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Cuff Pathology

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

Overview

Arthroscopy has become the gold standard for rotator cuff repair due to reduced invasiveness and fewer complications, though results still include a large number of recurrences [74]. The presence of a cuff tear does not necessitate surgical repair [1]. Current evidence is lacking to support routine use of acromioplasty in all cases of rotator cuff repair, as it does not improve clinical outcomes [68], [79]. Differences in complications between open and arthroscopic rotator cuff repair outcomes may be influenced by selection bias and narrowing indications for open repair [20].

The indications for the operative treatment of massive and irreparable rotator cuff tears were determined based on expert consensus and the best available evidence to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios [22]. Surgeons should consider the size of a cuff repair and corresponding surgical and patient factors to help maximize patient outcomes [66]. The major indication for revision rotator cuff repair is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure [16].

Concomitant cuff repairs or the degree of removal of calcification does not affect the clinical outcome in the treatment of chronic calcific tendinitis [5]. The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [13]. Human studies are necessary to confirm the appropriate indications and effectiveness of augmentation scaffolds for rotator cuff repair healing in the clinical setting [91]. The AAOS developed Appropriate Use Criteria (AUC) using the RAND/UCLA Appropriateness Method to guide treatment decisions for full-thickness rotator cuff tears by synthesizing evidence and expert opinion across 432 patient scenarios [86].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Optimal scapular function is a key component of all shoulder function [35], and alterations in scapular motion are associated with most types of shoulder pathology [35]. In patients with symptomatic rotator cuff tears, reaching at least 85° of elevation requires compensation for lost glenohumeral motion through increased scapulothoracic contribution, indicating that structural damage interferes with motion mechanics [72]. Three-dimensional glenohumeral kinematics at the early phase of arm elevation may affect shoulder function in patients with massive rotator cuff tears [55].

Tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics in a cadaveric model of the throwing shoulder [40]. Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increased glenohumeral translation and changed kinematics in a cadaveric biomechanical model [60]. Increased glenohumeral joint loads due to a full-thickness supraspinatus (SSP) tear can be reversed with rotator cuff repair (RCR) in a dynamic biomechanical cadaveric model [65]. The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in the functional planes of motion [56].

Surgical Reconstruction and Repair

The goal of tendon transfers is to achieve stable kinematics by restoring rotational strength and force coupling of the shoulder joint [52]. Performing a superior capsule reconstruction (SCR) only partially restored native glenohumeral joint loads in a dynamic shoulder model [45], although biomechanical studies suggest that the humeral head–stabilizing effect of SCR appears to translate into improved clinical outcomes [58]. Surgical techniques should be tailored to optimize residual cuff activation to restore balanced shoulder mechanics [73].

Recent modifications of suture configurations for rotator cuff repair offer no biomechanical advantage in tendon-grasping strength [77]. Biomechanical data does not translate to clinical re-rupture rates after shoulder rotator cuff repair using different suture techniques stratified by method of repair and tear size [95]. Dynamic elongation of repair tissue during scapular-plane abduction exhibited one of two distinct patterns, which may suggest different patterns of supraspinatus mechanical and neuromuscular function [63].

Clinical Outcomes and Stability

Shoulder strength and patient-reported outcomes improved significantly over 24 months, but the glenohumeral joint contact center gradually shifted superiorly, potentially reflecting altered loading patterns or loss of dynamic stability despite functional improvements [76]. 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 [89]. Findings from an animal model of rotator cuff tears are consistent with alterations in shoulder function observed with rotator cuff and other shoulder injuries in humans [92, 93].

Classification

Rotator cuff disease represents a continuum progressing from tendinitis to cuff arthropathy, with prevalence increasing significantly with age [12]. Pain in painful rotator cuff tears associates more strongly with histopathological changes in the bursa than in the rotator cuff itself [10]. Different tear morphologies do not influence clinical outcomes post-arthroscopic repair at mid-term follow-up [6].

ISAKOS: Provides sufficient interobserver reliability for communicating among surgeons and pooling data from clinical studies [61].

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

Modified Patte: Demonstrates excellent diagnostic performance for reparability and acceptable performance for healing, with high measurement reliability [59].

Snyder: Reproducible and usable in future research studies for analyzing treatment options of partial rotator cuff tears [51]. However, it does not reproduce the extension of the partial-thickness tear in the transverse and coronal planes related to its etiology and pathomorphology [64].

Ellman: Does not reproduce the extension of the partial-thickness tear in the transverse and coronal planes related to its etiology and pathomorphology [64].

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

Comprehensive Anatomic Scheme: Encompasses 97% of all tears to facilitate anatomic repair [28].

Other Considerations: Currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons, with the exception of distinguishing partial-thickness from full-thickness tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears [41]. Neither the Snyder nor the Ellman classification reproduces the extension of the partial-thickness rotator cuff tear in the transverse and coronal planes related to its etiology and pathomorphology [64]. Patients exhibiting higher classification of fatty infiltration in the rotator cuff muscles may be associated with increased levels of hidden blood loss during arthroscopic rotator cuff repair [62]. A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment [7]. The acromial morphology classification system is an unreliable method to assess the acromion [9]. The acromial index shows no association with the presence of rotator cuff disease [9].

Clinical Presentation

Rotator cuff disease represents a continuum progressing from tendinitis to cuff arthropathy [2]. This spectrum of disease, which includes tendinopathy and defects, increases significantly in prevalence with age [12]. The underlying pathophysiology involves degenerative changes that weaken the enthesis [32]. Patients often present with subjective mechanical symptoms in the affected shoulder [29]. In one-quarter of patients with painful cuff tears, pain subsequently developed in a contralateral asymptomatic cuff tear, resulting in a measurable decline in function within 3 years [3].

The clinical syndrome previously termed 'impingement' should be referred to as 'rotator cuff disease' or 'anterolateral shoulder pain syndrome' due to the wide variety of etiologies and the difficulty in reliably establishing the exact structure causing pain [37]. Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses [33]. Pain in painful rotator cuff tear is associated with histopathological changes in the bursa greater than those in the rotator cuff [10].

Clinical Examination: Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear [39]. Rotator cuff injuries are most accurately diagnosed with a combination of cuff- and impingement-specific clinical tests [8]. Clinical examination is useful in the diagnosis of rotator cuff tears, impingement syndrome, and biceps pathology [11].

Imaging and Morphology: Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality [15]. Acromial morphology classification is an unreliable method to assess the acromion [9]. The acromial index shows no association with the presence of rotator cuff disease [9].

Specific Pathologies: Subscapularis tendon pathology can present as isolated tears, partial-thickness tears, or complete rotator cuff avulsion [30]. Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology [31].

A complete history and physical, careful attention to auxiliary tests, and treatment of multiple diagnoses in the same shoulder avoids missed pathologic features and necessity for revision operations [14].

Investigations

Rotator cuff disease represents a continuum [2]. Imaging is integral to the workup of suspected rotator cuff abnormalities [15]. MRI is the test of choice for rotator cuff pathology due to its versatility and availability [81].

Plain radiography: Indications: Evaluate for greater tuberosity sclerosis or spurs, which warrant MRI to detect advanced lesions [67]. Maintain a high index of suspicion for rotator cuff tear when humeral cysts are detected on plain radiographs, particularly in patients aged over 60 years [90]. Findings: Focal diminished bone mineral density of the greater tuberosity occurs in rotator cuff disease with and without full-thickness tears [106]. The incidence of rotator cuff tears in calcific tendonitis is higher than previously reported [94].

MRI: Indications: Primary modality for diagnosis [81]. Consider for preoperative planning in select patients with chronic calcific tendinopathy and prolonged refractory pain, though the probability of identifying additional cuff pathology requiring surgical intervention is very low [78]. Findings: Radiologic severity of supraspinatus pathology correlates with dynamic clinical function across the full range of pathology [102]. Among patients with symptomatic rotator cuff tendinopathy remaining symptomatic at ≥1 year, 39% progressed to a partial or full-thickness tear on follow-up MRI [100]. Radiological evaluation of supraspinatus muscle alterations underestimates histological abnormalities [101]. Limitations: Neither MRI nor clinical tests are sufficiently reliable for diagnosing biceps lesions prior to rotator cuff repair [85]. Magnetic resonance arthrography is insufficiently accurate for this purpose [85]. Preoperative MRI does not reliably predict subscapularis tendon tears [96] and may not provide adequate information for their diagnosis [97]. Clinically significant disagreements in MRI parameters indicate a need for improved imaging tools [98].

Ultrasound: Indications: Perform if an unrecognized partial subscapularis tendon injury is suspected after MRI [81]. Capabilities: Artificial intelligence models are equally adept as musculoskeletal radiologists in using ultrasound to diagnose rotator cuff pathology [103].

Other Considerations: Diagnosis of long head biceps tendon and subscapularis pathology is challenging due to limitations in MRI and arthroscopic visualization [83]. Surgeons must maintain high suspicion and utilize specific techniques to prevent missing these pathologies [83]. Arthroscopy remains the gold standard for diagnosing subscapularis tears [97]. The integration of 3D imaging and volumetric analysis offers a novel advancement in diagnosing and classifying rotator cuff injuries, challenging conventional reliance on 2D MRI [88]. Artificial intelligence models exhibit statistically superior accuracy and specificity compared to orthopaedic surgeons when using MRI [103]. Traumatic and degenerative rotator cuff repairs yield comparable clinical and radiologic results [104].

Treatment

Non-Operative

Nonoperative treatment is an effective and lasting option for many patients with chronic, full-thickness rotator cuff tears [46, 47]. It remains efficacious for patients with chronic, massive, irreparable rotator cuff tears [69]. Conservative treatment is the mainstay for calcific tendinitis, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy [87]. Nonoperative treatment is appropriate as initial therapy for partial-thickness tears of the rotator cuff [84]. Operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears at one-year follow-up, and conservative treatment should be considered as the primary method of treatment for this condition [107]. There is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease [48]. In situ-forming fibrin gel encapsulation of MSC-exosomes may be a candidate for the nonoperative management of partial-thickness rotator cuff tears [108].

Operative

Indications: The major indication for revision rotator cuff repair is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure [16]. Cuff tears can be left unrepaired in selected patients [82]. The indications for the operative treatment of massive and irreparable rotator cuff tears were determined based on expert consensus and the best available evidence [22].

Surgical Approach / Technique: Shoulder surgeons must carefully interpret literature comparing open and arthroscopic rotator cuff repair outcomes, as differences in complications may be influenced by selection bias and narrowing indications for open repair [20]. Concomitant cuff repairs or the degree of removal of calcification does not affect the clinical outcome after arthroscopic treatment for chronic calcific tendinitis [5]. Arthroscopic removal of symptomatic calcium deposits is a safe and effective treatment when nonoperative methods fail, as long as the cuff is not markedly degenerative [109]. Debridement and balloon spacers offer reliable outcomes with documented improvements in pain and function for subacromial surgery for irreparable posterosuperior rotator cuff tears, though disease progression to rotator cuff arthropathy is possible [38]. Initial reports of graft augmentation demonstrate clinical improvements that could significantly change treatment approaches for arthroscopic rotator cuff repair [36]. Surgical advances including patch augmentation have improved the treatment of massive rotator cuff tears, though long-term studies are needed to identify prognostic factors and ideal techniques [43].

Outcomes and Patient Selection: Healed rotator cuff repairs show improved patient-reported and functional outcomes compared to physical therapy and unhealed rotator cuff repairs [44]. Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology [57]. Despite good healing rates, not all patients with healed rotator cuffs experience good outcomes [50]. At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes after massive rotator cuff repair [4]. The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair [13]. The best treatment for rotator cuff disease continues to be controversial and is currently based on the individual surgeon's clinical experience rather than firm scientific data [42].

Adjuncts: Excellent outcomes were observed following arthroscopic rotator cuff repair both with and without concomitant procedures in patients younger than 40 years [49]. Simultaneous surgical treatment of rotator cuff and long head of biceps tendon lesions in smokers allowed for functional outcomes approximating non-smokers in long-term follow-up, though smoking is a significant negative factor associated with massive rotator cuff tears and higher pain levels [99]. Shoulder function is significantly lower if the teres minor is atrophic or fatty infiltrated, and pseudoparalysis or severe cuff arthropathy are contraindications for arthroscopic biceps tenotomy and tenodesis for massive irreparable rotator cuff tears [105].

Complications

Tear Progression and Contralateral Disease: In patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear in one-quarter of cases, resulting in a measurable decline in function within 3 years [3]. For full-thickness degenerative cuff tears, tear progression ranges from 30% to 40% at 3- to 4-year follow-up [25]. Untreated chronic tears can lead to arthrosis [26].

Outcomes and Repair Integrity: Greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes at mid-term follow-up [4]. Different types of cuff tear morphology do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up [6]. Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome [17]. Improvement in supraspinatus atrophy did not affect long-term postoperative outcomes, although it was affected by 10-year postoperative cuff integrity [18]. A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up [19]. All intact rotator cuff tendons at 1 year remained intact at 2 years [21]. Patients undergoing arthroscopic repair of partial-thickness supraspinatus tears can expect excellent clinical outcomes with low failure rates at midterm follow-up, with no patient progressing to revision rotator cuff repair during follow-up [80].

Other Considerations: The short-term clinical influence of biceps complications on shoulder outcome is very limited [23]. Arthroscopic rotator cuff repair has evolved into one of the most common orthopedic surgical procedures worldwide, yet there is still much work to be carried out to improve healing rates, outcomes, and long-term durability [24].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or desk work return.

Full activity (months): Evidence does not specify a month range for full activity, manual work, or strength return.

Complete recovery / outcome plateau (months): Patients should expect similar improvement in pain and validated outcome measures for each side at a minimum of 1-year follow-up after rotator cuff repair [71]. However, patients may experience more pain during the middle portion of recovery on the contralateral side [71]. Shoulder scores may decline at mid- to long-term follow-up for large and massive irreparable rotator cuff tears treated with superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement, or balloon spacers [70].

Rehabilitation protocol: Evidence does not specify PT phasing, immobilisation duration, or sling removal timing.

Functional milestones: Greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes at mid-term follow-up [4]. Different types of cuff tear morphology do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up [6]. Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome [17]. Improvement in supraspinatus atrophy did not affect long-term postoperative outcomes, although it was affected by 10-year postoperative cuff integrity [18]. A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up [19]. All intact rotator cuff tendons at 1 year remained intact at 2 years [21]. The short-term clinical influence of biceps complications on shoulder outcome is very limited [23].

Other Considerations: In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear, resulting in a measurable decline in function within 3 years [3]. Tear progression for full-thickness degenerative cuff tears ranges from 30% to 40% at 3- to 4-year follow-up [25]. Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time [114]. The tear size of symptomatic rotator cuff tears progressed by 55% in 1.5 years, with a degree of progression of 6.0 mm in length and 3.6 mm in width per year [116]. The presence of a rotator cuff tear influences progression in Hamada grade, but the magnitude of radiographic progression is not influenced by tear severity or enlargement at midterm time points [115]. There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease [117]. Degenerative rotator cuff disease demonstrates a progressive nature [118]. Fatty infiltration of the rotator cuff appears as early as 6 weeks after surgical detachment, starts near the musculotendinous junction, and progresses medially over time, worsening over the course of 1 year in the unrepaired rotator cuff [112]. Arthroscopic rotator cuff repair has evolved into one of the most common orthopedic surgical procedures worldwide, yet there is still much work to be carried out to improve healing rates, outcomes, and long-term durability [24].

Key Evidence

  • [L1] The presence of a cuff tear does not necessitate surgical repair. (10.1177/1758573215620571)
  • [Paper] This issue reinforces the concept that rotator cuff disease is a continuum and brings readers up to date on rotator cuff disease, covering epidemiology, imaging, techniques, and outcomes. (10.1016/j.csm.2012.08.001)
  • [L2] In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years. (10.1016/j.jse.2023.09.008)
  • [L4] At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes. (10.1016/j.arthro.2023.06.031)
  • [L4] Concomitant cuff repairs or the degree of removal of calcification does not affect the clinical outcome. (10.5397/cise.2018.21.2.75)
  • [L3] Different types of cuff tear morphology, despite affecting surgical repair technique, do not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up. (10.1016/j.jisako.2023.10.014)
  • [L4] A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further. (10.1302/2058-5241.1.160005)
  • [L5] Current consensus suggests rotator cuff injuries are most accurately diagnosed with a combination of cuff- and impingement-specific clinical tests. (10.1016/j.arthro.2013.07.265)
  • [L3] The acromial morphology classification system is an unreliable method to assess the acromion, and the acromial index shows no association with the presence of rotator cuff disease. (10.1016/j.jse.2011.09.028)
  • [L4] This study defines the main clinical and histopathological features of painful rotator cuff tear, observing a greater association of pain with histopathological changes in the bursa compared with those in the rotator cuff. (10.1007/s00167-015-3650-4)
  • [L5] It is useful in the diagnosis of rotator cuff tears, impingement syndrome, and biceps pathology. (10.1016/j.pmrj.2012.08.019)
  • [L3] The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. (10.1007/s11999-008-0585-9)
  • [L4] A complete history and physical, careful attention to auxiliary tests, and treatment of multiple diagnoses in the same shoulder avoids missed pathologic features and necessity for revision operations. (10.1097/01.blo.0000063791.32430.59)
  • [Paper] Imaging plays an important role in the workup of a patient with suspected rotator cuff abnormality. (10.1016/j.csm.2012.07.010)
  • [L5] The major indication for revision rotator cuff repair is the persistence of clinical symptoms despite nonsurgical management in the absence of substantial risk factors for failure. (10.5435/00124635-201111000-00002)
  • [L3] Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. (10.2106/00004623-199907000-00012)
  • [Abstract] Although improvement in supraspinatus atrophy was affected by the 10-year postoperative cuff integrity, this improvement did not affect long-term postoperative outcomes. (10.1016/j.jse.2024.01.011)
  • [L2] A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up. (10.1016/j.jse.2020.01.083)
  • [L5] Shoulder surgeons must carefully interpret literature comparing open and arthroscopic rotator cuff repair outcomes, as differences in complications may be influenced by selection bias and narrowing indications for open repair. (10.1016/j.arthro.2017.11.026)
  • [L3] All intact rotator cuff tendons at 1 year remained intact at 2 years. (10.1177/0363546509335764)
  • [L5] The indications for the operative treatment of massive and irreparable rotator cuff tears were determined based on expert consensus and the best available evidence, seeking to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios. (10.1016/j.jisako.2024.01.001)
  • [L3] Nevertheless, the short-term clinical influence of biceps complications on shoulder outcome is very limited. (10.1177/2325967121s00362)
  • [L4] Arthroscopic rotator cuff repair has evolved into one of the most common orthopedic surgical procedures worldwide, yet there is still much work to be carried out to improve healing rates, outcomes, and long-term durability. (10.1016/j.xrrt.2021.01.004)
  • [Commentary] The article is a commentary on a systematic review, concluding that while tear progression for full-thickness degenerative cuff tears ranges from 30% to 40% at 3- to 4-year follow-up, further research is needed to define natural history in relation to tear size and location to refine surgical intervention. (10.1016/j.arthro.2018.09.010)
  • [L4] A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair. (10.1016/j.arthro.2007.05.002)
  • [L2] Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. (10.1016/j.jse.2024.02.024)
  • [L5] Subscapularis tendon pathology is infrequently identified but can present as isolated tears, partial-thickness tears, or complete rotator cuff avulsion. (10.5435/00124635-200509000-00009)
  • [L5] Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology. (10.5435/jaaos-d-15-00258)
  • [L4] Rotator cuff tendinopathy and defects are increasingly common with age and are related, with degenerate pathophysiology weakening the enthesis; management decisions should be based on the likelihood of a newly symptomatic chronic, degenerative defect rather than an acute traumatic injury. (10.1016/j.jhsa.2010.11.027)
  • [L3] Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses. (10.1177/23259671251332942)
  • [L5] Optimal scapular function is a key component of all shoulder function, and alterations in scapular motion are associated with most types of shoulder pathology. (10.5435/jaaos-20-06-364)
  • [L5] Despite little evidence of drastic outcome improvements in arthroscopic rotator cuff repair over the last 30 years, initial reports of graft augmentation demonstrate clinical improvements that could significantly change treatment approaches. (10.1016/j.arthro.2021.11.035)
  • [L5] Debridement and balloon spacers offer reliable outcomes with documented improvements in pain and function, though disease progression to rotator cuff arthropathy is possible. (10.1016/j.arthro.2024.02.003)
  • [L1] Individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. (10.1186/s13018-014-0070-y)
  • [L5] In this cadaveric shoulder model of the throwing shoulder, tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics. (10.1177/2325967117s00373)
  • [L2] With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. (10.1177/0363546506298108)
  • [L4] The best treatment for rotator cuff disease continues to be controversial and is currently based on the individual surgeon's clinical experience rather than firm scientific data. (10.5435/00124635-199807000-00007)
  • [L5] Surgical advances including patch augmentation have improved the treatment of massive rotator cuff tears; however, long-term studies are needed to identify prognostic factors and ideal techniques and to optimize selection of patients. (10.1016/j.jse.2015.04.005)
  • [L5] In this dynamic shoulder model, performing an SCR only partially restored native glenohumeral joint loads. (10.1016/j.jisako.2023.03.405)
  • [L2] Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. (10.1016/j.jse.2017.10.009)
  • [L2] Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. (10.1016/j.jseint.2024.11.018)
  • [L1] This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease. (10.5435/00124635-200701000-00002)
  • [L4] Excellent outcomes were observed following arthroscopic rotator cuff repair both with and without concomitant procedures in patients younger than 40 years. (10.1016/j.arthro.2007.09.005)
  • [L3] Despite good healing rates, not all patients with healed rotator cuffs experience good outcomes. (10.1016/j.jse.2021.03.112)
  • [L2] The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears. (10.1177/2325967116667058)
  • [L4] The goal of tendon transfers is to achieve stable kinematics by restoring rotational strength and force coupling of the shoulder joint. (10.1530/eor-22-0023)
  • [L5] Early surgical intervention can reliably treat significant shoulder impairment in acute traumatic tears, and understanding the Hamada classification helps predict appropriate care and outcomes in patients with massive rotator cuff pathology. (10.1016/j.arthro.2018.11.006)
  • [L3] This study was the first to create a classification system to divide coracoids according to their morphology and relative risk of associated subscapularis tears. (10.1016/j.jse.2020.01.074)
  • [Abstract] The 3D glenohumeral kinematics at the early phase of arm elevation may affect the shoulder function in patients with massive rotator cuff tears. (10.1016/j.jse.2020.01.004)
  • [L4] The supraspinatus and deltoid muscles are equally responsible for producing torque about the shoulder joint in the functional planes of motion. (10.2106/00004623-198668030-00013)
  • [L3] Operative management of cuff tears is increasingly cost-effective with time, given nonrepaired cuff tears are unlikely to heal and portend worse symptomatology. (10.1016/j.jseint.2025.04.038)
  • [L4] Biomechanical studies suggest that the humeral head–stabilizing effect of SCR appears to translate into improved clinical outcomes. (10.1016/j.jse.2019.07.005)
  • [L3] Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. (10.1002/ksa.12162)
  • [L5] Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increased glenohumeral translation and changed kinematics in our cadaveric biomechanical model. (10.1016/j.jse.2016.12.063)
  • [L2] The ISAKOS rotator cuff tear classification system provides sufficient interobserver reliability for communicating among surgeons and for pooling of data from clinical studies. (10.1016/j.jisako.2021.12.004)
  • [L3] Patients exhibiting higher classification of fatty infiltration in the rotator cuff muscles, as well as those with more extensive rotator cuff tears, may be associated with increased levels of hidden blood loss (HBL) during arthroscopic rotator cuff repair. (10.1186/s12891-025-09310-7)
  • [L4] Dynamic elongation of repair tissue during scapular-plane abduction exhibited 1 of 2 distinct patterns, which may suggest different patterns of supraspinatus mechanical and neuromuscular function. (10.1177/23259671221084294)
  • [L4] Neither the classification of Snyder nor that of Ellman reproduces the extension of the partial-thickness rotator cuff tear in the transverse and coronal planes related to its etiology and pathomorphology. (10.1016/j.jse.2008.06.007)
  • [L5] In a dynamic biomechanical cadaveric model, increased glenohumeral joint loads due to a full-thickness SSP tear can be reversed with RCR. (10.1016/j.arthro.2021.10.036)
  • [L3] Surgeons should consider the size of a cuff repair and corresponding surgical and patient factors to help maximize patient outcomes. (10.1177/2325967124s00130)
  • [L3] MR imaging is suggested for patients with radiographic greater tuberosity sclerosis or spurs to detect advanced rotator cuff lesions. (10.1016/j.jse.2019.03.010)
  • [Commentary] Current evidence is lacking to support routine use of acromioplasty in all cases of rotator cuff repair; the acromioplasty does not improve clinical outcomes of arthroscopic rotator cuff repair. (10.1016/j.arthro.2021.07.012)
  • [L1] Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. (10.1016/j.jse.2020.11.002)
  • [L1] Shoulder scores may decline at mid- to long-term follow-up. (10.1186/s13018-022-03411-y)
  • [L5] At a minimum of 1-year follow-up after rotator cuff repair, patients should expect similar improvement in pain and validated outcome measures for each side, though they may experience more pain during the middle portion of recovery on the contralateral side. (10.1016/j.arthro.2018.07.025)
  • [L4] Patients who reached at least 85° compensated for the loss of glenohumeral motion by increased scapulothoracic contribution, suggesting that structural damage interferes with motion mechanics. (10.1016/j.jse.2016.02.031)
  • [L5] The authors suggest that surgical techniques should be tailored to optimize residual cuff activation to restore balanced shoulder mechanics. (10.2106/jbjs.25.01543)
  • [L5] Arthroscopy has become the gold standard for rotator cuff repair due to reduced invasiveness and fewer complications, though results still include a large number of recurrences. (10.1007/s00167-015-3515-x)
  • [L3] Shoulder strength and patient-reported outcomes improved significantly over 24 months, but the glenohumeral joint contact center gradually shifted superiorly, potentially reflecting altered loading patterns or loss of dynamic stability despite functional improvements. (10.1016/j.jseint.2025.101421)
  • [L5] Recent modifications of the configurations offer no biomechanical advantage. (10.1007/s00167-010-1322-y)
  • [Commentary] Shoulder MRI may be warranted for preoperative planning in the select population of patients with chronic calcific tendinopathy and prolonged refractory pain, although the probability of identifying additional cuff pathology requiring surgical intervention is very low. (10.1016/j.arthro.2020.01.014)
  • [L5] Evidenced-based data is currently lacking to support routine use of acromioplasty in all cases of rotator cuff repair. (10.1016/j.arthro.2019.04.008)
  • [L4] Patients undergoing arthroscopic repair of PTRCTs can expect excellent clinical outcomes with low failure rates at midterm follow-up given that no patient progressed to revision rotator cuff repair during follow-up. (10.1016/j.arthro.2017.07.028)
  • [L5] In the author's practice, MRI is the test of choice for rotator cuff pathology due to its versatility and availability, though ultrasound can be performed if an unrecognized partial subscapularis tendon injury is suspected after MRI. (10.1016/j.arthro.2021.08.029)
  • [L3] Comparison of the 'tear' and 'non-tear' patient groups suggest that cuff tears can be left unrepaired in selected patients. (10.1111/j.1758-5740.2009.00015.x)
  • [L5] Diagnosis of long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology can be challenging due to limitations in MRI and arthroscopic visualization; surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing pathology. (10.1016/j.arthro.2017.09.005)
  • [L5] Nonoperative treatment is appropriate as initial therapy, while operative management including arthroscopic subacromial decompression, debridement, or repair is considered when nonoperative treatment fails. (10.5435/00124635-199901000-00004)
  • [L5] The authors maintain that magnetic resonance arthrography is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair, regardless of the gold standard used, and that neither MRI nor clinical tests are sufficiently reliable in this context. (10.1007/s00167-019-05775-x)
  • [L5] The AAOS developed Appropriate Use Criteria (AUC) using the RAND/UCLA Appropriateness Method to guide treatment decisions for full-thickness rotator cuff tears by synthesizing evidence and expert opinion across 432 patient scenarios. (10.5435/00124635-201312000-00008)
  • [L4] Conservative treatment remains the mainstay, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy. (10.1177/1758573214567559)
  • [L4] The integration of 3D imaging and volumetric analysis offers novel advancement in diagnosing and classifying rotator cuff injuries, challenging the conventional reliance on 2D MRI. (10.1016/j.jse.2024.08.030)
  • [L5] Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect and the physiologic load required remains unknown. (10.1016/j.arthro.2010.10.014)
  • [L3] When humeral cysts are detected on plain radiographs in a patient with a painful shoulder, the index of suspicion for rotator cuff tear should be high, particularly in those patients aged over 60 years. (10.1111/j.1758-5740.2011.00143.x)
  • [L5] Human studies are necessary to confirm the appropriate indications and effectiveness of augmentation scaffolds for rotator cuff repair healing in the clinical setting. (10.1016/j.jse.2017.12.016)
  • [L1] The findings in this study are consistent with the alterations in shoulder function observed with rotator cuff and other shoulder injuries in the human. (10.1016/j.jse.2008.10.008)
  • [L4] The incidence of rotator cuff tears in cases of calcific tendonitis in this cohort of patients who underwent MRI is higher than previously reported. (10.1016/j.arthro.2019.11.127)
  • [L5] Biomechanical data does not translate to clinical re-rupture rates after shoulder rotator cuff repair using different suture techniques stratified by method of repair and tear size. (10.1016/j.arthro.2015.05.018)
  • [L3] Preoperative MRI scans of the shoulder do not reliably predict which rotator cuff injury patients have subscapularis tendon tears. (10.1016/j.arthro.2010.02.028)
  • [L5] MRI might not provide adequate preoperative information, and arthroscopy remains the gold standard for diagnosing subscapularis tears. (10.1016/j.arthro.2015.12.011)
  • [L4] However, the presence of clinically significant disagreements, even in such favorable circumstances, indicates the need for improved imaging tools for precise rotator cuff evaluation. (10.1016/j.jse.2021.04.021)
  • [L3] Simultaneous surgical treatment of rotator cuff and long head of biceps tendon lesions in smokers allowed for functional outcomes approximating non-smokers in long-term follow-up, though smoking is a significant negative factor associated with massive rotator cuff tears and higher pain levels. (10.3390/jcm10040599)
  • [L3] Among patients with symptomatic rotator cuff tendinopathy that remained symptomatic at a minimum of 1 year and obtained a follow-up MRI, 39% progressed to a partial or full-thickness tear. (10.1016/j.asmr.2022.05.004)
  • [L3] Radiological evaluation of the supraspinatus muscle alterations seemed to underestimate the degree of the same abnormalities evaluated at histology. (10.1186/s12891-023-06237-9)
  • [L3] Radiologic severity of supraspinatus pathology was correlated with dynamic clinical function across the full range of pathology. (10.1177/2325967121s00337)
  • [L3] In particular, these models are equally adept as musculoskeletal radiologists in using ultrasound to diagnose rotator cuff pathology and exhibit statistically superior levels of accuracy and specificity when using MRI compared to orthopaedic surgeons. (10.1016/j.arthro.2023.06.018)
  • [L3] Traumatic and degenerative rotator cuff repairs lead to comparable clinical and radiologic results. (10.1016/j.asmr.2023.100867)
  • [L3] Shoulder function is significantly lower if the teres minor is atrophic or fatty infiltrated, and pseudoparalysis or severe cuff arthropathy are contraindications. (10.1016/j.arthro.2007.03.039)
  • [L4] The finding of focal diminished bone mineral density of the greater tuberosity in the absence of rotator cuff tears warrants further investigation. (10.1016/j.jse.2010.12.009)
  • [L1] At one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition. (10.1302/0301-620x.96b1.32168)
  • [L5] This approach may be a candidate for the nonoperative management of partial-thickness rotator cuff tears. (10.2106/jbjs.21.01157)
  • [L4] The results of this study indicate that arthroscopic removal of as much as possible of symptomatic calcium deposits of the rotator cuff is a safe and effective treatment when nonoperative methods fail, as long as the cuff is not markedly degenerative. (10.1177/0363546510396320)
  • [L5] Fatty infiltration of the rotator cuff appears as early as 6 weeks after surgical detachment, starts near the musculotendinous junction, and progresses medially over time, worsening over the course of 1 year in the unrepaired rotator cuff. (10.1016/j.arthro.2007.01.023)
  • [L4] Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time. (10.1016/j.arthro.2018.07.031)
  • [L2] Whereas the presence of a rotator cuff tear influences progression in Hamada grade, the magnitude of radiographic progression is not influenced by tear severity or enlargement at midterm time points. (10.1016/j.jse.2016.07.022)
  • [Abstract] The tear size of symptomatic rotator cuff tears progressed by 55% in 1.5 years and the degree of progression was 6.0 mm in length and 3.6 mm in width per year. (10.1016/j.jse.2015.08.022)
  • [L3] There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease. (10.1016/j.jse.2013.10.001)
  • [L2] This study demonstrates the progressive nature of degenerative rotator cuff disease. (10.2106/jbjs.n.00099)

See Also

References

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

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

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

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

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

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

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

[8] 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] 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[25] Editorial Commentary: Progression of Degenerative Full-Thickness Rotator Cuff Tears: Are We Finally Using Natural History Data to Define At-Risk Tears?. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019. DOI: 10.1016/j.arthro.2018.09.010

[26] Chapter 3 Rotator Cuff Disease. 2019.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[46] What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.10.009

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

[48] 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

[49] Arthroscopic Repair of Full‐Thickness Tears of the Rotator Cuff in Patients Younger Than 40 Years. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.09.005

[50] Arthroscopic Rotator Cuff Repair: Is Healing Enough?. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.112

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[68] Editorial Commentary: Acromioplasty Does Not Improve Clinical Outcome of Arthroscopic Rotator Cuff Repair: The Game Is Over!. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.07.012

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

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

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

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

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

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

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

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

[78] Editorial Commentary: Is Magnetic Resonance Imaging of the Shoulder Ever Appropriate in Evaluating Patients With Calcific Tendinopathy of the Rotator Cuff?. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2020.01.014

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

[80] Five‐Year Outcomes After Arthroscopic Repair of Partial‐Thickness Supraspinatus Tears. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.07.028

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

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

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

[84] 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

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

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

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

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

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

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

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

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

[93] Erratum_to_“Alterations_in_function_after_rotator_cuff_tears_in_an_animal_model”_S1058274609002973. n.d..

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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