the degree of removal of calcification does not affect the clinical outcome. [5] (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. [6] (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. [7] (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. [8] (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. [9] (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] (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. [11] (10.1007/s00167-015-3650-4)
  • [L5] It is useful in the diagnosis of rotator cuff tears, impingement syndrome, and biceps pathology. [12] (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. [14] (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. [15] (10.1097/01.blo.0000063791.32430.59)
  • [Paper] Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality. [16] (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. [17] (10.5435/00124635-201111000-00002)
  • [L3] Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. [18] (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. [19] (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. [20] (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. [21] (10.1016/j.arthro.2017.11.026)
  • [L3] All intact rotator cuff tendons at 1 year remained intact at 2 years. [22] (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. [23] (10.1016/j.jisako.2024.01.001)
  • [L3] Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited. [24] (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. [25] (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. [27] (10.2106/jbjs.19.00325)
  • [L4] Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time. [28] (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. [29] (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. [30] (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. [31] (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. [32] (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. [33] (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. [34] (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. [36] (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. [37] (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. [39] (10.1016/j.arthro.2024.02.003)
  • [L1] Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. [40] (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. [41] (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. [42] (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. [43] (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. [44] (10.1016/j.jse.2015.04.005)
  • [L5] In this dynamic shoulder model, performing an SCR only partially restored native glenohumeral joint loads. [46] (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. [47] (10.1016/j.jseint.2024.11.018)
  • [L4] This augmentation option has the potential to be safe and effective for improving rotator cuff repair healing rates. [49] (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. [50] (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. [51] (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. [52] (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. [53] (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. [54] (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. [55] (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. [56] (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. [57] (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. [58] (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. [59] (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. [60] (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. [61] (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. [62] (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. [63] (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. [64] (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. [65] (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. [66] (10.1177/2325967124s00130)
  • [L3] MR imaging is suggested for patients with radiographic greater tuberosity sclerosis or spurs to detect advanced rotator cuff lesions. [67] (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. [68] (10.1016/j.jse.2020.11.002)
  • [L1] Shoulder scores may decline at mid- to long-term follow-up. [69] (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. [70] (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. [71] (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. [72] (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. [73] (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. [75] (10.1016/j.jseint.2025.101421)
  • [L5] Recent modifications of the configurations offer no biomechanical advantage. [76] (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. [77] (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. [78] (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. [79] (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. [80] (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. [81] (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. [82] (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. [83] (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. [84] (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. [85] (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. [86] (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. [87] (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. [88] (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. [89] (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. [91] (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. [92] (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. [93] (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. [94] (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. [95] (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. [96] (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. [97] (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. [98] (10.1186/s12891-023-06237-9)
  • [L3] Radiologic severity of supraspinatus pathology was correlated with dynamic clinical function across the full range of pathology. [99] (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. [100] (10.1016/j.arthro.2023.06.018)
  • [L3] Traumatic and degenerative rotator cuff repairs lead to comparable clinical and radiologic results. [101] (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. [102] (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. [103] (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. [104] (10.1302/0301-620x.96b1.32168)
  • [L5] This approach may be a candidate for the nonoperative management of partial-thickness rotator cuff tears. [105] (10.2106/jbjs.21.01157)
  • [L4] This rotator cuff MRI protocol can be applied to evaluate morphological tendon outcomes after different treatment modalities. [106] (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. [107] (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. [108] (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. [111] (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. [113] (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. [114] (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. [115] (10.1016/j.jse.2013.10.001)
  • [L2] This study demonstrates the progressive nature of degenerative rotator cuff disease. [116] (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. [117] (10.1016/j.jse.2022.09.012)

See Also

References

[1] Medium- to long-term results of a randomized controlled trial to assess the efficacy of arthoscopic-subacromial decompression versus mini-open repair for the treatment of medium-sized rotator cuff tears. Shoulder & Elbow. 2015. DOI: 10.1177/1758573215620571

[2] Foreword. Clinics in Sports Medicine. 2012. DOI: 10.1016/j.csm.2012.08.001

[3] Predictors of pain development for contralateral asymptomatic degenerative rotator cuff tears based on features of an ipsilateral painful cuff tear: a prospective longitudinal cohort study. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.09.008

[4] Quantifying Threshold Scores for Patient Satisfaction After Massive Rotator Cuff Repair for the Interpretation of Mid‐Term Patient‐Reported Outcomes. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.06.031

[5] Functional Recovery of the Shoulder after Arthroscopic Treatment for Chronic Calcific Tendinitis. Clinics in Shoulder and Elbow. 2018. DOI: 10.5397/cise.2018.21.2.75

[6] Evaluation of Rotator Cuff Repair With and Without Concomitant Biceps Intervention: A Retrospective Review of Patient Outcomes. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221085661

[7] Different types of rotator cuff tear morphology do not affect post-repair clinical outcomes in large to massive tears. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2023.10.014

[8] Classification of full-thickness rotator cuff lesions: a review. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.160005

[9] Management of Disorders of the Rotator Cuff: Proceedings of the ISAKOS Upper Extremity Committee Consensus Meeting. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.07.265

[10] Relationship of radiographic acromial characteristics and rotator cuff disease: a prospective investigation of clinical, radiographic, and sonographic findings. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.09.028

[11] The role of tendon and subacromial bursa in rotator cuff tear pain: a clinical and histopathological study. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3650-4

[12] Clinical Examination of the Rotator Cuff. PM&R. 2013. DOI: 10.1016/j.pmrj.2012.08.019

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

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

[15] Suprascapular Nerve Entrapment Secondary to a Lipoma. Clinical Orthopaedics & Related Research. 2003. DOI: 10.1097/01.blo.0000063791.32430.59

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

[17] Arthroscopic Revision Rotator Cuff Repair. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201111000-00002

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

[19] Does the improvement of supraspinatus atrophy affect long-term postoperative outcomes?. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.01.011

[20] Is residual tendon a predictor of outcome following arthroscopic rotator cuff repair? A preliminary outlook at short-term follow-up. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.01.083

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

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

[23] Latin American formal consensus on the indications for the surgical treatment of massive and irreparable rotator cuff tears. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.01.001

[24] Biceps-related complications after tenotomy associated with arthroscopic rotator cuff repair: risk factors and clinical impact. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00362

[25] Current concepts in the evolution of arthroscopic rotator cuff repair. JSES Reviews, Reports, and Techniques. 2021. DOI: 10.1016/j.xrrt.2021.01.004

[26] Chapter 3 Rotator Cuff Disease. 2019.

[27] A Changing View: How Should We Define Our Goals with Rotator Cuff Tear Treatment?. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.00325

[28] Full‐Thickness Rotator Cuff Tears: What Is the Rate of Tear Progression? A Systematic Review. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.07.031

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

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

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

[32] Understanding the Importance of the Teres Minor for Shoulder Function: Functional Anatomy and Pathology. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-15-00258

[33] Rotator Cuff Defect: Acute or Chronic?. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.11.027

[34] The Challenge of Diagnosing Patients Presenting With Signs and Symptoms of Subacromial Pain Syndrome: A Descriptive Study of 741 Patients Seen in a Secondary Care Setting. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251332942

[35] Chapter 24 Shoulder Instability, Rotator Cuff Disorders, Muscular Ruptures, Adhesive Capsulitis, Calcific Tendinitis. 2020.

[36] Scapular Dyskinesis and Its Relation to Shoulder Injury. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-364

[37] Editorial Commentary : Rotator Cuff Repair: Graft Augmentation Provides Promising Clinical Outcomes. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2021.11.035

[38] McFarland, Edward G. MD 1; Selhi, Harpal Singh MD 2; Keyurapan, Ekavit MD 3. The Journal of Bone and Joint Surgery. American Volume. 2006.

[39] Subacromial Surgery for Irreparable Posterosuperior Rotator Cuff Tears. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.02.003

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

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

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

[43] Arthroscopic Management of Rotator Cuff Disease. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199807000-00007

[44] Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.04.005

[45] AAOS CPG: Management of Rotator Cuff Injuries. 2024.

[46] Physiologic Tensioning During Lower Trapezius Transfer For Irreparable Posterosuperior Rotator Cuff Tears Is Important For Improvement Of Shoulder Kinematics. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.405

[47] What happens to patients in the long term when we do not repair their cuff tears? Ten-year rotator cuff quality of life index (RC-QOL) outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. JSES International. 2025. DOI: 10.1016/j.jseint.2024.11.018

[49] Rotator Cuff Repair Augmentation With an Autograft Biceps Patch, the “Biceps Smash,” Results in Low Retear Rates at 6 Months and Promising Clinical Outcomes at 12 Months. Arthroscopy. 2026. DOI: 10.1002/arj.70379

[50] The Efficacy of Subacromial Corticosteroid Injection in the Treatment of Rotator Cuff Disease: A Systematic Review. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200701000-00002

[51] Interobserver Agreement in the Classification of Partial-Thickness Rotator Cuff Tears Using the Snyder Classification System. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116667058

[52] Tendon transfers for massive rotator cuff tears. EFORT Open Reviews. 2022. DOI: 10.1530/eor-22-0023

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

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

[55] Influence of subscapularis tears on three-dimensional glenohumeral kinematics in patients with massive rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.01.004

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

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

[58] Superior capsule reconstruction for irreparable rotator cuff tears: a systematic review of biomechanical and clinical outcomes by graft type. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.07.005

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

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

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

[62] Does fat infiltration of the rotator cuff muscles contribute to increased hidden blood loss (HBL) and other risk factors during arthroscopic rotator cuff repair for rotator cuff injuries?. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-025-09310-7

[63] In Vivo Static Retraction and Dynamic Elongation of Rotator Cuff Repair Tissue After Surgical Repair: A Preliminary Analysis at 3 Months. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221084294

[64] A new arthroscopic classification of articular-sided supraspinatus footprint lesions: A prospective comparison with Snyder's and Ellman's classification. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2008.06.007

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

[66] Poster 161: Rotator Cuff Repair and Minimum Clinically Important Difference: Does Number of Tendons Involved Affect the Minimum Clinically Important Difference Value?. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00130

[67] The radiographic morphology of the greater tuberosity is associated with muscle degeneration in patients with symptomatic rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.03.010

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

[69] Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03411-y

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

[71] Scapulohumeral rhythm relative to active range of motion in patients with symptomatic rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.02.031

[72] Harnessing the Mechanical Resilience of the Rotator Cuff. Journal of Bone and Joint Surgery. 2026. DOI: 10.2106/jbjs.25.01543

[73] State of the art in rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3515-x

[75] Longitudinal analysis of rotator cuff repair: joint kinematics and clinical outcomes. JSES International. 2026. DOI: 10.1016/j.jseint.2025.101421

[76] Tendon‐grasping strength of various suture configurations for rotator cuff repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1322-y

[77] Is Acromioplasty Ever Indicated During Rotator Cuff Repair?. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.04.008

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

[79] The Results of Subacromial Decompression in Patients with and without Rotator Cuff Tears. Shoulder & Elbow. 2009. DOI: 10.1111/j.1758-5740.2009.00015.x

[80] Editorial Commentary: You May Not Have Seen It, but It Has Seen You: Diagnosis of Long Head Biceps Tendon and Subscapularis Pathology in Association With Shoulder Rotator Cuff Pathology Can Be Challenging. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.09.005

[81] Partial-Thickness Tears of the Rotator Cuff: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1999. DOI: 10.5435/00124635-199901000-00004

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

[83] AAOS Appropriate Use Criteria: Optimizing the Management of Full-Thickness Rotator Cuff Tears. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/00124635-201312000-00008

[84] Spontaneous resorption of calcification at the long head of the biceps tendon. Shoulder & Elbow. 2015. DOI: 10.1177/1758573214567559

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

[86] Anatomy, Function, Injuries, and Treatment of the Long Head of the Biceps Brachii Tendon. Arthroscopy. 2011. DOI: 10.1016/j.arthro.2010.10.014

[87] The Association between Radiographic Greater Tuberosity Cystic Change and Rotator Cuff Tears: A Study of 105 Consecutive Cases. Shoulder & Elbow. 2011. DOI: 10.1111/j.1758-5740.2011.00143.x

[88] Augmentation with a reinforced acellular fascia lata strip graft limits cyclic gapping of supraspinatus repairs in a human cadaveric model. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.12.016

[89] Alterations in function after rotator cuff tears in an animal model. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.10.008

[90] Erratum_to_“Alterations_in_function_after_rotator_cuff_tears_in_an_animal_model”_S1058274609002973. Journal of Shoulder and Elbow Surgery. 2009.

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

[92] Editorial Commentary: Biomechanical Data Does Not Translate to Clinical Rerupture Rates After Shoulder Rotator Cuff Repair Using Different Suture Techniques. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.05.018

[93] Accuracy of Preoperative Magnetic Resonance Imaging in Predicting a Subscapularis Tendon Tear Based on Arthroscopy. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2010.02.028

[94] Editorial Commentary: Subscapularis Tendon Tears—Do We Know What Our Preoperative Magnetic Resonance and Arthroscopic Images Are Showing?. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2015.12.011

[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

[97] Conservatively Treated Symptomatic Rotator Cuff Tendinopathy May Progress to a Tear. Arthroscopy, Sports Medicine, and Rehabilitation. 2022. DOI: 10.1016/j.asmr.2022.05.004

[98] Histological, radiological and clinical analysis of the supraspinatus tendon and muscle in rotator cuff tears. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06237-9

[99] The Association between Radiologic Severity of Rotator Cuff Pathology and Supraspinatus Weakness on Biomechanical Assessment (229). Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00337

[100] Artificial Intelligence Aids Detection of Rotator Cuff Pathology: A Systematic Review. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.06.018

[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

[102] Arthroscopic Biceps Tenotomy And Tenodesis For Massive Irreparable Rotator Cuff Tears (SS‐27). Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.03.039

[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

[106] Reliability of a 3 T MRI protocol for objective grading of supraspinatus tendonosis and partial thickness tears. Journal of Orthopaedic Surgery and Research. 2014. DOI: 10.1186/s13018-014-0128-x

[107] Magnetic Resonance Imaging Identification of Rotator Cuff Retears After Repair. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512449424

[108] Arthroscopic Removal of Calcium Deposits of the Rotator Cuff. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546510396320

[111] Fatty Infiltration of the Torn Rotator Cuff Worsens Over Time in a Rabbit Model. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.01.023

[113] Radiographic progression of arthritic changes in shoulders with degenerative rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.07.022

[114] Assessment of the tear progression of symptomatic rotator cuff tear: a prospective study of 150 shoulders. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.08.022

[115] The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.10.001

[116] A Prospective Evaluation of Survivorship of Asymptomatic Degenerative Rotator Cuff Tears. Journal of Bone and Joint Surgery. 2015. DOI: 10.2106/jbjs.n.00099

[117] Risk factors of tear progression in symptomatic small to medium-sized full-thickness rotator cuff tear: relationship between occupation ratio of supraspinatus and work level. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.09.012

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.