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Muscles & Tendons

Subacromial pain syndrome, pectoralis major ruptures, and massive rotator cuff tears — pathophysiology, pseudoparalysis, and the impact of scapular dyskinesis.

Overview

Operative management of chronic pectoralis major tears and massive rotator cuff tears presents significant challenges due to tendon retraction, poor tissue quality, and muscle atrophy, often necessitating graft use [4]. While arthroscopic rotator cuff repair is favored for improving shoulder function in degenerative disease, other intraarticular treatments offer no significant benefits [84]. Reversal of muscle fiber atrophy in cases of grade >2 fatty degeneration requires altering the biomechanical and functional conditions of the muscle post-reconstruction [8]. For irreparable posterosuperior tears, trapezius transfer warrants further clinical evaluation, while latissimus dorsi transfer remains a reasonable salvage approach after failed massive tear repair [17, 79].

An intact subscapularis is vital to achieving a good result regardless of the treatment considered, making careful preoperative evaluation of the tendon and its function essential [18]. Surgical approaches utilizing partial or complete subscapularis take-down may impair recovery and negatively influence final outcomes [25]. In the setting of biceps pathology, SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years [24]. Both open and arthroscopic biceps tenodesis demonstrate low complication rates, with the modified Norwegian method appearing as a simple, efficient, and effective alternative that parallels other techniques [81, 86].

Augmentation strategies for massive rotator cuff tears include the use of a biceps autograft, though no definitive recommendations exist [82]. The choice of biceps tenodesis technique should be based on surgeon preference and patient factors [81]. Clinical trials utilizing bone-tendon allografts for chronic large rotator cuff tears are warranted to further define their utility [85].

Anatomy & Pathophysiology

Kinematics and Muscle Function

The supraspinatus and deltoid muscles contribute equally to torque production in functional planes of motion [37], with the deltoid providing a linear contribution to maximal strength ranging from 24% to 75% during abduction and 11% to 70% during flexion as the angle increases from 0° to 120° [54]. Glenohumeral decentering is significantly associated with diminished function and active range of motion in all planes [41], while dynamic superior migration of the humeral head occurs during abduction in patients with rotator cuff tears [48]. In the setting of an irreparable supraspinatus tear, superior capsular reconstruction restores key biomechanical parameters to intact levels [30], and a 6-mm acromiograft significantly reduces superior translation and improves subacromial contact mechanics compared to massive cuff tears [44]. Exercise therapy for supraspinatus tears does not alter glenohumeral kinematics during internal or external rotation with the arm at the side [43], whereas scapular exercises in a clinical fatigue model result in superior humeral head migration and altered kinematics in healthy subjects [39]. Altering scapular position affects shoulder strength in asymptomatic individuals [53], and specific patterns of scapular dyskinesis are associated with distinct alterations in muscular activation and kinematics [57].

Rotator Cuff and Biomechanics

The teres minor muscle engages force across all five ranges of shoulder motion, with maximum external rotation in abduction serving as a reliable evaluation method for its activity [42]. Biomechanical properties and bone quality decrease following partial-width full-thickness supraspinatus tendon injury in rats, gradually restoring over 8 weeks but remaining inferior to the intact shoulder [46]. Anterior-posterior glenohumeral kinematics is not fully restored after biceps rerouting [35], and the anterior deltoid is biomechanically critical for balanced function following reverse total shoulder arthroplasty [45]. Simulations based on musculoskeletal models provide relevant data on muscles directly involved in glenohumeral stability [55].

Clinical Outcomes and Measurement

Shoulder strength and patient-reported outcomes improve significantly over 24 months following rotator cuff repair, concurrent with a gradual superior shift of the glenohumeral joint contact center [56]. Updates on thrower's shoulder anatomy, mechanics, pathomechanics, and treatment remain essential for clinicians and researchers [29], and clinical studies evaluating both short- and long-term results of trapezius transfer are warranted [17]. A valid and repeatable measurement of extensibility would be a valuable addition to studies evaluating the pectoralis minor's effect on shoulder movement and biomechanics [36].

Classification

Rotator Cuff Defects: Rotator cuff tendinopathy and defects are increasingly common with age and are related, with degenerate pathophysiology weakening the enthesis [1]. Management decisions for rotator cuff defects should be based on the likelihood of a newly symptomatic chronic, degenerative defect rather than an acute traumatic injury [1]. A comprehensive rotator cuff tear classification scheme encompassing 97% of all tears was described to facilitate anatomic repair [47]. Gene expression in human rotator cuff muscles varies according to tendon injury severity [91]. Applying the Goutallier classification to more medial MRI sections (MSB-GC) results in assignment of lower grades for all rotator cuff muscles [99]. The MSB-Goutallier classification demonstrates excellent test-retest reliability and repeatability [99].

Long Head of Biceps: The function of the long head of the biceps (LHB) tendon remains unresolved [3]. Treatment decisions for LHB tendon disorders are guided by reviewing anatomy, pathophysiology, classification, diagnosis, and existing literature [3]. Severity of tendon histopathology in chronic biceps tendinopathy is more pronounced in the proximal and mid-portions of the tendon [9]. A requirement for type I and II muscle fiber hypertrophy is a change in the biomechanical and functional conditions of the muscle after its tendon is reconstructed [8].

Subscapularis: The most common type of subscapularis muscle anatomy is the muscle with three bellies [65]. The subscapularis muscle division into three parts aligns with Larson's model [65]. The subscapularis tendon is composed of 2 distinct fibrous layers [76]. The subscapularis tendon layers are arranged differently than those of the supraspinatus tendon [76].

Pectoralis Major: A contemporary injury classification system for pectoralis major tears includes injury timing, injury location, and standardized terminology addressing tear extent [59]. The requisite elements for classifying pectoralis major tears are timing, location, and extent of the tear [67]. Further subdividing pectoralis major tear categories beyond timing, location, and extent would not have clinical significance in treatment or outcome [67].

Other Considerations: Different subgroups of symptomatic tendons behave differently regarding the impact of therapeutic exercises on supraspinatus tendon thickness [10]. A nomenclature for skeletal muscle injuries should integrate topographic location with histoarchitectonic features of the damage to connective tissue structures [11]. The original graded transitional tissue of the fibrocartilaginous insertion is not re-created after the tendon is surgically reattached to bone [23]. Surgical reattachment of the tendon to bone results in mechanically inferior and disorganized tissue [23]. A pictorial essay provides a detailed review of the anatomy of the hamstring muscle–tendon complex, including proximal attachment, muscle course, and innervation [101].

Clinical Presentation

Rotator cuff tendinopathy and defects increase in prevalence with age, driven by degenerate pathophysiology that weakens the enthesis [1]. Management decisions for these defects must prioritize the likelihood of a newly symptomatic chronic, degenerative defect over an acute traumatic injury [1]. In the context of rotator cuff disease, anterior shoulder pain with macroscopic biceps tendon changes stems from a complex interaction between the tendon and surrounding soft tissues rather than a single entity [38]. While the function of the long head of the biceps (LHB) remains unresolved [3], preoperative imaging of bicipital groove morphology and subscapularis tears should prompt evaluation for LHB pathology as a pain generator [13]. An aberrant origin of the LHB does not appear to contribute to shoulder pathology [34].

Subjective mechanical symptoms are a common complaint in patients with suspected rotator cuff pathology [31]. Intratendinous rotator cuff tears are difficult to diagnose preoperatively [50], and the diagnosis of subscapularis tears remains challenging due to the limited sensitivity of both MRI and physical examination [16]. Severity of tendon histopathology in chronic biceps tendinopathy is more pronounced in the proximal and mid-portions of the tendon [9]. Larger tendon tears, longer delays after rupture, and older patient age correlate with more severe and frequent fatty infiltration in the infraspinatus [12]. Fatty infiltration of the teres minor without tear involvement may be an incidental finding of unknown clinical significance [51].

Scapular muscle detachment presents as a clinically identifiable syndrome with a homogeneous set of history and physical findings [5]. Active elevation lag sign and the triangle sign are simple clinical signs useful in diagnosing trapezius weakness [40]. Patients with subcoracoid impingement and full-thickness rotator cuff tears exhibit decreased recruitment of the serratus anterior and teres major muscles, exacerbating pain and scapular dysfunction [49]. Different subgroups of symptomatic tendons behave differently regarding the impact of therapeutic exercises on supraspinatus tendon thickness [10].

Operative treatment for chronic pectoralis major tears offers better functional outcomes but is complicated by tendon retraction, poor tissue quality, and muscle atrophy [4]. These repairs often necessitate graft use due to the aforementioned factors [4]. Myositis ossificans of the subscapularis is a rare condition that does not require surgical intervention when present without significant symptoms or functional impairment [33]. A nomenclature for skeletal muscle injuries should integrate topographic location with histoarchitectonic features of the damage to connective tissue structures [11].

Investigations

Plain radiography: Radiographic findings of greater tuberosity sclerosis or spurs should prompt MR imaging to detect advanced rotator cuff lesions [93].

MRI: Preoperative imaging of bicipital groove morphology and subscapularis tendon tears should prompt evaluation for long head of the biceps tendon disorder as a pain generator [13]. The diagnosis of subscapularis tears remains challenging due to the limited sensitivity of MRI and physical examination [16], with larger tears more easily detected while smaller tears are frequently missed [97]. Routine MRI assessment of the upper subscapularis muscle and coracohumeral distance can contribute to diagnostic accuracy and offer information regarding tear severity [103]. MRI is accurate for diagnosing the tear grade and location of pectoralis major tendon ruptures, particularly for acute, tendon-bone, and G3 tears [102]. The MRI tendinosis grade is associated with stiffness assessed using sonoelastography in patients with rotator cuff tendinopathy [71]. Immediate changes in the appearance of fatty infiltration and muscle atrophy of rotator cuff muscles occur on MRI after rotator cuff repair and should be considered when comparing preoperative and postoperative MRI [100]. Single-image slice magnetic resonance imaging assessments do not predict three-dimensional muscle volume [96], whereas three-dimensional MRI measurement of whole-muscle volume is required and is associated with shoulder strength [96]. Three-dimensional MRI appears useful for assessing rotator cuff muscles [66], and the integration of 3D imaging and volumetric analysis offers advancement in diagnosing and classifying rotator cuff injuries, challenging the conventional reliance on 2D MRI [104].

CT: Multidetector computed tomography (MDCT) is comparable with MRI for evaluating fatty degeneration of rotator cuff muscles [90]. CT provides nearly equivalent measures of cuff muscle area to an MRI technique with previously validated reliability and accuracy [94].

Other Considerations: Shear wave elastography ultrasound is reliable for assessing the supraspinatus tendon, particularly when used by a single experienced musculoskeletal sonographer [74]. Ultrasound, MRI, and histology failed to identify true tendon layers at the pectoralis major enthesis [75]. Surgical repair of torn hip abductor tendons is a viable option when MRI and clinical findings are consistent with tendon disruption and weakness [106].

Treatment

Non-Operative

Conservative management remains the mainstay for non-traumatic supraspinatus tears, demonstrating no superiority of operative treatment over conservative care at one-year follow-up [58]. Similarly, nonsurgical approaches are effective for full-thickness rotator cuff tears [89], calcific tendinitis of the rotator cuff [73], and isolated pectoralis minor tears at the costal origin [80]. Most patients with calcific tendinitis improve with oral anti-inflammatory medication, physical therapy, and corticosteroid injections [73]. Low molecular-weight hyaluronate is more effective than physiotherapy for supraspinatus tendinopathy, particularly in alleviating pain for at least three months [62]. Topical glyceryl trinitrate should be included as part of the nonsurgical management of chronic supraspinatus tendinopathy [68]. For scapular winging due to rhomboid muscle paralysis, conservative treatment is fundamental and requires management in a rehabilitation center with a multidisciplinary team [77]. In the absence of a surgical solution, conservative management is also indicated for scapular winging [77]. A patient with a teres major tendon avulsion can become asymptomatic with conservative management despite persistent MRI findings and experience no subsequent functional impairment during pitching [92].

Operative

Indications: Operative treatment for chronic pectoralis major tears provides better functional outcomes but is challenging due to tendon retraction, poor tissue quality, and muscle atrophy [4]. SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred over SLAP repair in lower-demand patients aged over 30 years [24]. Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis [70]. Delayed excision of the reflected head of the rectus femoris is indicated in rare cases that fail nonoperative management [87]. Untreated chronic rotator cuff tears can lead to arthrosis, necessitating consideration of salvage options [78]. Pre-operative deltoid impairment is not an absolute contraindication to reverse shoulder arthroplasty (RSA) in certain circumstances [95].

Surgical Approach / Technique: Arthroscopic rotator cuff repair (ARCR) is an effective and safe option for treating rotator cuff tear symptoms with durable clinical results over time [14]. An intact subscapularis tendon is vital to achieving a good result regardless of the treatment considered for rotator cuff pathology, making careful evaluation of the subscapularis tendon and its function an important preoperative consideration [18]. Directional muscle activity, apart from a tenodesis effect, is relevant for improved clinical outcome and pain relief after latissimus dorsi tendon transfer for massive rotator cuff tears [63]. Conjoined tendon transfer restores stability in patients with traumatic anterior glenohumeral instability, large bony defects, and anterior capsulolabral deficiency without significant range-of-motion loss in noncollision athletes [83]. Therapy for complete rupture through the short head of the biceps muscle belly results in better function and restoration of muscle strength [60].

Implant Selection: Suture tape anchors (STAs) are more effective than traditional suture anchors (TSAs) in preserving tendon thickness and improving muscle strength at 1 year after rotator cuff repair [2]. Chronic pectoralis major tear repairs often necessitate the use of grafts due to tissue quality and retraction issues [4]. Rotator cuff reconstruction with a dermal allograft demonstrates favorable structural healing rates compared to maximal repair in the short term [6].

Adjuncts: Intramuscular brown fat activation may be an effective clinical treatment strategy to improve muscle quality after rotator cuff repair, decreasing muscle atrophy and fatty infiltration after delayed rotator cuff repair [32]. This activation also improves gait after delayed rotator cuff repair [32]. Pharmacologic mobilization and chemokine-directed recruitment of mesenchymal stromal cells to the surgically repaired rotator cuff is associated with improvements in the static mechanical properties of the tendon-bone interface [64]. The same pharmacologic mobilization is associated with improvements in the dynamic mechanical properties of the tendon-bone interface [64].

Other Considerations: Early clinical outcomes (1-3 months) after rotator cuff repair correlate with higher signal intensity on the proximal cuff tendon, where worse outcomes are associated with higher intensity [7]. Hypertrophy of type I and II muscle fibers requires a change in the biomechanical and functional conditions of the muscle following tendon reconstruction [8]. Not all patients with healed rotator cuffs experience good clinical outcomes despite good healing rates [61]. Treatment for scapular winging ranges from conservative management and physical therapy to surgical options like muscle transfers or nerve grafting depending on etiology and duration of symptoms [69]. Both surgical and nonsurgical treatments for rotator cuff disease can be effective [78]. The relative deltoid moment arm index may provide insight into the variable presentation of massive cuff tear patients [98]. Biceps tenodesis is an appealing alternative to SLAP repair, but indications and techniques for elite pitchers still need to be defined [88].

Complications

Tendon & Muscle Pathophysiology: Rotator cuff tendinopathy and defects increase with age due to degenerate pathophysiology weakening the enthesis [1]. Surgical reattachment fails to recreate the original graded transitional tissue of the fibrocartilaginous insertion, resulting in mechanically inferior and disorganized tissue [23]. Muscle atrophy and fatty infiltration are irreversible phenomena that continue even after successful repair, though they do not significantly influence functional outcomes at short-term follow-up [19]. While chronic tendinosis in other tendons may stem from the ingrowth of fine vessels and nerves [105], the previously injured muscle cannot generate the same strength as a normal muscle even after a successful dynamic sonographic repair [27].

Repair Failure & Healing: Most rotator cuff repair failures occur within the first 3 months after surgery [22]. Early clinical outcomes correlate negatively with higher signal intensity on the proximal cuff tendon at 1 to 3 months post-surgery [7]. Although an increase in supraspinatus muscle volume is evident in patients with larger tears who heal successfully, this increase is measured toward the more medial portion of the muscle [28]. Management decisions for defects should rely on the likelihood of a newly symptomatic chronic, degenerative defect rather than acute traumatic injury [1].

Surgical Technique & Outcomes: Suture tape anchors (STAs) are more effective than tendon suture anchors (TSAs) in preserving tendon thickness and improving muscle strength at 1 year after repair [2]. Rotator cuff reconstruction with a dermal allograft demonstrates favorable structural healing rates and improved range of motion compared to maximal repair in the short term [6]. Muscle strength improvements in all directions are sustained mid- to long-term when no retear occurs after net-like bridging arthroscopic rotator cuff repair [15]. Surgical approaches using partial or complete subscapularis tendon take-down techniques may impair subscapularis recovery and negatively influence final clinical outcomes [25].

Revision & Transfer Procedures: The short-term clinical outcomes of patients undergoing revision rotator cuff repair are similar to primary rotator cuff repair [20]. Teres major tendon transfer provides long-term improvement of shoulder function and pain reduction at eight to 12 years' follow-up [21]. Pectoralis major transfer (PMT) for isolated and combined subscapularis tears is associated with good to excellent clinical results at long-term follow-up [26]. Scapular muscle detachment presents as a clinically identifiable syndrome with a homogeneous set of history and physical findings [5].

Other Considerations: More work is needed to identify patients who will do best with surgical repair for rotator cuff tears, and it remains undetermined if surgery can alter the natural history of rotator cuff tear progression [107]. Aberrant origins of the long head of the biceps can be seen with concomitant cuff tear pathology, though nonsynovitic and nondegenerative biceps origins of this nature have not clearly contributed to other shoulder pathology [108]. Muscle injuries of the triceps surae were more commonly found in players older than 23 years compared with those 23 years or younger [110].

Recovery

Light activity (weeks): Patients typically resume desk work, driving, and light activities of daily living within the first 3 months post-operatively. Early clinical outcomes during this 1- to 3-month window correlate with higher signal intensity on the proximal cuff tendon, where worse outcomes are observed [7]. Most structural failures of rotator cuff repair occur within this initial 3-month period, indicating that relatively short follow-up is sufficient for evaluating primary structural integrity [22].

Full activity (months): Functional improvements and strength gains are sustained mid- to long-term provided no retear occurs following net-like bridging arthroscopic rotator cuff repair [15]. At 1 year, both suture tape anchors (STAs) and tendon suture anchors (TSAs) demonstrate favorable clinical outcomes, with STAs showing superior efficacy in preserving tendon thickness and improving muscle strength [2]. Dynamic sonographic findings of a successful supraspinatus repair resemble those of a normal tendon, although the previously injured muscle may not generate equivalent strength [27].

Complete recovery / outcome plateau (months): Pain reduction and functional improvement from teres major tendon transfer are maintained at 8 to 12 years' follow-up [21]. Long-term outcomes for pectoralis major transfer in isolated and combined subscapularis tears remain good to excellent [26]. Improvement in functional outcomes after arthroscopic repair of subscapularis tendon tears is also maintained long-term [72]. While muscle atrophy and fatty infiltration are irreversible phenomena that persist even after successful repair, they do not significantly influence functional outcomes at short-term follow-up [19].

Rehabilitation protocol: Growth factors exhibit unique temporal profiles correlating with specific stages of supraspinatus tendon injury and repair, showing an initial increase in expression followed by a return to control or undetectable levels by 16 weeks [115]. The evaluation of visible tendon stump length combined with Goutallier staging significantly improves the preoperative prediction of repair success [113]. Delayed repair of isolated subscapularis tendon rupture is associated with less satisfactory results due to muscle atrophy and degeneration [111].

Functional milestones: Arthroscopic rotator cuff repair (ARCR) provides effective, safe, and durable clinical results for treating rotator cuff tear symptoms [14]. Short-term clinical outcomes for revision rotator cuff repair are similar to those of primary repair [20]. Rotator cuff reconstruction using a dermal allograft demonstrates favorable structural healing rates and improved range of motion compared to maximal repair in the short term [6]. Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time [109].

Other Considerations: Scapular muscle detachment presents as a clinically identifiable syndrome with a homogeneous set of history and physical findings [5]. Larger tendon tears, longer delays after rupture, and older patient age are associated with more severe and frequent fatty infiltration [12]. An increase in supraspinatus muscle volume is evident in patients with larger tears who heal successfully, particularly when measured toward the more medial portion of the muscle [28]. Low-grade progression in cuff tear arthropathy rates has been observed following long-term anterior latissimus dorsi tendon transfer for irreparable subscapularis tears [112]. Distal release of deltoid muscle contracture resulted in good clinical outcomes in 47 of 49 shoulders (96%) [114].

Key Evidence

  • [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] At 1 year, both STAs and TSAs showed favorable clinical outcomes, but STAs were more effective in preserving tendon thickness and improving muscle strength. (10.1186/s12891-025-08728-3)
  • [L5] The function of the LHB tendon remains unresolved, and treatment decisions are guided by reviewing anatomy, pathophysiology, classification, diagnosis, and existing literature. (10.1016/j.jse.2011.07.016)
  • [L5] Operative treatment provides better functional outcomes but is challenging due to tendon retraction, poor tissue quality, and muscle atrophy, often necessitating graft use. (10.5397/cise.2023.00129)
  • [L4] Scapular muscle detachment appears to be a clinically identifiable syndrome with a homogeneous set of history and physical findings. (10.1016/j.jse.2013.05.008)
  • [L1] Rotator cuff reconstruction with a dermal allograft demonstrated favorable structural healing rates and improved range of motion compared to maximal repair in the short term. (10.1016/j.arthro.2019.11.030)
  • [L4] Early after surgery (1-3 months), worse clinical outcomes correlated with higher signal intensity on the proximal cuff tendon. (10.1177/0363546519899357)
  • [L5] A requirement for type I and II muscle fibers hypertrophy is a change in the biomechanical and functional conditions of the muscle after its tendon is reconstructed. (10.1016/j.jse.2015.08.034)
  • [L4] Severity of tendon histopathology was more pronounced in the proximal and mid-portions of the tendon. (10.1016/j.arthro.2018.01.021)
  • [L2] Different subgroups of symptomatic tendons behave differently, emphasizing the need to potentially consider tendinopathy subtypes in research. (10.1016/j.jse.2024.03.055)
  • [L5] The authors propose a nomenclature for skeletal muscle injuries that integrates topographic location with histoarchitectonic features of the damage to connective tissue structures, arguing that this combined approach is essential for accurate prognosis and understanding recurrence. (10.1177/2325967120909090)
  • [L4] Larger tendon tears, longer delays after tendon rupture, and older patient age are associated with more severe and frequent fatty infiltration. (10.1016/j.jse.2009.12.002)
  • [L2] When these are found in preoperative images, the clinician should evaluate the patient for the presence of an LHB tendon disorder as a pain generator. (10.1016/j.jse.2015.12.015)
  • [L4] ARCR appears to be an effective and safe option to treat the symptoms of rotator cuff tears and to provide successful clinical results durable with time. (10.1007/s00167-014-3234-8)
  • [L4] Muscle strength improvements in all directions were sustained mid- to longterm when no retear occurred. (10.1016/j.jseint.2026.101660)
  • [L3] The diagnosis of subscapularis tears remains challenging because of the limited sensitivity of MRI and physical examination. (10.1016/j.arthro.2015.11.019)
  • [L5] Clinical studies to evaluate both the short-term and long-term results of the trapezius transfer are warranted. (10.1016/j.jse.2015.02.008)
  • [L5] An intact subscapularis is vital to achieving a good result regardless of the treatment considered, and careful evaluation of this tendon and its function remains an important preoperative consideration. (10.1016/j.arthro.2018.02.028)
  • [L4] Muscle atrophy and fatty infiltration are irreversible phenomena that continue even after successful repair; however, they do not have a significant influence on the functional outcome at short-term follow-up after cuff repair. (10.1016/j.jse.2020.03.040)
  • [L3] The short term clinical outcomes of patients undergoing revision rotator cuff repair were similar to primary rotator cuff repair. (10.1177/2325967114s00016)
  • [L3] Teres major tendon transfer provides long-term improvement of shoulder function and pain reduction at eight to 12 years' follow-up. (10.1302/0301-620x.100b3.bjj-2017-0920.r1)
  • [L5] Most rotator cuff repair failures occur within the first 3 months after surgery, suggesting that relatively short follow-up is sufficient for evaluating primary structural integrity, though longer follow-up is beneficial for assessing symptomatic improvement. (10.1177/0363546511424268)
  • [L5] The original graded transitional tissue of the fibrocartilaginous insertion is not re-created after the tendon is surgically reattached to bone, resulting in mechanically inferior and disorganized tissue. (10.1016/j.jse.2017.10.030)
  • [L5] SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years. (10.1016/j.jse.2024.09.040)
  • [L4] Different clinical studies indicate that surgical approaches using partial or complete subscapularis tendon take-down techniques may impair subscapularis recovery and can negatively influence the final clinical outcome. (10.1016/j.jse.2007.11.005)
  • [L4] At long-term follow-up, PMT for isolated and combined subscapularis tears is associated with good to excellent clinical results. (10.2106/jbjs.19.00172)
  • [L3] The dynamic sonographic finding of a successful repair of a supraspinatus tendon is similar to that of a normal tendon, even though the previously injured muscle appears unable to generate the same strength as a normal muscle. (10.1016/j.arthro.2011.05.014)
  • [L4] The increase was evident in patients who had larger tears and healed successfully and when measured toward the more medial portion of the supraspinatus muscle. (10.1177/0363546517706699)
  • [L5] Updates on the thrower's shoulder, including anatomy, mechanics, pathomechanics, and treatment, are essential for clinicians and researchers treating or investigating the shoulder. (10.1016/j.arthro.2022.02.024)
  • [L5] In the setting of an irreparable supraspinatus tear, superior capsular reconstruction restores key biomechanical parameters of the shoulder to intact levels. (10.1016/j.jse.2020.03.007)
  • [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] This may be an effective clinical treatment strategy for patients to improve muscle quality after rotator cuff repair. (10.1177/0363546520910421)
  • [L4] Myositis ossificans of the subscapularis is a rare condition that, when present without significant symptoms or functional impairment, does not require surgical intervention. (10.1016/j.jse.2007.07.021)
  • [L4] This variant does not appear to contribute to shoulder pathology because standard treatment of concomitant diagnoses resulted in resolution of symptoms. (10.1016/j.jse.2011.05.006)
  • [L3] However, A-P glenohumeral kinematics was not fully restored after BR, and its effect on long-term clinical outcomes requires further investigation. (10.1177/03635465241301778)
  • [Letter] A valid and repeatable measurement of extensibility would be a valuable addition to studies evaluating the effect of PM on shoulder movement and biomechanics, and additional work is needed to improve or develop new measurement instruments and methods. (10.1016/j.jht.2017.06.007)
  • [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)
  • [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. (10.1016/j.jse.2008.05.044)
  • [L5] In the context of a clinical model of fatigue, these scapular exercises resulted in superior migration of the humeral head and alterations in shoulder kinematics on radiographic analysis in healthy subjects. (10.1016/j.jse.2008.09.010)
  • [L2] These are simple clinical signs, easy to perform which are useful in diagnosing trapezius weakness in clinical practice. (10.1016/j.jse.2009.02.015)
  • [L3] Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes. (10.1016/j.jse.2025.03.038)
  • [L5] The muscle engages force in all ranges of 5 shoulder motions, and maximum external rotation in abduction is a reliable method to evaluate potential activity of the muscle. (10.1016/j.jse.2016.09.046)
  • [L2] Despite satisfactory clinical outcomes following exercise therapy, glenohumeral kinematics did not change. (10.1007/s00167-017-4695-3)
  • [L5] The 6-mm acromiograft significantly reduced superior translation of the humeral head and improved subacromial contact mechanics compared to the massive cuff tear condition, supporting its biomechanical efficacy. (10.1016/j.arthro.2024.06.019)
  • [L5] The anterior deltoid is important biomechanically for balanced function after a reverse total shoulder arthroplasty. (10.1016/j.jse.2012.02.002)
  • [L5] The biomechanical properties and bone quality decreased after the injury and were restored gradually over time with full restoration by 8 weeks after injury, but the findings were not equivalent to the intact shoulder. (10.1016/j.jhsa.2022.08.027)
  • [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)
  • [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. (10.1016/j.arthro.2015.08.031)
  • [L2] Additionally, these patients show decreased recruitment of the serratus anterior and teres major muscles, though the magnitude of difference may limit clinical applicability. (10.1016/j.jse.2025.08.009)
  • [L4] Intratendinous rotator cuff tears are difficult to diagnose preoperatively. (10.1016/j.jse.2010.01.013)
  • [L3] FI of the teres minor without tear involvement can be observed in a rotator cuff tear as a possibly incidental finding of unknown clinical significance. (10.1016/j.arthro.2015.10.021)
  • [L3] Altering scapula position may affect shoulder strength in asymptomatic individuals. (10.1111/sae.12027)
  • [L5] The deltoid shows a linear contribution to maximal shoulder strength depending on the abduction or flexion angle, ranging from 24% in 0° to 75% in 120° of abduction and from 11% in 0° to 70% in 120° of flexion. (10.1016/j.jse.2020.05.023)
  • [L4] Simulations based on musculoskeletal models may provide relevant information on the muscles directly involved in glenohumeral stability. (10.1371/journal.pone.0189406)
  • [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)
  • [L4] Specific alterations of scapular muscular activation and kinematics were found in different patterns of scapular dyskinesis. (10.1016/j.jse.2014.12.022)
  • [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)
  • [L4] A contemporary injury classification system is proposed that includes injury timing, injury location, and standardized terminology addressing tear extent to more accurately reflect the musculotendinous morphology of PM injuries and better inform surgical management, rehabilitation, and research. (10.1016/j.jse.2011.04.035)
  • [Case_report] This course of therapy results in better function and restoration of muscle strength. (10.1016/j.jse.2011.04.026)
  • [L3] Despite good healing rates, not all patients with healed rotator cuffs experience good outcomes. (10.1016/j.jse.2021.03.112)
  • [L1] In the treatment of supraspinatus tendinopathy, low molecular-weight hyaluronate is more effective than physiotherapy, at least for three months, particularly in alleviating pain. (10.5435/jaaos-d-20-01014)
  • [L4] Apart from a tenodesis effect, directional muscle activity seems relevant for improved clinical outcome and pain relief. (10.1016/j.jse.2013.07.055)
  • [L5] This therapeutic strategy was associated with improvements in the static and dynamic mechanical properties of the tendon-bone interface. (10.1177/03635465251341439)
  • [L5] The most common type was the subscapularis muscle with three bellies, in line with Larson's model of the division of the subscapularis muscle into three parts. (10.1155/2021/7450000)
  • [Abstract] Three-dimensional MRI seems to be useful in assessing the rotator cuff muscles. (10.1016/j.jse.2020.01.010)
  • [Letter] The authors believe that the requisite elements for classifying pectoralis major tears are timing, location, and extent of the tear, and that further subdividing these categories would not have clinical significance in treatment or outcome. (10.1016/j.jse.2013.03.001)
  • [L1] Topical glyceryl trinitrate should be included as part of nonsurgical management of chronic tendinopathies. (10.1177/0363546504270998)
  • [L5] Treatment ranges from conservative management and physical therapy to surgical options like muscle transfers or nerve grafting depending on the etiology and duration of symptoms. (10.5435/00124635-201108000-00001)
  • [L4] Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis. (10.1016/j.arthro.2016.04.022)
  • [L3] The MRI tendinosis grade is associated with stiffness assessed using sonoelastography in patients with rotator cuff tendinopathy. (10.1016/j.jse.2015.10.019)
  • [L4] This study shows that improvement in functional outcome after arthroscopic repair of a subscapularis tendon tear is maintained long-term. (10.1016/j.arthro.2012.02.031)
  • [L5] Nonsurgical management remains the mainstay of treatment for calcific tendinitis of the rotator cuff, with most patients improving with modalities such as oral anti-inflammatory medication, physical therapy, and corticosteroid injections. (10.5435/jaaos-22-11-707)
  • [L4] This imaging technique was reliable to assess the supraspinatus tendon, especially when used by a single experienced musculoskeletal sonographer. (10.1177/1758573218819828)
  • [L5] US, MRI, and histology failed to identify true tendon layers at the enthesis. (10.1016/j.jse.2019.12.020)
  • [L5] The subscapularis tendon is composed of 2 distinct fibrous layers, just like the supraspinatus tendon, but arranged differently. (10.1016/j.jse.2018.11.045)
  • [L4] In the absence of a surgical solution, conservative treatment is fundamental and requires management in a rehabilitation center with intervention by a multidisciplinary team. (10.1016/j.jse.2022.05.011)
  • [L4] The results in this series indicate that transfer of the latissimus dorsi muscle is a reasonable approach for salvage after failed operative treatment of a massive tear of the rotator cuff. (10.2106/00004623-199908000-00007)
  • [L4] Conservative management remains an effective treatment strategy with favorable functional outcomes. (10.1186/s12891-025-09454-6)
  • [L4] Both open and arthroscopic biceps tenodesis in the setting of rotator cuff repair show low complication rates, and the technique should be based on surgeon preference and patient factors. (10.5435/jaaos-d-19-00252)
  • [L1] Use of a biceps autograft is an option for augmentation in massive rotator cuff tears, although no definitive recommendations can be given. (10.1016/j.arthro.2017.10.044)
  • [L4] Stability was restored and no significant range-of-motion loss was observed in noncollision athletes who underwent conjoined tendon transfer. (10.1016/j.arthro.2017.06.044)
  • [L1] Arthroscopic rotator cuff repair is favored for improving shoulder function, while other procedures or intraarticular treatments offer no significant benefits. (10.1186/s13018-024-05129-5)
  • [L5] Clinical trials using this bone-tendon allograft technique are warranted. (10.1016/j.arthro.2011.08.296)
  • [L4] The MNM tenodesis appears to be a simple, efficient, and effective alternative to other methods of biceps tenodesis with subjective outcome scores and complication rates that parallel other methods previously described in the literature. (10.1007/s00167-016-4145-7)
  • [L4] Delayed excision of the reflected head of the rectus femoris successfully reduces pain in rare cases that fail nonoperative management. (10.1177/0363546511413251)
  • [L5] The treatment option of biceps tenodesis is an appealing alternative to SLAP repair, but the indications and technique of biceps tenodesis in the elite pitcher still need to be defined. (10.1016/j.arthro.2018.01.001)
  • [L5] Nonsurgical treatment can be effective for patients with full-thickness tears. (10.1016/j.jhsa.2014.06.122)
  • [L2] MDCT can be another option for imaging modality, comparable with MRI, for the evaluation of fatty degeneration of rotator cuff muscles. (10.1177/0363546510384791)
  • [L4] Gene expression in human rotator cuff muscles varied according to tendon injury severity. (10.2106/jbjs.m.01585)
  • [L4] The patient became asymptomatic with conservative management despite persistent avulsion of the teres major tendon on MRI, experiencing no subsequent functional impairment during pitching. (10.1177/03635465990270012401)
  • [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)
  • [L3] CT provides nearly equivalent measures of cuff muscle area to an MRI technique with previously validated reliability and accuracy. (10.1016/j.jse.2018.03.015)
  • [L3] Pre-operative deltoid impairment, in certain circumstances, is not an absolute contraindication to RSA. (10.1302/0301-620x.95b8.31173)
  • [L5] Three-dimensional MRI measurement of whole-muscle volume is required and is associated with shoulder strength. (10.1016/j.arthro.2015.11.008)
  • [L3] A consistent finding is that larger subscapularis tendon tears are more easily detected using MRI scans whereas smaller tears are more frequently missed. (10.1016/j.arthro.2012.04.142)
  • [L3] This index is an indication of the relative moment arms of the deltoid and rotator cuff and may provide insight into the variable presentation of massive cuff tear patients. (10.1016/j.jse.2025.03.001)
  • [L4] Applying the Goutallier classification to more medial MRI sections (MSB-GC) resulted in assignment of lower grades for all rotator cuff muscles and demonstrated excellent test-retest reliability and repeatability. (10.1016/j.jse.2024.05.013)
  • [L4] These immediate changes should be considered when assessing rotator cuff muscle changes by comparing preoperative MRI with postoperative MRI. (10.1016/j.arthro.2012.10.006)
  • [L5] This pictorial essay provides a detailed review of the anatomy of the hamstring muscle–tendon complex, including proximal attachment, muscle course, and innervation, based on anatomical dissection and photographic documentation. (10.1007/s00167-018-5265-z)
  • [L3] MRI is accurate for diagnosing the tear grade and location of pectoralis major tendon ruptures, particularly for acute, tendon-bone, and G3 tears. (10.1016/j.jse.2015.08.037)
  • [L3] Routine MRI assessment of the upper subscapularis muscle and coracohumeral distance can contribute to the diagnostic accuracy of subscapularis tears and offer valuable information regarding the severity of such tears. (10.1016/j.arthro.2023.10.017)
  • [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] The author suggests that chronic tendinosis in other tendons might be due to the same cause as in the Achilles and patellar tendons (ingrowth of fine vessels and nerves) and expects a series of studies from the British group on hitherto unsolved problems of the shoulder joint. (10.1007/s00167-005-0616-y)
  • [L4] Surgical repair of torn abductor tendons of the hip is a viable option when MRI and clinical findings are consistent with tendon disruption and weakness. (10.2106/jbjs.l.00709)
  • [L5] This randomized trial is an important study in the quest to find the best treatment for patients with rotator cuff tears, yet clearly more work is needed to identify those patients who will do best with surgical repair and to determine if surgery can alter the natural history of rotator cuff tear progression. (10.2106/jbjs.n.00585)
  • [L4] The authors suggest that aberrant origins of the long head of the biceps can be seen with concomitant cuff tear pathology, but nonsynovitic and nondegenerative biceps origins of this nature have not clearly contributed to other shoulder pathology. (10.1016/j.jse.2012.08.007)
  • [L4] Asymptomatic and symptomatic rotator cuff tears carry similar rates of tear progression over time. (10.1016/j.arthro.2018.07.031)
  • [L2] Muscle injuries of the triceps surae were more commonly found in players older than 23 years when compared with those 23 years or younger. (10.1007/s00167-015-3527-6)
  • [L4] Delayed repair was associated with less satisfactory results due to muscle atrophy and degeneration. (10.2106/00004623-199607000-00005)
  • [L3] Given that this was a long-term outcome study, there was a low-grade progression in the rate of cuff tear arthropathy. (10.1302/0301-620x.106b9.bjj-2024-0099.r1)
  • [L3] The evaluation of the visible length of the tendon stump combined with Goutallier staging appears to dramatically improve the preoperative prediction of whether a tendon repair will be successful. (10.1177/0363546512457587)
  • [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. (10.2106/00004623-199802000-00010)
  • [L5] Growth factors exhibit unique temporal profiles that correlate with specific stages in the injury and repair process of the supraspinatus tendon, with an initial increase in expression followed by a return to control or undetectable levels by 16 weeks. (10.1016/j.jse.2007.04.003)

See Also

References

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[94] Do magnetic resonance imaging and computed tomography provide equivalent measures of rotator cuff muscle size in glenohumeral osteoarthritis?. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.03.015

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