Rotator Cuff Tears
Original Editor - Lina TaingJenna Fried
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Introduction
A rotator cuff tear involves disruption of one or more tendons of the rotator cuff (supraspinatus, infraspinatus, teres minor, subscapularis). Rotator cuff tears are a common cause of shoulder pain and disability, and prevalence rises markedly with age, although many tears are asymptomatic. Tears range from small partial-thickness tears to massive tears.[1]
Large to massive tears are the most challenging subgroup: they are defined inconsistently, often cannot be repaired, and are associated with weakness, loss of active elevation and, in some individuals, progression to rotator cuff arthropathy.[2]
This page gives an overview of rotator cuff tears, with particular emphasis on the assessment and management of massive tears. For general cuff anatomy and tendinopathy see Rotator Cuff and Rotator Cuff Tendinopathy; for tears of a single tendon see Supraspinatus Tear; for repair and post-operative protocols see Rotator Cuff Surgery and Post-Surgical Rehabilitation; for biomechanics see Clinical Biomechanics of Rotator Cuff Tears.
Classification
Defining massive rotator cuff tears remains challenging within the shoulder surgery literature, with no universally accepted criteria. Traditional classification systems have utilised either tear size measurements or the number of tendons involved to categorise severity.[3]
The Cofield classification
The Cofield classification system (1982) defines tear size based on anteroposterior or mediolateral dimensions:[4]
| Category | Size |
|---|---|
| Small | less than 1 cm, |
| Medium | 1 to 3 cm |
| Large | 3 to 5 cm |
| Massive | exceed 5 cm |
However, this size-based approach has limitations as it does not account for functional implications or tendon quality.[2]
The Collin classification
The Collin anatomical classification provides an alternative framework by dividing the rotator cuff into five components: supraspinatus, superior subscapularis, inferior subscapularis, infraspinatus, and teres minor. This system categorises massive tears into five types based on specific tendon combinations involved.[3]
| Type | Muscle and Tendon Involvement |
|---|---|
| Type A | Supraspinatus and Superior Subscapularis tears |
| Type B | Supraspinatus and Entire Subscapularis |
| Type C | supraspinatus, superior subscapularis and infraspinatus |
| Type D | supraspinatus and infraspinatus |
| Type E | supraspinatus, infraspinatus and teres minor |
| This classification demonstrates clinical utility as it correlates with functional deficits and guides treatment decisions. | |
Goutallier grades
Goutallier grades were described on computed tomography (CT)[5] and adapted to MRI by Fuchs et al.:[6]
| Grade | MRI appearance |
|---|---|
| 0 | No fatty infiltration |
| 1 | Some fatty streaks |
| 2 | Less fat than muscle |
| 3 | Equal amounts of fat and muscle |
| 4 | More fat than muscle |
Modified Hamada classification
Modified Hamada classification (radiographic). This grades progression towards cuff tear arthropathy using the acromio-humeral interval (AHI) and glenohumeral changes, and helps guide treatment.[7][8]
| Grade | Radiographic finding |
|---|---|
| 1 | AHI ≥ 6 mm |
| 2 | AHI ≤ 5 mm |
| 3 | AHI ≤ 5 mm with acetabularisation of the acromion |
| 4A | Glenohumeral narrowing without acetabularisation |
| 4B | Glenohumeral narrowing with acetabularisation |
| 5 | Humeral head collapse (cuff tear arthropathy) |
Clinically Relevant Anatomy
The shoulder complex consists of five articulations working synergistically to provide extensive range of motion whilst maintaining dynamic stability. The glenohumeral joint, acromioclavicular joint, and sternoclavicular joint are true synovial joints, complemented by the subacromial space and scapulothoracic articulation.[9]
The rotator cuff comprises four muscles providing both mobility and stability. The subscapularis enables internal rotation, whilst infraspinatus and teres minor control external rotation. The supraspinatus initiates and assists shoulder abduction. During shoulder elevation, these muscles work cooperatively through concavity compression, maintaining the humeral head centred within the glenoid fossa whilst allowing controlled motion.
The rotator cuff muscles contribute significantly to shoulder elevation throughout the 60 to 120 degree arc.[11] All muscles except supraspinatus produce a depressor force on the humeral head, counteracting the superior pull of the deltoid during glenohumeral abduction.[12] This coordinated muscle action is essential for normal shoulder biomechanics, and disruption through massive tears leads to characteristic functional deficits including pseudo-paralysis in severe cases.[3]
Epidemiology
Rotator cuff tears represent the common cause of shoulder pain and disability, with prevalence increasing substantially with advancing age. Full-thickness tears affect approximately 20-22% of the general population, with prevalence increasing from less than 5% in individuals under 40 years to over 35% in those aged 80 and above.[1]
Risk factors
Age, body mass index, hypertension, coronary heart disease, history of shoulder trauma, hyperlipidaemia, type III acromion morphology, and critical shoulder angle all independently increase tear risk.[13] In younger individuals, traumatic injury plays more prominent roles, whereas degenerative processes dominate in older populations.[14]
Modifiable risk factors
Several risk factors for rotator cuff tears are modifiable, and addressing them may lower the risk of a tear or its progression and support better treatment outcomes.[13] Smoking, diabetes mellitus, dyslipidaemia, and metabolic syndrome[13]
Natural history of rotator cuff tears is essential for treatment planning. Approximately 50% of tears demonstrate progression over time, with medium and large tears are more likely to progress or respond poorly in people with physically demanding work and supraspinatus muscle atrophy[15]
Mechanism of Injury
Rotator cuff tears result from an acute injury, from gradual degeneration of the tendon, or from a combination of the two. The mechanism influences the tear pattern, tissue quality and treatment choice:
- Acute: a fall on the outstretched arm, shoulder dislocation (especially over 40 years), or a sudden heavy lift.[13]
- Degenerative: accumulated microtrauma and age-related changes in tendon structure and blood supply.[13][15]
- Consequences: loss of force-couple balance, superior humeral head migration, muscle atrophy and fatty infiltration, and in the long term cuff tear arthropathy.[16]
Clinical Presentation
The clinical presentation of massive rotator cuff tears varies considerably depending on tear location, chronicity, and individual compensation patterns. Common presenting features include:
- Shoulder pain that typically worsens with overhead activities and at night, particularly when lying on the affected side.[17]
- Progressive weakness affecting daily activities such as reaching overhead, lifting objects, or performing personal care tasks.
- A positive painful arc sign during active shoulder elevation between 60 and 120 degrees is characteristic. The degree of functional impairment correlates with tear pattern, with anterosuperior tears affecting internal rotation strength and posterosuperior tears compromising external rotation capacity.[3]
On clinical examination, a rotator cuff tear may present with:
- Muscle atrophy may be visible in the supraspinatus and infraspinatus fossae, particularly in chronic massive tears.
- Superior migration of the humeral head may be palpable with the humeral head abutting the acromion.
- Passive range of motion is typically preserved, though limited active motion may be present, reflecting motor weakness rather than joint stiffness.[17]
- Pseudo-paralysis, defined as active forward elevation less than 90 degrees with preserved passive motion, may occur in severe cases. This finding typically indicates extensive cuff disruption with inadequate compensatory muscle function.[3]
Diagnostic Assessment
Clinical Examination
A systematic physical examination protocol is essential for accurate diagnosis and tear localisation. The examination should include inspection for muscle atrophy, palpation of bony landmarks and tendons, active and passive range of motion assessment, strength testing, and special provocative tests.[9]
Recent systematic reviews and meta-analyses have clarified the diagnostic accuracy of common special tests.[19]
| Special Test | Structure assessed | Positive Findings | Notes |
|---|---|---|---|
| The Jobe test (empty can test) | Supraspinatus tears | Pain and/or weakness on resisted elevation in the scapular plane | Useful for supraspinatus tears |
| Drop arm test | Supraspinatus | Inability to lower the arm smoothly from 90° abduction, or pain | Indicates large tears |
| The external rotation lag sign | Infraspinatus and Supraspinatus | Arm cannot hold passive external rotation | Useful for large to massive posterosuperior tear[20] |
| Hornblower's Sign | Teres Minor | Inability to externally rotate with the arm in 90° abduction | Teres minor tears occur mainly in massive posterosuperior tears[9] |
| Belly press, lift-off test, and bear hug test | Subscapularis | Weakness or inability to perform the position | Generally high specificity but variable sensitivity |
A 2024 systematic review confirmed that combinations of clinical tests improve diagnostic accuracy over individual tests alone. Experienced clinicians can achieve diagnostic accuracy comparable to imaging for full-thickness tears when using structured examination protocols.[19]
Imaging Studies
Plain radiography: information about acromiohumeral distance, acromial morphology, greater tuberosity changes, and glenohumeral joint integrity. Narrowing of the acromiohumeral interval 5 to 7 mm suggests chronic massive tears with superior humeral migration.[17]
Magnetic Resonance Imaging (MRI): It demonstrates tear size, location, tendon retraction, muscle atrophy, and fatty infiltration of the rotator cuff muscles. The Goutallier classification system, described on CT (Goutallier 1994) and adapted to MRI by Fuchs et al. (1999). MRI signal characteristics, grades fatty muscle degeneration from 0 to 4 and provides prognostic information regarding surgical repairability and outcomes.[5]
Ultrasound Imaging: Accuracy for full-thickness tears. Used for dynamic assessment capabilities and point-of-care evaluation but depends heavily on operator skill and experience.[21]
Differential Diagnosis
Several shoulder conditions may present with similar symptoms and require differentiation from massive rotator cuff tears.
- Rotator cuff tendinopathy, Subacromial bursitis.[9]
- Cervical spine pathology including cervical radiculopathy and spondylosis.
- Adhesive capsulitis[17]
- Acromioclavicular joint disorders, glenohumeral osteoarthritis, shoulder instability, and labral pathology including SLAP lesions and Bankart lesions.
- Parsonage-Turner syndrome (neuralgic amyotrophy)
- Calcific tendinopathy.[21]
- Suprascapular neuropathy and biceps Injury.
Outcome Measures
Valid and reliable outcome measures are essential for evaluating treatment effectiveness and facilitating clinical research. Several shoulder-specific instruments have been validated for rotator cuff pathology, each offering distinct advantages.[22]
| Measure | What it measures | Notes |
|---|---|---|
| WORC (Western Ontario Rotator Cuff index) | Disease-specific quality of life | Cuff-specific |
| RC-QOL (Rotator Cuff Quality of Life Index) | Quality of life across five domains: symptoms/physical complaints, work, sport/recreation, lifestyle, social/emotional | Cuff-specific [24] |
| The American Shoulder and Elbow Surgeons (ASES) | Pain (VAS) and function | 100-point scale |
| The Constant-Murley Score (also called the Constant Score) | Pain, ADLs, range of motion and strength | 100 points; combines patient-reported and examiner-assessed items |
| SPADI (Shoulder Pain and Disability Index) | Pain and disability | 13 items, two domains |
| DASH / QuickDASH (Disabilities of the Arm, Shoulder and Hand) | Upper limb function | Region-specific |
Conservative Management
Indications and Evidence
Conservative management represents an appropriate initial treatment approach for many patients with massive rotator cuff tears.[25] Recent evidence from the MOON Shoulder Group demonstrated that 75% of patients with atraumatic full-thickness tears avoided surgery following 6 to 12 weeks of structured physiotherapy, with most surgical decisions occurring within the first 12 weeks.[25]
Conservative treatment is particularly indicated for older patients (over 70 years) with chronic tears, individuals with significant medical comorbidities or low functional demands, and those with irreparable tears characterised by extensive muscle atrophy, fatty infiltration, and superior humeral migration.[17] In pooled analysis research, it found no significant differences in functional outcomes between conservative treatment, surgical repair, and reverse total shoulder arthroplasty for selected patient populations, supporting conservative approaches in appropriate cases.[24]
Ten-year follow-up data from nonoperatively treated patients demonstrate that successful conservative management can provide sustained improvement in quality of life measures, with many patients maintaining functional independence.[24] However, clinicians must inform patients that conservative treatment does not repair the tear and that initially reparable tears may become irreparable over time due to tear progression and muscle degeneration.[17]
Physiotherapy Interventions
Aims of treatment
The primary objectives of physiotherapy for massive rotator cuff tears include pain reduction, restoration of functional movement patterns, strengthening of intact rotator cuff and scapular stabiliser muscles, and improving overall shoulder function for daily activities.[26]
The exercise evidence shows
A recent systematic review examining exercise therapy found that motor control exercise programmes demonstrated superior outcomes compared to non-specific exercise programmes for rotator cuff-related shoulder pain. However, the review noted that effects may be attributable to programme characteristics such as progression and individualisation rather than exercise type alone[27].
Early phase: pain, mobility and scapular control
Initial treatment focuses on pain management, addressing muscle tension in the cervicoscapular region (pectoralis minor, upper trapezius and levator scapulae) and gentle range of motion exercises. Scapular positioning and mobilisation receive early attention, because scapulothoracic dysfunction commonly accompanies rotator cuff tears.[9]
Mid phase: progressive strengthening
Progressive strengthening of the intact rotator cuff muscles and scapular stabilisers is the foundation of mid-phase rehabilitation.
- External rotation strengthening emphasises infraspinatus and teres minor, using side-lying or standing resistance exercises.
- Scapular stabilisation targets serratus anterior and middle/lower trapezius, which provide proximal stability for shoulder function.[17]
Dosage and duration
Exercise dosage follows a principle of diminishing returns, with minimal added benefit from excessive exercise volume. A single well-chosen exercise performed consistently may be as effective as a complex multi-exercise programme for many patients. Rehabilitation typically takes at least 3 months, and some patients need 6 months or longer to achieve optimal outcomes.[27]
Adjunctive Treatments
Several non-operative treatments can be used alongside exercise. The 2025 American Academy of Orthopaedic Surgeons (AAOS) guideline on rotator cuff injuries gives recommendations for many of them. The evidence for most is limited.
Corticosteroid injections
Subacromial corticosteroid injections may give short-term pain relief. They should be limited, because repeated injections may weaken the tendon. The guideline advises no more than three to four injections.[28]
Platelet-rich plasma, hyaluronic acid and prolotherapy
The evidence for platelet-rich plasma (PRP) injections in full-thickness tears is inconclusive, and the guideline found insufficient evidence to recommend for or against them. Hyaluronic acid injections and prolotherapy also lack robust supporting evidence.[28]
Medication
Non-steroidal anti-inflammatory drugs (NSAIDs) can give symptomatic relief and can be part of a multimodal programme. [28]
Manual therapy
Joint mobilisation and soft tissue techniques may address secondary restrictions and make exercise easier. Manual therapy should be an adjunct to active exercise, not a stand-alone treatment.[26]
Education and passive modalities
Patient education covers activity modification, sleep positioning and self-management. There is moderate evidence that passive treatment with modalities is not justified for rotator cuff tears, and active exercise remains the cornerstone of conservative care.[26]
Surgical Management
Indications
Surgical intervention for massive rotator cuff tears requires careful consideration of multiple factors including patient age, functional demands, tear characteristics, muscle quality, and patient expectations. The 2025 AAOS guidelines note that high-level evidence supporting surgical treatment for full-thickness tears over conservative management remains limited, though surgery may be appropriate for selected patients.[28]
Early surgical repair should be considered for significant acute traumatic tears (greater than 1 to 1.5 cm) in younger patients, particularly when imaging demonstrates limited muscle degeneration and fatty infiltration. These patients face higher risks of irreversible muscle changes including tear progression, atrophy, and fatty degeneration if repair is delayed. Recent evidence suggests timing of repair for acute tears may be more critical than previously recognised.[29]
Surgical candidacy depends heavily on tear repairability, determined by tendon quality, degree of retraction, muscle atrophy, and fatty infiltration. Tears with Goutallier grade 3 or 4 fatty infiltration generally demonstrate poor healing potential and may be better managed with alternative approaches including debridement, partial repair, or arthroplasty.[5]
Surgical Techniques
Surgery for rotator cuff tears can repair the tendon back to bone, repair part of it, or reconstruct or replace the cuff when repair is not possible. Technique depends on tear pattern, tissue quality and patient factors.
Arthroscopic repair
Arthroscopic repair is now the predominant approach to rotator cuff repair overall. In a US insurance database, the arthroscopic share of repairs rose from 56.9% in 2007 to 75.1% in 2015.[30] Compared with open repair, the arthroscopic approach gives smaller incisions, less soft tissue dissection, easier access to the glenohumeral joint and less potential harm to the deltoid.[31] In chronic massive tears, arthroscopic repair improves pain, range of motion and function, but the repair failure rate is high (about 36% at a mean of 31 months in one systematic review).[32][7]
Single-row and double-row repair
For repairable tears, both single-row and double-row fixation are used. Systematic reviews found no significant differences in patient-reported outcomes between them, although double-row repair may give lower retear rates in some studies. The choice depends on tear configuration and surgeon preference.[28]
Muscle advancement
All-arthroscopic rotator cuff muscle advancement is based on the Debeyre-Patte procedure. It involves release of the medial insertions of the supraspinatus and infraspinatus muscles. Early reports describe retear rates below 6% with significant clinical improvement, which makes it an option for large to massive tears that were once considered difficult to repair.[29]
Partial repair
When complete repair is not feasible due to tear size or tissue quality, partial repair restoring the anterior or posterior cable may improve pain and function despite incomplete cuff reconstruction. This approach follows the suspension bridge concept, emphasising restoration of force couples rather than complete defect closure.[33]
Irreparable tears
For irreparable massive tears without arthropathy, superior capsular reconstruction and tendon transfers represent alternative options in selected younger patients. Reverse total shoulder arthroplasty has emerged as the treatment of choice for irreparable tears with rotator cuff arthropathy or in older patients with pseudoparalysis, with recent studies demonstrating superior outcomes compared to other salvage procedures.[22]
Postoperative Rehabilitation
Rehabilitation Protocols
Postoperative rehabilitation following rotator cuff repair progresses through four distinct phases: protection and immobilisation, passive range of motion, active motion, and strengthening and functional training. The specific timeline and progression criteria vary based on tear size, tissue quality, repair security, and surgeon preference.[34]
The table below summarises the key principles that guide rehabilitation after repair, and how they change for massive tears. Each row gives the principle, what it means in practice, and the evidence behind it.
| Principle | Summary |
|---|---|
| Structure:
Immediately after surgery the arm is usually kept in a sling or immobiliser, typically for 4 to 6 weeks, with the early phases aiming to protect the repair and reduce pain and inflammation.[32] Range of movement is then restored in stages, from passive to active-assisted to active, which introduces stress to the healing tendon gradually. Strengthening comes last. Scapular muscle activation is started first, then isometric and finally isotonic cuff exercises. Progression is based on criteria such as the movement and control the person has achieved, not only on the number of weeks. Even so, tendon-to-bone healing takes time, so excessive stress on the repair is avoided for up to about 12 weeks. [32] |
Protection, passive motion, active motion, strengthening; criteria-based and not time-based |
| Massive repairs:
Repairs of large and massive tears are under more tension and are more likely to fail. Larger tear size is associated with poorer outcomes and higher structural failure rates. Reported retear rates vary widely depending on how a massive tear is defined and how long people are followed: about 36% in one review, 39% in a long-term review, and 79% in a pooled analysis of chronic tears. For this reason, progression is usually slower, with longer protection and later loading, and the exact timing is set by the surgeon. A retear does not always mean a poor result. Outcomes after a retear are often still better than before surgery, and a meta-analysis found that retears had a statistically significant but clinically small effect on pain and function. This is why the person should be supported through the whole programme even if the repair is not intact.[35][36] |
More conservative progression, with longer protection and delayed loading, because of higher tension and retear risk |
| Early versus delayed motion:
Pooled trials show that early passive or active motion gives better range of movement than delayed motion, with no difference in retear rate or in the Constant-Murley score. Another review found the gains in shoulder flexion were small and became smaller over time, with no important differences in pain or function, and no increase in retear risk.[34] These findings should be applied carefully to massive tears. Earlier reviews raised a concern about recurrent tears with early motion in large tears, and the 2021 review noted that most trials were at high risk of bias and that data for large tears were lacking. The surgeon’s protocol therefore still guides the timing. |
Similar long-term outcomes; possible retear concern for early motion in larger tears |
| Individualisation:
Retear risk rises with age and with larger preoperative tear size, and fatty infiltration of the cuff muscles also affects healing. The therapist should therefore expect a slower and more cautious progression for larger or more complex tears, and for older people or those with poorer tissue quality, and should adapt the programme to the individual.[37] |
Tear size, tissue quality, tendon number, age, BMI, diabetes |
| Communication:
Good results depend on constant communication between the surgical and rehabilitation teams. The therapist needs to know the tear size, tissue quality, how secure the repair is and any restrictions, and the person should be educated early so they have realistic expectations of the time frames involved.[38] |
Close contact between surgeon and therapist is essential |
Exercise Progression
Range of motion (about 6–8 weeks)
Active-assisted and then active range of motion typically begin at 6 to 8 weeks, once adequate tendon healing has occurred.
- Supine active-assisted elevation using a cane or pulley system
- Standing active elevation in pain-free ranges
- External and internal rotation range of motion, advanced gradually according to repair site protection principles.[38]
Strengthening
Strengthening exercises generally starts at 10 to 12 weeks
- Isometric contractions first
- Isotonic exercises with resistance bands and light weights
- Rotator cuff, scapular stabiliser and deltoid strengthening, in coordination patterns that protect the repair
- Scapulothoracic joint rehabilitation, which may improve outcomes after arthroscopic repair.[38]
Functional and sport-specific training represents the final rehabilitation phase, typically occurring 4 to 6 months after surgery. Patients progress to higher-level activities based on achievement of range of motion and strength milestones, with return to full activities guided by tissue healing, functional performance, and individual goals.[39]
Rehabilitation Outcomes
Understanding that communication between surgeon and therapist is essential for optimal outcomes, rehabilitation programmes should be individualised based on specific tear and repair characteristics. Larger tears and repairs under greater tension require more conservative progression, whilst smaller tears may advance more quickly through rehabilitation phases.
Recent systematic reviews examining long-term outcomes demonstrate that repair of massive rotator cuff tears leads to maintained improvements in outcome measures over extended follow-up periods. Failure of repair is common, with retear rates exceeding 50% at 12-month follow-up for large and massive tears. However, results following retear are often superior to preoperative outcomes when patients undergo comprehensive rehabilitation, suggesting rehabilitation may contribute more responsible for outcome improvements than repair integrity alone.[39]
Studies have shown that patients with failed repairs demonstrate similar satisfaction and clinical outcomes to those with intact repairs when both groups undergo comprehensive rehabilitation. This finding emphasises the critical importance of structured postoperative rehabilitation programmes regardless of structural repair integrity.[26][4]
Clinical Bottom Line
Massive rotator cuff tears are heterogeneous. Classify them by size, tendon pattern, fatty infiltration and the presence of arthropathy, because these guide treatment. Assess for pseudoparalysis and weakness in external rotation and elevation, and use clusters of tests followed by MRI where indicated. Non-operative care, centred on a structured exercise programme, is a reasonable first option for many patients. Evidence comes largely from atraumatic full-thickness tears in general rather than massive tears specifically. Surgery is considered for acute traumatic tears in younger patients with good muscle quality, or after failed non-operative care. Choice of procedure depends on repairability and arthropathy. Retears are common, and rehabilitation after repair of massive tears should be slower than for smaller tears. Use shared decision-making and set realistic expectations.
References
- ↑ 1.0 1.1 Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, Kobayashi T. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010 Jan;19(1):116-120.
- ↑ 2.0 2.1 Lädermann A, Denard PJ, Collin P. Massive rotator cuff tears: definition and treatment. Int Orthop. 2015;39(12):2403-2414.
- ↑ 3.0 3.1 3.2 3.3 3.4 Noh KC, Seo JB. Arthroscopic-guided Release of Supraspinatus and Infraspinatus Muscles for Repair of Large-to-Massive Rotator Cuff Tear and Suprascapular Nerve Release. Arthroscopy Techniques. 2024 Sep;13(9):102908.
- ↑ 4.0 4.1 DeOrio JK, Cofield RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am. 1984;66(4):563-567.
- ↑ 5.0 5.1 5.2 Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures: pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;(304):78-83.
- ↑ Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8(6):599-605.
- ↑ 7.0 7.1 Hamada K, Fukuda H, Mikasa M, Kobayashi Y. Roentgenographic findings in massive rotator cuff tears: a long-term observation. Clin Orthop Relat Res. 1990;(254):92-96.
- ↑ Hamada K, Yamanaka K, Uchiyama Y, Mikasa T, Mikasa M. A radiographic classification of massive rotator cuff tear arthritis. Clin Orthop Relat Res. 2011;469(9):2452–2460. doi:10.1007/s11999-011-1896-9.
- ↑ 9.0 9.1 9.2 9.3 9.4 Littlewood C, Malliaras P, Mawson S, May S, Walters SJ. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy. 2025 Apr;55(4):235-274.
- ↑ Rotator Cuff Anatomy. Available from: https://www.youtube.com/watch?v=ubpzaRjH7vA [last accessed 31/1/2026]
- ↑ Magee DJ.Orthopaedic physical assessment.5th ed. St Louis: Elsevier; 2020 publication.
- ↑ Halder AM, Zhao KD, O'Driscoll SW, Morrey BF, An KN. Dynamic contributions to superior shoulder stability. J Orthop Res. 2001;19(2):206–212. doi: 10.1016/S0736-0266(00)00028-0
- ↑ 13.0 13.1 13.2 13.3 13.4 Liao W, Jiang Q, Huang J, Li Z, Lin J, Chen J. Risk factors for symptomatic rotator cuff tears: A case-control study. Frontiers in Medicine. 2023 Dec 11;10:1321939.
- ↑ Lazarides AL, Alentorn-Geli E, Choi JH, Stuart JJ, Lo IK, Garrigues GE, Taylor DC. Rotator cuff tears in young patients: a different disease than rotator cuff tears in elderly patients. J Shoulder Elbow Surg. 2015;24(11):1834-1843. doi:10.1016/j.jse.2015.05.031.
- ↑ 15.0 15.1 Keener JD, Galatz LM, Teefey SA, et al. A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears. J Bone Joint Surg Am. 2015;97(2):89-98.
- ↑ Lädermann A, Denard PJ, Collin P. Massive rotator cuff tears: definition and treatment. Int Orthop. 2015;39(12):2403-2414.
- ↑ 17.0 17.1 17.2 17.3 17.4 17.5 17.6 Park JG, Ha YC. Conservative treatment of older adult patients with shoulder diseases: rotator cuff tears and osteoarthritis. Ewha Medical Journal. 2025 Jan;48(1):e1.
- ↑ Rotator Cuff Examination. Available from: https://www.youtube.com/watch?v=lkWZAo3XCvI [last accessed 31/1/2026]
- ↑ 19.0 19.1 Zhao Q, Palani P, Kassab NS, Brounstein DE, Haydel C. Evidence-based approach to the shoulder examination for subacromial bursitis and rotator cuff tears: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2024 Dec 19;25(1):1028.
- ↑ Jain NB, Luz J, Higgins LD, Dong Y, Warner JJP, Matzkin E, Katz JN. The Diagnostic Accuracy of Special Tests for Rotator Cuff Tear: The ROW Cohort Study. Am J Phys Med Rehabil. 2017 Mar;96(3):176-183.
- ↑ 21.0 21.1 Moya D, Rashid M, Rowinski S, Laver L, Maffulli N. Therapeutic options in rotator cuff calcific tendinopathy. SICOT Journal. 2025 Jan;11:9.
- ↑ 22.0 22.1 Antonacci C, Longo UG, Schena E, De Salvatore S, Carnevale A, Nazarian A, Denaro V. Treatment of degenerative massive rotator cuff tears: a study protocol for a randomised non-inferiority comparative surgical trial. BMC Musculoskeletal Disorders. 2025 Jul 14;26(1):600.
- ↑ Tintu KK, Lakshmanan C, Binu M. Comparative study of conservative and surgical management of rotator cuff tears. International Journal of Medical and Public Health. 2025 Jan;15(1):1838-1843.
- ↑ 24.0 24.1 24.2 Boorman RS, More KD, Koles SL. Ten-year rotator cuff quality of life index (RC-QOL) outcomes following nonoperative treatment of patients with chronic full-thickness rotator cuff tears. JSES International. 2025 Feb;9(1):268-273.
- ↑ 25.0 25.1 Kuhn JE, Dunn WR, Sanders R, An Q, Baumgarten KM, Bishop JY, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013 Oct;22(10):1371–1379. doi:10.1016/j.jse.2013.01.026.
- ↑ 26.0 26.1 26.2 26.3 Littlewood C, May S, Walters S. Exercise rehabilitation in the non-operative management of rotator cuff tears: A review of the literature. International Journal of Sports Physical Therapy. 2023 Jun;18(3):763-777.
- ↑ 27.0 27.1 Wu XJ, Wen CX, Ke JZ, Liang JQ, Ding WQ, Zhong ZM. Specific modes of exercise to improve rotator cuff-related shoulder pain: systematic review and meta-analysis. Frontiers in Sports and Active Living. 2025 Jan 7;6:1506406.
- ↑ 28.0 28.1 28.2 28.3 28.4 American Academy of Orthopaedic Surgeons. Management of Rotator Cuff Injuries: Evidence-Based Clinical Practice Guideline. Rosemont, IL: AAOS; 2025.
- ↑ 29.0 29.1 Morihara T, Kida Y, Furukawa R, Hirose M, Matsumoto T, Takatori R, Kawakami Y, Kuroda R, Matsushita T. Clinical outcomes of primary repair for large and massive rotator cuff tears using an all-arthroscopic rotator cuff muscle advancement technique. JSES International. 2024 May 15;9(3):655-665.
- ↑ Day MA, Westermann RW, Bedard NA, et al. Trends associated with open versus arthroscopic rotator cuff repair. HSS J. 2019;15(2):133-136. doi:10.1007/s11420-018-9628-2. PMID: 31327943.
- ↑ Yamaguchi K, Ball CM, Galatz LM. Arthroscopic rotator cuff repair: transition from mini-open to all-arthroscopic. Clin Orthop Relat Res. 2001;(390):83-94.
- ↑ 32.0 32.1 32.2 Sgroi TA, Cilenti M. Rotator cuff repair: post-operative rehabilitation concepts. Curr Rev Musculoskelet Med. 2018;11(1):86–91. doi:10.1007/s12178-018-9462-7.
- ↑ Alaqaili S, Ali Y, Benzouak T, Altarkait A, Alrajhi K, Shah S, Corban J. Outcomes of partial vs complete repair for large to massive rotator cuff tears: a systematic review and meta-analysis. JSES Rev Rep Tech. 2026;6(4):100834. doi:10.1016/j.xrrt.2026.100834.
- ↑ 34.0 34.1 Lee YJ, Wu CL, Hsu CC, Chiang ER, Lo SF. Early versus delayed mobilisation for arthroscopic rotator cuff repair: a meta-analysis of randomised controlled trials. BMC Musculoskeletal Disorders. 2024 Dec 4;25(1):974.
- ↑ Haleem A, Gohal C, Leroux T, Henry P, Alolabi B, Khan M. Primary arthroscopic repair of massive rotator cuff tears results in significant improvements with low rate of re-tear. Knee Surg Sports Traumatol Arthrosc. 2021;29(7):2134-42. doi:10.1007/s00167-020-06190-3.
- ↑ Shah NS, Suriel Peguero E, Umeda Y, Crawford ZT, Grawe BM. Long-term outcomes of massive rotator cuff tear repair: a systematic review. HSS J. 2022 Feb;18(1):130-7. doi:10.1177/15563316211008137. Epub 2021 Apr 15. PMID:35087343; PMCID:PMC8753535.
- ↑ Longo UG, Carnevale A, Piergentili I, et al. Retear rates after rotator cuff surgery: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2021;22:749. doi:10.1186/s12891-021-04634-6.
- ↑ 38.0 38.1 38.2 Rezaie M, Negahban H, Mostafaee N, Tabatabaei Hashemi ST, Dehghani MR. Comparison of the physiotherapy with and without focus on the scapulothoracic joint on pain, range of motion, functional disability, quality of life, and treatment effectiveness of patients after arthroscopic shoulder rotator cuff tendon repair. Journal of Hand Therapy. 2024 Jul;37(3):319-330.
- ↑ 39.0 39.1 Nuvoli N, Troiano E, Masini A, Bucci A, Oliva F, Maffulli N. Long-Term Outcomes of Massive Rotator Cuff Tear Repair: A Systematic Review. Journal of Clinical Medicine. 2024 Sep 23;13(18):5596.