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This article addresses the role of MR imaging in the spectrum of impingement and rotator cuff tears. Rotator cuff and coracoacromial arch anatomy, the cause of impingement syndrome, and the pathology and imaging of calcific tendinitis are reviewed.
Most complex humeral head fractures are associated with a longitudinal tear of the rotator cuff. Reconstruction of this tear is frequently omitted from surgical reduction and fixation procedures. In 48 patients treated by surgery or by conservative means, we investigated the relationship between rotator cuff integrity and the functional results. The rotator cuff was assessed by ultrasonography, the functional results by the Constant Score. Common signs of rotator cuff alterations were partial or complete atrophy. In all patients affected, a longitudinal defect located at the rotator interval was detected. A classification of rotator cuff alterations resulting from humeral head fractures was introduced, yielding three categories: none, moderate, or severe. In three patients, sonographic results were confirmed by magnetic resonance imaging (MRI). Rotator cuff alterations were often associated with displaced consolidation results. Furthermore, the integrity of the rotator cuff significantly correlated with the function achieved. The results support the need for a careful rotator cuff repair in order to optimise treatment results.
BACKGROUND: Very little comparative information is available regarding the demographic and morphological characteristics of asymptomatic and symptomatic rotator cuff tears. This information is important to provide insight into the natural history of rotator cuff disease and to identify which factors may be important in the development of pain. The purpose of the present study was to compare the morphological characteristics and prevalences of asymptomatic and symptomatic rotator cuff disease in patients who presented with unilateral shoulder pain. METHODS: Five hundred and eighty-eight consecutive patients in whom a standardized ultrasonographic study had been performed by an experienced radiologist for the assessment of unilateral shoulder pain were evaluated with regard to the presence and size of rotator cuff tears in each shoulder. The demographic factors that were analyzed included age, gender, side, and cuff thickness. All of these factors were evaluated with regard to their correlation with the presence of pain. RESULTS: Of the 588 consecutive patients who met the inclusion criteria, 212 had an intact rotator cuff bilaterally, 199 had a unilateral rotator cuff tear (either partial or full thickness), and 177 had a bilateral tear (either partial or full thickness). The presence of rotator cuff disease was highly correlated with age. The average age was 48.7 years for patients with no rotator cuff tear, 58.7 years for those with a unilateral tear, and 67.8 years for those with a bilateral tear. Logistic regression analysis indicated a 50% likelihood of a bilateral tear after the age of sixty-six years (p < 0.01). In patients with a bilateral rotator cuff tear in whom one tear was symptomatic and the other tear was asymptomatic, the symptomatic tear was significantly larger (p < 0.01). The average size of a symptomatic tear was 30% greater than that of an asymptomatic tear. Overall, patients who presented with a full-thickness symptomatic tear had a 35.5% prevalence of a full-thickness tear on the contralateral side. CONCLUSIONS: There is a high correlation between the onset of rotator cuff tears (either partial or full thickness) and increasing age. Bilateral rotator cuff disease, either symptomatic or asymptomatic, is common in patients who present with unilateral symptomatic disease. As the size of a tear appears to be an important factor in the development of symptoms, we recommend surveillance at yearly intervals for patients with known rotator cuff tears that are treated nonoperatively.
BACKGROUND: While reverse shoulder arthroplasty (rTSA) is commonly utilized for rotator cuff tear arthropathy, indications have expanded to include, primary glenohumeral osteoarthritis (GHOA) with intact cuff. The presence of an intact cuff may influence outcomes after rTSA because preserved cuff musculature can contribute to shoulder stability and force which could potentially improve postoperative function and reduce complication rates. However, studies have reported contradictory results on whether or not an intact cuff would provide better outcomes in patients receiving an rTSA. METHODS: This is a systematic review and Meta-analysis performed according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Cochrane, Embase, and Google Scholar (pages 1-20) were queried through December 2025. Inclusion criteria consisted of studies comparing the outcomes of rTSA based on whether patients had a diagnosis of GHOA with intact cuff, or had a deficient rotator cuff (ie had a diagnosis of rotator cuff tears without OA, or cuff tear arthropathy). Extracted data included adverse events, improvement in patient reported outcome measures, and improvement in range of motion. RESULTS: Eleven retrospective articles and 1 prospective article met the inclusion criteria with 4,542 in the GHOA with intact cuff group and 16,382 in the cuff-deficient group (cuff tear arthropathy: 15,423 patients; rotator cuff tear: 959 patients). Patients undergoing rTSA for GHOA and intact cuff had a lower rate of revisions (odds ratio [OR] = 0.53; 95% CI: 0.41- 0.68, P < .001; I2 = 0%), overall complications (OR = 0.57; 95% CI: 0.46-0.71, P < .001; I2 = 0%), acromial stress fracture (OR = 0.22; 95% CI: 0.08- 0.59, P = .003; I2 = 0%), infection (OR = 0.43; 95% CI: 0.26- 0.73, P = .002; I2 = 37%), and instability (OR = 0.60; 95% CI: 0.40- 0.90, P = .01; I2 = 0%). In addition, GHOA patients had a better improvement in both American Shoulder and Elbow Surgeons scores (mean difference = 7.17; 95% CI: 2.13- 12.21, P = .005; I2 = 81%) without exceeding the minimal clinically important difference, and external rotation (mean difference = 12.00°; 95% CI: 9.63- 14.37, P < .001; I2 = 38%). CONCLUSION: Rotator cuff-deficient patients undergoing rTSA have a higher risk of postoperative complications compared to patients undergoing rTSA for GHOA with an intact cuff. They also showed less improvement in American Shoulder and Elbow Surgeons scores and external rotation. However, the clinical significance of these differences should be interpreted with caution, as not all improvements exceeded established thresholds for clinical importance.
BACKGROUND: Recurrent defects after open and arthroscopic rotator cuff repair are common. Double-row repair techniques may improve initial fixation and quality of rotator cuff repair. PURPOSE: To evaluate the load to failure, cyclic displacement, and anatomical footprint of 4 arthroscopic rotator cuff repair techniques. HYPOTHESIS: Double-row suture anchor repair would have superior structural properties and would create a larger footprint compared to single-row repair. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty fresh-frozen cadaveric shoulders were randomly assigned to 4 arthroscopic repair techniques. The repair was performed as either a single-row technique or 1 of 3 double-row techniques: diamond, mattress double anchor, or modified mattress double anchor. Angle of loading, anchor type, bone mineral density, anchor distribution, angle of anchor insertion, arthroscopic technique, and suture type and size were all controlled. Footprint length and width were quantified before and after repair. Displacement with cyclic loading and load to failure were determined. RESULTS: There were no differences in load to failure and displacement with cyclic loading between the single-row repair and each double-row repair. All repair groups demonstrated load to failure greater than 250 N. A significantly greater supraspinatus footprint width was seen with double-row techniques compared to single-row repair. CONCLUSIONS: The single-row repair technique was similar to the double-row techniques in load to failure, cyclic displacement, and gap formation. The double-row anchor repairs consistently restored a larger footprint than did the single-row method. CLINICAL RELEVANCE: The arthroscopic techniques studied have strong structural properties that approached the reported performance of open repair techniques. Double-row techniques provide a larger footprint width; although not addressed by this study, such a factor may improve the biological quality of repair.
Subscapularis transposition into a supraspinatus or supraspinatus and infraspinatus rotator cuff defect has been overlooked as a method of tendon repair. The surgical technique for this type of repair, with or without the concomitant use of a glenohumeral resurfacing prosthesis, is described. Postoperatively, the extremity is supported in a position that does not allow stress to be placed on a repair until healing has occurred. Generally, physical therapy is begun early and continued for many months. In the present series, satisfactory relief of pain was achieved in 22 of the 26 patients. Active abduction in the plane of the scapula averaged 120 degrees for patients with rotator cuffs repair and prosthetic replacement and 130 degrees for those with rotator cuff repair alone. Twelve patients gained more than 30 degrees active abduction, and four lost this amount of motion, or greater, as compared with preoperative capabilities. In two of the 26 patients, the rotator cuff repair was completely disrupted during the acute postoperative period. Twenty-five of the 26 patients were satisfied with the surgical procedure. This type of repair seems to be a secure repair, bring healthy tendon tissue into an area of tendon degeneration and loss of tissue substance. As such, it satisfies the basic surgical principles of achieving repair with healthy tissue that is not under tension. The results compare favorably with those reported in the literature on rotator cuff repair and further suggest that this technique is an acceptable alternative for repairing large or massive rotator cuff tears that have tendon substance loss. However, this technique should not be used for smaller tears, for which more simple techniques are more adequate, because if a retear occurs during the postoperative period, the cuff detect might be quite large, with significant pain postoperatively and functional limitations resulting.
Our study assessed the accuracy of shoulder ultrasonography in detecting complete and partial rotator cuff tears. We performed a prospective study in 24 patients scheduled for shoulder arthroscopy for impingement, partial-thickness or full-thickness (complete) rotator cuff tears, adhesive capsulitis, or arthritis. Before surgery, all patients underwent diagnostic shoulder ultrasonography followed by a shoulder arthroscopy with examination of the rotator cuff. The arthroscopic findings of rotator cuff integrity were compared with the diagnoses made from ultrasonography. The ultrasonographer was not blinded to the history and examination findings, and the surgeon was not blinded to the results of the ultrasonography. Ultrasound had sensitivity and specificity rates of 80% and 100%, respectively (positive and negative predictive rates of 100% and 88%), in the diagnosis of full-thickness rotator cuff tears and sensitivity and specificity rates of 71% and 100%, respectively (positive and negative predictive values of 100% and 88%), for partial-thickness tears. Although the potential for bias exists in this study, the results suggest that diagnostic ultrasound is effective in the diagnosis of rotator cuff tears.
Forty-eight patients with shoulder pain and 15 normal volunteers underwent rotator cuff imaging using high resolution real time ultrasound. The potential diagnostic value of sonography in detecting rotator cuff tears was evaluated by correlating ultrasound findings with surgical findings in 19 patients, 12 of whom also underwent preoperative arthrography. The preoperative ultrasound diagnosis was correct in 18 of the 19 patients undergoing surgery for possible rotator cuff tears. In the group of 12 surgical patients undergoing both preoperative arthrography and sonography, ultrasound correctly predicted the presence of a rotator cuff tear in 12 of 12 patients, while arthrography predicted cuff tears in only nine of 12. Good anatomic definition of the rotator cuff was obtained in both symptomatic and asymptomatic groups. The characteristic appearance of the normal and pathologic rotator cuff is described. Rotator cuff sonography promises to be a valuable new diagnostic tool for evaluating patients with suspected rotator cuff tears.
To adapt the Western Ontario Rotator Cuff (WORC) index for use in Turkey and to investigate its reliability and validity; the Turkish version of the WORC was developed according to the guidelines in the literature. Seventy-two patients with rotator cuff disease were administered the questionnaire and were also evaluated by using the University of California Los Angeles (UCLA) shoulder rating scale, Constant score, and Short Form (SF)-36 to test validity. The WORC questionnaire was repeated in 35 patients after a mean interval of 2.9 days (range 2-7 days) to evaluate test-retest reliability. Cronbach's alpha was calculated as 0.92 for the total questionnaire. The intraclass correlation coefficients were very high and ranged between 0.96 and 0.98 for each section. There was a significant negative correlation between the Turkish version of WORC and UCLA (r = -0.598, P < 0.01), Constant score (r = -0.630, P < 0.01), and all subscales of SF-36 (P < 0.01). The Turkish version of the WORC index is a reliable and valid instrument for use in clinical trials in patients with rotator cuff disorders.
The diagnosis of chronic lesions of the rotator cuff is challenging. We have developed a new index to improve the sonographic diagnosis of chronic tears of the cuff. In a pilot study, we examined 50 asymptomatic healthy volunteers by ultrasound to establish the diameter of the rotator cuff in relation to the tendon of the long head of biceps. Subsequently, the index was calculated in 64 patients who had had shoulder pain for more than three months caused by clinically diagnosed lesions of the rotator cuff. The compensatory hypertrophy of the biceps tendon was quantified sonographically in relation to the diameter of the cuff. Comparison with the contralateral shoulder revealed a significantly higher biceps rotator-cuff ratio (p < 0.05) for patients with torn rotator cuffs. A ratio greater than 0.8 was considered pathological (index positive); the mean ratio in the control group was 0.43. The sensitivity of a positive index was 97.8%, the specificity 63.2%, the positive predictive value 86.3%, and the negative predictive value 92.4% in comparison with surgical findings. Use of the index improves sensitivity in the diagnosis of chronic tears of the cuff by ultrasound.
AIM: Extracorporeal shockwave application (ESWA) is in clinical use to promote disintegration of symptomatic calcifications of the rotator cuff of the shoulder. However, disintegration of roentgenologically comparable calcifications of the rotator cuff is not always successfull. It is known from urologic stone lithotripsy that the susceptibility for disintegration of stone-like concrements depends on their mineral content. Therefore, in the present investigation the relative contents of calcium and phosphorus in rotator cuff calcifications were determined. METHOD: 39 surgically removed rotator cuff calcifications were analyzed by means of atomic emission spectrometry. RESULTS: The relative content of calcium of the rotator cuff calcifications was found to be 22.3 % +/- 5.7 % (mean +/- SD; 6.8 % - 32.4 %), that of phosphorus as 10.5 % +/- 2.4 % (2.7 % - 14.4 %). The data neither depend on the gender of the patients nor on their age at the time point of surgical removal of the rotator cuff calcifications. CONCLUSION: Roentgenologically comparable calcifications of the rotator cuff demonstrated distinct individual differences concerning the relative contents of calcium and phosphorus. The present results may serve as the first indication that the susceptibility of rotator cuff calcifications for disintegration may depend on their relative contents of calcium and phosphorus.
During rotator cuff repairs, it is recommended that the hypovascular tissue edge be resected. To investigate rotator cuff tendon histopathology, we performed immunohistochemistry on 8 surgical and 6 cadaveric specimens. Hoechst nuclear stain and standard hematoxylin-eosin were used for morphologic analysis. Antibody to human von Willebrand factor tagged with fluorescein isothiocyanate, conjugated, was used to visualize vascularity, and antibody to human procollagen type I tagged with Cy3 was used to visualize new procollagen synthesis. There were no significant differences in the vascularity of surgical specimens sectioned near the tear site (<2.5 mm from tear margin) and matched cadaveric controls. However, sections taken 2.5 to 5 mm away from the tear demonstrated more vessels than those taken from either control or surgical specimens within 2.5 mm of the tear (P <.001). There were no differences in nuclear distribution patterns or in procollagen production and distribution between surgical specimens from sites near the tear or away from the tear. On the basis of morphologic architecture, these data suggest that minimal debridement of tendon edges only is required to maximize healing of the rotator cuff tendon at the time of repair.
Twelve cadaveric shoulders were used to determine the effects of release of the superior capsule and the coracohumeral ligament on the strain in the repaired rotator cuff tendon. A rotator cuff tear (2 cm wide and 1.5 cm long) was created and repaired under a 3-kg tensile force. The strain in the repaired tendon was measured with use of linear transducers with the arm in 50 different positions. Release of either the superior capsule or the coracohumeral ligament diminished the tension of the repaired rotator cuff by an average of 25% with the arm in adduction. Release of both of these structures further reduced the tension by an average of 44% in adduction and 43% to 60% with the arm in 15 degrees of elevation. The maximum reduction of tension in the repaired rotator cuff occurred when both the superior capsule and coracohumeral ligament were divided and when the arm was positioned in adduction and in 60 degrees of external rotation. Release of the coracohumeral ligament is equally as efficient as releasing the superior capsule in reducing the strain of the repaired rotator cuff. Releasing both structures seems to be desirable when releasing one structure or the other is not sufficient.
The size and morphologic features of rotator cuff tears may influence treatment selection and affect final outcomes. Magnetic resonance arthrography allows observation of these features and other intraarticular structures. To assess the utility of magnetic resonance imaging in assessing size and morphologic features, we retrospectively reviewed observations on 41 shoulders in 37 consecutive surgically treated patients (mean age, 63.2 years) who had magnetic resonance imaging followed by magnetic resonance arthrography. The maximum rotator cuff defect size in the anteroposterior direction defined transverse size, and the maximum rotator cuff defect size in the mediolateral direction defined longitudinal size. Sensitivities for detecting full-thickness rotator cuff tears by magnetic resonance imaging and magnetic resonance arthrography were 90.2% and 100%, respectively. Maximum longitudinal and transverse dimensions of the tear as shown by magnetic resonance arthrography correlated better with intraoperative measurements (r2 = 0.85 transversely, 0.92 longitudinally) than magnetic resonance imaging measurements (r2 = 0.47 transversely, 0.26 longitudinally). The reproducibility of the two methods is similar. Magnetic resonance arthrography also allowed morphologic classification of the torn tendon as blunt end, tapering end, indistinct end, horizontal tear, and global tear. There was good agreement in classifying torn edges; the imaging findings agreed with findings at surgery. Magnetic resonance arthrography was more accurate in evaluating rotator cuff tear size and morphologic features than conventional magnetic resonance imaging.
OBJECTIVE: An accurate sonographic diagnosis of rotator cuff lesions significantly depends on image quality and on the experience of the operator. The present study was performed to determine whether the use of three dimensional (3D) sonography further increases the diagnostic yield of ultrasound. METHODS: In an experimental study 22 artificial rotator cuff lesions (seven full thickness and 15 partial thickness tears) of cadaveric shoulder joints were evaluated by ultrasound with two and three dimensional imaging in a water basin. RESULTS: With 3D ultrasound, rotator cuff lesions were more often correctly diagnosed (sensitivity of 77%) than with conventional 2D sonography (sensitivity of 64%). Specificity was 85 and 69%, respectively. In partial thickness tears in particular, 3D imaging was the superior method reaching a sensitivity and specificity of 73 and 77%, respectively, compared to 53 and 61%, respectively, with 2D ultrasound. With 2D and 3D ultrasound eight and 11 out of 13 tendons, respectively, were correctly diagnosed as intact confirmed by histopathological examination. CONCLUSION: Although the results of an experimental study may not reflect the clinical situation, 3D ultrasound appears to facilitate diagnosis of partial thickness rotator cuff tears.
Increases security of fixation in rotator cuff repair is usually achieved by increasing the strength of fixation. Paradoxically, the problem can be approached by techniques that decrease the strain at the margins of the tear so that weaker fixation will still be adequate. Such techniques provide greater safety tolerances for the strength characteristics of suture, tendon, and bone. The principle of margin convergence can be applied to rotator cuff repair as a means to enhance the security of fixation by decreasing the mechanical strain at the margins of the tear. This strain reduction should also contribute to pain reduction by virtue of decreased stimulation of mechanoreceptors in the rotator cuff. The cliché no pain, no strain can be converted to a paradigm by reversal of its components to no strain, no pain.
PURPOSE: Golfers continue to play through the years that rotator cuff disease becomes more common. We sought to establish the results of acromioplasty and rotator cuff repair in golfers, including their ability to return to the sport. STUDY TYPE: Case series. METHODS: Of 30 golfers who underwent 32 rotator cuff repairs, 29 were interviewed, completed a detailed questionnaire, and returned for a physical examination. All of the patients were recreational or regional tournament golfers. Fifteen had open acromioplasty and rotator cuff repair and 16 had arthroscopic acromioplasty and mini-open repair. The average age at surgery was 60 years (range, 39 to 76 years). At surgery, most were moderate size tears (2 to 6 cm(2)). RESULTS: At average follow-up of 37 months (range, 24 to 60 months), all but 3 patients are currently golfing. For patients who are currently golfing, there was no significant difference in handicaps or drive distances at most recent follow-up compared with presymptomatic handicaps and drive distances (P >.05). Twenty-three patients report that they are playing at their presymptomatic competitive level without pain. Three patients report playing at a lower competitive level than before. CONCLUSION: In our experience, acromioplasty and rotator cuff repair predictably allow for eventual return to pain-free golfing at a similar competitive level for most recreational-level athletes.
The traumatic etiology of rotator cuff lesions is a matter of controversial discussed in legal assessments. Because of the relatively high prevalence of degenerative changes with increasing age, including partial and complete rotator cuff tears, it may be difficult to demonstrate the cause of an acute traumatic rotator cuff tear. This article presents a review of the literature concerning current knowledge of the anatomy, biomechanics and pathogenesis of rotator cuff pathology. According to this, a catalogue of potentially adequate and inadequate trauma mechanisms is proposed. Another focus of this work is in the post-traumatic diagnostic steps following persistent rotator cuff-deficient shoulder function. X-ray, ultrasound, MRI and operative findings in rotator cuff tears underline the criteria for distinguishing between traumatic and degenerative lesions. From a legal point of view (e.g., private accident insurance, workers compensation claims), various minor and major arguments are defined, which could help the expert in judging the cause of post-traumatic rotator cuff deficiency.