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Rotator Cuff

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

215 citationsUpdated Oct 2026

Overview

Management of rotator cuff tears remains complex due to a lack of consensus among orthopaedic surgeons and the absence of specific guidance from American Academy of Orthopaedic Surgeons clinical practice guidelines or Cochrane systematic reviews [1]. Patients are generally categorised into three groups based on the risks of nonoperative treatment and the potential benefits of surgery: those requiring urgent or early operative repair, those who may benefit from a trial of conservative treatment, and those best suited for nonoperative management [1]. The AAOS Appropriate Use Criteria, developed using the RAND/UCLA Appropriateness Method, synthesise evidence and expert opinion across 432 patient scenarios to guide treatment decisions for full-thickness tears [235]. While the major indication for revision repair is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure [36, 37], treatment options for large and massive tears must be based on individual patient indications [253].

Arthroscopic rotator cuff repair is favoured for improving shoulder function, whereas other procedures or intraarticular treatments offer no significant benefits [218]. Open repair remains a valid option in specific indications and settings where arthroscopic resources are limited [52], though surgeons must interpret comparative literature carefully as selection bias may influence complication rates [168]. For irreparable tears, bridging reconstruction performs best for superior-posterior tears with an intact or reparable subscapularis [253], and reverse total shoulder arthroplasty provides comparable clinical outcomes at two years across indications of irreparable tear, tear arthropathy, and primary osteoarthritis [49]. Proper indications for subacromial decompression result in excellent outcomes [222], and prevention of complications through successful primary repair yields better functional results than revision strategies [227].

Complications after rotator cuff repair are not common and are equivalent between arthroscopic and open techniques [257]. The procedure is cost-effective for all populations [239]. Although the widely accepted two-year benchmark for outcomes may be arbitrary, with one-year follow-up appearing clinically sufficient [234], patients must live with long-term outcomes, obliging authors to evaluate these extended periods [10]. Critical Shoulder Angle and Acromial Index do not appear to influence 24-month functional outcomes and are not contraindications to arthroscopic repair [250]. Definitive conclusions regarding the most relevant predictors of outcome remain elusive due to the low methodological quality of included studies [240].

Anatomy & Pathophysiology

Anatomy

The rotator cuff comprises four muscles originating from the scapula: subscapularis, supraspinatus, infraspinatus, and teres minor [121]. The subscapularis arises from the anterior scapula and inserts on the lesser tuberosity [121]. The supraspinatus originates from the fossa superior to the scapular spine, passes beneath the acromion and acromioclavicular joint, and attaches to the superior aspect of the greater tuberosity [121]. The infraspinatus arises from the fossa below the scapular spine and inserts on the posterolateral greater tuberosity [121]. The teres minor originates from the lower lateral scapula and attaches to the lower portion of the greater tuberosity [121]. Innervation is provided by the upper and lower subscapular nerves for the subscapularis [121], the suprascapular nerve after passing through the suprascapular notch for the supraspinatus [121], the suprascapular nerve after passing through the spinoglenoid notch for the infraspinatus [121], and a branch of the axillary nerve for the teres minor [121].

The rotator cuff tendons blend with the subjacent capsule at their humeral tuberosity attachments [121]. The supraspinatus footprint measures 13 mm in width (medial-lateral) and 20 mm in the anteroposterior dimension [38]. The infraspinatus footprint measures 14 mm in width and 20 mm in the superoinferior dimension [38]. A supraspinatus tear of 7 mm medial-lateral width corresponds to a 50% partial thickness tear [38]. Significant interdigitation of supraspinatus and infraspinatus tendons occurs near the footprint, with the infraspinatus insertion occupying the preponderance of the footprint on the greater tuberosity [121].

The rotator cable is a thick bundle of fibers running perpendicular to the supraspinatus tendon fibers, connecting the supraspinatus and infraspinatus tendons [38]. It stretches in an arc to attach on the anterior 8 to 12 mm of the supraspinatus and posteriorly in the infraspinatus insertion [265]. The rotator crescent is the thinner, stress-shielded area of the supraspinatus/infraspinatus attachment lateral to the cable between its insertion points [265].

Histologic studies describe five distinct layers in the rotator cuff tendons [121]. The most superficial layer consists of coracohumeral ligament fibers oriented obliquely to the muscle axis [121]. The second layer comprises tendon fibers grouped into large bundles extending from the supraspinatus tendon over the biceps tendon groove [121]. The third layer contains smaller, less tightly packed tendon fascicles with less uniform orientation [121]. The fourth layer is composed of loose connective tissue with thick bands of collagen fibers that merge with the coracohumeral ligament at the anterior edge of the supraspinatus [121]. The fifth and deepest layer is the continued sheet of collagen fibrils composing the superior joint capsule [121].

The long head of the biceps tendon attaches to the supraglenoid tubercle, runs between the subscapularis and supraspinatus, and exits through the bicipital groove under the transverse humeral ligament [121]. The coracohumeral ligament and transverse humeral ligament keep the biceps tendon aligned in the groove [121]. The bicipital groove travels on the biceps tendon like a monorail on its track, helping guide the head of the humerus as it is elevated [121]. The long head of the biceps tendon may serve as a passive restraint during most shoulder motions and contribute to anterior stability in abduction and external rotation [121]. Changes in elbow position and loading of the biceps can lead to altered shoulder motion and muscle recruitment [121]. The humerus is capable of substantial rotation when adducted and allows very little rotation when maximally abducted due to tuberosity constraints near the biceps tendon attachment [121].

The coracoacromial arch is formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [6]. The subacromial bursa separates the rotator cuff tendons from the coracoacromial arch, allowing them to glide [6]. The hypovascular critical zone is located on the articular side of the rotator cuff close to the insertion on the greater tuberosity [38]. The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in functional planes of motion [154].

Pathophysiology

Rotator cuff disease is a continuum beginning with mild impingement, progressing through partial tear, full-thickness tear, and massive tear, to rotator cuff tear arthropathy [310]. The prevalence of full-thickness rotator cuff tears is approximately 25% in patients over 60 years of age [2] and increases to 50% in patients over 80 years of age [2]. If a patient has a symptomatic full-thickness rotator cuff tear in one shoulder, they have a 50% chance of an asymptomatic full-thickness rotator cuff tear in the contralateral shoulder [2]. The overall prevalence of asymptomatic partial-thickness rotator cuff tears is 20%, increasing to 26% in patients older than 60 years [4]. Rotator cuff tear prevalence ranges from 13% for patients in their fifties to 50% for patients aged 80 years or older [18].

Intrinsic degeneration involves age-related changes in collagen, proteoglycan, water content, and vascularity, usually involving the supraspinatus and infraspinatus starting on the articular side [38]. Extrinsic injury mechanisms involve chronic impingement on the coracoacromial arch, with tears usually starting on the bursal side of the tendon [38]. Acute traumatic tears typically occur after a fall and/or dislocation of the shoulder in patients under 40 years of age [38]. Risk factors for rotator cuff tear development include male sex, manual labor, and history of trauma [18]. Risk factors for rotator cuff disease include age, smoking, female sex, family history, diabetes, and high cholesterol [38].

Degenerative rotator cuff tears initiate approximately 13 to 17 mm posterior to the long head of the biceps tendon [64]. Ultrasound data suggest degenerative rotator cuff tears initiate at the middle of the rotator crescent tissue and propagate in both directions from the initiation site [64]. Loss of integrity of the anterior supraspinatus tissue (rotator cable) leads to accelerated retraction and degeneration of muscle tissue [64]. Partial-thickness rotator cuff tears have a limited ability to spontaneously heal [4]. As many as 53% of partial-thickness rotator cuff tears will progress in tear size [4]. A portion of partial-thickness rotator cuff tears will progress to full-thickness rotator cuff tears [4]. Small full-thickness rotator cuff tears and painful partial-thickness tears become 25% to 50% larger within 3 to 4 years [38]. Larger rotator cuff lesions progress faster than smaller ones [38]. Tear progression correlates with presenting tear size [5].

The articular side of the rotator cuff is less vascular and has a higher modulus of elasticity, greater stiffness, and a less favorable stress-strain curve compared with the bursal surface [158]. Eccentric forces tend to be concentrated more along the articular surface fibers of the rotator cuff [158]. Tears associated with chronic impingement syndrome typically begin on the bursal surface or within the tendon substance [310]. Tears occurring on the articular surface are typically due to tension failure in younger athletes participating in overhead activities or owing to intrinsic degeneration [310]. Bursal-side tears are considered more ominous than articular-side tears [310]. As rotator cuff tears increase in size or chronicity, the muscle atrophies and fatty infiltration occurs [310].

The presence of a rotator cuff tear is associated with a disruption of normal glenohumeral kinematics characterized by superior migration of the humeral head [113]. Patients with rotator cuff tearing demonstrate abnormal glenohumeral kinematics with superior translation of the humeral head in the scapular plane [152]. Partial-thickness articular-sided rotator cuff tears involving the rotator cable with a thickness >50% increase glenohumeral translation and change kinematics [169]. Tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics [104]. Simulated anterosuperior rotator cuff tears involving the superior half of the subscapularis lead to increased anterosuperior and superior glenohumeral translation under higher loads [143]. Tears of the subscapularis have greater biomechanical consequences than tears of the infraspinatus [135]. The critical tear size leading to the loss of normal shoulder biomechanics is identified as a half tear of the infraspinatus accompanied by a complete tear of the supraspinatus tendon [160]. Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes [163].

The critical shoulder angle (CSA) is defined as the angle between lines drawn from the inferior glenoid to the superior glenoid and from the inferior glenoid to the inferolateral acromion [265]. A CSA greater than 35° to 38° has been shown to correlate with rotator cuff tears and postoperative retears [265]. The acromial index (AI) is the ratio of the medial/lateral length from the glenoid to the lateral acromion divided by the length from the glenoid to the lateral aspect of the greater tuberosity [265]. An acromial index above 0.7 has been associated with full-thickness rotator cuff tears and higher retear rates [265]. Increased lateralization of the acromion and increased superior glenoid inclination may increase the shear forces of deltoid contraction [265]. Genetic predisposition contributes to intrinsic degenerative tendinopathic changes in molecular composition and vascularity, resulting in tendinosis and tearing [265]. Two correlated single nucleotide polymorphisms have been identified as associated with full-thickness rotator cuff tears [5].

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

The prevalence of calcific tendinitis in a working population is 2.7%, with 35% of these shoulders being symptomatic [213]. Calcific tendinitis typically affects patients aged 30 to 60 years and women more commonly than men [213]. The supraspinatus tendon is most often involved [213]. Calcific tendinitis is characterized by a cyclical progression of reactive calcium hydroxyapatite crystal intratendinous deposition followed by spontaneous resorption and healing [302]. The reported prevalence varies between 2% and 20% [302]. It most commonly affects the "critical zone" of relative hypovascularity of the supraspinatus tendon in 70% to 83% of cases [302]. Calcific tendinitis is the result of a metaplastic cell-mediated transformation of tenocytes into chondrocytes, which then induce calcification [302]. The precalcific stage consists of predominantly fibrocartilaginous metaplasia within less vascular areas of the tendon [213]. In the formative phase of the calcific stage, matrix vesicles unite to form calcium hydroxyapatite deposits separated by fibrocollagenous tissue [213]. The resorption phase involves an inflammatory response and is exquisitely painful [213]. Pain during the proliferative phase is variable and correlated with macrophage activity during the resorptive phase [213].

Rotator cuff impingement is thought to arise from repetitive compression or rubbing of the tendons, mainly the supraspinatus, under the coracoacromial arch [155]. The "impingement position" is defined as abduction, slight flexion, and internal rotation [155]. Intrinsic factors for impingement include tendon degeneration, changes in highly sulphated glycosaminoglycans, changes in collagen composition with loading, and changes in vascularity [155]. Extrinsic factors include spurs growing down the coracoacromial ligament and osteoarthritic thickening of the acromioclavicular joint [155]. Primary impingement results from encroachment of the rotator cuff in the subacromial space due to swelling or scarring, acromial morphologies (type II or III), or selective hypomobility of noncontractile tissues [166]. Secondary impingement results from microinstability of the glenohumeral joint due to acquired ligamentous laxity, inadequate dynamic muscular stabilization, and scapular dysfunction [166]. Internal impingement is commonly involved in overhead athletes or when the arm is used in an abducted, externally rotated, and horizontally extended position [166].

The rotator interval is central to normal glenohumeral kinematics, and any insult to its integrity alters shoulder motion throughout abduction [96]. The supraspinatus tendon is most often initially involved in subacromial bursitis and rotator cuff tendinosis [15]. The Neer impingement sign is discomfort experienced when the internally rotated shoulder is moved into forward flexion [15]. A painful arc, where pain occurs between 60° and 120° of passive abduction, is nearly always present in symptomatic rotator cuff disease [354]. The presence of a painful arc is associated with a positive likelihood ratio of 3.7 for rotator cuff disease [354]. The absence of a painful arc is associated with a negative likelihood ratio of 0.36 for rotator cuff disease [354]. Symptoms typically include pain in the upper outer arm, aggravated by overhead activities, and often worse at night and when lying on the affected side [354]. Night pain is typical of rotator cuff tears and is related to poor outcomes after nonsurgical treatment [38]. A combination of age >65 years, night pain, and weakness has 95% specificity for rotator cuff tears [38]. The supraspinatus and infraspinatus muscles are the most commonly involved in rotator cuff tears [310].

Classification

Full-Thickness Rotator Cuff Tears

The overall prevalence of full-thickness rotator cuff tears is approximately 25% in patients over 60 years of age [2]. Patients with a symptomatic full-thickness rotator cuff tear in one shoulder have a 50% chance of an asymptomatic full-thickness rotator cuff tear in the contralateral shoulder [2]. MRI allows for the characterization of the location, size, and amount of retraction of the rotator cuff tear [2]. MRI also allows for the assessment of the degree of atrophy and fatty infiltration of the rotator cuff musculature [2].

Goutallier: The quality of rotator cuff musculature is classified according to the degree of fatty infiltration originally described by Goutallier et al. for CT evaluation and modified by Fuchs et al. for MRI evaluation [2]. In the Goutallier classification, grade 0 is normal muscle [2]. Grade 1 has some fatty streaks [2]. Grade 2 has more muscle than fat [2]. Grade 3 has equal amounts of muscle and fat [2]. Grade 4 has more fat than muscle [2]. Goutallier grades 3 and 4 indicate a long-term chronic rotator cuff tear [2]. Goutallier grades 3 and 4 have a higher potential for failure when surgery is undertaken [2]. Goutallier grades 3 and 4 are likely deemed irreparable [2]. The Goutallier Staging System of Fatty Infiltration in Rotator Cuff Tear defines Level 0 as normal muscle with no fatty streak [331]. Level 1 is some fatty streaks in the muscle [331]. Level 2 is fatty infiltration being important, but more muscle existing than fat [331]. Level 3 is equal amounts of fat and muscle [331]. Level 4 is more fat than muscle [331]. An imaging-based evaluation of muscle quality was developed by Goutallier and colleagues using a five-stage classification extrapolated to sagittal MRI imaging [340]. In supraspinatus tears, progression to severe fibro-adipogenic degeneration (Stage III–IV) took four years [340]. In infraspinatus tears, progression to severe fibro-adipogenic degeneration (Stage III–IV) occurred within 3–6 years depending on the age of the patient [340].

Patte: The Patte classification system assesses the extent of the tear, topography in the sagittal plane, topography in the frontal plane, trophic quality of the muscle of the torn tendon, and state of the long head of the biceps [50]. In the Patte classification, Segment 1 is a subscapularis tear [50]. Segment 2 is a coracohumeral ligament tear [50]. Segment 3 is an isolated supraspinatus tear [50]. Segment 4 is a tear of the entire supraspinatus and one-half of the infraspinatus [50]. Segment 5 is a tear of the supraspinatus and infraspinatus [50]. Segment 6 is a tear of the subscapularis, supraspinatus, and infraspinatus [50]. Anteriorly situated rotator cuff defects are more painful than posterior lesions [50]. Posterior rotator cuff lesions interfere more with function than anterior lesions [50]. Isolated subscapularis tears (Patte Segment 1) are seldom exclusively involved in degenerative tears and are generally due to traumatic avulsions often associated with a medial dislocation of the long head of the biceps [50]. Isolated coracohumeral ligament tears (Patte Segment 2) are traumatic in nature and do not contribute to the pathology of the cuff [50]. Segment 4 and Segment 5 tears merit special attention given the inherent difficulties of repair [50]. Secondary osteoarthritis was most common among patients with total-cuff tears (Patte Segment 6) [50]. The diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability [185].

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

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

Ellman: The Ellman classification system for full-thickness tears designates grades that can be substituted for the adjectives small and large [348]. A fourth grade is added to the Ellman classification to include cuff arthropathy [348]. Cuff arthropathy is defined as a massive tear with articular irregularity, collapse of the humeral head, chronic synovitis, and capsular laxity [348]. Estimates of the total area of defect in the Ellman classification are obtained by multiplying the length of the base of the tear by the distance of maximum retraction [348].

Other Considerations: The presence of a tendon stump attached to the greater tuberosity decreases the length of tendon for repair [2]. Factors associated with failure after rotator cuff repair include larger tears, greater retraction, advanced Goutallier grade, older age, smoking status, osteoporosis, diabetes mellitus, hypercholesterolemia, and more aggressive rehabilitation protocols [2]. The best potential for healing is in patients younger than 70 years with acute, small tears (<3 cm) and a healthy tendon-bone interface who are compliant with sling wear and are able to undergo an extended rehabilitation program of 6 to 9 months [2]. Goutallier stages III and IV tears accompanied by a tendinous stump of less than 15 mm and a positive tangent sign have a 90% failure rate [2]. Tears with Goutallier grades III and IV are usually deemed irreparable and are treated with alternative strategies such as debridement, tendon transfer, superior capsular reconstruction, or reverse shoulder arthroplasty [2]. A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair [81]. The ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communicating among surgeons and for pooling of data from clinical studies [141]. Massive rotator cuff tears can be divided into three types: anterosuperior, posterosuperior, and anteroposterior [171]. Each type of massive rotator cuff tear shows distinctive characteristics and different results in preoperative and postoperative metrics [171]. The geometric classification and 2-dimensional measurement of rotator cuff tears using MR arthrography have good to excellent intraobserver agreement and moderate to good interobserver agreement among experienced observers [177]. The size of the rotator cuff tear could be categorized into one of four groups with accuracy in only 56% of the cases using shoulder arthrography [182]. Different types of cuff tear morphology do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up [215]. The term irreparable rotator cuff tear is commonly and often incorrectly used interchangeably with the term massive rotator cuff tear [331]. Not all massive cuff tears are irreparable [331]. Massive rotator cuff tears are classified based on their size, but several definitions have been proposed [331]. Cofield et al. were the first to define a massive rotator cuff tear [331]. Fatty degeneration has been shown to correlate with chronicity of rotator cuff tears and is a negative prognostic factor [331].

Partial-Thickness Rotator Cuff Tears

The overall prevalence of asymptomatic partial-thickness rotator cuff tears is 20% [4]. The prevalence of asymptomatic partial-thickness rotator cuff tears increases to 26% in patients older than 60 years [4]. Partial-thickness rotator cuff tears can be classified as articular-sided, bursal-sided, or intratendinous tears [4].

Ellman: Ellman described a classification of partial-thickness rotator cuff tears based on location and depth of tearing noted at the time of shoulder arthroscopy [4]. In the Ellman classification, partial-thickness tears are classified as articular-sided (A), bursal-sided (B), or intratendinous (C) [4]. In the Ellman classification, grade 1 partial-thickness tears involve 3 mm or less of tendon [4]. Grade 2 partial-thickness tears involve 3 to 6 mm of tendon [4]. Grade 3 partial-thickness tears involve more than 6 mm of tendon [4]. Grade 3 partial-thickness tears represent tears of more than 50% of tendon width [4]. With MRI evaluation, partial-thickness tears are classified as low grade or high grade depending on whether they involve less than or more than 50% of the tendon width [4]. Ellman proposed a classification scheme that included specific consideration of the site and extent of partial cuff tears [61]. In Ellman's classification, the location of the partial tear is recorded as articular surface, bursal surface, or intratendinous [61]. In Ellman's classification, grade I tears have a depth of less than 3 mm [61]. Grade II tears have a depth of 3 to 6 mm [61]. Grade III tears involve more than half of the cuff thickness [61]. The average cuff thickness is 9 to 12 mm [61]. Tears involving more than half of the tendon thickness are considered a significant threat to cuff integrity [61]. The presence of a grade III partial-thickness rotator cuff tear is often considered a relative indication for surgical repair in the symptomatic patient [61]. Classification of partial-thickness rotator cuff tears should be descriptive in terms of location (tendon involved and surface affected), size (depth) of the tear, and cause [61]. The Ellman classification for partial-thickness tears classifies lesions according to depth and anatomical site [238]. In the Ellman classification, grade-1 lesions demonstrate definite disruption of the tendon fibers but involve less than one-fourth (less than three millimeters) of the thickness of the tendon [238]. Grade-2 lesions involve less than one-half of the thickness of the tendon and are three to six millimeters deep [238]. The normal cuff is considered to be 10–12-mm thick [348]. A Grade 1 partial tear is less than 3-mm deep and involves definite disruption of the tendinous fibres [348]. Superficial fraying of the articular capsule does not constitute a cuff tear [348]. Grade 2 lesions are 3–6-mm deep and extend well into the substance of the cuff but do not exceed one-half of the thickness of the tendon [348]. Grade 3 lesions are more than 6 mm in depth and represent significant disruptions of more than one-half the substance of the cuff [348]. In the Ellman classification, partial-thickness tears are designated as A (Articular surface), B (Bursal surface), or C (Interstitial) [348]. The area of defect for partial-thickness tears is calculated as the base of the tear multiplied by maximum retraction in mm² [348].

Neer: Neer's classification described three stages of rotator cuff disease: stage I (hemorrhage and cuff edema), stage II (cuff fibrosis), and stage III (cuff tear) [61]. Partial tears were not categorized separately in Neer's classification [61]. Neer originally described three gradations of tears of the rotator cuff: Stage I (hemorrhage and edema), Stage II (tendinitis and fibrosis), and Stage III (incomplete or full-thickness tear) [238]. Most orthopaedic literature has been devoted to the diagnosis and treatment of either stage-II lesions or full-thickness tears [238]. Partial tears did not fit well into the Neer classification because they represent more damage than a stage-II lesion but cannot be categorized properly as a stage-III lesion [238].

Other Considerations: The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears [112]. A proposed classification system may assist decision making in the treatment of partial thickness rotator cuff tears [118]. With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons [133]. In experienced hands, sonography has a low level of interobserver variability for the detection, classification, and localization of rotator cuff tears [216].

Other Classifications and Assessment Systems

Other Considerations: The acromial morphology classification system is an unreliable method to assess the acromion [28]. The acromial index shows no association with the presence of rotator cuff disease [28]. A classification system was created to divide coracoids according to their morphology and relative risk of associated subscapularis tears [139]. The classification of rotator cuff tears should take into account the site of the tear since it may help physicians predict the outcome of the disease more precisely [145]. The appearance of the teres minor in isolated and multiple rotator cuff tendon tears is defined using a morphologic classification system [146]. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes [165]. A model provides a framework to stage the continuity of rotator cuff pathology [191]. Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair [76]. All other outcomes and classifications did not show acceptable reliability for preoperative evaluation of a rotator cuff tear, requiring caution when using them [211]. Long head of the biceps instability was associated with long head of the biceps lesions and rotator cuff tear size, leading to the creation of a new arthroscopic classification [219]. A study proposes a three-stage classification based on the occupation ratio to improve indications for rotator cuff tear treatment [221]. Multiple classification systems exist for calcifying tendinitis of the rotator cuff, including Uhthoff's stages of disease evolution, Gärtner and Heyer's radiologic staging, Bosworth's size classification, and Molé et al.'s morphological classification [226]. Using the Sugaya classification to assess post-operative rotator cuff healing was associated with substantial intra-observer and fair inter-observer agreement [233]. The unclassified types of mechanoreceptors in the rotator cuff were thought to be related to the dysfunction and painful condition in the rotator cuff tear [223].

Clinical Presentation

History and Symptoms

The most common and consistent presenting symptom of rotator cuff pathology is shoulder pain, with weakness of the shoulder and arm as a common secondary complaint [85]. Patients with symptomatic full-thickness rotator cuff tears typically complain of anterolateral shoulder pain that radiates into the subdeltoid location [2]. Complaints of pain with overhead activity and lifting objects with an outstretched arm are common in patients with symptomatic full-thickness rotator cuff tears [2]. Frequent night pain and sleep disturbance are reported in patients with symptomatic full-thickness rotator cuff tears [2]. In cases of chronic rotator cuff disease, patients often describe an insidious onset of lateral and/or anterior shoulder pain associated with overhead activities [208]. Night pain is a common presenting symptom in chronic rotator cuff disease [208]. A patient may present with a clear history of trauma resulting in acute pain and weakness, strongly suggesting acute rotator cuff tear [208]. A family or personal history of rotator cuff disease makes the diagnosis more likely [208]. Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology [86]. For subacromial bursitis and rotator cuff tendinosis, pain is present with activity involving overhead motion, and there is usually no pain or only mild pain with the arm at the side [15]. The patient with rotator cuff tendinosis may occasionally be awakened by pain at night [15]. In rotator cuff syndrome, pain is located over the front and lateral aspect of the shoulder for supraspinatus involvement, tears of the cuff, and tendinitis, and over the front for biceps pathology [6]. If the rotator cuff or biceps has ruptured, there will also be weakness [6]. For cuff tear arthropathy, patients present with chronic shoulder pain, night pain, weakness, and stiffness [14]. A patient with a full-thickness rotator cuff tear may experience sudden pain and be unable to abduct the arm [292]. In long-standing cases of partial or complete rotator cuff rupture, secondary osteoarthritis of the shoulder may supervene and movements are then severely restricted [292]. The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features [30]. Pain and duration of symptoms are not associated with the severity of rotator cuff tears in atraumatic, full-thickness tears [19]. The status of the rotator cuff is not the primary variable that results in patient symptom severity or decline in shoulder-specific health-related quality of life [114]. Symptoms of rotator cuff disease usually wax and wane periodically while a physiological decline occurs over time [18]. For calcifying tendinitis of the rotator cuff, patients are counseled regarding the expected peak of inflammation and pain often experienced during the acute resorptive phase of the disease [351].

Physical Examination

A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders [24]. Clinical assessment followed by specific imaging may help define the pathology in patients with shoulder symptoms severe enough to consider surgery [22]. Advanced practice providers should be acquainted with physical examination findings and special testing consistent with rotator cuff pathology to prompt appropriate advanced imaging [105]. The authors argue that shoulder 'special tests' for rotator cuff-related shoulder pain should be discontinued as they lack validity for isolating specific structures or identifying the cause of symptoms [88]. The diagnostic approach for rotator cuff-related shoulder pain should focus on functional assessment, psychosocial factors, and evidence-informed management [88]. Current consensus suggests rotator cuff injuries are most accurately diagnosed with a combination of cuff- and impingement-specific clinical tests [84]. As no single clinical test is sufficiently reliable to diagnose posterosuperior rotator cuff tears, clinicians should consider various combinations of patient characteristics and clinical tests, as well as imaging modalities [95]. Weakness is characterized by loss of active elevation and external rotation in rotator cuff tears [38]. Insidious onset of pain on the lateral aspect of the shoulder, worse with overhead activities, is part of the history for rotator cuff tears [38]. Night pain is typical and related to poor outcomes after nonsurgical treatment in rotator cuff tears [38].

Inspection of the shoulder in the upright position at rest and in motion may reveal rotator cuff muscle atrophy, signs of rotator cuff dysfunction, and anterosuperior escape [284]. Inspection for muscular atrophy of the deltoid and supraspinatus and infraspinatus fossa is performed for chronic rotator cuff tears [38]. For cuff tear arthropathy, inspection reveals supraspinatus and infraspinatus atrophy, anterior prominence of the humeral head with arm elevation (anterosuperior escape), and subcutaneous effusion [14]. Subacromial/glenohumeral crepitus with movement is observed in cuff tear arthropathy [14]. Very limited range of motion for elevation, external, and internal rotation is observed in cuff tear arthropathy [14]. Pseudoparalysis in cuff tear arthropathy is defined as less than 60º elevation, lack of active external rotation, and incompetent subscapularis [14]. Chronic long head of biceps rupture is usually present in cuff tear arthropathy [14]. The external rotation lag sign and hornblower sign indicate teres minor insufficiency in cuff tear arthropathy [14].

Palpation of the greater tuberosity, acromioclavicular joint, bicipital groove, and coracoid process is part of the physical examination for rotator cuff tears [38]. Cervical spine palpation, range of motion, and Spurling test are performed to rule out cervical spine pathologies as a cause of shoulder pain [38]. Active range of shoulder motion may be limited by pain in subacromial bursitis and rotator cuff tendinosis [15]. No atrophy of the shoulder muscles is present in subacromial bursitis and rotator cuff tendinosis [15]. Manual muscle testing demonstrates mild weakness in subacromial bursitis and rotator cuff tendinosis [15]. When the internally rotated shoulder is moved into forward flexion, the patient will experience discomfort, known as the Neer impingement sign [15]. Pain from the Neer impingement test resolves, and there is a dramatic increase in strength and range of motion with the injection of 10 mL of lidocaine into the subacromial space [15].

The drop arm test examines failure of the superior rotator cuff [284]. The Jobe or empty can test isolates the supraspinatus with resistance testing of the arm at 90° of abduction, 30° of flexion in the scapular plane, and thumb pointed down [284]. External rotation strength tests the infraspinatus with the arm in adduction and the elbow at 90° of flexion [284]. The lift-off and belly press tests assess the subscapularis [284]. The external rotation lag sign and hornblower’s sign both assess for massive failure of the infraspinatus and teres minor [284]. A positive hornblower sign suggests a massive posterosuperior cuff tear that prohibits the active positioning of the hand in space [208]. Patients with an external rotation lag sign at the side likely have a large posterosuperior tear involving the infraspinatus [208]. No one test for rotator cuff disease has reliably high diagnostic value, and a combination of tests increases diagnosis specificity [284]. The empty can test has a sensitivity of 71.7% and a specificity of 64.6% for full-thickness supraspinatus tears [208]. The lift-off and belly-press tests have high specificity but low sensitivity for full-thickness subscapularis tears [208]. The crepitus test has a sensitivity of 67%, specificity of 80%, positive predictive value of 91%, and negative predictive value of 43% for all types of rotator cuff tears [89]. The sensitivity and specificity for full-thickness or high-grade partial tears using the crepitus test is 82% and 73%, respectively [89]. The positive predictive value and negative predictive value for full-thickness or high-grade partial tears using the crepitus test are 77% and 79%, respectively [89]. In patients older than 55 years, the presence of crepitus has a sensitivity of 76%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 38% [89]. A clinical diagnosis of a full-thickness tear of the rotator cuff cannot be conclusively reached using one or more of the lag signs [107]. Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear [90]. None of the physical examination tests were highly sensitive for diagnosing rotator cuff tears or tendinosis [77]. Tests for subscapularis tears were all highly specific [77]. No optimal combination of tests improved the ability to correctly diagnose rotator cuff tears [77]. The internal rotation and lateral rotation lag sign did not improve the diagnostic ability for rotator cuff tears [77]. When evaluating for subacromial bursitis or rotator cuff tears, the Neer, Hawkins, and painful arc tests have greater sensitivity than specificity and are useful screening tests in ruling out these conditions if they are negative [98]. The Neer sign is the only test to reliably predict subacromial bursitis or rotator cuff tears among the impingement tests [98].

Imaging and Diagnostic Studies

An MRI is obtained in the evaluation of a potential rotator cuff tear if the patient has no contraindications [2]. MRI allows the surgeon to characterize the location, size, and amount of retraction of the rotator cuff tear, as well as the degree of atrophy and fatty infiltration of the rotator cuff musculature [2]. The quality of the rotator cuff musculature is classified according to the degree of fatty infiltration originally described by Goutallier et al. for CT evaluation and modified by Fuchs et al. for MRI evaluation [2]. In the Goutallier-Fuchs classification, grade 0 is normal muscle, grade 1 has some fatty streaks, grade 2 has more muscle than fat, grade 3 has equal amounts of muscle and fat, and grade 4 has more fat than muscle [2]. Goutallier grades 3 and 4 are indications of a long-term chronic rotator cuff tear, which has a higher potential for failure when surgery is undertaken and likely is deemed irreparable [2]. An important consideration on MRI evaluation is whether any tendon stump remains attached to the greater tuberosity, which decreases the length of tendon for repair [2]. An MRI is indicated in younger, active patients with acute rotator cuff tears and in patients with chronic rotator cuff tears in whom a trial of nonoperative treatment has failed [2]. MRI is the benchmark for diagnosing rotator cuff tears with 94% sensitivity and 93% specificity [38]. T2-weighted images best visualize rotator cuff tears [38]. T1 sagittal oblique cuts reveal muscle/tendon retraction and muscle atrophy to determine chronicity, reparability, and outcome of surgical rotator cuff repairs [38]. Intra-articular contrast-enhanced magnetic resonance arthrography (MRA) is best for detecting partial-thickness rotator cuff tears with 95% sensitivity and 95% specificity [38]. Ultrasonography has good accuracy with 92% sensitivity and 93% specificity for rotator cuff tears [38]. Ultrasonography allows for dynamic assessment of the cuff insertion [38]. Ultrasonography is operator dependent and has limited assessment of chondral lesions [38]. Ultrasonography has poor sensitivity to diagnose partial-thickness rotator cuff tears [38]. CT arthrography is uncommon in the United States but useful in postoperative assessment, retear evaluation in patients with retained metallic anchors causing artifact on MRI, and when MRI is contraindicated [38]. Radiographs are used to rule out glenohumeral and acromioclavicular arthritis [38]. The true AP view evaluates the acromiohumeral interval (normal = 7 to 14 mm), the critical shoulder angle, and acromion index [38]. Greater tuberosity excrescences on AP view in external and internal rotation are pathognomonic for cuff disease [38]. The supraspinatus outlet view evaluates acromial morphology according to Bigliani (type 1 = flat; type 2 = curved; type 3 = hooked) [38]. The axillary view assesses glenohumeral joint morphology and joint space and rules out dislocations [38]. For full-thickness rotator cuff tears, ultrasonography approaches the sensitivity and specificity of MRI for detecting the presence of a tear with an experienced practitioner [208]. Ultrasonography is relatively inexpensive, allowing for dynamic testing, guided injections, and immediate feedback [208]. MRI accurately assesses muscle, bone, and cartilage, which has advantages for surgical planning [208]. MRI continues to be the imaging modality of choice for most providers, with ultrasonography becoming common in certain centers [208]. The goal of diagnostic imaging is to determine the presence, size, and orientation of the rotator cuff tear; evaluate the healing capacity of the tendon; and assess associated pathology such as long head biceps tendinitis, acromioclavicular joint pathology, and arthrosis [208]. Imaging findings of rotator cuff disease must be considered in a clinical context and should never be used as the only basis for operative intervention [29]. When combined with a careful history and clinical examination, plain radiographs help guide the use of further radiological investigations, obviating unnecessary waiting times and tests for many without cuff tears [33]. The acromial morphology classification system is an unreliable method to assess the acromion, and the acromial index shows no association with the presence of rotator cuff disease [28]. When patients with clinical suspicion of rotator cuff tear present with combinations of radiographic signs such as greater tuberosity spurs and narrow acromiohumeral intervals, a prompt MRI examination and a referral to a shoulder specialist are recommended [20]. Effective management of rotator cuff pathology critically relies on initial identification of all cuff tears, including nonobvious, partial and/or obscured full tears [21]. Diagnosis of a rotator cuff tear requires a full clinical examination, combined with imaging studies (ultrasound, arthrocomputed tomography, magnetic resonance imaging/arthroemagnetic resonance imaging) [74]. Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality [31]. The Society of Radiologists in Ultrasound convened a panel of specialists to reach a consensus about the recommended imaging evaluation of painful shoulders with clinically suspected rotator cuff disease [27]. A thorough understanding of the anatomy and function of the rotator cuff and of the consequences of rotator cuff disorders is essential for optimal treatment planning and prognostic accuracy [109]. For cuff tear arthropathy, radiographs show acetabularization of the acromion and femoralization of the humeral head [14]. Radiographs for cuff tear arthropathy show eccentric superior glenoid wear [14]. Radiographs for cuff tear arthropathy show absence of typical peripheral osteophytes around the humeral head as seen on osteoarthritis [14]. Radiographs for cuff tear arthropathy show osteopenia and subarticular sclerosis (snowcap sign) [14]. Radiographs for cuff tear arthropathy show loss of the coracoacromial arch, indicating anterosuperior escape [14]. MRI/CT scan is not routinely necessary for cuff tear arthropathy, especially if radiographs show anterosuperior escape [14]. MRI/CT scan establishes the extent of rotator cuff tear, retraction, and fatty infiltration in cuff tear arthropathy [14]. CT is helpful to quantify glenoid bone stock when reverse shoulder replacement is considered in cases of advanced arthropathy [14]. Radiographic views of the subacromial space such as the supraspinatus outlet view may show a spur on the undersurface of the acromion, causing narrowing of the subacromial space [15]. Advances in imaging methods such as ultrasonography and MRI have aided in the diagnosis of subacromial bursitis, rotator cuff tendinosis, and rotator cuff tendon tear [15]. MRI demonstrates cystic changes at the greater tuberosity with rotator cuff tear [15]. The diagnosis of rotator cuff disease is established by clinical examination and imaging (radiography and magnetic resonance imaging) of the involved shoulder [92]. Tendinosis, partial-thickness cuff tear, and full-thickness cuff tear are considered for the diagnosis of rotator cuff disease [92]. A rotator cuff tear is a clinical syndrome, and a case definition simply based on imaging findings is incomplete and clinically inaccurate [93]. The sensitivity of MRI in partial-thickness rotator cuff tears is 64% [93]. Rotator cuff tears are documented on imaging in asymptomatic individuals

Investigations

Clinical Presentation and History

Patients with subacromial bursitis or rotator cuff tendinosis present with mild to moderate pain during overhead shoulder motion and occasional night pain, typically following a history of repetitive overhead activity [15]. These patients exhibit no muscle atrophy and either no weakness or mild weakness secondary to pain [15]. Pain in these conditions is relieved by a subacromial lidocaine injection [15]. In contrast, patients with cuff tear arthropathy present with chronic shoulder pain, night pain, weakness, and stiffness [14]. Inspection of the shoulder in cuff tear arthropathy may reveal supraspinatus and infraspinatus atrophy, anterior prominence of the humeral head with arm elevation (anterosuperior escape), and subcutaneous effusion [14]. Range of motion is characterized by subacromial and glenohumeral crepitus with movement and very limited elevation, external, and internal rotation [14]. Chronic long head of biceps rupture is usually present in patients with cuff tear arthropathy [14].

Physical Examination

The Neer impingement sign is defined as discomfort experienced when the internally rotated shoulder is moved into forward flexion [15]. The Neer impingement test involves injecting 10 mL of lidocaine into the subacromial space, which results in a dramatic increase in strength and range of motion [15]. The tangent sign is defined as failure of the supraspinatus muscle belly to cross a line from the superior border of the coracoid to the superior border of the scapular spine [224]. This sign correlates with muscle atrophy and fatty infiltration of the supraspinatus [224]. Patients with the presence of the tangent sign are more likely to have an irreparable rotator cuff tear [224], and a positive tangent sign predicts the repairability of rotator cuff tears [21].

Plain Radiography

Shoulder radiographs may demonstrate classic changes within the acromion or coracoacromial ligament, including spurring and calcification [224]. Cystic changes within the greater tuberosity may be present in rotator cuff disease [224]. With chronic rotator cuff disease, superior migration of the humeral head with extensive degenerative change may be visible [224]. Radiographs of patients with cuff tear arthropathy show acetabularization of the acromion and femoralization of the humeral head [14]. These radiographs also show eccentric superior glenoid wear [14] and an absence of typical peripheral osteophytes around the humeral head as seen in osteoarthritis [14]. Osteopenia and subarticular sclerosis, known as the snowcap sign, are also observed [14]. Loss of the coracoacromial arch on radiographs indicates anterosuperior escape in cuff tear arthropathy [14].

Radiographic greater tuberosity spurs and narrow acromiohumeral intervals are associated with advanced retraction of the supraspinatus tendon in patients with symptomatic rotator cuff tears [20]. When patients with clinical suspicion of rotator cuff tear present with combinations of these radiographic signs, a prompt MRI examination and referral to a shoulder specialist are recommended [20]. Shoulder radiographs of subjects with a documented rotator cuff tear have greater tuberosity radiographic abnormalities that are not noted in asymptomatic subjects without a rotator cuff tear [299]. Secondary radiographic findings on conventional views are useful for initial screening of patients with shoulder pain [324]. Irreparable rotator cuff tears are more likely to occur when the acromiohumeral distance appears shorter than 7 mm on AP radiograph [224]. A deep learning-based algorithm improves the role of shoulder radiography as an initial imaging modality to rule out rotator cuff tears [316]. Radiographs combined with active tasks offer possibilities in diagnosing early-stage rotator cuff tears [329]. MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions [258].

Ultrasonography

Ultrasonography is increasing in popularity as a tool for the diagnosis of rotator cuff disease [224] and is used for confirmation of intraarticular or subacromial location of injections [224]. Ultrasonography is more accurate for full-thickness rotator cuff tears, comparable to MRI [22]. Full-thickness rotator cuff tears can be identified using ultrasound and MRI with comparable accuracy [318]. The diagnostic accuracy of ultrasonography for full-thickness rotator cuff tears has overall estimates of sensitivity and specificity over 0.90 [336]. Ultrasonography can be used to evaluate the repaired rotator cuff and potential complications [297]. MRI and ultrasound provide similar assessments of postoperative rotator cuff healing, although ultrasound is less sensitive [322]. MRI and ultrasound are useful in the postoperative assessment of the rotator cuff for evaluating integrity, detecting hardware complications, and identifying other etiologies of shoulder pain [308]. Ultrasound can be performed if an unrecognized partial subscapularis tendon injury is suspected after MRI [345].

Magnetic Resonance Imaging (MRI)

MRI is obtained in the evaluation of a potential rotator cuff tear if the patient has no contraindications [2]. MRI allows the surgeon to characterize the location, size, and amount of retraction of the rotator cuff tear [2]. It also allows characterization of the degree of atrophy and fatty infiltration of the rotator cuff musculature [2]. MRI is used to define the extent of tear, degree of tear retraction, and presence of muscular atrophy [224]. MRI is key for evaluating fatty infiltration, although the Goutallier classification was originally based on CT [224]. MRI is indicated in younger, active patients with acute rotator cuff tears [2] and in patients with chronic rotator cuff tears in whom a trial of nonoperative treatment has failed [2]. MRI provides valuable information about the nature of the rotator cuff injury [231]. MRI is generally superior to ultrasound for evaluation of rotator cuff pathology due to its versatility and availability [345]. The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits, and suspected cuff tendinopathy other than full-thickness tears provides negative value in management [327]. Rotator cuff tears are frequently asymptomatic [23].

MRI sensitivity for detecting full-thickness rotator cuff tears is 92.1% [242], with a specificity of 92.9% [242]. MRI sensitivity for detecting partial-thickness rotator cuff tears is 63.6% [242], with a specificity of 91.7% [242]. The major role of MR imaging in the investigation of rotator cuff disorders is in the detection of full-thickness rotator cuff tears [319]. MRI seems to be the most sensitive procedure in diagnosing cuff tears [323]. Analysis of data supports the reliability of MRI assessment by shoulder specialists for rotator cuff disorders [305]. Three-dimensional MRI seems to be useful in assessing the rotator cuff muscles [317]. Three-dimensional magnetic resonance imaging appears to be useful to assess the rotator cuff muscles [321]. The integration of 3D imaging and volumetric analysis offers novel advancement in diagnosing and classifying rotator cuff injuries, challenging the conventional reliance on 2D MRI [334]. Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with a systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears [337]. The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term [339]. The presence of clinically significant disagreements in inter-rater agreement of rotator cuff tendon and muscle MRI parameters indicates the need for improved imaging tools for precise rotator cuff evaluation [341]. One should use caution in the interpretation of magnetic resonance imaging scans of the shoulder soon after the injection of corticosteroids [343]. MRI appears to be accurate in detecting the presence of a recurrent rotator cuff tear in shoulders with suspected failed cuff repairs, with a sensitivity of 91% [289].

Magnetic Resonance Arthrography (MRA)

MRA sensitivity for detecting full-thickness rotator cuff tears is 95.4% [242], with a specificity of 98.9% [242]. MRA sensitivity for detecting partial-thickness rotator cuff tears is 85.9% [242], with a specificity of 96.0% [242]. MRA is more sensitive for the detection of partial-thickness, particularly articular-sided tears, which can be filled with contrast when the cuff relaxes with the arm in ABER position [242]. Magnetic resonance arthrography was more accurate in evaluating rotator cuff tear size and morphologic features than conventional magnetic resonance imaging [259]. MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears [320]. Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears [286].

Computed Tomography (CT)

The Goutallier classification for fatty infiltration was originally based on CT evaluation [2].

Imaging Interpretation and Classification

In the Goutallier classification, grade 0 is normal muscle, grade 1 has some fatty streaks, grade 2 has more muscle than fat, grade 3 has equal amounts of muscle and fat, and grade 4 has more fat than muscle [2]. A full-thickness rotator cuff tear is identified if fiber discontinuity spans the entire thickness of the tendon, with the defect filled with fluid signal intensity on T2-weighted sequences or with gadolinium on T1-weighted sequences of an MRA [242]. If a rotator cuff tear is chronic and retracted, the humeral head migrates superiorly, contacting the undersurface of the acromion and resulting in osseous remodeling of the humeral head and acromion (acetabularization) [242]. The description of a full-thickness tear should include the tendon(s) involved, the location within the tendon (footprint, critical zone, or myotendinous junction), the AP dimension measured on the sagittal view, and the extent of retraction measured on the coronal sequence for supraspinatus and infraspinatus and on the axial sequence for the subscapularis [242].

A partial-thickness rotator cuff tear spans only a portion of the tendon thickness [242]. The description of a partial-thickness tear should include the tendon(s) involved, the location within the tendon (footprint, critical zone, or myotendinous junction), the percentage of tendon thickness that is affected (greater or less than 50%), and the side of the tendon that is torn (bursal surface and/or articular surface) [242]. Articular-side thickening of the supraspinatus and infraspinatus on images obtained in the neutral position suggests the presence of a partial-thickness articular-side rotator cuff tear [242]. The rotator cable can be reliably identified with the shoulder in ABER position, even in the absence of a rotator cuff tear [242]. Partial-thickness articular-surface tears are more common than bursal-surface tears [242]. External pressure on the bursal surface of the cuff leads to tensile stretching of the articular surface and therefore tears [242]. Articular-surface fibers are stiffer and therefore tear more easily when subject to a stretching load [242]. Blood supply is poorer on the bursal-surface compared with the articular surface, and therefore the articular surface does not heal as well in response to stresses [242].

In the Ellman classification, tears are classified as articular-sided (A), bursal-sided (B), or intratendinous (C) and are grade 1 if involving 3 mm or less, grade 2 if 3 to 6 mm, and grade 3 if more than 6 mm of tendon is torn [4]. The extent of the rotator cuff lesion is measured in centimetres at the level of the bony insertion according to the Patte classification [46]. In the Patte classification, Group I includes partial tears or full-substance tears measuring less than 1 cm in sagittal diameter at bony detachment [46]. Group II includes full-substance tears of the entire supraspinatus [46]. Group III includes full-substance tears involving more than one tendon [46]. Group IV includes massive tears with secondary osteoarthritic changes in the humeral head [46]. In the Patte classification, Group II tears usually have a sagittal diameter of approximately 2 cm at the bony insertion [46]. Group III tears have a sagittal extent of 4 cm or more [46]. Group III defects result in cranial and frontal migration of the humeral head, gradually impinging against the coracoacromial arch [46]. Group IV lesions are characterized by massive tears and secondary OA of the humeral head, with acromiohumeral arthrosis and glenohumeral OA [46].

The critical shoulder angle (CSA) and acromial index (AI) are radiographic measurements associated with rotator cuff disease [11]. Patients with CSA greater than 38° and AI greater than 0.7 had higher retear rates after arthroscopic rotator cuff repair [11]. CSA was higher in the patient group with rotator cuff tears but was a static measure that did not change over time [12]. Differences in CSA between groups are small and depend on excellent radiographic technique [

Treatment

Non-Operative

Nonoperative management is the preferred initial approach for non-traumatic rotator cuff injuries [290] and remains a viable option for chronic, full-thickness tears, particularly in patients over 65 years of age [2, 194, 195]. Conservative protocols typically involve 6 to 12 weeks of rest and activity modification, symptom management with non-steroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2-selective inhibitors, and physical therapy [245, 252]. Physical therapy focuses on passive and active range of motion, stretching, strengthening, and scapular stabilization [245, 252]. Intraarticular or bursal steroid injections may be used for pain control, though preoperative injections within one month of surgery and postoperative injections up to three months are associated with concerns regarding tissue quality and infection risk [245, 252]. Nonoperative treatment yields successful outcomes in 60% of patients with symptomatic full-thickness tears [2] and is effective in 75% of patients with atraumatic full-thickness tears after two years [19]. However, the risk of tear progression is approximately 50% at two years [2], and failure rates for partial-thickness tears are higher in bursal-sided, dominant-arm, or greater-than-50%-thickness tears [245].

Operative

Indications: Rotator cuff repair is indicated for acute full-thickness tears or chronic full-thickness tears that have failed nonoperative treatment [2, 229]. Relative indications for revision surgery include symptomatic tear recurrence in active, nonsmoking patients [203]. For massive, irreparable tears, indications are based on expert consensus and best available evidence [47]. Tendon transfer is ideally indicated for irreparable supraspinatus and infraspinatus tears with intact teres minor and subscapularis, forward elevation greater than 90 degrees, and no prior surgery [198]. Single medial-row anchor with biceps tenodesis in a transosseous double-row construct is indicated for rotator cuff tears unresponsive to nonoperative management, provided there is no concurrent subscapularis tear or irreparable cuff [254].

Surgical Approach / Technique: Arthroscopic repair is the current standard of care, offering similar outcomes to open repair with decreased short-term pain and faster return to activity [45, 137]. Arthroscopy allows comprehensive assessment of intra-articular pathology and facilitates tendon mobilization through precise adhesion releases, minimizing deltoid injury and preserving the acromial deltoid origin [277]. The goal is to restore the tendon to its anatomic footprint to encourage healing, as the cuff tends to fail at the tendon-bone junction [45]. If anatomic repair cannot be achieved without significant tension, a medialised repair may be performed [2]. Strong fixation is essential to prevent gapping [2]. Intraoperative prognostic factors include tendon and bone quality and the ability to reduce the tendon to its footprint without undue tension [2]. Goutallier stages III and IV tears with a tendinous stump less than 15 mm and a positive tangent sign have a 90% failure rate and are typically treated with debridement, tendon transfer, superior capsular reconstruction, or reverse shoulder arthroplasty [2].

Implant Selection: Arthroscopic repair utilizes suture anchors in single-row, double-row, or transosseous-equivalent configurations [45]. Controlled laboratory studies indicate that double-row techniques offer superior initial and ultimate failure strength, decreased gap formation, decreased strain, and improved vascularity compared to single-row repairs [45]. While double-row constructs are biomechanically superior and more anatomic, clinical superiority over single-row fixation remains controversial [277]. The SpeedBridge Knotless Double-Pulley technique maintains clinically significant outcomes and repair survivorship [13].

Adjuncts: Routine distal clavicle resection is not recommended with arthroscopic rotator cuff repair [204]. The effectiveness of arthroscopic subacromial decompression on clinical outcomes for small to medium-sized tears is small, with no significant difference in scores or re-tear rates [187]. Bilateral arthroscopic repair, whether single-stage or staged, yields similarly good clinical outcomes [205].

Other Considerations: The timing of acute tear repair is debated, but surgeons generally aim to repair within three months, as outcomes are inferior after four months [2]. The best healing potential exists in patients younger than 70 years with acute, small tears (<3 cm), healthy tendon-bone interfaces, and compliance with a 6- to 9-month rehabilitation program [2]. Carefully selected patients older than 70 years also achieve functional improvements comparable to younger patients [2]. Factors associated with repair failure include muscle degeneration, tear size, chronicity, advanced age, and environmental factors [45]. The rotator cuff presents unique healing challenges due to its intra-articular location, complex mechanical loading, lack of fibrocartilaginous reconstitution, and chronic tendinopathy [45]. Long-term follow-up (≥15 years) shows durable patient-reported outcomes for all-arthroscopic repair [7, 140]. Clinical improvement is sustained beyond five years, with most gains occurring within the first six months but continuing to 24 months [186]. Healed repairs show improved outcomes compared to physical therapy or unhealed repairs [161]. Surgical repair provides significantly better long-term outcomes and a higher probability of substantial improvement compared to nonoperative treatment, despite potentially better short-term nonoperative results [269, 282, 307]. Operative management is increasingly cost-effective over time, as nonrepaired tears are unlikely to heal and portend worse symptomatology [247]. However, the superiority of operative over nonoperative treatment in all rotator cuff tears is not convincingly demonstrated [206].

Revision: Revision rotator cuff surgery is indicated for symptomatic recurrence in active, nonsmoking patients [203]. The rate of recurrent tears has not changed significantly despite technological advances, with re-tear rates around 20% and higher for larger tears [63].

Pain Management: Postoperative pain is reduced in arthroscopic repair due to less soft tissue trauma, which aids rehabilitation and reduces pain-induced muscle inhibition [277].

Setting of Care: No specific evidence regarding outpatient versus inpatient settings is provided in the source text.

Complications

Re-tear: Re-tear rates after rotator cuff repair are reported to be about 20%, with higher rates for larger tears [63]. Most rotator cuff repair failures occur within the first 3 months after surgery [55]. Goutallier stages III and IV tears accompanied by a tendinous stump of less than 15 mm and a positive tangient sign have a 90% failure rate [2].

Risk Factors: A history of bariatric surgery is associated with increased failure rates, worse postoperative pain, and worse patient-reported outcomes after arthroscopic rotator cuff repair [304]. Individuals with a family history of rotator cuff tearing were more likely to have repair failures [266]. Steroid injections performed within 6 months of the index surgical procedure are correlated with a greater likelihood of revision rotator cuff surgery [344].

Other Considerations: Rotator cuff repair has a low incidence of short-term complications [100], and short-term complications after rotator cuff repair are rare [126]. Preoperative testosterone replacement therapy use was not linked to increased short-term complications after arthroscopic rotator cuff repair [196]. The short-term clinical influence of biceps-related complications on shoulder outcome is very limited [197].

Recovery

Natural History and Progression: Symptoms improve over the first year after treatment for full-thickness rotator cuff tears, regardless of whether surgical or nonsurgical treatment is used, after which improvement plateaus [7]. The natural history of patients with rotator cuff tears included in randomized controlled trials is to improve over time, whether treated operatively or nonoperatively [56]. Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time [356]. Approximately 50% of asymptomatic rotator cuff tears have a significant increase in size at a median time of 2.8 years [19]. In a study of 59 full and partial-thickness tears, 48% were found to have progression of tear size in those followed for at least 18 months, compared with 19% in those followed for less than 18 months [19]. Tear progression occurred in 54% of tears in patients over the age of 60 years versus 17% in patients under 60 years [19]. In a cohort of patients under the age of 60 years treated nonoperatively for full-thickness rotator cuff tears, 49% of the tears increased in size [19]. 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 [359]. A critical tear area of 175 mm2, which correlates to tear dimensions of approximately 15 mm × 12 mm, is associated with proximal humeral migration [19]. Time from symptom onset greater than 5.5 years and critical shoulder angle greater than 38 degrees are significant independent factors of acromiohumeral interval reversibility in patients with massive rotator cuff tears [360].

Nonoperative Management Outcomes: In cases of rotator cuff tears treated conservatively, at 13 years after diagnosis, about 90% of patients had no or only slight pain and about 70% had no disturbance in activities of daily life [363]. The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term [53].

Operative Outcomes and Survivorship: Overall survivorship was 94% at 5 years after open rotator cuff surgery and 83% at 10 years [44]. Long-term functional outcomes and structural integrity are maintained after arthroscopic DR-TOE repair of medium to large rotator cuff tears at a minimum follow-up of 10 years [151]. Although long term rotator cuff integrity following repair is maintained in only 2/3 of operated shoulders, function is equivalent to the contralateral shoulder [156]. During long-term follow-up, arthroscopic in situ repair of partial-thickness rotator cuff tears produces excellent functional outcomes in more than 80% of patients, and revision rates are low [180]. Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome [210]. Long-term outcomes from primary tendon repair remained superior to physiotherapy up to 15 years of follow-up for small-to-medium-sized rotator cuff tears [202]. The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair [34, 39, 40]. 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 [11]. 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 [188]. The persistent or recurrent rotator cuff tear rate of 31% after simultaneous rotator cuff and Bankart repair did not appear to significantly impact functional outcomes [51]. All intact rotator cuff tendons at 1 year after arthroscopic repair remained intact at 2 years [361].

Rehabilitation and Follow-up Considerations: Successful management of rotator cuff disease is dependent on appropriate rehabilitation, which should be based on an evaluation of underlying tissue quality and structural integrity rather than solely on empirical clinical experience or fixed healing timelines [362]. Most rotator cuff repair failures occur within the first 3 months after surgery, suggesting that relatively short follow-up is sufficient for evaluating primary structural integrity, though longer follow-up is beneficial for assessing symptomatic improvement [55]. Surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease, with patients demonstrating clinically relevant differences in pain and functional outcomes compared to nonoperative treatment [60]. Rotator cuff repair may not alter natural history [42].

Key Evidence

• [L4] At long-term follow-up (≥15 years), the patient-reported outcomes of all-arthroscopic rotator cuff repair show significant improvement from baseline preoperative function and remain durable over a period of 15 years. [7] (10.1016/j.jse.2022.01.116)
• [L5] One-year follow-up is not the last word for rotator cuff repair outcomes; patients must live with the long-term outcomes of surgical procedures, and authors are obliged to evaluate these long-term outcomes. [10] (10.1016/j.arthro.2024.12.040)
• [L4] At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes. [11] (10.1016/j.arthro.2023.06.031)
• [L5] It maintains clinically significant patient-reported and functional outcomes and rotator cuff repair survivorship. [13] (10.1016/j.eats.2021.12.039)
• [L5] The authors describe the rationale, current indications, and technical strategies for different types of rotator cuff repair constructs. [16] (10.1097/bte.0b013e31824aeae1)
• [L4] When patients with clinical suspicion of rotator cuff tear present with combinations of these radiographic signs, a prompt MRI examination and a referral to a shoulder specialist are recommended. [20] (10.1016/j.jseint.2020.09.015)
• [L4] Effective management of rotator cuff pathology critically relies on initial identification of all cuff tears, including nonobvious, partial and/or obscured full tears. [21] (10.1016/j.eats.2022.01.003)
• [L2] In patients with shoulder symptoms severe enough to consider surgery, clinical assessment followed by specific imaging may help define the pathology in order to direct appropriate management. [22] (10.1007/s10067-013-2260-0)
• [L4] Rotator cuff tears are frequently asymptomatic. [23] (10.1308/003588406x94968)
• [L5] A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders. [24] (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. [26] (10.1007/s11999-008-0585-9)
• [L5] The Society of Radiologists in Ultrasound convened a panel of specialists to reach a consensus about the recommended imaging evaluation of painful shoulders with clinically suspected rotator cuff disease. [27] (10.1148/radiol.13121947)
• [L3] The acromial morphology classification system is an unreliable method to assess the acromion, and the acromial index shows no association with the presence of rotator cuff disease. [28] (10.1016/j.jse.2011.09.028)
• [L4] Imaging findings of rotator cuff disease must be considered in a clinical context and should never be used as the only basis for operative intervention. [29] (10.1016/s0720-048x(03)00159-1)
• [L3] There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease. [30] (10.1016/j.jse.2013.10.001)
• [Paper] Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality. [31] (10.1016/j.csm.2012.07.010)
• [L3] When combined with a careful history and clinical examination, it will help guide the use of further radiological investigations, obviating unnecessary waiting times and tests for many without cuff tears. [33] (10.1177/1758573217743942)
• [L3] The short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to those after primary rotator cuff repair. [34] (10.1177/0363546514560729)
• [L4] The major indication for revision rotator cuff repair is the persistence of clinical symptoms, despite nonsurgical management, in the absence of substantial risk factors for failure. [36] (10.1055/b-0041-179892)
• [L5] The major indication for revision rotator cuff repair is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure. [37] (10.5435/00124635-201111000-00002)
• [L3] The short term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair. [39] (10.1177/2325967114s00016)
• [L3] Short-term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair. [40] (10.1016/j.jse.2015.05.015)
• [L4] Thus, rotator cuff repair may not alter natural history. [42] (10.2106/jbjs.oa.17.00043)
• [L1] While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented rotator cuff repair, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations. [43] (10.1136/bmjopen-2020-039552)
• [L4] Overall survivorship was 94% at 5 years after open rotator cuff surgery and 83% at 10 years. [44] (10.1016/j.jse.2010.11.019)
• [L5] The indications for the operative treatment of massive and irreparable rotator cuff tears were determined based on expert consensus and the best available evidence, seeking to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios. [47] (10.1016/j.jisako.2024.01.001)
• [L3] rTSA provides comparable clinical outcomes across indications of irreparable rotator cuff tear, rotator cuff tear arthropathy, and primary osteoarthritis at 2 years, supporting its broad applicability. [49] (10.1016/j.jsea.2026.100080)
• [L4] The persistent or recurrent rotator cuff tear rate of 31% did not appear to significantly impact functional outcomes in this patient population. [51] (10.1016/j.arthro.2014.04.041)
• [L4] Open rotator cuff repair surgery remains a valid option and has some appeal in specific indications and in settings where arthroscopic resources are limited. [52] (10.1007/s43465-020-00345-7)
• [L1] The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. [53] (10.1302/0301-620x.99b6.bjj-2016-0569.r1)
• [L1] Although the arthroscopic procedure may be indicated in selected patients, this study could not delineate any factors that would allow preoperative selection of these patients, and therefore we would recommend rotator cuff repair for patients with full-thickness tears of the rotator cuff. [54] (10.1016/s1058-2746(09)80113-4)
• [L5] Most rotator cuff repair failures occur within the first 3 months after surgery, suggesting that relatively short follow-up is sufficient for evaluating primary structural integrity, though longer follow-up is beneficial for assessing symptomatic improvement. [55] (10.1177/0363546511424268)
• [L1] The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively. [56] (10.1177/0363546518780694)
• [L2] Surgical intervention has the potential to alter the early natural history of degenerative rotator cuff disease, with patients demonstrating clinically relevant differences in pain and functional outcomes compared to nonoperative treatment. [60] (10.1016/j.jse.2024.05.056)
• [L5] [61] (10.5435/00124635-199901000-00004)
• [L5] [74] (10.1016/j.eats.2024.103145)
• [L4] Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. [76] (10.1007/s00167-014-3486-3)
• [L1] [77] (10.1177/0363546514538390)
• [L4] A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair. [81] (10.1016/j.arthro.2007.05.002)
• [L5] Current consensus suggests rotator cuff injuries are most accurately diagnosed with a combination of cuff- and impingement-specific clinical tests. [84] (10.1016/j.arthro.2013.07.265)
• [L4] The most common and consistent presenting symptom is shoulder pain, with weakness of the shoulder and arm as a common secondary complaint. [85] (10.1016/s1058-2746(95)80145-6)
• [L2] Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. [86] (10.1016/j.jse.2024.02.024)
• [L5] The authors argue that shoulder 'special tests' for rotator cuff-related shoulder pain should be discontinued as they lack validity for isolating specific structures or identifying the cause of symptoms, and recommend evolving the diagnostic approach to focus on functional assessment, psychosocial factors, and evidence-informed management. [88] (10.2519/jospt.2020.0606)
• [L2] [89] (10.1016/j.jse.2013.12.037)
• [L1] Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. [90] (10.1186/s13018-014-0070-y)
• [L3] [92] (10.1016/j.jse.2013.07.053)
• [L2] [93] (10.1177/2325967118784897)
• [L2] As no single clinical test is sufficiently reliable to diagnose posterosuperior rotator cuff tears, clinicians should consider various combinations of patient characteristics and clinical tests, as well as imaging modalities, to confirm diagnosis and select the appropriate treatment option. [95] (10.1007/s00167-020-06136-9)
• [L5] The rotator interval is central to normal glenohumeral kinematics, and any insult to its integrity alters shoulder motion throughout abduction. [96] (10.1186/s12891-016-0898-x)
• [L4] [98] (10.5435/jaaos-d-17-00090)
• [L4] Rotator cuff repair has a low incidence of short-term complications. [100] (10.1016/j.arthro.2017.10.040)
• [L5] In this cadaveric shoulder model of the throwing shoulder, tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics. [104] (10.1177/2325967117s00373)
• [L5] Advanced practice providers should be acquainted with physical examination findings and special testing consistent with rotator cuff pathology to prompt appropriate advanced imaging. [105] (10.1097/nor.0000000000000441)
• [L4] The findings of this investigation suggest that a clinical diagnosis of a full-thickness tear of the rotator cuff cannot be conclusively reached using one or more of the lag signs. [107] (10.1016/j.apmr.2007.10.046)
• [L5] A thorough understanding of the anatomy and function of the rotator cuff and of the consequences of rotator cuff disorders is essential for optimal treatment planning and prognostic accuracy. [109] (10.1148/rg.264055087)
• [L2] The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears. [112] (10.1177/2325967116667058)
• [L4] The presence of a rotator cuff tear was associated with a disruption of normal glenohumeral kinematics in the scapular plane, characterized by superior migration of the humeral head. [113] (10.1016/s1058-2746(00)90002-8)
• [L5] The status of the rotator cuff is not the primary variable that results in patient symptom severity or decline in shoulder-specific health-related quality of life. [114] (10.2106/jbjs.o.01085)
• [L4] The proposed classification system may assist decision making in the treatment of partial thickness rotator cuff tears. [118] (10.4103/0019-5413.136249)
• [L3] Short-term complications after rotator cuff repair are rare. [126] (10.1016/j.arthro.2017.10.027)
• [L2] With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. [133] (10.1177/0363546506298108)
• [L5] Tears of the subscapularis have greater biomechanical consequences than do tears of the infraspinatus. [135] (10.1016/j.arthro.2009.09.007)
• [L1] There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. [137] (10.1302/0301-620x.99b1.bjj-2016-0424.r1)
• [L3] This study was the first to create a classification system to divide coracoids according to their morphology and relative risk of associated subscapularis tears. [139] (10.1016/j.jse.2020.01.074)
• [L4] ARCR appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time. [140] (10.1007/s00167-014-3234-8)
• [L2] The ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communicating among surgeons and for pooling of data from clinical studies. [141] (10.1016/j.jisako.2021.12.004)
• [L5] The Hamada classification is a commonly used classification scheme that uses a mechanistic approach to explain the radiographic changes seen with chronic massive rotator cuff tears, highlighting the progressive nature of massive rotator cuff tears leading to CTA. [142] (10.1007/s11999-017-5340-7)
• [L5] Simulated anterosuperior rotator cuff tears involving the superior half of the subscapularis significantly alter shoulder biomechanics and lead to increased anterosuperior and superior glenohumeral translation under higher loads. [143] (10.1016/j.arthro.2008.10.005)
• [L3] The classification of rotator cuff tears should take into account the site of the tear since it may help physicians predict the outcome of the disease more precisely. [145] (10.1080/000164702317281387)
• [L4] The appearance of the teres minor in isolated and multiple rotator cuff tendon tears is defined in this study using a morphologic classification system. [146] (10.1007/s00256-011-1178-3)
• [L3] Long-term functional outcomes and structural integrity are maintained after arthroscopic DR-TOE repair of medium to large rotator cuff tears at a minimum follow-up of 10 years. [151] (10.1016/j.jse.2021.03.073)
• [L3] Patients with rotator cuff tearing demonstrate abnormal glenohumeral kinematics with superior translation of the humeral head in the scapular plane and a strong trend toward abnormal glenohumeral-scapulothoracic motion relationships before surgery. [152] (10.1016/s1058-2746(97)90084-7)
• [L4] The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in the functional planes of motion. [154] (10.2106/00004623-198668030-00013)
• [L4] Although long term rotator cuff integrity following repair is maintained in only 2/3 of operated shoulders, function is equivalent to the contralateral shoulder. [156] (10.1016/s1058-2746(98)90082-9)
• [L5] The critical tear size which leads to the loss of normal shoulder biomechanics was identified as half tear of the infraspinatus accompanied by a complete tear of the supraspinatus tendon. [160] (10.1109/access.2019.2895997)
• [L3] Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes. [163] (10.1016/j.jse.2025.03.038)
• [Paper] Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes. [165] (10.1016/j.clinbiomech.2010.08.001)
• [L4] This study demonstrates the effectiveness of rotator cuff repair in an older population, with good or excellent results in 84 (87%) of 97 shoulders. [167] (10.1067/mse.2001.110513)
• [L5] Shoulder surgeons must carefully interpret literature comparing open and arthroscopic rotator cuff repair outcomes, as differences in complications may be influenced by selection bias and narrowing indications for open repair. [168] (10.1016/j.arthro.2017.11.026)
• [L5] Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increased glenohumeral translation and changed kinematics in our cadaveric biomechanical model. [169] (10.1016/j.jse.2016.12.063)
• [L2] Massive rotator cuff tears can be divided into 3 types (anterosuperior, posterosuperior, and anteroposterior), each showing distinctive characteristics and different results in preoperative and postoperative metrics, providing a reasonable basis for subclassification. [171] (10.1177/0363546516667498)
• [L4] Both patient-reported outcomes and achievement of clinically significant outcomes show small differences at 1 and 2 years after rotator cuff repair. [172] (10.1016/j.arthro.2023.09.024)
• [L3] The geometric classification and the 2-dimensional measurement of rotator cuff tears using MR arthrography have good to excellent intraobserver agreement and moderate to good interobserver agreement among experienced observers. [177] (10.1016/j.arthro.2012.04.054)
• [L4] During long-term follow-up, arthroscopic in situ repair of partial-thickness rotator cuff tears produces excellent functional outcomes in more than 80% of patients, and revision rates are low. [180] (10.1016/j.arthro.2018.09.026)
• [L1] One trial compared manual therapy and exercise with placebo in 120 participants with chronic rotator cuff disease and found high quality evidence of small improvements in overall pain and function, and a higher proportion of participants reporting treatment success. [181] (10.1002/14651858.cd012224)
• [L4] The size of the rotator cuff tear could be categorized into one of four groups with accuracy in only 56% of the cases. [182] (10.1016/s1058-2746(09)80127-4)
• [L1] Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive. [184] (10.7326/0003-4819-153-4-201008170-00263)
• [L3] Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. [185] (10.1002/ksa.12162)
• [L2] Rotator cuff repairs provide sustained clinical improvement out past 5 years, with most functional improvement and pain relief occurring within the first 6 months but continuing to 24 months. [186] (10.1177/23259671221119222)
• [L3] The effectiveness of ASD on clinical outcomes of ARCR for small to medium-sized rotator cuff tears is small, with no significant difference in clinical scores or re-tear rates between groups with and without ASD. [187] (10.1016/j.jseint.2022.11.004)
• [L1] Shoulder scores may decline at mid- to long-term follow-up. [188] (10.1186/s13018-022-03411-y)
• [L5] This model is relevant for the rotator cuff and provides a framework to stage the continuity of rotator cuff pathology. [191] (10.1136/bjsm.2008.054817)
• [L4] Rotator cuff repair in patients aged >75 years could achieve high clinical success rates with good outcomes and pain relief. [193] (10.3389/fpubh.2022.1060700)
• [L2] Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. [194] (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. [195] (10.1016/j.jse.2017.10.009)
• [L2] Preoperative TRT use was not linked to increased short-term complications after arthroscopic rotator cuff repair. [196] (10.1016/j.jse.2025.12.013)
• [L3] Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited. [197] (10.1177/2325967121s00362)
• [L1] Long-term outcomes from primary tendon repair remained superior to physiotherapy up to 15 years of follow-up, supporting its use as the primary treatment for small-to-medium-sized rotator cuff tears. [202] (10.2106/jbjs.24.00065)
• [L5] Relative indications for revision rotator cuff surgery include the symptomatic recurrence of a rotator cuff tear in an active, nonsmoking patient. [203] (10.1097/bte.0b013e31824c2574)
• [L1] We do not recommend doing routine DCR with arthroscopic rotator cuff repair. [204] (10.1016/j.otsr.2020.08.006)
• [L3] Patients receiving single-stage or staged bilateral arthroscopic rotator cuff repair showed similarly good clinical outcomes at follow-ups longer than 6 months. [205] (10.1186/s12891-021-04304-7)
• [L3] This progress can be questioned, since there are not convincing data of the superiority of the operative treatment over non-operative management in all rotator cuff tears. [206] (10.1186/s12891-015-0639-6)
• [L3] Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. [210] (10.2106/00004623-199907000-00012)
• [L4] All other outcomes and classifications did not show acceptable reliability; therefore, caution is needed when using them for preoperative evaluation of a rotator cuff tear. [211] (10.1177/03635465231166077)
• [L1] Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. [214] (10.1016/j.jse.2020.11.002)
• [L3] Different types of cuff tear morphology, despite affecting surgical repair technique, do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up. [215] (10.1016/j.jisako.2023.10.014)
• [L3] In experienced hands, sonography has a low level of interobserver variability for the detection, classification, and localization of rotator cuff tears. [216] (10.2214/ajr.183.5.1831465)
• [L1] Arthroscopic rotator cuff repair is favored for improving shoulder function, while other procedures or intraarticular treatments offer no significant benefits. [218] (10.1186/s13018-024-05129-5)
• [L4] LHB instability was associated with LHB lesions and rotator cuff tear size, leading to the creation of a new arthroscopic classification. [219] (10.1016/j.arthro.2006.08.025)
• [L3] The study proposes a three-stage classification based on the occupation ratio to improve indications for rotator cuff tear treatment. [221] (10.3109/17453679608994685)
• [L5] Proper indications for shoulder subacromial decompression result in excellent outcomes. [222] (10.1016/j.arthro.2021.04.023)
• [L5] The unclassified types of the mechanoreceptors were thought to be related to the dysfunction and painful condition in the rotator cuff tear. [223] (10.1016/s1058-2746(96)80452-6)
• [L4] Despite the availability of revision strategies and treatment options, the prevention of complications and successful primary rotator cuff repair results in better functional outcomes. [227] (10.2106/jbjs.rvw.17.00052)
• [L1] Therefore, rotator cuff repair may be suggested after failed non-surgical treatment. [229] (10.1136/annrheumdis-2020-219099)
• [L5] Diagnostic imaging of the rotator cuff, performed by MRI, provides valuable information about the nature of the injury. [231] (10.1016/j.ejrad.2008.02.018)
• [L4] Using the Sugaya classification to assess post-operative rotator cuff healing was associated with substantial intra-observer and fair inter-observer agreement. [233] (10.1016/j.otsr.2017.06.006)
• [L5] The widely accepted 2-year benchmark for rotator cuff repair outcomes may be arbitrary and does not add clinical relevance, as 1-year follow-up appears clinically sufficient. [234] (10.1016/j.arthro.2023.11.002)
• [L5] The AAOS developed Appropriate Use Criteria (AUC) using the RAND/UCLA Appropriateness Method to guide treatment decisions for full-thickness rotator cuff tears by synthesizing evidence and expert opinion across 432 patient scenarios. [235] (10.5435/00124635-201312000-00008)
• [L4] Rotator cuff repair is cost-effective for all populations. [239] (10.2106/jbjs.l.01495)
• [L4] Despite the large number of outcomes and prognostic factors evaluated, it was not possible to reach any definitive conclusion regarding the most relevant predictors of outcome of rotator cuff repair due to low methodological quality of included studies. [240] (10.1007/s00167-015-3700-y)
• [L3] Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology. [247] (10.1016/j.jseint.2025.04.038)
• [L4] The non-surgical route with an appropriate physiotherapy programme has a role in the management of degenerative rotator cuff tears, especially in patients with significant risk factors for surgery, those who do not wish to go through a surgical treatment and those with small, partial and irreparable tears. [248] (10.1308/rcsann.2019.0173)
• [L3] CSA and AI do not appear to influence 24-month functional outcomes postoperatively and hence are not contraindications to arthroscopic rotator cuff repair. [250] (10.1177/0363546517717947)
• [L4] Use of these higher values should be considered when evaluating improvements of individual patients after rotator cuff repair, to determine comparative effectiveness of various rotator cuff repair techniques and to determine sample sizes for prospective comparative trials of rotator cuff repair methods. [251] (10.1016/j.jse.2019.11.018)
• [L4] [252] (10.1159/000328910)
• [L5] Treatment options for large and massive rotator cuff tears must be based on individual patient indications, with bridging reconstruction performing best for irreparable tears of the superior-posterior rotator cuff with an intact or reparable subscapularis. [253] (10.1016/j.arthro.2024.08.034)
• [L5] [254] (10.1016/j.eats.2022.03.035)
• [L5] Complications after rotator cuff repair are not common and are equivalent between arthroscopic and open techniques. [257] (10.1007/s12178-014-9247-6)
• [L2] MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions. [258] (10.1016/j.jse.2015.06.005)
• [L2] Magnetic resonance arthrography was more accurate in evaluating rotator cuff tear size and morphologic features than conventional magnetic resonance imaging. [259] (10.1097/01.blo.0000176142.01262.35)
• [L1] There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. [260] (10.1080/09638288.2016.1198431)
• [L2] Individuals with a family history of rotator cuff tearing were more likely to have repair failures. [266] (10.1016/j.jse.2016.02.019)
• [L3] Patients with rotator cuff tears who undergo surgical or nonsurgical treatment tend to improve, with patients allocated to surgery improving to a greater degree across three years of follow-up. [269] (10.1177/2325967113s00100)
• [L4] Patients undergoing rotator cuff repair had fewer comorbidities than those undergoing nonoperative treatments. [270] (10.1016/j.jse.2016.05.001)
• [L4] [272] (10.1016/j.jse.2020.11.016)
• [L3] [275] (10.1016/j.arthro.2019.02.017)
• [L3] [279] (10.1016/j.jse.2009.06.011)
• [L3] Patients with rotator cuff tears who undergo surgical or nonsurgical treatment tend to improve, with surgical patients improving to a greater degree. [282] (10.1177/2325967114s00059)
• [L2] Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears. [286] (10.1148/radiol.12112062)
• [L3] MRI appears to be accurate in detecting the presence of a recurrent rotator cuff tear in shoulders with suspected failed cuff repairs, with a sensitivity of 91%. [289] (10.1067/mse.2002.120139)
• [L3] Additionally, non-surgical treatment is recommended as the preferred approach for patients with non-traumatic rotator cuff injuries. [290] (10.1186/s13018-024-04858-x)
• [L4] Nonoperative treatment remains a viable option for certain patients with traumatic rotator cuff tears; however, the results of our study demonstrate a considerable early failure rate. [296] (10.1016/j.jse.2023.11.012)
• [L5] Both MRI and ultrasound can be used to evaluate the repaired rotator cuff and potential complications. [297] (10.2214/ajr.18.19648)
• [L4] These results indicate that shoulder radiographs of subjects with a documented rotator cuff tear have greater tuberosity radiographic abnormalities that are not noted in asymptomatic subjects without a rotator cuff tear. [299] (10.1067/mse.2003.19)
• [L3] A history of bariatric surgery is associated with increased failure rates, worse postoperative pain, and worse patient-reported outcomes after arthroscopic rotator cuff repair. [304] (10.1177/23259671261447216)
• [L4] Analysis of our data supports the reliability of MRI assessment by shoulder specialists for rotator cuff disorders. [305] (10.1016/j.pmrj.2014.08.949)
• [L5] This commentary highlights that while nonoperative treatment may yield better short-term outcomes, surgical repair provides significantly better long-term outcomes and a higher probability of substantial improvement for symptomatic rotator cuff tears, supporting its use in shared decision-making. [307] (10.2106/jbjs.20.00400)
• [L4] MRI and US are useful in the postoperative assessment of the rotator cuff, not only for evaluation of the integrity of the rotator cuff, but also for detecting hardware complications and other etiologies of shoulder pain. [308] (10.1007/s12178-018-9463-6)
• [L5] [313] (10.2214/ajr.14.13815)
• [L2] Thus, the algorithm improved the role of shoulder radiography as an initial imaging modality to rule out rotator cuff tears. [316] (10.1016/j.jse.2023.02.066)
• [Abstract] Three-dimensional MRI seems to be useful in assessing the rotator cuff muscles. [317] (10.1016/j.jse.2020.01.010)
• [L4] Full-thickness rotator cuff tears can be identified using ultrasound and MRI with comparable accuracy. [318] (10.4103/0973-6042.63218)
• [L4] The major role of MR imaging in the investigation of rotator cuff disorders is in the detection of full-thickness rotator cuff tears. [319] (10.1148/radiology.194.3.7862988)
• [L1] MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears. [320] (10.2214/ajr.08.1241)
• [Abstract] Three-dimensional magnetic resonance imaging appears to be useful to assess the rotator cuff muscles. [321] (10.1016/j.jse.2016.11.032)
• [L3] MRI and US provide similar assessments of postoperative rotator cuff healing, although US is less sensitive. [322] (10.1016/j.otsr.2015.06.006)
• [L3] MRI seems to be the most sensitive procedure in diagnosing cuff tears. [323] (10.1016/s1058-2746(96)80177-7)
• [L3] These secondary radiographic findings on conventional views are useful for initial screening of patients with shoulder pain. [324] (10.1067/mse.2001.117123)
• [L4] The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients, at both the individual and population level. [327] (10.1016/j.jse.2019.04.003)
• [L4] Possibly, radiographs combined with active tasks offer new possibilities in diagnosing early-stage rotator cuff tears. [329] (10.1007/s11517-013-1057-2)
• [L5] [331] (10.5435/jaaos-21-08-492)
• [L4] The integration of 3D imaging and volumetric analysis offers novel advancement in diagnosing and classifying rotator cuff injuries, challenging the conventional reliance on 2D MRI. [334] (10.1016/j.jse.2024.08.030)
• [L1] The diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness rotator cuff tears is high with overall estimates of sensitivity and specificity over 0.90. [336] (10.1136/bjsports-2014-094148)
• [L3] Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with the described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies. [337] (10.1016/j.arthro.2012.04.142)
• [L4] The presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic total shoulder replacement in the medium term. [339] (10.1016/j.jse.2020.07.037)
• [L3] [340] (10.1002/jor.24847)
• [L4] However, the presence of clinically significant disagreements, even in such favorable circumstances, indicates the need for improved imaging tools for precise rotator cuff evaluation. [341] (10.1016/j.jse.2021.04.021)
• [L4] One should use caution in the interpretation of magnetic resonance imaging scans of the shoulder soon after the injection of corticosteroids. [343] (10.1016/j.arthro.2007.01.024)
• [L5] The historical treatment paradigm of steroid injections for painful rotator cuff conditions warrants reconsideration as they are correlated with a greater likelihood of revision rotator cuff surgery when performed within 6 months of the index surgical procedure. [344] (10.1016/j.arthro.2018.12.017)
• [L5] In the author's practice, MRI is the test of choice for rotator cuff pathology due to its versatility and availability, though ultrasound can be performed if an unrecognized partial subscapularis tendon injury is suspected after MRI. [345] (10.1016/j.arthro.2021.08.029)
• [L1] [354] (10.1002/14651858.cd005619.pub3)
• [L4] Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time. [356] (10.1016/j.arthro.2018.07.031)
• [L5] Fatty infiltration of the rotator cuff appears as early as 6 weeks after surgical detachment, starts near the musculotendinous junction, and progresses medially over time, worsening over the course of 1 year in the unrepaired rotator cuff. [359] (10.1016/j.arthro.2007.01.023)
• [L3] Time from symptom onset greater than 5.5 years and critical shoulder angle greater than 38 degrees were significant independent factors of acromiohumeral interval reversibility. [360] (10.1177/23259671241306121)
• [L3] All intact rotator cuff tendons at 1 year remained intact at 2 years. [361] (10.1177/0363546509335764)
• [L5] Successful management of rotator cuff disease is dependent on appropriate rehabilitation, which should be based on an evaluation of underlying tissue quality and structural integrity rather than solely on empirical clinical experience or fixed healing timelines. [362] (10.5435/00124635-200610000-00002)
• [L2] In cases of rotator cuff tears treated conservatively, at 13 years after diagnosis, about 90% of patients had no or only slight pain and about 70% had no disturbance in activities of daily life. [363] (10.1016/j.jse.2011.10.012)

See Also

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

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