Rotator Cuff Disorders Info In-depth Evidence

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• The majority of rotator cuff conditions are amenable to conservative treatment, although rotator cuff dysfunction may necessitate surgical treatment [1].
• Neither the American Academy of Orthopaedic Surgeons clinical practice guidelines nor Cochrane systematic reviews provide guidance on the management of rotator cuff tears [2].
• Clinical decision-making for the management of rotator cuff tears is complex and lacks consensus among orthopedic surgeons [2].
• Patients with rotator cuff tears can be divided into three main categories based on the potential risk of nonoperative treatments and the proposed benefits of surgical intervention: those needing urgent or early operative repair, those that can benefit from a trial of conservative treatment, and those that may be best suited for nonoperative treatment [2].
• 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 [3].
• Deltoid complications combined with rotator cuff pathology represent a rare but devastating complication with no well-described surgical option [9].
• Treatment of patients with chronic massive rotator cuff tears is challenging, and results are comparatively inferior to those of treating patients with smaller rotator cuff tears [18].
• Shoulder arthroscopy literature remains controversial, conclusions are often unsupported due to bias and limitations, and no clinical guidelines are definitive pending higher levels of evidence [37].
• No recommendations regarding suprascapular nerve release in conjunction with rotator cuff repair can be made at this time, and further research is necessary to better delineate the indications in the future [43].
• Open approaches for rotator cuff repairs continue to have indications in certain circumstances, such as complete rotator cuff tendon avulsion and glenohumeral joint incarceration following high-velocity trauma [44].
• There is no statistically significant difference in subjective outcome after arthroscopic rotator cuff repair with or without acromioplasty at intermediate follow-up [47].
• Critical Shoulder Angle and Acromial Index do not appear to influence 24-month functional outcomes postoperatively and hence are not contraindications to arthroscopic rotator cuff repair [85].
• Arthroscopic surgeons who treat rotator cuff disorders will be able to use information regarding surgical techniques irrespective of their preferred surgical technique [91].
• Data on predictors of pain and functional outcomes can be used to select optimal candidates for operative treatment of rotator cuff tears and assist with patient education and expectations before treatment [94].
• There were no differences of clinically relevant size between arthroscopic and open rotator cuff surgery in a comparative series [111].

Anatomy & Pathophysiology

Anatomy

• The rotator cuff consists of four muscles arising from the scapula whose tendons blend with the subjacent capsule to attach to the humeral tuberosities [56].
• The subscapularis arises from the anterior aspect of the scapula and attaches to the lesser tuberosity, innervated by the upper and lower subscapular nerves [56].
• The supraspinatus arises from the fossa superior to the scapular spine, passes beneath the acromion and acromioclavicular joint, and attaches to the superior aspect of the greater tuberosity [56].
• The supraspinatus is innervated by the suprascapular nerve after it passes through the suprascapular notch [56].
• The infraspinatus arises from the fossa below the scapular spine and attaches to the posterolateral aspect of the greater tuberosity [56].
• The infraspinatus is innervated by the suprascapular nerve after it passes through the spinoglenoid notch [56].
• The teres minor arises from the lower lateral aspect of the scapula and attaches to the lower portion of the greater tuberosity, innervated by a branch of the axillary nerve [56].
• The rotator cuff tendons blend together to form a continuous cuff around the humeral head [56].
• Histologic studies describe the rotator cuff tendons as having five distinct layers [56].
• The most superficial layer of the rotator cuff tendon is composed of coracohumeral ligament fibers oriented obliquely to the muscle axis [56].
• The second layer consists of tendon fibers grouped into large bundles extending from the supraspinatus tendon over the biceps tendon groove [56].
• The third layer contains smaller, less tightly packed tendon fascicles with less uniform orientation than the second layer [56].
• 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 [56].
• The fifth and deepest layer is a continued sheet of collagen fibrils composing the superior joint capsule [56].
• There is significant interdigitation and overlap of the supraspinatus and infraspinatus tendons near the footprint on the greater tuberosity [56].
• The infraspinatus insertion occupies the preponderance of the footprint on the greater tuberosity, while the supraspinatus insertion is smaller than previously believed [56].
• 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 [56].
• The coracohumeral ligament and transverse humeral ligament keep the long head of the biceps tendon aligned in the groove [56].
• The rotator cable is a thick bundle of fibers running perpendicular to the supraspinatus tendon fibers, connecting the supraspinatus and infraspinatus tendons [25].
• The rotator cable is divided into anterior, middle, and posterior segments [57].
• The anterior segment of the rotator cable forms the lateral part of the rotator interval [57].
• The middle segment of the rotator cable runs under the supraspinatus tendon perpendicular to the longitudinal axes of the supraspinatus and infraspinatus tendons [57].
• The posterior segment of the rotator cable is covered by the infraspinatus tendon and ends at the insertion region between the infraspinatus and teres minor tendons [57].
• The supraspinatus footprint measures 13 mm in width medial-lateral and 20 mm anteroposterior [25].
• A 7 mm medial-lateral tear of the supraspinatus corresponds to a 50% partial thickness tear [25].
• The infraspinatus footprint measures 14 mm wide and 20 mm superoinferior [25].
• A hypovascular critical zone exists on the articular side of the rotator cuff close to the insertion on the greater tuberosity [25].
• The coracoacromial arch is a fibro-osseous canopy formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [22].
• The subacromial bursa separates the rotator cuff tendons from the coracoacromial arch and allows them to glide [22].
• The rotator cuff muscles stabilize the humeral head by pulling it firmly into the glenoid when the deltoid lifts the arm forwards or sideways [22].
• The human scapula is characterized by a lateral orientation of the glenoid cavity and a narrow coraco-acromial arch [52].
• The primary passive stabilizers of the glenohumeral joint are the capsule and scapulohumeral ligaments, which act as checkreins near the extremes of range of motion [62].
• The glenohumeral joint capsule is thickest in the inferior pouch at 2.8 mm, 2.4 mm in the anterior portion, and 2.2 mm in the posterior portion [62].
• The superior glenohumeral ligament crosses the rotator interval capsule and lies between the supraspinatus and subscapularis tendons [62].
• The coracohumeral ligament originates at the base of the coracoid, blends into the cuff tendons, and inserts into the greater and lesser tuberosities [62].
• The superior glenohumeral ligament and coracohumeral ligament come under tension with glenohumeral flexion, extension, external rotation, and adduction [62].
• The middle glenohumeral ligament is tensioned by external rotation when the humerus is abducted to 45 degrees [62].

Pathophysiology

• Rotator cuff tears are a spectrum of disease starting with tendinitis in patients aged 20 to 35, progressing to tendinosis in patients aged 35 to 45, rotator cuff tears in patients over 45, and cuff arthropathy in patients over 65 [25].
• The prevalence of rotator cuff tears is 28% in patients under 50 years and 65% in patients over 70 years [25].
• The prevalence of full-thickness rotator cuff tears ranges from 7% to 40%, while partial-thickness tears have a 50% higher prevalence [25].
• Small full-thickness rotator cuff tears and painful partial-thickness tears become 25% to 50% larger within 3 to 4 years [25].
• Larger rotator cuff lesions progress faster than smaller ones [25].
• Risk factors for rotator cuff tear development include age, smoking, female sex, family history, diabetes, and high cholesterol [25].
• Intrinsic degeneration involves age-related changes in collagen, proteoglycan, water content, and vascularity, usually involving the supraspinatus and infraspinatus starting on the articular side [25].
• Extrinsic injury mechanisms involve chronic impingement on the coracoacromial arch, with tears usually starting on the bursal side of the tendon [25].
• Acute traumatic rotator cuff tears typically occur after a fall and/or dislocation of the shoulder in patients under 40 years old [25].
• Associated lesions with rotator cuff tears include acromioclavicular arthritis, proximal biceps tendinitis, and adhesive capsulitis [25].
• Biopsy specimens of retrieved tendon from rotator cuff tears show disorganized collagen, scar tissue, and minimal attempts at a healing process [6].
• The confluence of age-related tendinosis and apoptosis leads to rotator cuff tendon failure [6].
• Apoptosis is an organized form of cell death involving a programmed sequence of events leading to cellular elimination [6].
• The prevalence of rotator cuff tears increases with each decade of life after the age of 50 years [12].
• Tear prevalence ranges from 13% for patients in their fifties to 50% for patients aged 80 years or older [12].
• Rotator cuff abnormalities are prevalent in both symptomatic and asymptomatic patients, and bilateral tears are common despite often unilateral symptoms [12].
• Symptom emergence in previously asymptomatic shoulders is linked to tear progression from partial to full thickness, full-thickness tear size worsening, muscle atrophy/fatty infiltration development, and/or new biceps pathology [12].
• Known risk factors for rotator cuff tear development include male sex, manual labor, and history of trauma [12].
• Symptoms usually wax and wane periodically while a physiological decline occurs over time, resulting in eventual cuff tear arthropathy [12].
• A rotator cuff repair procedure could save up to $78,000 compared with nonsurgical management, depending on patient age [12].
• Increased age is associated with a higher prevalence of rotator cuff pathology [23].
• One-quarter of patients above 60 years of age and half of patients above 80 years will have a rotator cuff tear [23].
• Tendon degeneration and tearing occur with aging [23].
• The prevalence of calcific tendinitis in a working population is 2.7%, with 35% of these shoulders being symptomatic [35].
• Calcific tendinitis typically affects patients aged 30 to 60 years and women more commonly than men [35].
• The supraspinatus tendon is most often involved in calcific tendinitis [35].
• Calcific tendinitis pathogenesis involves an active, cell-mediated process with three main stages: precalcific, calcific, and postcalcific [35].
• The precalcific stage of calcific tendinitis consists of predominantly fibrocartilaginous metaplasia within less vascular areas of the tendon [35].
• In the formative phase of the calcific stage, matrix vesicles unite to form calcium hydroxyapatite deposits separated by fibrocollagenous tissue [35].
• The resorption phase of calcific tendinitis involves an inflammatory response and is exquisitely painful [35].
• Calcific tendinitis is generally self-limited, with most cases resolving spontaneously [35].
• Pain in calcific tendinitis is variable during the proliferative phase and is correlated with macrophage activity during the resorptive phase [35].
• Rotator cuff syndromes are thought to have both intrinsic causes, such as tendon degeneration over time, and extrinsic causes, such as impingement against other structures [24].
• The tissue with the most pain fibers in the shoulder is the bursa, but pain fibers are also found in the biceps tendon, transverse humeral ligament, and rotator cuff tendons [24].
• Pain associated with rotator cuff disease typically occurs in the anterior and lateral shoulder [24].
• The most useful physical examination findings for symptomatic rotator cuff disease are weakness to manual muscle testing with resisted abduction or weakness to resisted external rotation with the arm at the side [24].
• Intrinsic degeneration of the tendon is associated with patient age, decreased vascularization of the tissue, atrophy and fatty infiltration of the muscle, and genetic predisposition [132].
• Extrinsic factors leading to rotator cuff tears include characteristic changes in acromial morphology, internal impingement, and altered scapulothoracic kinematics [132].
• Extrinsic factors lead to mechanical compression of the rotator cuff and surrounding soft tissue, causing external impingement syndrome [132].
• The theory of typical outlet impingement postulates that bursal-sided compression of the undersurface of the acromion leads to narrowing of the subacromial space and injuries to the rotator cuff, mainly the supraspinatus tendon [132].
• Intrinsic factors for rotator cuff tears include degenerative change, hypovascularity, and microstructural collagen fiber abnormalities [134].
• Recognized extrinsic factors for rotator cuff tears include subacromial impingement, tensile overload, and repetitive use [134].
• The coracoacromial ligament, shape of the acromion, and formation of acromial spurs relate to impingement and their association with rotator cuff tears [134].
• Large acromial spurs measuring 5 mm or greater are of diagnostic value due to a high rate of association with bursal-side tears and complete rotator cuff tears [134].
• Acromial keel spurs, characterized by central, longitudinal, and downward-sloping features on the acromial undersurface, are related to bursal-side partial-thickness and full-thickness tears [134].
• The cause of partial-thickness rotator cuff tears is likely multifactorial, with degeneration, impingement, and overload as contributors [136].
• Tensile overload during eccentric contraction with overhead activities is a common mechanism of injury for specific athletes and vocations [136].
• An avascular "critical zone" develops at the site of injury due to an intrinsically underdeveloped microvascular system, reducing the potential for recovery [136].
• Extrinsic causes of partial-thickness rotator cuff tears refer to injuries caused by external impingement from compressive forces exerted by surrounding structures such as the acromion, coracoacromial ligaments, coracoid process, and acromioclavicular joint [136].
• Glenohumeral instability can lead to secondary compressive forces such as impingement of the rotator cuff during subluxation of the glenohumeral joint [136].
• Tension overload from distractive forces of throwing or trauma can overpower the ability of the rotator cuff to maintain the stability of the glenohumeral joint [136].
• Weakness of the rotator cuff muscle causes the glenohumeral joint to subluxate [136].
• Cuff tear arthropathy is the final stage of the shoulder impingement syndrome spectrum, affecting patients with long-term insufficient massive rotator cuff tears [30].
• Cuff tear arthropathy is characterized by superior migration of the humeral head toward the acromion, subchondral osteoporosis, humeral head collapse, and painful debilitating shoulder arthritis [30].
• Cuff tear arthropathy affects women at a 3:1 female to male ratio, more commonly in patients over 70 years old, and more commonly on the dominant shoulder [30].
• Risk factors for cuff tear arthropathy include chronic rotator cuff tears, hemorrhagic shoulder, rheumatic disease, and crystal-induced arthropathy [30].
• Mechanical factors in cuff tear arthropathy pathogenesis include insufficient cuff, superior migration of the humeral head, instability, eccentric wear of the glenoid, humeral head deformity, and decreased shoulder function [30].
• Nutritional factors in cuff tear arthropathy pathogenesis include hypomobility-induced cartilage atrophy, poor nutrition with decreased glycosaminoglycans, dehydration, and subchondral osteoporosis [30].
• Crystalline-induced arthropathy in cuff tear arthropathy involves synovial-based matrix proteins degradation destroying rotator cuff tendons and cartilage, with end-stage calcium-phosphate crystal deposition [30].
• Pseudoparalysis in cuff tear arthropathy is defined as less than 60 degrees of elevation, lack of active external rotation, and incompetent subscapularis [30].
• The external rotation lag sign and hornblower sign indicate teres minor insufficiency in cuff tear arthropathy [30].
• Radiographic findings of cuff tear arthropathy include acetabularization of the acromion and femoralization of the humeral head [30].
• Radiographic findings of cuff tear arthropathy include eccentric superior glenoid wear and absence of typical peripheral osteophytes around the humeral head [30].
• Osteopenia and subarticular sclerosis, known as the snowcap sign, are radiographic findings in cuff tear arthropathy [30].
• Loss of the coracoacromial arch on radiographs indicates anterosuperior escape in cuff tear arthropathy [30].
• Dynamic superior migration of the humeral head during abduction occurs in patients with rotator cuff tears [70].
• In massive rotator cuff tears, the pectoralis major and latissimus dorsi muscles are effective in improving glenohumeral kinematics and reducing acromiohumeral pressures [75].
• Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions [82].
• Increasing supraspinatus tendon loading causes a mechanical interaction between the supraspinatus and infraspinatus tendons, paralleling the increase in supraspinatus tendon strain [90].
• Shoulders with rotator cuff tears require considerable compensatory deltoid function to prevent abduction motion loss [97].
• Pain reduction from subacromial injection causes shifts in scapulohumeral rhythm resulting in an increase in glenohumeral motion and a reduced reliance on scapular rotation [99].
• Simulated isolated supraspinatus cord tears significantly reduce shoulder abduction force more than strap tears [103].
• Tears of the subscapularis have greater biomechanical consequences than do tears of the infraspinatus [61].
• Additional repair of a partial subscapularis tear combined with a supraspinatus tear did not affect external rotation or glenohumeral kinematics [93].
• The critical shoulder angle, posterior acromial height, and posterior acromial tilt do not change significantly over a long-term follow-up of at least 10 years [102].
• The critical shoulder angle

Classification

General Disease Progression and Etiology

• Rotator cuff disease is a continuum beginning with mild impingement and progressing through partial tear, full-thickness tear, and massive tear, to rotator cuff tear arthropathy [129].
• Tears associated with chronic impingement syndrome typically begin on the bursal surface or within the tendon substance [129].
• Tears occurring on the articular surface are typically due to tension failure in younger athletes participating in overhead activities or owing to intrinsic degeneration [129].
• Bursal-side tears are considered more ominous than articular-side tears [129].
• The majority of rotator cuff tears involve the supraspinatus and infraspinatus tendons [129].
• As rotator cuff tears increase in size or chronicity, the muscle atrophies and fatty infiltration occurs [129].
• Biopsy specimens of retrieved tendon from rotator cuff tears have shown disorganized collagen, scar tissue, and minimal attempts at a healing process [6].
• Gene expression in human rotator cuff muscles varies according to tendon injury severity [106].

Neer Classification

• Neer's classification describes three stages of rotator cuff disease: stage I (hemorrhage and cuff edema), stage II (cuff fibrosis), and stage III (cuff tear) [38].
• In Neer's classification, partial tears were not categorized separately and have been considered advanced stage II lesions by some authors and early stage III lesions by others [38].

Ellman Classification

• Ellman proposed a classification scheme that includes specific consideration of the site and extent of partial cuff tears [38].
• In the Ellman classification, the location of a partial tear is recorded as articular surface, bursal surface, or intratendinous [38].
• In the Ellman classification, tear grade is defined by depth: Grade I is less than 3 mm deep, Grade II is 3 to 6 mm deep, and Grade III involves more than half of the cuff thickness [38].
• The normal rotator cuff is considered to be 10–12 mm thick in the context of the Ellman classification [113].
• In the Ellman classification, a Grade 1 partial tear is less than 3 mm deep and represents relatively minor disruption of tendinous fibers [113].
• In the Ellman classification, a Grade 2 lesion is 3–6 mm deep and extends well into the substance of the cuff but does not exceed one-half of the tendon thickness [113].
• In the Ellman classification, a Grade 3 lesion is more than 6 mm deep and represents a significant disruption of more than one-half the substance of the cuff [113].
• The Ellman classification includes a subclassification for full-thickness tears based on location (supraspinatus, infraspinatus, teres minor, subscapularis) and size (small <2 cm, large 2–4 cm, massive >5 cm) [113].
• The Ellman classification adds a fourth grade for full-thickness tears to include cuff arthropathy, defined as a massive tear with articular irregularity, collapse of the humeral head, chronic synovitis, and capsular laxity [113].
• The area of defect in the Ellman classification is estimated by multiplying the length of the base of the tear by the distance of maximum retraction [113].
• Ellman stated that any tear, whether partial or complete, should be classified as Stage III (impingement according to Neer) [113].

DeOrio and Cofield Classification

• The DeOrio and Cofield classification is based on tear size: small (less than 1 cm), medium (1 to 3 cm), large (3 to 5 cm), and massive (larger than 5 cm or two tendons) [129].
• The DeOrio and Cofield classification does not predict prognosis [129].

Patte Classification

• The Patte classification 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 [123].
• In the Patte classification, Segment 1 represents a subscapularis tear [123].
• In the Patte classification, Segment 2 represents a coracohumeral ligament tear [123].
• In the Patte classification, Segment 3 represents an isolated supraspinatus tear [123].
• In the Patte classification, Segment 4 represents a tear of the entire supraspinatus and one-half of the infraspinatus [123].
• In the Patte classification, Segment 5 represents a tear of the supraspinatus and infraspinatus [123].
• In the Patte classification, Segment 6 represents a tear of the subscapularis, supraspinatus, and infraspinatus [123].
• In the Patte classification, isolated subscapularis tears (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 [123].
• In the Patte classification, isolated coracohumeral ligament tears (Segment 2) are traumatic in nature and do not contribute to the pathology of the cuff [123].
• In the Patte classification, secondary osteoarthritis was most common among patients with total-cuff tears (Segment 6) [123].

MRI Signal Grading

• A modified grading system for rotator cuff tendons on MRI defines Grade 0 as a tendon with completely homogeneous low signal intensity on all imaging sequences [50].
• In the modified MRI grading system, Grade 1A is a low signal intensity tendon with a diffuse area of intermediate signal intensity within the substance of the tendon [50].
• In the modified MRI grading system, Grade 1B is a low signal intensity tendon with an area of intermediate signal intensity that extends to either the articular or bursal surface [50].
• In the modified MRI grading system, Grade 1C is a low signal intensity tendon with a focal area of intermediate signal intensity [50].
• In the modified MRI grading system, Grade 2 (partial tear) is a tendon with an area of diffuse, linear, or focal high signal intensity, but less than full thickness [50].
• In the modified MRI grading system, Grade 3 (full tear) is a tendon with a focal or diffuse area of high signal intensity through the full thickness of the tendon [50].
• Grade 1 (A through C) lesions in the modified MRI grading system may be interpreted as normal, degeneration/tendinopathy, or “magic angle” artifact [50].

Fatty Infiltration and Muscle Quality

• The Goutallier classification grades fatty infiltration of the rotator cuff musculature: 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 [20].
• Goutallier grades 3 and 4 indicate a long-term chronic rotator cuff tear with a higher potential for failure when surgery is undertaken and are likely deemed irreparable [20].
• The Goutallier classification was originally based on CT evaluation and modified by Fuchs et al. for MRI evaluation [20].
• 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 [39].
• The tangent sign correlates with muscle atrophy and fatty infiltration of the supraspinatus [39].
• Patients with the presence of the tangent sign are more likely to have an irreparable rotator cuff tear [39].

Partial-Thickness Tear Specifics

• Partial-thickness rotator cuff tears can be classified as articular-sided, bursal-sided, or intratendinous tears [33].
• On MRI evaluation, partial-thickness tears are generally classified as low grade or high grade depending on whether they involve less than or more than 50% of the tendon width [33].
• Partial-thickness tears have a limited ability to spontaneously heal as shown by histological and radiographic studies [33].
• As many as 53% of partial-thickness rotator cuff tears will progress in tear size, and a portion of these will progress to full-thickness rotator cuff tears [33].
• Tears involving more than 50% of tendon width are best treated with repair, while those involving less than 50% are best treated with debridement and potential decompression [33].
• A higher failure rate of debridement has been suggested for partial-thickness bursal-sided rotator cuff tears compared to articular-sided rotator cuff tears [33].
• Delamination-type tears of the articular side, which commonly occur in athletes involved in throwing and in sports requiring overhead motion, require transtendinous repair if delamination is present [33].
• Intratendinous tears identified on MRI must be localized through preoperative planning and use of a spinal needle to identify the tear site [33].
• The etiology of partial-thickness rotator cuff tears is not considered in most classification schemes but may be important for prognosis and treatment selection [38].
• 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 [38].

Radiographic and Other Classifications

• 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 [5].
• A radiographic classification of massive rotator cuff tear arthritis exists that grades temporal evolution based on radiographic features [77].
• A classification system has been created to divide coracoids according to their morphology and relative risk of associated subscapularis tears [58].
• The Hamada et al. classification is a five-grade system based on radiographic features including narrowing of the subacromial space and degenerative changes of the glenohumeral joint [126].
• In the Hamada et al. classification, Grade 4 or 5 corresponds to cuff tear arthropathy (CTA), while Grade 1, 2, or 3 corresponds to massive cuff tear (MCT) [126].

Clinical Presentation

History and Symptoms

• The most common causes of pain around the shoulder are disorders of the rotator cuff, specifically rotator cuff syndrome, calcific tendinitis, and adhesive capsulitis [22].
• In rotator cuff syndrome, pain is typically located over the front and lateral aspect of the shoulder [22].
• Pain associated with supraspinatus involvement, rotator cuff tears, and tendinitis is accompanied by weakness on abduction [22].
• Pain associated with biceps pathology is located over the front of the shoulder [22].
• Patients with rotator cuff tears or biceps rupture present with weakness in addition to pain [22].
• Chronic rotator cuff disease often presents with an insidious onset of lateral and/or anterior shoulder pain associated with overhead activities [68].
• Night pain is a common presenting symptom in chronic rotator cuff disease [68].
• A family or personal history of rotator cuff disease makes the diagnosis of rotator cuff tears more likely [68].
• Patients with subacromial bursitis and rotator cuff tendinosis report mild or moderate pain with overhead shoulder motion [31].
• Patients with subacromial bursitis and rotator cuff tendinosis may experience occasional night pain [31].
• A history of repetitive overhead activity is a clinical feature of subacromial bursitis and rotator cuff tendinosis [31].
• In subacromial bursitis and rotator cuff tendinosis, pain is usually absent or mild with the arm at the side [31].
• A clear history of trauma resulting in acute pain and weakness strongly suggests an acute rotator cuff tear [68].
• In full-thickness rotator cuff tears, patients may report sudden pain and an inability to abduct the arm [83].
• In long-standing cases of partial or complete rotator cuff rupture, secondary osteoarthritis may supervene, resulting in severely restricted movements [83].
• In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years [17].
• Rotator cuff injuries in adolescents may be overlooked as a cause of disability, leading to significant delays in diagnosis [63].

Physical Examination

• The patient history alone may not accurately identify the source of shoulder pain, which is classically attributed to a rotator cuff syndrome [24].
• Pain associated with other shoulder conditions, such as stiff shoulder, arthritis, and biceps pathologies, can radiate into the anterior and lateral deltoid areas [24].
• Visual inspection of the shoulder may reveal rotator cuff muscle atrophy, signs of rotator cuff dysfunction, and anterosuperior escape [84].
• Passive range of motion assessment can rule out adhesive capsulitis [84].
• 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 [84].
• External rotation strength tests assess the infraspinatus with the arm in adduction and the elbow at 90° of flexion [84].
• The lift-off and belly press tests assess the subscapularis [84].
• The external rotation lag sign and hornblower’s sign assess for massive failure of the infraspinatus and teres minor [84].
• The drop arm test examines failure of the superior rotator cuff [84].
• No single test for rotator cuff disease has reliably high diagnostic value, and a combination of tests increases diagnosis specificity [84].
• The empty can test has a sensitivity of 71.7% and a specificity of 64.6% for full-thickness supraspinatus tears [68].
• The lift-off and belly-press tests have high specificity but low sensitivity for full-thickness subscapularis tears [68].
• Patients with an external rotation lag sign at the side likely have a large posterosuperior tear involving the infraspinatus [68].
• A positive hornblower sign suggests a massive posterosuperior cuff tear that prohibits the active positioning of the hand in space [68].
• 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 [53].
• For full-thickness or high-grade partial tears, the crepitus test has a sensitivity of 82% and a specificity of 73% [53].
• 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% [53].
• If active abduction is impossible after subacromial local anesthetic injection, a complete rotator cuff tear is likely [83].
• If active abduction becomes possible after subacromial local anesthetic injection, the tear is likely only partial [83].
• Wasting of the supraspinatus and infraspinatus is usually present in full-thickness rotator cuff tears [83].
• Tenderness of the acromioclavicular joint is often present in rotator cuff tears [83].
• In subacromial bursitis and rotator cuff tendinosis, no atrophy of the shoulder muscles is present [31].
• Manual muscle testing in subacromial bursitis and rotator cuff tendinosis demonstrates mild weakness [31].
• Active range of shoulder motion may be limited by pain in subacromial bursitis and rotator cuff tendinosis [31].
• The Neer impingement sign involves discomfort when the internally rotated shoulder is moved into forward flexion [31].
• Pain from the Neer impingement sign resolves with a dramatic increase in strength and range of motion following a subacromial lidocaine injection [31].

Diagnostic Imaging

• MRI is the benchmark for diagnosing rotator cuff tears with 94% sensitivity and 93% specificity [25].
• T2-weighted MRI images best visualize rotator cuff tears [25].
• T1 sagittal oblique MRI cuts reveal muscle and tendon retraction and muscle atrophy to determine chronicity, reparability, and outcome of surgical repairs [25].
• Intra-articular contrast-enhanced magnetic resonance arthrography is best for detecting partial-thickness rotator cuff tears with 95% sensitivity and 95% specificity [25].
• Ultrasonography has good accuracy with 92% sensitivity and 93% specificity for rotator cuff tears [25].
• Ultrasonography allows for dynamic assessment of the cuff insertion [25].
• Ultrasonography is operator dependent and has limited assessment of chondral lesions [25].
• Ultrasonography has poor sensitivity to diagnose partial-thickness rotator cuff tears [25].
• 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 [68].
• Ultrasonography is more accurate for full-thickness rotator cuff tears, comparable to MRI [22].
• CT arthrography is useful in postoperative assessment, retear evaluation in patients with retained metallic anchors causing artifact on MRI, and when MRI is contraindicated [25].
• In the setting of an intact rotator cuff, the sensitivity, specificity, and accuracy of postoperative ultrasound were all 100% [60].
• If the index procedure included a rotator cuff repair, the sensitivity, specificity, and accuracy of postoperative ultrasound were 90%, 79%, and 85%, respectively [60].
• The diagnostic role of magnetic resonance imaging of a shoulder that has undergone surgical treatment is controversial, with reported accuracy rates ranging from 70% to 90% [60].
• Sutures, suture anchors, and/or osseous changes from prior surgery may alter signal intensities within the acromion, humeral head, and rotator cuff tissue, making them indistinguishable from an acute rotator cuff tear on MRI [60].
• Ultrasound is a useful tool for discovering subjects in pre-symptomatic stages who may undergo shoulder symptomatic pathologies [26].
• Intratendinous rotator cuff tears are difficult to diagnose preoperatively [67].

Associated Pathology and Risk Factors

• Long head of biceps tendinopathy is associated with age and cuff tendinopathy on MRI obtained for evaluation of shoulder pain [54].
• Supraspinatus tendinopathy is nearly universal in the presence of long head of biceps tendinopathy [54].
• About half of long head of biceps tendons are normal with supraspinatus tendinopathy alone [54].
• Long head of biceps tendinopathy may come later in the progression of rotator cuff tendinopathy [54].
• In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues [15].
• Risk factors for rotator cuff tears include age, smoking, female sex, family history, diabetes, and high cholesterol [25].
• Deltoid complications combined with rotator cuff pathology represent a rare but devastating complication [9].

Investigations

Plain Radiography

• The shoulder plain radiograph series includes a Grashey AP view, lateral outlet view/scapular Y, and an axillary lateral view [133].
• Plain radiographs may demonstrate spurring and calcification within the acromion or coracoacromial ligament [39].
• Plain radiographs may demonstrate cystic changes within the greater tuberosity [39].
• In chronic rotator cuff disease, plain radiographs may show superior migration of the humeral head with extensive degenerative change [39].
• Plain radiographs may show a diminished acromiohumeral interval and glenohumeral joint space narrowing suggestive of osteoarthritis [133].
• Cuff tear arthropathy features on plain radiographs include morphologic changes of the humeral head, glenoid, and acromial arch [133].
• Irreparable rotator cuff tears are more likely to occur when the acromiohumeral distance appears shorter than 7 mm on AP radiograph [39].
• The critical shoulder angle (CSA) is a static radiographic measure that does not change over time [4].
• Patients with a CSA greater than 38° and an acromial index (AI) greater than 0.7 had higher retear rates after arthroscopic rotator cuff repair [4].
• A study of 1,552 radiographs determined that CSA was higher in patients with rotator cuff tears but that these differences are small and depend on excellent radiographic technique [4].
• The acromial morphology classification system is an unreliable method to assess the acromion [5].
• The acromial index shows no association with the presence of rotator cuff disease [5].
• A study of 147 patients found no difference in functional scores at 24 months between patients with higher CSA/AI and patients with lower values [4].

Magnetic Resonance Imaging (MRI)

• MRI is used to define the extent of the tear, degree of tear retraction, and presence of muscular atrophy [39].
• MRI allows characterization of the location, size, and amount of retraction of the rotator cuff tear [20].
• MRI allows evaluation of the degree of atrophy and fatty infiltration of the rotator cuff musculature [20].
• MRI is key for evaluating fatty infiltration, although the Goutallier classification was originally based on CT [39].
• The Goutallier classification grades fatty infiltration from 0 (normal muscle) to 4 (more fat than muscle) [20].
• Goutallier grades 3 and 4 indicate a long-term chronic rotator cuff tear with a higher potential for surgical failure and are likely deemed irreparable [20].
• MRI is indicated in younger, active patients with acute rotator cuff tears and in patients with chronic rotator cuff tears who have failed nonoperative treatment [20].
• MRI and MRA are both sensitive and specific for full-thickness rotator cuff tears [116].
• The sensitivity of MRI for full-thickness rotator cuff tears is 92.1% [116].
• The specificity of MRI for full-thickness rotator cuff tears is 92.9% [116].
• The sensitivity of MRI for partial-thickness rotator cuff tears is 63.6% [116].
• The specificity of MRI for partial-thickness rotator cuff tears is 91.7% [116].
• The sensitivity of MRA for full-thickness rotator cuff tears is 95.4% [116].
• The specificity of MRA for full-thickness rotator cuff tears is 98.9% [116].
• The sensitivity of MRA for partial-thickness rotator cuff tears is 85.9% [116].
• The specificity of MRA for partial-thickness rotator cuff tears is 96.0% [116].
• A full-thickness rotator cuff tear is identified on MRI if fiber discontinuity spans the entire thickness of the tendon, with the defect filled with fluid signal intensity on T2-weighted sequences [116].
• MRA is more sensitive for the detection of partial-thickness, particularly articular-sided tears [116].
• Articular-side thickening of the supraspinatus and infraspinatus on neutral position images suggests the presence of a partial-thickness articular-side rotator cuff tear [116].
• The description of a full-thickness tear on MRI should include the tendon(s) involved, location within the tendon, AP dimension, and extent of retraction [116].
• The description of a partial-thickness tear on MRI should include the tendon(s) involved, location within the tendon, percentage of tendon thickness affected, and side of the tendon torn [116].
• Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders [79].
• 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 [45].
• Tendinosis severity assessed by preoperative MRI was the only factor associated with failure to heal in patients with partial-thickness and small full-thickness rotator cuff tears [117].
• A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists [110].
• Preoperative MRI scans interpreted by orthopaedic surgeons with a systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears [104].
• MRI and ultrasound provide similar assessments of postoperative rotator cuff healing, although ultrasound is less sensitive [98].

Ultrasonography

• Ultrasonography is increasing in popularity as a tool for diagnosis of rotator cuff disease and for confirmation of intraarticular or subacromial location of injections [39].
• The diagnostic accuracy of ultrasonography for full-thickness rotator cuff tears is comparable to MRI [4].
• The overall estimates of sensitivity and specificity for ultrasonography in the characterisation of full-thickness rotator cuff tears are over 0.90 [107].
• Ultrasonography may not be as sensitive as MRI in detecting partial-thickness tears [133].
• Ultrasonography accurately assesses the muscle degeneration degree in chronic rotator cuff tears [133].
• Ultrasonography is less expensive than MRI and may be used to monitor repair integrity in postoperative patients, especially those with metallic implants [133].
• The MRI tendinosis grade is associated with stiffness assessed using sonoelastography in patients with rotator cuff tendinopathy [112].

Other Imaging and Diagnostic Tools

• A positive tangent sign predicts the repairability of rotator cuff tears [4].
• 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 [20].
• Shoulders with a symptomatic rotator cuff tear showed higher radioisotope uptake on bone scintigraphy than those with an asymptomatic tear [128].

Treatment

General Principles and Decision-Making

• Patients are generally divided into three categories based on the risk of nonoperative treatments and proposed benefits of surgical intervention: those needing urgent or early operative repair, those who can benefit from a trial of conservative treatment, and those best suited for nonoperative treatment [2].
• Orthopedic surgeons have significant variation in their decision-making process for the management of rotator cuff tears due to a lack of high-quality evidence available to guide management [23].
• The majority of clinical practice guidelines set out by the American Academy of Orthopaedic Surgeons are limited or inconclusive regarding rotator cuff disease [23].
• Cochrane reviews fail to provide an evidence basis for the treatment of rotator cuff disease [23].
• Current physiotherapy practice in relation to rotator cuff disorders is variable, which might reflect the lack of high-quality evidence available [32].
• The shoulder arthroscopy literature remains controversial, with conclusions often unsupported due to bias and limitations, and no clinical guidelines are definitive pending higher levels of evidence [37].

Non-Operative Management

• Treatment of rotator cuff tears begins with nonsurgical measures such as activity modification, physical therapy, nonsteroidal anti-inflammatory medications, and corticosteroid injection [28].
• A systematic review indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease [66].
• 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 at both the individual and population level [45].
• In a meta-analysis of randomized controlled trials for full-thickness rotator cuff tears, symptoms improved over the first year after treatment regardless of whether surgical or nonsurgical treatment was used, but then plateaued [4].
• A prospective cohort study found that patients undergoing operative treatment had significantly better pain and functional outcomes compared with patients undergoing nonoperative treatment for rotator cuff tears [72].
• The first line of treatment for the majority of patients with partial-thickness rotator cuff tears should consist of activity modification, avoidance of overhead sports or pain-provoking activities, a short course of nonsteroidal anti-inflammatory drugs, and home exercises or physical therapy programs [73].
• On failure of initial nonoperative modalities for partial-thickness rotator cuff tears, subacromial injections of corticosteroid can be considered [73].
• There is a lack of high-quality literature evaluating the efficacy of subacromial corticosteroid injections for the treatment of partial-thickness rotator cuff tears [73].
• Some patients with partial-thickness rotator cuff tears, particularly those with bursal-sided tears, receive benefit from subacromial corticosteroid injections [73].
• For throwers with a partial articular supraspinatus tendon avulsion (PASTA) lesion, focused stretching that addresses a tight anterior capsule can lead to significant improvement in both the short and long term [73].
• The currently limited available evidence on platelet-rich plasma (PRP) for nonoperative treatment of chronic rotator cuff disease suggests that in the short term, PRP injections may not be beneficial [96].
• Orthobiologics offer a relatively safe management option with inconclusive evidence for or against their use for rotator cuff pathology [81].
• Improvement in symptoms and functional outcomes after subacromial platelet-rich plasma injections was significantly worse in patients who had a partial-thickness rotator cuff tear compared with patients who had an isolated tendinopathy [80].
• Steroid injection with physical therapy, extracorporeal shockwave therapy, ultrasound-guided needle lavage, and arthroscopic débridement are all valid options for treatment of rotator cuff calcific tendinitis [36].
• Arthroscopy is a safe and effective treatment for symptomatic calcific tendonitis of the shoulder, excluding or including patients with rotator cuff tears, but patients with intact cuffs could benefit from needling or extracorporeal shockwave therapy in some cases [86].
• Eleven interventions or strategies related to return to work were identified among clinical practice guidelines, with the most commonly recommended strategies including intervening early, use of a multidisciplinary approach, and adaptation of work organization [109].
• Intervening early, establishing a return-to-work plan using shared decision-making, maintaining communication between the worker and employer, and establishing realistic goals for return to work were recommended or considered essential in all guidelines that covered the subject [109].

Operative Indications and Timing

• Early operative treatment appears to be better for rotator cuff tears with a sudden onset of symptoms and poor function to achieve maximal return of shoulder function [34].
• Treatment of chronic massive rotator cuff tears is challenging, and results are comparatively inferior to those of treating patients with smaller rotator cuff tears [18].
• Severely impaired deltoid function, an isolated supraspinatus tear, and the presence of full active shoulder elevation with a massive rotator cuff tear and arthritis are contraindications to reverse total shoulder arthroplasty [21].
• When tears are irreparable, or the patient has concomitant advanced glenohumeral arthrosis, alternative options such as arthroplasty can be recommended [28].

Partial-Thickness Rotator Cuff Tears

• Most partial-thickness rotator cuff tears are best initially managed with nonoperative treatment [33].
• Surgical treatment with either rotator cuff repair or debridement is indicated for patients with partial-thickness rotator cuff tears in whom nonoperative treatment fails [33].
• Most surgeons agree that partial-thickness tears involving more than 50% of tendon width are best treated with repair and those involving less than 50% with debridement and potential decompression [33].
• A higher failure rate of debridement has been suggested for partial-thickness bursal-sided rotator cuff tears compared to articular-sided rotator cuff tears, leading some surgeons to favor repair in even low-grade bursal-sided tears [33].
• There is no difference in functional outcome scores or re-tear rates between in situ rotator cuff repair and completion to a full-thickness rotator cuff tear with subsequent repair [33].
• For partial-thickness tears with poor-quality tendon remaining and involving more than 80% of tendon thickness, debridement is favored [33].
• If delamination of the tear is present in delamination-type tears of the articular side, a transtendinous repair is indicated [33].
• Intratendinous tears are repaired side-to-side using arthroscopic technique after the tear is opened using an arthroscopic knife and the edge is debrided back slightly to promote local healing [33].
• Extensive debridement is unnecessary for intratendinous rotator cuff tears [33].
• The presence of a grade III partial-thickness rotator cuff tear (involving more than half of the cuff thickness) is often considered a relative indication for surgical repair in the symptomatic patient [38].
• Clinical data suggest that treating grade III partial-thickness rotator cuff tears with surgical repair is a reasonable management guideline [38].
• In a randomized clinical trial of 74 patients with PASTA tears, there was no difference between treatment groups at a minimum of 2-year follow-up when comparing transtendon repair or completion and repair [11].
• Outcomes after repair of partial- and full-thickness rotator cuff tears using a bioinductive implant show safety and efficacy at 1-year follow-up [19].

Surgical Techniques and Adjuncts

• The current standard of care for rotator cuff repair is arthroscopic repair, although the superiority of arthroscopic versus open or mini-open repair is still somewhat controversial [28].
• Arthroscopic repair has been shown to have similar outcomes and failure rates compared to open or mini-open repair, with decreased short-term pain and more rapid return to activity [28].
• The goal of rotator cuff repair is to restore the tendon to its anatomic footprint to encourage healing [28].
• Controlled laboratory studies have generally shown superiority of double-row techniques over single-row in terms of initial and ultimate failure strength, decreased gap formation, decreased strain and suture cut-through, and improved vascularity in transosseous-equivalent double-row repair [28].
• Platelet-rich plasma (PRP) does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair [42].
• Routine arthroscopic suprascapular nerve release is not recommended when treating patients with rotator cuff tear [87].
• No recommendations regarding suprascapular nerve release in conjunction with rotator cuff repair can be made at this time, and further research is necessary to better delineate the indications [43].
• Following nonoperative treatment for at least 6 weeks, arthroscopic subacromial decompression is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff [74].
• Arthroscopic subacromial decompression without cuff repair appears to be a safe, efficacious, and sustainable procedure for patients with partial rotator cuff tears [76].

Postoperative Rehabilitation

• An evidence-based postoperative rehabilitation program for patients following rotator cuff repair includes concepts such as immobilization, range of motion, and strengthening [131].
• Progression of resistance exercise and range of motion in postoperative rehabilitation depends on patient tolerance [131].
• Resistance exercise should not be performed with specific shoulder joint pain or pain over the incision site [131].
• A sling is provided for support as needed with daily activities and to wear at night, and the patient should be weaned from the sling as tolerated and under the direction of the referring surgeon [131].
• Early home exercises given to the patient following surgery should include stomach rubs, sawing, and distal gripping activity [131].
• Progression to assisted range of motion against gravity and duration of sling use is determined by the size of the rotator cuff tear and the quality of the tissue and fixation [131].
• Early postoperative range of motion to patient tolerance is recommended during the first 4–6 weeks [131].
• Postoperative weeks 1 and 2 include mobilization of the glenohumeral joint and scapulothoracic joint, passive stretching of elbow, forearm, and wrist to terminal ranges, and side-lying scapular protraction/retraction resistance [131].
• Postoperative week 3 includes continuing above-shoulder range of motion, adding an isometric strength program to patient tolerance, beginning active scapular strengthening exercises, and beginning submaximal rhythmic stabilization [131].
• Postoperative weeks 5 and 6 include initiating isometric and isotonic resistance exercise focusing on specific movements such as standing internal/external rotation isometric step-outs, side-lying external rotation, prone extension, and prone horizontal abduction [131].
• A low-resistance/high-repetition format is recommended initially using no resistance during postoperative weeks 5 and 6 [131].
• Postoperative week 10 includes beginning closed chain step-ups and quadruped rhythmic stabilization exercise, and initiating upper extremity plyometric chest passes and functional two-hand rotation simulations [131].
• Postoperative week 12 includes initiation of submaximal isokinetic exercise for internal/external rotation in the modified neutral position [131].
• Criteria for progression to isokinetic exercise include having internal/external rotation range of motion greater than that used during the exercise and completing the isotonic exercise program pain-free with a 2- to 3-lb weight or medium resistance surgical tubing [131].
• Postoperative week 16 includes progression to maximal isokinetics in internal/external rotation and isokinetic test results to assess strength in the modified base 30/30/30 position [131].
• Criteria for interval return programs include internal/external rotation strength at a minimum of 85% of the contralateral extremity, an external/internal rotation ratio of 60% or higher, pain-free range of motion, and negative impingement and instability signs during clinical examination [131].

Complications

Postoperative Structural Failure and Healing

• Re-tear rates after rotator cuff repair are reported to be about 20%, with rates even greater for larger tears [125].
• Arthroscopic rotator cuff repair leads to a structural failure rate of 33% [48].
• Increased age and longer duration of follow-up were associated with lower healing rates after double-row rotator cuff repair [41].
• Goutallier stages III and IV tears, if accompanied by a tendinous stump of less than 15 mm and a positive tangient sign, have a 90% failure rate [20].
• 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 [20].
• The rate of recurrent rotator cuff tears has not changed significantly over time despite advances in technology and techniques [125].

Rehabilitation and Functional Complications

• Immobilizing the shoulder after surgery to protect the repair site risks shoulder stiffness and decreased shoulder function [125].
• Early mobilization to improve early shoulder function may put the repair construct at risk [125].

Disease Progression and Natural History Complications

• With nonoperative treatment of chronic full-thickness rotator cuff tears, the risk of tear progression is approximately 50% at 2 years [20].
• With long-standing rotator cuff tears, size, retraction, and degree of fatty infiltration can increase and can compromise the structural integrity and functional outcomes after rotator cuff repair [20].
• Cuff tear arthropathy is the final stage of the shoulder impingement syndrome spectrum, affecting patients with long-term insufficient massive rotator cuff tears, superior migration of the humeral head toward the acromion, subchondral osteoporosis, humeral head collapse, and painful debilitating shoulder arthritis [30].
• Pseudoparalytic shoulders usually do not improve with conservative measures [30].

Specific Pathological Complications

• In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity [15].
• Chronic long head of biceps rupture is usually present in patients with cuff tear arthropathy [30].

Surgical Contraindications and Limitations

• Contraindications for surgical treatment of cuff tear arthropathy include deltoid dysfunction, noncompliant patients to postoperative rehabilitations, chronic infection, and poor glenohumeral bone stock [30].
• Hemiarthroplasty outcomes for cuff tear arthropathy are limited to pain relief only, with no function improvement over 90º elevation promised to patients [30].
• Arthroscopic débridement for cuff tear arthropathy has unpredictable outcomes [30].
• Arthrodesis for cuff tear arthropathy is poorly tolerated by older patients (other than 60 years) [30].

Recovery

Natural History and Prognosis

• Bilateral rotator cuff tears are common despite often unilateral symptoms [12].
• Younger age, lower BMI, more functional capacity, a shorter symptomatic period, reversible changes on MRI, and higher Constant and ASES scores at the first evaluation were good prognostic factors for the natural course of subacromial impingement syndrome [138].
• The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term [29].

Non-Operative Management

• Nonoperative treatment of full-thickness rotator cuff tears is effective in 75% of patients after 2 years [114].
• A patient’s perception of whether physical therapy would be beneficial was a strong predictor of whether conservative treatment would be successful [114].
• Patients with rotator cuff disease treated without surgery who have a 2-point change in the Simple Shoulder Test (SST) score or a 12 to 17-point change in the American Shoulder and Elbow Surgeons (ASES) score experience a clinically important change in self-assessed outcome [137].
• Arthroscopic acromioplasty significantly improves long-term clinical outcomes up to 2 years for chronic rotator cuff tendinopathy [108].

Operative Indications and Timing

• Clinical decision-making for the management of rotator cuff tears can be complex and lacks consensus among orthopedic surgeons [2].
• Patients can be divided into three main categories based on the potential risk of nonoperative treatments and the proposed benefits of surgical intervention: those needing urgent or early operative repair, those that can benefit from a trial of conservative treatment, and those best suited for nonoperative treatment [2].

Post-Operative Outcomes and Healing

• Arthroscopic rotator cuff repair leads to a structural failure rate of 33% but satisfactory functional results with high patient satisfaction at midterm follow-up [48].
• Although functional status improved with time after 6 months, the structural status of repaired cuffs remained unchanged between 6 and 19 months [95].
• Improvement in functional outcome after arthroscopic repair of a subscapularis tendon tear is maintained long-term [100].
• The 'critical period' for healing following rotator cuff repair, during which risks of retears are high, extends to the first 6 months [139].

Key Evidence

• [L4] The majority of conditions are amenable to conservative treatment, although rotator cuff dysfunction may necessitate surgical treatment. [1] (10.1002/art.20668)
• [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. [3] (10.5435/00124635-201111000-00002)
• [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. [5] (10.1016/j.jse.2011.09.028)
• [L5] [6] (10.1016/j.arthro.2013.07.265)
• [Case_report] Deltoid complications combined with rotator cuff pathology represent a rare but devastating complication with no well-described surgical option. [9] (10.1016/j.jse.2011.09.023)
• [L4] In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity. [15] (10.1016/j.jse.2008.05.044)
• [L2] In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years. [17] (10.1016/j.jse.2023.09.008)
• [L5] However, treatment of these patients is challenging, and results are comparatively inferior to those of treating patients with smaller rotator cuff tears. [18] (10.5435/00124635-200309000-00005)
• [L4] Outcomes after repair of partial- and full-thickness rotator cuff tears using a bioinductive implant show safety and efficacy at 1-year follow-up. [19] (10.1016/j.arthro.2019.02.019)
• [L5] Severely impaired deltoid function, an isolated supraspinatus tear, and the presence of full active shoulder elevation with a massive rotator cuff tear and arthritis are contraindications to RTSA. [21] (10.1007/s11999-009-1188-9)
• [L4] [24] (10.5435/jaaos-d-16-00076)
• [L3] Ultrasound is an useful tool for discovering in pre-symptomatic stages the subjects that may undergo shoulder symptomatic pathologies. [26] (10.1186/1471-2474-11-278)
• [L1] The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. [29] (10.1302/0301-620x.99b6.bjj-2016-0569.r1)
• [L4] Current physiotherapy practice in relation to rotator cuff disorders is variable, which might reflect the lack of high-quality evidence available. [32] (10.1111/j.1758-5740.2011.00164.x)
• [L3] Early operative treatment appears to be better for rotator cuff tears with a sudden onset of symptoms and poor function to achieve maximal return of shoulder function. [34] (10.1016/j.jse.2005.07.006)
• [L5] The editorial states that shoulder arthroscopy literature remains controversial, conclusions are often unsupported due to bias and limitations, and no clinical guidelines are definitive pending higher levels of evidence. [37] (10.1016/j.arthro.2012.07.001)
• [L5] [38] (10.5435/00124635-199901000-00004)
• [L4] Increased age and longer duration of follow-up were associated with lower healing rates after double-row rotator cuff repair. [41] (10.1177/0363546510382835)
• [L1] PRP does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair. [42] (10.1016/j.arthro.2012.03.007)
• [L4] No recommendations regarding suprascapular nerve release in conjunction with rotator cuff repair can be made at this time, and further research is necessary to better delineate the indications in the future. [43] (10.1016/j.jse.2011.11.033)
• [Case_report] This case highlights the importance of the initial workup after high-velocity trauma and that open approaches for rotator cuff repairs continue to have indications in certain circumstances. [44] (10.1016/j.jse.2009.07.014)
• [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. [45] (10.1016/j.jse.2019.04.003)
• [L1] On the basis of the currently available literature, there is no statistically significant difference in subjective outcome after arthroscopic rotator cuff repair with or without acromioplasty at intermediate follow-up. [47] (10.1016/j.arthro.2011.11.022)
• [L4] Arthroscopic rotator cuff repair leads to a structural failure rate of 33% but satisfactory functional results with high patient satisfaction at midterm follow-up. [48] (10.1016/j.jse.2015.05.051)
• [L4] [50] (10.1177/03635465020300012501)
• [L5] The study identified two distinctive characteristics of the human scapula: a lateral orientation of the glenoid cavity and a narrow coraco-acromial arch. [52] (10.1016/j.otsr.2014.09.011)
• [L2] [53] (10.1016/j.jse.2013.12.037)
• [L3] [54] (10.1097/corr.0000000000003342)
• [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. [58] (10.1016/j.jse.2020.01.074)
• [L2] [60] (10.2106/00004623-200306000-00016)
• [L5] Tears of the subscapularis have greater biomechanical consequences than do tears of the infraspinatus. [61] (10.1016/j.arthro.2009.09.007)
• [L4] Rotator cuff injuries in adolescents may be overlooked as a cause of disability, leading to significant delays in diagnosis. [63] (10.1177/0363546504269033)
• [L1] This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease. [66] (10.5435/00124635-200701000-00002)
• [L4] Intratendinous rotator cuff tears are difficult to diagnose preoperatively. [67] (10.1016/j.jse.2010.01.013)
• [L3] This study confirms dynamic superior migration of the humeral head during abduction in patients with rotator cuff tears using in vivo 3D kinematic analysis. [70] (10.1016/j.arthro.2015.08.031)
• [L3] In this prospective cohort study, patients undergoing operative treatment had significantly better pain and functional outcomes as compared with patients undergoing nonoperative treatment for rotator cuff tears. [72] (10.1177/0363546519873840)
• [L5] Following nonoperative treatment for at least 6 weeks, SAD is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff. [74] (10.1016/j.arthro.2019.06.012)
• [L5] In massive rotator cuff tear, the pectoralis major and latissimus dorsi muscles are effective in improving glenohumeral kinematics and reducing acromiohumeral pressures. [75] (10.1016/j.jse.2013.11.030)
• [L4] ASD without cuff repair appears to be a safe, efficacious, and sustainable procedure for patients with partial rotator cuff tears. [76] (10.1016/j.arthro.2015.08.026)
• [L3] [77] (10.1007/s11999-011-1896-9)
• [L3] Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. [79] (10.1016/j.jse.2019.04.001)
• [L2] However, improvement in symptoms and functional outcomes was significantly worse in patients who had a partial-thickness rotator cuff tear compared with patients who had an isolated tendinopathy. [80] (10.1016/j.arthro.2023.03.019)
• [L2] Orthobiologics offer a relatively safe management option with inconclusive evidence for or against its use for rotator cuff pathology. [81] (10.3233/bmr-201844)
• [L5] Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect and the physiologic load required remains unknown. [82] (10.1016/j.arthro.2010.10.014)
• [L3] CSA and AI do not appear to influence 24-month functional outcomes postoperatively and hence are not contraindications to arthroscopic rotator cuff repair. [85] (10.1177/0363546517717947)
• [L5] Arthroscopy is a safe and effective treatment for symptomatic calcific tendonitis of the shoulder, excluding or including patients with rotator cuff tears, but patients with intact cuffs could benefit from needling or ESWT in some cases. [86] (10.1016/j.arthro.2015.11.003)
• [L1] Routine arthroscopic SSNR is not recommended when treating patients with rotator cuff tear. [87] (10.1007/s00167-022-07066-4)
• [L5] Increasing supraspinatus tendon loading causes a mechanical interaction between the two tendons, paralleling the increase in supraspinatus tendon strain. [90] (10.1016/j.jse.2009.10.003)
• [L5] Arthroscopic surgeons who treat rotator cuff disorders will be able to use this information in treating their patients irrespective of their preferred surgical technique. [91] (10.1016/j.arthro.2016.05.016)
• [L5] Additional repair of the partial subscapularis tear with supraspinatus tear did not affect external rotation or glenohumeral kinematics. [93] (10.1016/j.jse.2013.09.015)
• [L2] These data can be used to select optimal candidates for operative treatment of rotator cuff tears and assist with patient education and expectations before treatment. [94] (10.1016/j.jse.2018.04.016)
• [L4] Although functional status improved with time after 6 months, the structural status of repaired cuffs remained unchanged between 6 and 19 months. [95] (10.1016/j.jse.2011.05.027)
• [L2] The currently limited available evidence on PRP for nonoperative treatment of chronic rotator cuff disease suggests that in the short term, PRP injections may not be beneficial. [96] (10.1016/j.arthro.2018.10.115)
• [L5] Shoulders with rotator cuff tears require considerable compensatory deltoid function to prevent abduction motion loss. [97] (10.1177/0363546518768276)
• [L3] MRI and US provide similar assessments of postoperative rotator cuff healing, although US is less sensitive. [98] (10.1016/j.otsr.2015.06.006)
• [L3] Pain reduction caused shifts in scapulohumeral rhythm resulting in an increase in glenohumeral motion and a reduced reliance on scapular rotation. [99] (10.1016/j.jse.2007.05.010)
• [L4] This study shows that improvement in functional outcome after arthroscopic repair of a subscapularis tendon tear is maintained long-term. [100] (10.1016/j.arthro.2012.02.031)
• [L3] The critical shoulder angle, posterior acromial height, and posterior acromial tilt do not change significantly over a long-term follow-up of at least 10 years, supporting the hypothesis that these scapular morphologic parameters are stable anthropometric characteristics. [102] (10.1016/j.jse.2020.09.042)
• [L5] Simulated isolated supraspinatus cord and strap tears significantly reduced shoulder abduction force, with cord tears causing a larger decline than strap tears. [103] (10.1016/j.jse.2023.07.003)
• [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. [104] (10.1016/j.arthro.2012.04.142)
• [L4] Gene expression in human rotator cuff muscles varied according to tendon injury severity. [106] (10.2106/jbjs.m.01585)
• [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. [107] (10.1136/bjsports-2014-094148)
• [L1] Arthroscopic acromioplasty significantly improves long-term clinical outcomes up to 2 years. [108] (10.1177/0363546515608485)
• [L1] [109] (10.1016/j.apmr.2019.12.017)
• [L4] A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists. [110] (10.1007/s00167-014-3102-6)
• [L2] There were no differences of clinically relevant size between arthroscopic and open rotator cuff surgery in this comparative series. [111] (10.1007/s11999-014-3715-6)
• [L3] The MRI tendinosis grade is associated with stiffness assessed using sonoelastography in patients with rotator cuff tendinopathy. [112] (10.1016/j.jse.2015.10.019)
• [L3] Tendinosis severity assessed by preoperative MRI was the only factor associated with failure to heal in patients with partial-thickness and small full-thickness rotator cuff tears. [117] (10.1177/0363546514561004)
• [L4] [126] (10.1007/s11999-011-1833-y)
• [L3] Shoulders with a symptomatic rotator cuff tear showed higher radioisotope uptake on bone scintigraphy than those with an asymptomatic tear. [128] (10.1177/0363546513494741)
• [L4] [132] (10.1007/s00167-014-3499-y)
• [L4] [134] (10.1007/s11999-009-1058-5)
• [L4] [136] (10.5397/cise.2022.01417)
• [L2] Patients with rotator cuff disease who are treated without surgery and have a 2-point change in the SST score or a 12 to 17-point change in the ASES score experience a clinically important change in self-assessed outcome. [137] (10.2106/jbjs.h.01296)
• [L2] Younger age, lower BMI, more functional capacity, a shorter symptomatic period, reversible changes on MRI, and higher Constant and ASES scores at the first evaluation were good prognostic factors for the natural course of subacromial impingement syndrome. [138] (10.1016/j.jse.2015.06.007)
• [L3] The 'critical period' for healing following rotator cuff repair, during which risks of retears are high, extends to the first 6 months. [139] (10.1007/s00167-016-4276-x)

References

[1] Rotator cuff disorders: Recognition and management among patients with shoulder pain. Arthritis & Rheumatism. 2004. DOI: 10.1002/art.20668

[2] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > Indications for Rotator Cuff Repair.

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

[4] Orthopaedic Knowledge Update Sports Medicine 6. Rotator Cuff Disease > Annotated References.

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

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

[9] Rotator cuff tear arthropathy and deltoid avulsion treated with reverse total shoulder arthroplasty and latissimus dorsi transfer: case report and review of the literature. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.09.023

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

[12] Orthopaedic Knowledge Update Sports Medicine 6. Rotator Cuff Disease > Natural History and Societal Impact.

[15] Biceps tendinitis in chronic rotator cuff tears: A histologic perspective. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2008.05.044

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

[18] Chronic Massive Rotator Cuff Tears: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200309000-00005

[19] Patient‐Reported Outcomes After Use of a Bioabsorbable Collagen Implant to Treat Partial and Full‐Thickness Rotator Cuff Tears. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.02.019

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

[21] Indications for Reverse Total Shoulder Arthroplasty in Rotator Cuff Disease. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-009-1188-9

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

[23] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > NATURAL HISTORY OF ROTATOR CUFF PATHOLOGY AND IMPLICATIONS ON SURGICAL INDICATIONS.

[24] Diagnostic Injections About the Shoulder. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00076

[25] Aaos Comprehensive Orthopaedic Review 3. Rotator Cuff Tears and Cuff Tear Arthropathy > I. Rotator Cuff Tears.

[26] Sonographic evaluation of the shoulder in asymptomatic elderly subjects with diabetes. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-278

[28] Orthopaedic Basic Science Fifth Edition Print Ebook. Lumbar Spondylosis, Degenerative Disk Disease, and Radiculopathy > Clinical Example: Rotator Cuff Repair.

[29] Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b6.bjj-2016-0569.r1

[30] Aaos Comprehensive Orthopaedic Review 3. Rotator Cuff Tears and Cuff Tear Arthropathy > II. Cuff Tear Arthropathy.

[31] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 3Sports Medicine > 1. Subacromial Bursitis and Rotator Cuff Tendinosis.

[32] Rotator Cuff Disorders: A Survey of Current Uk Physiotherapy Practice. Shoulder & Elbow. 2012. DOI: 10.1111/j.1758-5740.2011.00164.x

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

[34] Results of early operative treatment of rotator cuff tears with acute symptoms. Journal of Shoulder and Elbow Surgery. 2006. DOI: 10.1016/j.jse.2005.07.006

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

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

[37] Shoulder Arthroscopy Literature Remains Controversial. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.07.001

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

[39] Miller S Review Of Orthopaedics. ROTATOR CUFF DISEASE > 4. Imaging.

[41] Factors Affecting Healing Rates after Arthroscopic Double-Row Rotator Cuff Repair. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510382835

[42] The Role of Platelet‐Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review With Quantitative Synthesis. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.03.007

[43] Suprascapular neuropathy: what does the literature show?. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.033

[44] Complete rotator cuff tendon avulsion and glenohumeral joint incarceration in a young patient: A case report. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.07.014

[45] A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.04.003

[47] The Role of Subacromial Decompression in Patients Undergoing Arthroscopic Repair of Full‐Thickness Tears of the Rotator Cuff: A Systematic Review and Meta‐analysis. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2011.11.022

[48] Arthroscopic rotator cuff repair in the weight-bearing shoulder. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.05.051

[50] Magnetic Resonance Imaging of the Shoulder in Asymptomatic Professional Baseball Pitchers. The American Journal of Sports Medicine. 2002. DOI: 10.1177/03635465020300012501

[52] The human acromion viewed from an evolutionary perspective. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2014.09.011

[53] Rotator cuff crepitus: could Codman really feel a cuff tear?. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.12.037

[54] Long Head of Biceps Tendinopathy Is Associated With Age and Cuff Tendinopathy on MRI Obtained for Evaluation of Shoulder Pain. Clinical Orthopaedics & Related Research. 2024. DOI: 10.1097/corr.0000000000003342

[56] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > RELEVANT SHOULDER ANATOMY > Rotator Cuff.

[57] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > Rotator Cuff.

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

[60] ACCURACY OF ULTRASOUND IMAGING OF THE ROTATOR CUFF IN SHOULDERS THAT ARE PAINFUL POSTOPERATIVELY. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200306000-00016

[61] The Effect of Posterosuperior Rotator Cuff Tears and Biceps Loading on Glenohumeral Translation. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2009.09.007

[62] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > Rotator Cuff > Scapulohumeral Ligaments.

[63] Rotator Cuff Tears in Adolescent Athletes. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504269033

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

[67] Surgical treatment of confirmed intratendinous rotator cuff tears: Retrospective analysis after an average of eight years of follow-up. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.01.013

[68] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Shoulder Instability, Rotator Cuff Disorders, Muscular Ruptures, Adhesive Capsulitis, Calcific Tendinitis > Rotator Cuff Tears > Evaluation.

[70] Alterations in Glenohumeral Kinematics in Patients With Rotator Cuff Tears Measured With Biplane Fluoroscopy. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.08.031

[72] Comparative Effectiveness of Operative Versus Nonoperative Treatment for Rotator Cuff Tears: A Propensity Score Analysis From the ROW Cohort. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519873840

[73] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > Partial Rotator Cuff Tears.

[74] Indications for Arthroscopic Subacromial Decompression. A Level V Evidence Clinical Guideline. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.06.012

[75] The role of pectoralis major and latissimus dorsi muscles in a biomechanical model of massive rotator cuff tear. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.11.030

[76] Patients With Impingement Syndrome With and Without Rotator Cuff Tears Do Well 20 Years After Arthroscopic Subacromial Decompression. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.08.026

[77] A Radiographic Classification of Massive Rotator Cuff Tear Arthritis. Clinical Orthopaedics & Related Research. 2011. DOI: 10.1007/s11999-011-1896-9

[79] Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.04.001

[80] Subacromial Platelet‐Rich Plasma Injections Produce Significantly Worse Improvement in Functional Outcomes in Patients With Partial Supraspinatus Tears Than in Patients With Isolated Tendinopathy. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.03.019

[81] Non-operative orthobiologic use for rotator cuff disorders and glenohumeral osteoarthritis: A systematic review. Journal of Back and Musculoskeletal Rehabilitation. 2021. DOI: 10.3233/bmr-201844

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

[83] Apley And Solomon S Concise System Of Orthopaedics And Trauma. SECONDARY ARTHROPATHY > TEARS OF THE ROTATOR CUFF.

[84] Orthopaedic Knowledge Update Sports Medicine 6. Rotator Cuff Disease > Physical Examination.

[85] Critical Shoulder Angle and Acromial Index Do Not Influence 24-Month Functional Outcome After Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517717947

[86] Editorial Commentary: Options Abound for Calcific Tendonitis of the Shoulder Without a Rotator Cuff Tear. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2015.11.003

[87] Suprascapular nerve release does not provide additional benefits in arthroscopic rotator cuff repair surgery: a systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07066-4

[90] Effect of anterior supraspinatus tendon partial-thickness tears on infraspinatus tendon strain through a range of joint rotation angles. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.10.003

[91] Editorial Commentary: Your Surgical “Tool Box” Just Got a Little Bit Bigger. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.05.016

[93] The influence of partial subscapularis tendon tears combined with supraspinatus tendon tears. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.09.015

[94] Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.04.016

[95] Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively?. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.05.027

[96] Nonoperative Treatment of Rotator Cuff Disease With Platelet‐Rich Plasma: A Systematic Review of Randomized Controlled Trials. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.10.115

[97] Relationship Between Deltoid and Rotator Cuff Muscles During Dynamic Shoulder Abduction: A Biomechanical Study of Rotator Cuff Tear Progression. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518768276

[98] Evaluating postoperative rotator cuff healing: Prospective comparison of MRI and ultrasound. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2015.06.006

[99] Shoulder kinematics in patients with full-thickness rotator cuff tears after a subacromial injection. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.05.010

[100] Long‐Term Outcome of a Consecutive Series of Subscapularis Tendon Tears Repaired Arthroscopically. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.02.031

[102] The critical shoulder angle does not change over time: a radiographic study. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.042

[103] Relative contributions of the supraspinatus cord and strap tendons to shoulder abduction and translation. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.07.003

[104] A Systematic Approach for Diagnosing Subscapularis Tendon Tears With Preoperative Magnetic Resonance Imaging Scans. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.04.142

[106] Muscle Gene Expression Patterns in Human Rotator Cuff Pathology. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01585

[107] Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis. British Journal of Sports Medicine. 2015. DOI: 10.1136/bjsports-2014-094148

[108] Platelet-Rich Plasma Injection With Arthroscopic Acromioplasty for Chronic Rotator Cuff Tendinopathy. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515608485

[109] Shoulder Rotator Cuff Disorders: A Systematic Review of Clinical Practice Guidelines and Semantic Analyses of Recommendations. Archives of Physical Medicine and Rehabilitation. 2020. DOI: 10.1016/j.apmr.2019.12.017

[110] Moderate value of non‐contrast magnetic resonance imaging after non‐dislocating shoulder trauma. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3102-6

[111] No Difference in Postoperative Pain After Arthroscopic versus Open Rotator Cuff Repair. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-014-3715-6

[112] Real-time sonoelastography in the diagnosis of rotator cuff tendinopathy. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.10.019

[113] Classifications And Scores Of The Shoulder. 5.3 Arthroscopic classification of partial-thickness rotator cuff tears according to Ellman [32].

[114] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > Natural History of Symptomatic Rotator Cuff Tears.

[116] Orthopaedic Knowledge Update Sports Medicine 6. Magnetic Resonance Imaging of the Glenohumeral Joint > The Rotator Cuff.

[117] Arthroscopic Repair of Partial-Thickness and Small Full-Thickness Rotator Cuff Tears. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514561004

[123] Classifications And Scores Of The Shoulder. Classifications of rotator cuff.

[125] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > Rehabilitation After Rotator Cuff Repair.

[126] Reverse Prostheses in Arthropathies With Cuff Tear: Are Survivorship and Function Maintained Over Time?. Clinical Orthopaedics & Related Research. 2011. DOI: 10.1007/s11999-011-1833-y

[128] Symptomatic Rotator Cuff Tears Show Higher Radioisotope Uptake on Bone Scintigraphy Compared With Asymptomatic Tears. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513494741

[129] Miller S Review Of Orthopaedics. ROTATOR CUFF DISEASE > 1. Overview.

[131] Orthopaedic Knowledge Update Sports Medicine 6. Current Concepts in Rehabilitation of Rotator Cuff Pathology: Nonsurgical and Postoperative Considerations > Postoperative Concepts.

[132] Differences in acromial morphology of shoulders in patients with degenerative and traumatic supraspinatus tendon tears. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3499-y

[133] Orthopaedic Knowledge Update Sports Medicine 6. Rotator Cuff Disease > Diagnostic Imaging.

[134] Classification and Clinical Significance of Acromial Spur in Rotator Cuff Tear: Heel-type Spur and Rotator Cuff Tear. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-009-1058-5

[136] Partial-thickness rotator cuff tears: a review of current literature on evaluation and management. Clinics in Shoulder and Elbow. 2024. DOI: 10.5397/cise.2022.01417

[137] Minimal Clinically Important Differences in ASES and Simple Shoulder Test Scores After Nonoperative Treatment of Rotator Cuff Disease. The Journal of Bone & Joint Surgery. 2010. DOI: 10.2106/jbjs.h.01296

[138] Medium-term natural history of subacromial impingement syndrome. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.06.007

[139] Critical period and risk factors for retear following arthroscopic repair of the rotator cuff. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4276-x