SITS Muscles | Supraspinatus Most Common | Tear Size Predicts Outcome | Repair vs Reconstruction
COFIELD CLASSIFICATION BY SIZE
Critical Must-Knows
- SITS muscles: Supraspinatus, Infraspinatus, Teres minor, Subscapularis - rotator cuff components
- Force couple concept: RC depresses humeral head while deltoid elevates - loss disrupts mechanics
- Tear progression: Natural history shows increasing size and fatty infiltration over time
- Double-row repair: Improved footprint contact and biomechanical strength vs single-row
- Irreparable tears: Massive retracted tears with Goutallier Grade 3-4 fatty infiltration
Clinical Pearls
- "Supraspinatus initiates abduction - tear causes painful arc 60-120 degrees
- "External rotation lag sign indicates infraspinatus/teres minor insufficiency
- "Subscapularis tear: belly-press test, lift-off test, bear-hug test positive
- "MRI shows tendon gap, retraction, muscle atrophy, fatty infiltration (Goutallier)
Clinical Imaging
Imaging Gallery
Critical Rotator Cuff Tear Exam Points
SITS Anatomy
Four muscles form the rotator cuff: Supraspinatus (superior), Infraspinatus (posterior-superior), Teres minor (posterior-inferior), Subscapularis (anterior). SITS mnemonic. Supraspinatus is the most commonly torn tendon - critical area at footprint 1cm medial to greater tuberosity.
Blood Supply Critical Zone
Hypovascular zone exists 1cm medial to supraspinatus insertion - watershed area between osseous and muscular blood supply. This critical zone is prone to degeneration and tears. Blood supply from suprascapular, anterior circumflex humeral, and posterior circumflex humeral arteries.
Force Couple Biomechanics
The rotator cuff creates a force couple with deltoid: RC compresses and depresses humeral head while deltoid elevates arm. Loss of this balance causes superior migration of humeral head and subacromial impingement. Subscapularis counterbalances posterior cuff.
Tear Progression and Irreparability
Natural history shows progression in size and quality. Goutallier grading (0-4) quantifies fatty infiltration - Grade 3-4 predicts poor repair outcomes. Patte staging (1-3) measures retraction. Tangent sign on MRI indicates advanced atrophy.
Quick Decision Guide - Tear Management
| Patient Profile | Tear Characteristics | Treatment | Key Pearl |
|---|---|---|---|
| Young active (less than 60), acute traumatic | Small-medium tear, minimal retraction | Arthroscopic single or double-row repair | Early repair prevents progression and muscle atrophy |
| Middle-aged (60-70), chronic symptoms | Large tear (3-5cm), moderate fatty change | Double-row repair with margin convergence | Repair still possible but rehabilitation longer |
| Elderly low demand (over 75), chronic | Massive tear, Goutallier 3-4 | Conservative management or reverse TSA | Repair likely to fail - focus on function |
| Young high demand, massive irreparable | Greater than 5cm, severe retraction, fatty change | Superior capsular reconstruction or graft augmentation | Bridging option before arthroplasty |
SITSSITS - Rotator Cuff Components
| S | Supraspinatus Superior cuff, initiates abduction, most commonly torn |
| I | Infraspinatus Posterior cuff, external rotation, suprascapular nerve |
| T | Teres minor Inferior posterior cuff, external rotation, axillary nerve |
| S | Subscapularis Anterior cuff, internal rotation, upper and lower subscapular nerves |
| S | Supraspinatus Superior cuff, initiates abduction, most commonly torn | T | Teres minor Inferior posterior cuff, external rotation, axillary nerve |
| I | Infraspinatus Posterior cuff, external rotation, suprascapular nerve | S | Subscapularis Anterior cuff, internal rotation, upper and lower subscapular nerves |
Hook:The rotator cuff SITS on the humeral head - four muscles stabilizing the glenohumeral joint
EMPTYEMPTY CAN - Supraspinatus Testing
| E | Elevation to 90 degrees Arm abducted in scapular plane (30 degrees forward) |
| M | Maximal internal rotation Thumb pointing down (empty can position) |
| P | Push down against resistance Examiner applies downward force on arm |
| T | Test for pain or weakness Pain indicates tendinitis, weakness indicates tear |
| Y | Yes to supraspinatus pathology Positive test suggests supraspinatus involvement |
| E | Elevation to 90 degrees Arm abducted in scapular plane (30 degrees forward) | T | Test for pain or weakness Pain indicates tendinitis, weakness indicates tear |
| M | Maximal internal rotation Thumb pointing down (empty can position) | Y | Yes to supraspinatus pathology Positive test suggests supraspinatus involvement |
| P | Push down against resistance Examiner applies downward force on arm |
Hook:EMPTY CAN test - like emptying a can with thumb down - isolates supraspinatus function
LAGERLAGER - External Rotation Lag Signs
| L | Lag sign present Arm drops from externally rotated position |
| A | Arm at side Elbow at 90 degrees flexion, arm at side of body |
| G | Greater than 10 degrees drop Positive if more than 10 degrees lag when released |
| E | External rotation attempted Patient tries to maintain external rotation |
| R | Rupture of posterior cuff Indicates infraspinatus/teres minor tear |
| L | Lag sign present Arm drops from externally rotated position | E | External rotation attempted Patient tries to maintain external rotation |
| A | Arm at side Elbow at 90 degrees flexion, arm at side of body | R | Rupture of posterior cuff Indicates infraspinatus/teres minor tear |
| G | Greater than 10 degrees drop Positive if more than 10 degrees lag when released |
Hook:LAGER - like a lager falling when you let go - the arm lags in external rotation with posterior cuff tear
BEARBEAR - Subscapularis Testing
| B | Belly-press test Press hand against belly with elbow forward |
| E | Elbow drops back Positive if elbow moves posterior to trunk |
| A | Arm internal rotation Tests subscapularis function in IR |
| R | Rupture of subscapularis Also lift-off test, bear-hug test |
| B | Belly-press test Press hand against belly with elbow forward | A | Arm internal rotation Tests subscapularis function in IR |
| E | Elbow drops back Positive if elbow moves posterior to trunk | R | Rupture of subscapularis Also lift-off test, bear-hug test |
Hook:BEAR HUG test - hugging like a bear tests the anterior cuff subscapularis muscle
Overview and Epidemiology
Rotator cuff tears are among the most common shoulder pathologies, representing a spectrum from partial-thickness tears to massive full-thickness defects involving multiple tendons. They result from a combination of intrinsic tendon degeneration and extrinsic mechanical factors.
Epidemiology:
- Prevalence increases dramatically with age - rare under 40, common over 60
- Many tears are asymptomatic (up to 50% of individuals over 60 have tears on imaging)
- Symptomatic tears often present with pain, weakness, and functional limitations
- Occupational and sports-related overhead activities increase risk
Asymptomatic Tears
Many rotator cuff tears are asymptomatic, particularly in older individuals. The decision to treat is based on symptoms, functional impairment, and patient goals - not just the presence of a tear on imaging. Asymptomatic tears may progress over time to become symptomatic.
Etiology - Multifactorial:
Intrinsic Factors
- Tendon degeneration: Age-related collagen breakdown, decreased vascularity
- Hypovascular zone: Critical zone 1cm medial to insertion
- Genetics: Family history increases risk
- Smoking: Impairs healing, increases tear size
Extrinsic Factors
- Subacromial impingement: Type I (flat), II (curved), III (hooked) acromion
- Os acromiale: Unfused acromial apophysis causing impingement
- Trauma: Acute on chronic, fall on outstretched hand
- Overuse: Repetitive overhead activity (swimmers, painters, throwers)
Natural History:
- Tear size tends to increase over time (approximately 40% enlarge within 2 years)
- Muscle atrophy and fatty infiltration progress (often irreversible)
- Pain may decrease over time even as tear enlarges (pseudoparalytic shoulder)
- Functional deficits worsen with tear progression
Pathophysiology and Mechanisms
The Rotator Cuff Complex:
The rotator cuff consists of four muscles and their tendons that originate from the scapula and insert on the humeral head, forming a circumferential cuff around the glenohumeral joint.
SITS Muscles - Origins, Insertions, Function, Innervation
| Muscle | Origin | Insertion | Function | Nerve |
|---|---|---|---|---|
| Supraspinatus | Supraspinous fossa scapula | Superior facet greater tuberosity | Initiates abduction 0-30 degrees | Suprascapular (C5-6) |
| Infraspinatus | Infraspinous fossa scapula | Middle facet greater tuberosity | External rotation, stabilization | Suprascapular (C5-6) |
| Teres minor | Lateral border scapula | Inferior facet greater tuberosity | External rotation, adduction | Axillary (C5-6) |
| Subscapularis | Subscapular fossa scapula | Lesser tuberosity | Internal rotation, anterior stability | Upper/lower subscapular (C5-7) |
Blood Supply - Critical Zone:
Hypovascular Critical Zone
The critical zone is a hypovascular area approximately 1cm medial to the supraspinatus insertion on the greater tuberosity. This represents a watershed zone between the osseous blood supply (from the humeral circumflex arteries) and the muscular blood supply (from the suprascapular and thoracoacromial arteries). This zone is particularly prone to degeneration and tear formation.
Arterial supply:
- Suprascapular artery - supplies supra/infraspinatus
- Anterior humeral circumflex artery - supplies anterior cuff and subscapularis
- Posterior humeral circumflex artery - supplies posterior cuff
- Thoracoacromial artery - contributes to anterior structures
Biomechanics - Force Couple Concept:
The rotator cuff creates force couples that stabilize the humeral head:
- Coronal plane: Deltoid (superior force) vs. infraspinatus/teres minor/subscapularis (inferior force)
- Transverse plane: Subscapularis (anterior force) vs. infraspinatus/teres minor (posterior force)
Force Couple Disruption
When the rotator cuff is torn, the force couple is disrupted. The deltoid pulls the humeral head superiorly without the opposing inferior force from the cuff. This causes superior migration of the humeral head, leading to subacromial impingement, acromioclavicular joint arthritis, and eventually rotator cuff arthropathy.
Functional Roles:
- Supraspinatus: Initiates abduction, provides superior compression
- Infraspinatus/Teres minor: External rotation, posterior stabilization
- Subscapularis: Internal rotation, anterior stabilization, resists posterior subluxation
Classification Systems
Cofield Classification by Tear Size
Based on maximum tear dimension in any plane:
| Size | Dimension | Typical Repair | Prognosis |
|---|---|---|---|
| Small | Less than 1cm | Single-row arthroscopic | Excellent healing |
| Medium | 1-3cm | Double-row arthroscopic | Good healing potential |
| Large | 3-5cm | Double-row with convergence | Guarded, longer rehab |
| Massive | Greater than 5cm or 2+ tendons | SCR or reverse TSA | Poor repair outcomes |
Massive Tear Definition
A massive tear is defined as either: (1) greater than 5cm in maximum dimension, OR (2) involvement of two or more complete tendons. These tears have poor healing potential with standard repair and may require alternative treatments like superior capsular reconstruction or reverse total shoulder arthroplasty.
Clinical Assessment
History:
Pain Characteristics
- Location: Anterolateral shoulder, often radiates to deltoid insertion
- Timing: Night pain common (lying on shoulder), difficulty sleeping
- Activity: Pain with overhead activities, reaching behind back
- Onset: Acute traumatic vs insidious degenerative
Functional Deficits
- Weakness: Difficulty with overhead activities, lifting
- Loss of motion: Active motion reduced more than passive
- Activities: Difficulty with hair combing, reaching for wallet
- Occupational: Impact on work, sports, daily living
Physical Examination:
Inspection and Range of Motion
- Inspect: Muscle atrophy (supraspinatus/infraspinatus fossae), asymmetry, scapular dyskinesis
- Active ROM: Often limited by pain and weakness (pseudoparalysis if massive tear)
- Passive ROM: Should be preserved (if limited, consider frozen shoulder, arthritis)
- Painful arc: Pain between 60-120 degrees abduction indicates impingement
Specific Tests for Individual Tendons
Rotator Cuff Physical Examination Tests
| Test | Tendon Tested | Technique | Positive Finding |
|---|---|---|---|
| Empty can (Jobe's) | Supraspinatus | Arm 90deg abducted, 30deg forward, thumb down, resist downward force | Pain or weakness |
| Full can | Supraspinatus | Arm 90deg abducted, 30deg forward, thumb up, resist downward force | Pain or weakness (more specific) |
| External rotation lag sign | Infraspinatus | Elbow 90deg flexed, arm at side, passively externally rotate, patient maintains | Arm drops greater than 10 degrees |
| Hornblower's sign | Teres minor | Arm 90deg abducted, elbow 90deg, externally rotate against resistance | Cannot maintain external rotation |
| Lift-off test | Subscapularis | Hand behind back, lift off from back against resistance | Cannot lift hand off back |
| Belly-press test | Subscapularis | Press hand against belly with elbow forward | Elbow moves posterior to trunk |
| Bear-hug test | Subscapularis | Hand on opposite shoulder, resist pull-off | Cannot resist or elbow drops |
External Rotation Lag Sign Importance
The external rotation lag sign is highly specific for a posterosuperior rotator cuff tear (infraspinatus/teres minor). A positive lag greater than 10 degrees indicates a large tear. The hornblower's sign (inability to externally rotate at 90 degrees abduction) suggests an even larger tear involving teres minor.
Impingement Tests
- Neer impingement sign: Passive forward flexion causes pain (subacromial impingement)
- Hawkins-Kennedy test: 90deg forward flexion, internal rotation causes pain
- These tests are sensitive but not specific for rotator cuff tears
Strength Testing
- Supraspinatus strength: Empty can or full can test
- External rotation strength: Resisted ER at side and at 90deg abduction
- Internal rotation strength: Resisted IR (belly press, lift-off)
- Pseudoparalysis: Inability to actively elevate arm despite full passive motion (massive tear)
Differential Diagnosis
Differential Diagnosis of the Painful, Weak Shoulder
| Condition | Key Distinguishing Features | Discriminating Test/Imaging |
|---|---|---|
| Rotator cuff tear | Active more than passive motion loss, night pain, weakness in plane of torn tendon | Positive lag/empty-can tests; MRI or ultrasound shows tendon defect |
| Adhesive capsulitis (frozen shoulder) | Global loss of BOTH active AND passive motion, especially external rotation | Equal active/passive restriction; near-normal cuff on imaging |
| Subacromial impingement / cuff tendinopathy | Painful arc with preserved strength, no true tendon discontinuity | Positive Neer/Hawkins; MRI shows tendinopathy without full-thickness gap |
| Glenohumeral osteoarthritis | Stiffness, crepitus, deep joint-line pain, reduced passive rotation | Radiographs show joint-space loss, osteophytes, often intact cuff |
| Cervical radiculopathy (C5-C6) | Neck pain, dermatomal radiation, sensory change, reflex changes | Spurling test positive; normal shoulder exam; MRI cervical spine |
| Suprascapular neuropathy | Isolated infraspinatus/supraspinatus weakness and wasting without tendon tear | EMG/nerve conduction; MRI may show spinoglenoid/suprascapular ganglion cyst |
| Calcific tendinitis | Acute severe pain, often self-limiting, may mimic tear | Radiographs/ultrasound show calcific deposit in tendon |
Investigations
Imaging Protocol for Suspected Rotator Cuff Tear
Standard shoulder series: AP (3 views - neutral, internal rotation, external rotation), scapular Y, axillary lateral
What to assess:
- Acromiohumeral distance (normal greater than 7mm, less than 7mm suggests massive tear)
- Acromial morphology (Type I flat, II curved, III hooked - Bigliani)
- Os acromiale (unfused acromial apophysis)
- Greater tuberosity cysts, sclerosis, osteophytes
- Glenohumeral arthritis, acromioclavicular arthritis
- Superior migration of humeral head (chronic massive tear)
MRI is the gold standard for rotator cuff assessment
Sensitivity/Specificity: Greater than 90% for full-thickness tears
What MRI shows:
- Tear presence, size (anteroposterior and mediolateral), location
- Partial vs full-thickness, articular vs bursal side
- Tendon retraction (Patte staging 1-3)
- Muscle atrophy (tangent sign on sagittal view)
- Fatty infiltration (Goutallier grading 0-4)
- Associated pathology (labral tears, biceps pathology, bone marrow edema)
Operator-dependent but useful in experienced hands
- Dynamic assessment, lower cost than MRI
- Good for full-thickness tears (sensitivity 90%)
- Less accurate for partial tears, muscle quality
- Useful for guided injections
Less commonly used, but helpful in specific scenarios
- Cannot have MRI (pacemaker, metallic implants)
- Assessment of bone quality (revision surgery, arthroplasty planning)
- Goutallier grading of fatty infiltration possible
Imaging Examples
MRI Prognostic Factors
Key MRI findings that predict poor repair outcomes:
- Goutallier Grade 3-4 fatty infiltration (more fat than muscle)
- Patte Stage 3 retraction (medial to glenoid)
- Positive tangent sign (muscle belly below superior glenoid line)
- Massive tear size (greater than 5cm or 2 tendons)
- Acromiohumeral distance less than 7mm (chronic massive tear with superior migration)
MRI Grading Scheme
Management Algorithm
Non-Operative Treatment
Indications:
- Elderly, low-demand patients
- Asymptomatic or minimally symptomatic tears
- Massive tears with Goutallier 3-4 (poor repair prognosis)
- Medical comorbidities precluding surgery
- Patient preference
Conservative Treatment Steps
- Avoid painful overhead activities
- Modify work and sport activities
- Ergonomic adjustments
- Scapular stabilization: Strengthen periscapular muscles
- Deltoid strengthening: Compensate for cuff weakness
- Stretching: Maintain or improve passive range of motion
- Posterior capsule: Address tightness contributing to superior migration
- NSAIDs: Reduce inflammation and pain
- Analgesics: Paracetamol for pain control
- Subacromial corticosteroid injection: Reduce pain and inflammation
- Limit to 3 injections per year (tendon weakening risk)
- May provide temporary relief but does not heal tear
Tear Progression with Conservative Treatment
40% of rotator cuff tears increase in size within 2 years of conservative management. Muscle atrophy and fatty infiltration also progress and are largely irreversible. Delaying surgery may worsen repairability. In young, active patients with symptomatic tears, consider early surgery.
Management Algorithm
Surgical Technique
Single-Row Repair Technique
Indications: Small to medium tears (less than 3cm), good tissue quality
Pre-operative Planning:
Consent Points
- Re-tear: 10-30% depending on tear size and quality
- Stiffness: 5-10% risk, may require manipulation
- Infection: Less than 1% arthroscopic
- Nerve injury: Axillary nerve at risk (rare)
- Failure to heal: May require revision or alternative treatment
Equipment Checklist
- Arthroscope: 30-degree and 70-degree
- Anchors: Suture anchors (typically 2-4 for small-medium tear)
- Suture: High-strength non-absorbable (FiberWire, MaxBraid)
- Instruments: Graspers, suture retrievers, knot pushers
- Radiofrequency device: For debridement, hemostasis
Patient Positioning
Beach chair position (most common) or lateral decubitus:
Beach Chair Setup
Beach chair at 60-70 degrees upright
- Head secured in headrest with neutral position
- Arm free-draped to allow full range of motion
- Arm holder or assistant to position limb
- Bony prominences: Pad sacrum, heels, contralateral elbow
- Blood pressure: Monitor on contralateral arm
- Hypotensive anesthesia: Consider to reduce bleeding (MAP 55-65)
- Mark bony landmarks: acromion, clavicle, coracoid, AC joint
- Plan portal sites: posterior, lateral, anterior
Surgical Steps
Arthroscopic Repair Steps
Posterior portal (standard viewing portal)
- Glenohumeral joint: Assess cartilage, labrum, biceps, subscapularis
- Identify tear location, size, mobility
- Assess articular-side partial tears
Subacromial space visualization
- Lateral portal for instrument access
- Bursectomy to visualize cuff tear
- Acromioplasty if Type II or III acromion
- Avoid aggressive acromioplasty (weakens deltoid origin)
Prepare tendon for repair
- Release adhesions (interval slide for anterior-posterior mobility)
- Debride frayed edges (minimal debridement to preserve tissue)
- Prepare footprint on greater tuberosity (remove soft tissue, light decortication)
Single-row medial anchors
- Place anchors at articular margin (medial footprint)
- Spacing: 1-1.5cm apart, typically 2-4 anchors depending on tear size
- 45-degree deadman angle for optimal pull-out strength
Pass sutures through tendon
- Suture passer through tear, retrieve anchor suture
- Horizontal mattress configuration for strength
- Ensure adequate tissue bites (5-8mm from edge)
- Consider medial-lateral or side-to-side sutures if large gap
Secure repair
- Tie sliding or non-sliding knots (surgeon preference)
- Assess repair integrity, tension, footprint coverage
- Check range of motion (should achieve 140deg forward flexion without undue tension)
Single-Row Limitations
Single-row repair restores partial footprint contact but may have higher re-tear rates for larger tears compared to double-row. The tendon is fixed to the medial edge of the footprint only. For medium to large tears, double-row provides better biomechanical strength and footprint restoration.
Complications
Complications of Rotator Cuff Surgery
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Re-tear | 10-30% (size-dependent) | Large tears, poor tissue quality, Goutallier 3-4, age over 65 | Revision repair, SCR, or arthroplasty |
| Stiffness/frozen shoulder | 5-10% | Pre-existing stiffness, diabetes, prolonged immobilization | Aggressive PT, manipulation under anesthesia |
| Infection | Less than 1% arthroscopic | Diabetes, immunosuppression, revision surgery | Antibiotics, irrigation/debridement, anchor removal |
| Deltoid dysfunction | 1-2% | Aggressive acromioplasty, nerve injury | Observation, nerve recovery, physio |
| Nerve injury (axillary, suprascapular) | Less than 1% | Traction, retractor placement, anchor misplacement | Observation (most recover), nerve exploration if no recovery |
| Anchor pull-out | 1-3% | Poor bone quality, osteoporosis, incorrect angle | Revision with larger anchors or different location |
Re-tear - Most Common Complication:
Re-tear Risk Factors
Factors predicting rotator cuff re-tear:
- Tear size: Small (10%), medium (15%), large (20%), massive (30-40%)
- Fatty infiltration: Goutallier 3-4 dramatically increases re-tear
- Age: Over 65 years higher risk
- Smoking: Impairs healing, doubles re-tear rate
- Diabetes: Poor tissue quality, delayed healing
- Repair technique: Single-row higher re-tear than double-row for medium-large tears
Despite re-tear, many patients remain clinically improved with reduced pain even if MRI shows persistent defect.
Stiffness Prevention:
- Early passive range of motion (start within first week)
- Progress to active-assisted motion at 6 weeks
- Avoid prolonged immobilization
- Diabetic patients at highest risk - aggressive PT protocol
Postoperative Care and Rehabilitation
Rehabilitation Protocol:
Standard Rehabilitation Timeline
Goals: Protect repair, prevent stiffness, minimize pain
- Sling: Wear at all times except for exercises and hygiene (4-6 weeks)
- Passive ROM: Start within first week, pendulums, table slides
- Forward flexion passive: Progress to 140 degrees by 6 weeks
- External rotation passive: Progress to 30-40 degrees by 6 weeks
- No active motion: Avoid activating repaired tendons
- Cryotherapy and pain control: Ice, analgesics, minimize NSAIDs (may impair healing)
Goals: Transition to active motion, gentle strengthening
- Discontinue sling at 6 weeks
- Active-assisted ROM: Pulley exercises, wand exercises
- Progress to active ROM: Deltoid-initiated elevation, avoid substitution patterns
- Begin gentle isometrics: Sub-maximal contractions, avoid pain
- Scapular stabilization: Periscapular muscle activation
Goals: Restore strength and function
- Progressive resistance exercises: Light weights progressing to heavier
- Rotator cuff strengthening: Resistance band exercises (IR, ER, abduction)
- Functional activities: Return to daily activities, work
- Sport-specific training: Gradual return to overhead sports (6 months minimum)
Goals: Full strength and function
- Most patients achieve maximal improvement by 12 months
- Continued home exercise program for maintenance
- Return to full sport/work as tolerated
Outcomes and Prognosis
Outcomes by Tear Size:
| Tear Size | Healing Rate | Functional Outcome | Notes |
|---|---|---|---|
| Small (less than 1cm) | 90-95% | Excellent | Most reliable results |
| Medium (1-3cm) | 80-90% | Good to excellent | Double-row improves healing |
| Large (3-5cm) | 60-80% | Good | Healing less predictable, longer rehab |
| Massive (greater than 5cm) | 30-60% | Fair to good | Even with re-tear, pain often improved |
Prognostic Factors for Success:
Favorable factors:
- Younger age (less than 60 years)
- Acute traumatic tear (as opposed to chronic degenerative)
- Small to medium tear size
- Good tissue quality (Goutallier 0-1)
- Minimal retraction (Patte 1-2)
- Non-smoker
- Compliant with rehabilitation
Unfavorable factors:
- Advanced age (over 70)
- Massive tear
- Chronic tear (greater than 6 months)
- Goutallier Grade 3-4 fatty infiltration
- Patte Stage 3 retraction
- Smoking, diabetes, worker's compensation
- Poor patient compliance
Clinical vs Structural Outcomes
Important distinction: Structural healing (tendon heals on MRI) does not always correlate with clinical outcome (pain and function). Many patients with re-tears on imaging have good clinical outcomes with improved pain and function compared to pre-operative state. The goal is a satisfactory clinical result, not necessarily perfect anatomic healing.
Evidence Base and Key Trials
Single-Row vs Double-Row Repair - Systematic Review and Meta-Analysis
- Systematic review and meta-analysis including 6 Level I RCTs of single-row versus double-row repair
- Odds of an intact (healed) tendon were significantly higher with double-row repair (OR 1.93)
- No clinically significant difference in Constant, UCLA or ASES scores between techniques
- Structural benefit of double-row was concentrated in tears greater than 3cm (large/massive)
Natural History of Asymptomatic Rotator Cuff Tears
- Longitudinal sonographic study of patients with a contralateral asymptomatic rotator cuff tear
- 51% (23/45) of initially asymptomatic tears became symptomatic over a mean of 2.8 years
- Onset of symptoms was associated with a significant rise in pain and fall in ADL scores
- 9 of 23 re-imaged shoulders showed tear enlargement; no tear ever decreased in size
MOON Shoulder Group - Physical Therapy for Atraumatic Cuff Tears
- Multicentre prospective cohort of 452 patients with atraumatic full-thickness tears on a structured physiotherapy programme
- Patient-reported outcomes improved significantly at 6 and 12 weeks
- Fewer than 25% elected surgery; most who converted did so between 6 and 12 weeks
- Approximately 75% avoided surgery at 2-year follow-up
Superior Capsular Reconstruction for Irreparable Tears (Original Series)
- Original clinical series: 24 shoulders in 23 patients (mean age 65) with irreparable tears, arthroscopic SCR using fascia lata autograft
- Active elevation improved from 84 to 148 degrees and external rotation from 26 to 40 degrees
- Acromiohumeral distance restored from 4.6mm to 8.7mm (reversed superior migration)
- 83.3% had no graft or tendon retear; ASES score improved from 23.5 to 92.9
Reverse Total Shoulder Arthroplasty - Survivorship Analysis
- Multicentre survivorship study of 80 reverse total shoulder replacements followed 5 to 10 years
- Implant survival 91% at 120 months (endpoint: prosthesis replacement); 84% for glenoid loosening
- Shoulders with cuff-tear arthropathy survived significantly better than other aetiologies
- Functional survival (Constant score under 30 as endpoint) fell to 58% at 120 months, with deterioration after 6 years
Prevalence and Risk Factors in the General Population
- Population-based ultrasound survey of 1,366 shoulders (683 residents) in a Japanese village
- Full-thickness rotator cuff tears present in 20.7% overall, with prevalence rising steeply with age
- Tears found in 36% of symptomatic but also 16.9% of asymptomatic individuals
- Independent risk factors on regression: history of trauma, dominant arm and increasing age
Exam Viva Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Scenario 1: Chronic Rotator Cuff Tear Assessment (~2-3 min)
"A 62-year-old recreational golfer presents with 12 months of progressive right shoulder pain and weakness. He has failed physiotherapy and a subacromial steroid injection. On examination, he has full passive range of motion, painful arc 60-120 degrees, positive empty can test, and external rotation lag sign of 15 degrees. MRI shows a full-thickness supraspinatus tear measuring 2.5cm with minimal retraction and Goutallier Grade 1 fatty infiltration of supraspinatus and infraspinatus. What is your assessment and management?"
Scenario 2: Massive Irreparable Tear (~3-4 min)
"A 55-year-old manual laborer presents with severe right shoulder pain and inability to lift his arm. He fell off a ladder 6 months ago but delayed seeking treatment. Examination shows pseudoparalysis - he cannot actively elevate beyond 40 degrees but has full passive forward flexion. External rotation lag is 30 degrees. MRI shows a massive retracted tear of supraspinatus and infraspinatus (5.5cm), Patte Stage 3 retraction medial to the glenoid, Goutallier Grade 3 fatty infiltration, and positive tangent sign. Acromiohumeral distance is 4mm. How would you manage this patient?"
Scenario 3: Post-Operative Stiffness Complication (~2-3 min)
"A 68-year-old diabetic woman underwent arthroscopic rotator cuff repair for a medium-sized tear 3 months ago. She returns to clinic with severe stiffness - active forward flexion is 60 degrees and passive forward flexion is 90 degrees. She reports shoulder pain at rest and with movement. She has been compliant with physiotherapy. How do you assess and manage this complication?"
MCQ Practice Points
Anatomy Question
Q: Which rotator cuff muscle is NOT innervated by the suprascapular nerve? A: Teres minor (innervated by axillary nerve). Supraspinatus and infraspinatus are both innervated by the suprascapular nerve (C5-6). Subscapularis is innervated by upper and lower subscapular nerves (C5-7).
Blood Supply Question
Q: What is the critical zone of the rotator cuff and why is it significant? A: The critical zone is a hypovascular area approximately 1cm medial to the supraspinatus insertion. It represents a watershed zone between the osseous blood supply (humeral circumflex arteries) and muscular blood supply (suprascapular artery). This area is particularly prone to degeneration and tear formation.
Classification Question
Q: A rotator cuff tear measuring 4cm with Goutallier Grade 3 fatty infiltration and Patte Stage 3 retraction - what is the prognosis for repair? A: Poor prognosis. This is a large tear (3-5cm by Cofield) with unfavorable prognostic factors: Goutallier Grade 3 (more fat than muscle) predicts poor healing, and Patte Stage 3 retraction (medial to glenoid) makes repair technically difficult. This tear may be irreparable and alternative treatments (partial repair, SCR, reverse TSA) should be considered.
Examination Question
Q: What does a positive external rotation lag sign indicate? A: An external rotation lag sign (arm drops more than 10 degrees when released from passive external rotation) indicates a posterosuperior rotator cuff tear involving infraspinatus and possibly teres minor. It is highly specific for a significant tear and suggests the need for surgical intervention.
Surgical Technique Question
Q: What is the biomechanical advantage of double-row repair over single-row repair for medium to large rotator cuff tears? A: Double-row repair provides: (1) Increased footprint contact area - better anatomic restoration, (2) Higher ultimate load to failure - stronger construct, (3) Better pressure distribution across repair site, (4) Lower re-tear rates for medium-large tears compared to single-row. However, clinical outcome scores are similar between techniques.
Complication Question
Q: A patient has a confirmed rotator cuff re-tear on MRI at 1 year post-repair but reports good pain relief and improved function. What is your management? A: No further surgery. This demonstrates that structural healing (MRI) does not always correlate with clinical outcome. Many patients with re-tears have good clinical outcomes with improved pain and function. If the patient is satisfied and functional, no additional intervention is needed. Surgery would only be considered for symptomatic re-tear with significant pain or functional impairment.
Guidelines, Registries & Global Practice
Global Epidemiology
Prevalence
- Population ultrasound prevalence of full-thickness tears approximately 20% overall, rising steeply with age (Yamamoto, Japan)
- Tears in 16.9% of asymptomatic and 36% of symptomatic individuals - many tears are clinically silent
- Prevalence increases markedly beyond the sixth decade across all studied populations
Risk Factors and Burden
- Independent risk factors: increasing age, history of trauma, and dominant arm involvement
- Higher rates in heavy manual and repetitive overhead work; smoking and diabetes impair tendon quality and healing
- Ageing populations worldwide are driving a rising burden of degenerative tears and cuff-tear arthropathy
According to PubMed, the population prevalence figures above are from Yamamoto et al (DOI).
Major Guidelines - Side by Side
Guideline Positions on Rotator Cuff Tear Management
| Body (Region) | Position on Non-operative Care | Position on Surgery | Evidence Strength |
|---|---|---|---|
| AAOS (USA) CPG | Structured exercise reasonable first-line for many tears | Repair appropriate for symptomatic full-thickness tears failing non-operative care; routine acromioplasty not required | Mostly moderate/limited - few strong recommendations |
| BESS / BOA (UK) | Time-limited physiotherapy trial for atraumatic/degenerative tears | Early referral and repair for acute traumatic tears in suitable patients | Consensus-based national pathway |
| NICE / NHS (UK) | Conservative care and physiotherapy as initial management | Surgery reserved for persistent symptoms after appropriate non-operative care | Pragmatic, resource-aware guidance |
| EFORT / European consensus | Non-operative care for degenerative tears, especially low-demand patients | Earlier repair favoured in young/active and acute traumatic tears to limit irreversible change | Expert consensus and cohort evidence |
Where Guidelines Genuinely Differ
The strongest cross-guideline agreement is that acute traumatic tears in active patients warrant early repair, while degenerative/atraumatic tears merit a structured physiotherapy trial first - supported by the MOON cohort showing roughly 75% avoid surgery (Kuhn et al, DOI). Practice variation is greatest around the value of routine acromioplasty and the role of superior capsular reconstruction.
Registry and High-Level Evidence
- Rotator cuff repair is a soft-tissue procedure and is not captured by the major arthroplasty joint registries (NJR, AJRR, AOANJRR, SHAR). The evidence base therefore rests on RCTs and meta-analyses (e.g. single- vs double-row, DOI) and large prospective cohorts (MOON).
- Reverse total shoulder arthroplasty for cuff-tear arthropathy is registry-tracked: national arthroplasty registries (NJR, AOANJRR, AJRR, Nordic registries) report rising reverse-TSA volumes and implant survival, complementing survivorship series such as Guery et al (DOI).
Global Practice Variation
High-Resource Settings
- Arthroscopic repair is standard; MRI used routinely for staging
- Ready access to reverse TSA and graft augmentation (SCR, dermal allograft)
- Earlier surgical intervention in active patients
Limited-Resource Settings
- Ultrasound often the primary imaging modality (lower cost, dynamic)
- Open or mini-open repair more common where arthroscopic expertise/equipment is limited
- Greater reliance on physiotherapy and longer non-operative trials
Consent and Documentation (Universal)
Core Consent Points
Applicable to any health system, informed consent for rotator cuff repair should cover:
- Re-tear risk (10-30%, size-dependent), and that re-tear does not always mean symptomatic failure
- Stiffness (5-10%, higher in diabetics), infection (under 1% arthroscopic), nerve injury and anchor complications
- Prolonged recovery (6-12 months to maximal improvement; longer for large/massive tears)
- Possibility of failed repair requiring revision, SCR or arthroplasty
- Documented trial and failure of appropriate non-operative care, and pre-operative staging of tear size, retraction and muscle quality (Goutallier)
ROTATOR CUFF TEARS
Clinical summary
Key Anatomy - SITS
- •Supraspinatus: Superior cuff, initiates abduction, most commonly torn (suprascapular nerve C5-6)
- •Infraspinatus: Posterior cuff, external rotation (suprascapular nerve C5-6)
- •Teres minor: Posterior-inferior cuff, external rotation (axillary nerve C5-6)
- •Subscapularis: Anterior cuff, internal rotation (upper/lower subscapular nerves C5-7)
- •Critical zone: Hypovascular area 1cm medial to insertion - prone to degeneration
Classification Systems
- •Cofield by size: Small (less than 1cm), Medium (1-3cm), Large (3-5cm), Massive (greater than 5cm or 2 tendons)
- •Goutallier fatty infiltration: Grade 0 (normal) to Grade 4 (severe fat) - Grade 3-4 predicts poor repair
- •Patte retraction: Stage 1 (near tuberosity), Stage 2 (glenoid rim), Stage 3 (medial to glenoid)
- •Tangent sign: Muscle belly below superior glenoid line on sagittal MRI indicates severe atrophy
Clinical Assessment
- •Empty can test: Supraspinatus (arm 90deg abducted, 30deg forward, thumb down)
- •External rotation lag sign: Infraspinatus (drop greater than 10 degrees when released from ER)
- •Belly-press, lift-off, bear-hug tests: Subscapularis tears
- •Pseudoparalysis: Cannot actively elevate but full passive motion (massive tear)
Surgical Techniques
- •Single-row repair: Medial anchors only, suitable for small tears
- •Double-row repair: Medial and lateral rows, better for medium-large tears (improved footprint, lower re-tear)
- •Margin convergence: Side-to-side sutures for large U-shaped tears before bone fixation
- •Superior capsular reconstruction: Fascia lata graft for irreparable tears in young patients
- •Reverse TSA: Gold standard for cuff arthropathy with pseudoparalysis in elderly
Complications and Outcomes
- •Re-tear: 10-30% (size-dependent) - many asymptomatic, good clinical outcomes despite re-tear
- •Stiffness: 5-10%, higher in diabetics - early mobilization, aggressive PT, consider MUA
- •Prognostic factors: Tear size, Goutallier grade, Patte stage, age, smoking, diabetes
- •Rehabilitation: Passive immediate, active-assisted 6 weeks, strengthening 12 weeks, maximal improvement 12-24 months
Key Evidence and Pearls
- •Double-row reduces re-tear for medium-large tears but similar clinical outcomes to single-row
- •Tears progress in size (40% enlarge in 2 years) and fatty change (irreversible)
- •Goutallier 3-4 and Patte 3 indicate irreparable tear - consider SCR or reverse TSA
- •Force couple concept: RC compresses humeral head, deltoid elevates - disruption causes superior migration
- •Asymptomatic tears common (50% over age 60) - treat symptoms, not imaging