REPAIR, REGENERATION, OR RETIREMENT?
– Written by Erdi Ozdemir, Ozgur Ahmet Atay, Türkiye, and Gazi Huri, Qatar
INTRODUCTION
Rotator cuff is composed of four muscles including supraspinatus, infraspinatus, teres minor and subscapularis. Its primary function is providing dynamic motion and stability to the shoulder joint. As shoulder joint has the greatest range of motion than any of the joints in the human body, stability provided by the rotator cuff poses significant clinical importance.
Rotator cuff tears (RCT) are not uncommon injuries. RCTs have a reported prevalence of 20% to 30% in adults over 60 years of age and its incidence increases as the age gets older1. Although the majority of the RCTs has a degenerative pattern, athletic population including throwing athletes, overhead athletes are at risk. In addition, acute RCTs can be observed in athletes participating in contact sports such as rugby, American football, and ice hockey2.
CLINICAL PRESENTATION OF RCTS
RCTs often present with pain and functional limitations, pose a considerable challenge for athletes. These findings can range from mild conditions like tendinitis and tendinosis to more severe issues such as partial or complete tendon tears. The anatomy of RCTs can vary significantly depending on the underlying cause and individual patient characteristics.
Overhead athletes are prone to certain types of rotator cuff problems due to the unique biomechanical stresses encountered on their shoulders during sports. Common observed includes: 1) Articular sided partial-thickness tears often related to internal impingement, which may occur alone or alongside labral or capsular instability, 2) Intratendinous delamination or bursal-sided tears, typically resulting from chronic tendinopathy, 3) Less commonly, acute full-thickness tears that may develop due to direct trauma or in the setting of pre-existing chronic tendinosis3.
In young athletes, the vast majority of tears—up to 91% in some studies—are articular-sided partial tears. Specific types of these injuries include PASTA lesions (partial articular-sided supraspinatus tendon avulsions) and PAINT lesions (partial articular tears that extend within the tendon itself). A unique concern in overhead athletes is the gradual weakening and displacement of the supraspinatus tendon from its original attachment point, due to repeated microtrauma4.
Initial clinical evaluation involves visual inspection, palpation, and assessment of range of motion. Visible signs such as atrophy of the infraspinatus or supraspinatus muscles and scapular winging can suggest rotator cuff issues. When pain is accompanied by weakness during physical tests, it may indicate a large or full-thickness tear rather than a minor or partial injury. Multiple physical examination maneuvers with varying sensitivity and specificity have been reported5.
IMAGING
Magnetic resonance imaging (MRI) is considered the gold standard for evaluating rotator cuff injuries. MRI provides detailed information on various aspects of the injury, including the number of tendons affected, whether the tear is partial or full thickness, the specific location of the tear (articular, bursal, or within the tendon), the extent of tendon retraction in full-thickness tears, the presence of fatty infiltration, and the tear’s borders. These factors are crucial for assessing the severity of the injury and determining appropriate treatment strategies.
Muscle quality, in other words fatty infiltration is a critical entity predicting the outcomes of surgical procedures of RCTs. The Goutallier classification system is commonly used to evaluate fatty infiltration in rotator cuff muscles. Originally introduced in 1994, Goutallier’s five-stage grading scale utilized computed tomography (CT) to predict the likelihood of successful rotator cuff repair and to identify potentially irreparable tears6. This system was later adapted by Fuchs et al. for use with MRI which has since become the preferred method for assessing fatty infiltration7. Both versions of the classification rely on sagittal oblique images to compare the proportion of fat to muscle tissue (Table 1).
Recent literature has demonstrated a correlation between higher preoperative Goutallier stages and increased rates of rotator cuff retear following surgical repair. Patients with Goutallier stages 0 to 1 typically exhibit good to excellent postoperative outcomes. In contrast, stage 4 is generally considered a contraindication for primary repair due to consistently poor clinical outcomes and a markedly elevated risk of retear. Management strategies for patients with Goutallier stages 2 and 3 remain a crossroad in the treatment of RCTs with no clear consensus regarding the optimal surgical approach8.
NATURAL HISTORY OF ROTATOR CUFF TEARS
When counseling the patients with RCTs regarding treatment options, clinicians should understand the natural history of these injuries when managed non-operatively. It is well established that full-thickness RCTs do not have the capacity to heal without surgical intervention. Moreover, these tears tend to enlarge over time, with the rate of progression influenced by factors such as initial tear size, degree of fatty infiltration, and patient age.
A long-term study with an average follow-up of 22 years evaluating 69 patients who underwent isolated acromioplasty without rotator cuff repair showed that 87% of full-thickness tears had increased in size, and 74% had developed cuff arthropathy. In addition, 42% of partial-thickness tears showed progression, with only 7% advancing to cuff arthropathy9. In a Level II study involving 49 patients with small- to medium-sized full-thickness tears, the mean tear size increased by 8.3 mm in the anteroposterior dimension and 4.5 mm in the mediolateral dimension over a mean follow-up of 8.8 years10.
Another study noted that over 50% of non-operatively treated full-thickness tears increased in size within a minimum follow-up of six months11. Furthermore, a recent prospective case–control study from Japan involving 174 patients demonstrated that tear size progressed in 47% of symptomatic shoulders over a mean follow-up of 19 months, with an average increase of 3.8 mm per year in length and 2 mm in width12.
NON-OPERATIVE TREATMENT OF RCTS
The primary aim of conservative treatment is to restore a pain-free range of motion, flexibility, muscle balance, and both scapulothoracic and glenohumeral muscle control and stability. A well-structured rotator cuff exercise program should focus on enhancing scapular stability, ensuring proper neuromuscular coordination of the shoulder girdle, and maintaining good thoracic posture. Factors that may contribute to abnormal scapular movement include pain, tightness in soft tissues, imbalanced or altered muscle activation, muscle fatigue, and poor posture in the thoracic spine.
Physical therapy is the primary nonoperative treatment option for individuals with symptomatic rotator cuff tendinopathy or partial- to full-thickness tears. It has proven to be effective, often leading to a faster recovery and return to daily activities compared to surgical intervention13. In a study conducted by the MOON Shoulder Group investigated 381 patients with a mean age of 62 years (range,31 to 90) sustaining non-traumatic full-thickness rotator cuff tears over a two-year period. The results showed significant improvements in patient-reported outcomes, including American Shoulder and Elbow Surgeons (ASES) scores, and a lower rate of surgical intervention following physical therapy14.
Moosmeyer et al. randomized 103 patients to either a physiotherapy or a primary rotator cuff repair group and demonstrated slightly superior outcomes in the surgical group at five-year follow-up, although the differences did not reach clinical significance. Notably, approximately one-third of patients managed conservatively required subsequent surgical intervention due to treatment failure. Furthermore, among the remaining 38 patients who continued with nonoperative management, one-third exhibited a clinically relevant increase in tear size, which was associated with poorer prognostic outcomes15.
SURGICAL TREATMENT OF RCTS
Surgical repair is the treatment of choice for full-thickness rotator cuff tears that do not respond to conservative management. However, the most common complication following rotator cuff repair is retear, with reported rates ranging from 20% to 68%16. The etiology of retear is multifactorial and may include compromised tendon or bone quality, suture or knot failure, insufficient tendon-to-bone fixation, impaired tendon-to-bone healing, or suboptimal postoperative rehabilitation17. Studies evaluating tendon healing following surgical intervention have identified several key risk factors associated with failed tendon regeneration. These include advanced patient age (greater than 65 years), larger tear size with significant retraction, increased degrees of fatty infiltration, and a shortened residual tendon stump18. Beyond these pathological considerations, establishing patient expectations is one of the keys to success. The prolonged rehabilitation period required after rotator cuff repair must be clearly stated to all patients undergoing surgical treatment. Despite advancements in surgical technique and postoperative management, the timeline for functional recovery remains largely unchanged, with a minimum of six months typically required to achieve satisfactory pain relief and restoration of shoulder function.
The treatment approach for each patient should be individual aiming reliable pain relief and functional restoration, while minimizing the risk of complications. In younger patients with favorable healing potential in cases involving large tears, disruption of the rotator cable, or fatty infiltration of the musculature, early surgical intervention is generally recommended. Conversely, in older individuals, patients with small full-thickness or partial-thickness tears, or those who are asymptomatic, nonoperative management may be appropriate. In such cases, a structured regimen of physiotherapy, analgesic therapy, and, when indicated, corticosteroid injection may be sufficient to control symptoms and maintain function19.
Arthroscopic tendon repair is the preferred surgical technique for RCTs. The arthroscopic technique most commonly utilizes suture anchors, arranged in either a single-row or double-row configuration (Figure 1). To enhance the tendon-to-bone contact area and promote superior healing outcomes, Lo et al. introduced the double-row repair technique. This method involves placement of a medial row of anchors, with sutures passed through the rotator cuff tendon in a mattress fashion, followed by the placement of a second, lateral row of anchors along the lateral aspect of the anatomical footprint20.
Single-row rotator cuff repair is also described for the RCTs involving placement of suture anchors along the lateral margin of the tendon footprint. Multiple biomechanical studies have compared single-row and double-row repair techniques21. While findings have varied, the majority of these studies suggest that double-row fixation offers superior biomechanical properties, including increased load to failure and greater tendon-to-bone contact area22,23. However, clinical studies comparing the two methods have not consistently demonstrated a significant difference in patient-reported outcomes24. Consequently, the superiority of double-row over single-row repair in terms of healing rates remains a crossroad in the treatment of RCTs.
In recent years, patch augmentation has emerged as a promising tool in the management of challenging arthroscopic rotator cuff repairs. A diverse range of graft materials is available for patch augmentation, including allografts, most commonly human acellular dermal matrix, as well as xenografts derived from sources such as porcine dermis and bovine pericardium. Synthetic options, such as polyethylene terephthalate, are also utilized. Additionally, autografts, including the use of the long head of the biceps tendon, represent viable alternatives in select cases25. This technique involves the use of biological or synthetic scaffolds to support the native tendon repair, promote tissue regeneration, and reinforce biomechanical strength. By providing additional structural support at the repair site, patch augmentation aims to facilitate tendon healing, improve repair integrity, and reduce the incidence of retears, thereby potentially enhancing long-term functional outcomes.
Patches can be used either as augmentation by reinforcing a reparable tear or as interposition to bridge a gap between irreparable tears. Patch augmentation and interposition represent two distinct surgical strategies employed in the treatment of RCTs, each with unique indications and technical applications26.
Patch augmentation involves the placement of a biological or synthetic graft over the surface of a repaired rotator cuff tendon (Figure 2). The graft is secured with sutures or suture anchors to reinforce the repair construct, with the primary objective of enhancing structural integrity and promoting more reliable tendon healing. This technique is particularly indicated in cases of large or complex tears and in patients with known risk factors for compromised healing—such as advanced age, significant tendon retraction, muscular atrophy with fatty infiltration, and reduced bone mineral density. Patch augmentation is applicable in both primary and revision cases25.
Interposition grafting, in contrast, entails the placement of a graft or spacer between the retracted tendon and the humeral footprint. This technique serves primarily as a biological scaffold or mechanical spacer to bridge the gap when direct tendon-to-bone repair is not feasible—such as in cases of massive or irreparable rotator cuff tears. By occupying the defect, interposition grafts reduce frictional forces and distribute mechanical load, potentially enhancing healing conditions and function. Materials used for interposition include autografts, allografts, and various synthetic spacers25.
Despite having theoretical advantages of patch use in the treatment of RCTs, clinical studies supporting its use are still scarce. In 2022, Lee et al. conducted a prospective randomized case–control study among patients presenting with massive rotator cuff tears, those who underwent allograft augmentation using acellular human dermis and those without patch. reported At an average follow-up of approximately 5.7 years, patients with patch demonstrated a significantly lower retear rate compared to those who received repair without patch augmentation (9.1% vs. 38.1%, p = 0.034). Subgroup analysis further revealed that achieving complete footprint coverage intraoperatively was associated with improved outcomes in both groups. Both cohorts exhibited significant improvements in clinical scores with the patch-augmented group showing a significantly greater degree of functional enhancement27. The use of autografts such as the long head of the biceps tendon is gaining popularity (Figure 3). A systematic review covering eight case series with a total of 170 patients reported that outcomes following biceps autograft augmentation were comparable to those of other augmentation techniques. MRI follow-up was available for 112 patients, of whom 68 demonstrated intact reconstructed tendons28.
Sometimes rotator cuffs may need to be retired. The definition of an “irreparable” rotator cuff tear remains variable and subject to differing clinical interpretations. Basically, a tear is considered irreparable when the tendon stump cannot be mobilized to the anatomical footprint or to a medialized position adjacent to the articular margin without excessive tension. Although the concept of a “tension-free” repair is inherently subjective, it is generally defined as the ability to approximate the tendon to the native or medialized footprint with the shoulder in neutral rotation and abduction29. Currently, there is no clinical evidence supporting specific limitations on the degree of abduction permissible during tendon mobilization for repair.
The optimal surgical approach for managing large and massive RCTs remains a subject of ongoing debate. A variety of surgical techniques are available for especially young adults, including latissimus dorsi transfer (LDT)30, lower trapezius transfer (LTT)31, superior capsular reconstruction (SCR)32, and partial rotator cuff repair. While each modality presents potential theoretical advantages, interpretation of comparative effectiveness is complicated by significant heterogeneity among studies and methodological limitations in the existing literature33.
Baek et al. compared arthroscopy assisted LDT with LTT in 90 irreparable RCTs. In a mean 2 years follow-up, both groups showed significant improvement in clinical scores, but LTT was superior to LDT in terms of shoulder range of motion (ROM) and functional scores (34). Recently, Kimmeyer et al. compared 29 arthroscopy assisted LDT with 8 arthroscopy assisted LTT. Both cohorts demonstrated significant improvements in active ROM, visual analog scale (VAS) scores, and subjective shoulder value (SSV). At final follow-up, the median Constant–Murley scores were 73 in the arthroscopy assisted LDT (aaLDT) group and 77 in the arthroscopy assisted LTT (aaLTT) group. The overall failure rates, including cases requiring revision surgery, were 14% for aaLDT and 13% for aaLTT35.
When biological treatments are no longer feasible for RCTs, the crossroad directs joint replacement surgery. In this patient population, the indications for reverse shoulder arthroplasty (RSA) included persistent, significant shoulder pain and dysfunction despite a minimum of six months of nonoperative management, the presence of at least a two-tendon rotator cuff tear, and radiographic evidence of Hamada stage 1, 2, or 3 changes, in cases where no viable non-arthroplasty surgical alternatives remained. Some authors advocate for reserving RSA for patients with chronic loss of shoulder elevation, particularly among younger, active individuals. Interestingly, preoperative forward flexion exceeding 90 degrees has been associated with less favorable outcomes, including a higher complication rate and, in some cases, a postoperative decline in shoulder mobility. In a systematic review by Sevivas et al including a total of six studies comprising 266 shoulders with follow-up periods ranging from 24 to 61.4 months. Statistically significant improvements were observed in postoperative outcomes compared to baseline, including clinical scores, forward flexion, external rotation, functional capacity, and pain levels. The authors concluded that patients with irreparable massive RCTs demonstrate a high probability of achieving pain relief and functional improvement following RSA36.
It is important to underscore that complication rates following RSA can reach up to 20%, equating to approximately one in every five cases. Additionally, the revision rate has been reported at approximately 8% or one in every twelve patients in the short to medium-term follow-up. Moreover, these outcomes were documented in high-volume, specialized centers with surgeons experienced in RSA for this specific patient population. Therefore, it is expected that complication and revision rates may be even higher in settings with less surgical expertise. Accordingly, transparent communication of these risks is essential when counseling patients regarding RSA as a treatment option36.
CONCLUSION
Rotator cuff tears present a complex clinical challenge, with treatment options ranging from conservative management to advanced surgical interventions. Decisions must be individualized based on patient age, activity level, tear characteristics, and the presence of degenerative changes. While nonoperative treatments can be effective, especially in partial or small tears, larger and irreparable tears often require surgical solutions such as tendon transfers or arthroplasty. Emerging techniques like patch augmentation and biologic scaffolds show promise but require further long-term evidence. Ultimately, the goal remains to optimize shoulder function and pain relief while carefully weighing the risks and benefits of each treatment path.
Erdi Ozdemir MD1
Ozgur Ahmet Atay MD1
Gazi Huri MD1,2
Orthopaedics Surgeon
Aspetar Sports Orthopaedics Fellowship Programme Coordinator
1 Hacettepe University Department of Orthopaedics and Traumatalogy
Ankara, Türkiye
2 Aspetar Orthopaedic and Sports Medicine Hospital
Doha, Qatar
Contact: erdiozdemir@gmail.com
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