Levels of Evidence for Primary Research Question
Grades of Recommendation for Summaries or Reviews of Orthopaedic Surgical Studies

Rotator cuff disease represents a significant percentage of presentations to the general orthopaedic surgeon, as well as to subspecialty sports and shoulder surgeons. These presentations can be problematic for a variety of reasons:

  • Poor understanding of the natural history of the disease
  • Inadequately described surgical indications
  • Conflicting information regarding surgical techniques all pose treatment dilemmas

This review article will address some of these issues.

Disease Incidence

It is widely accepted that rotator cuff disease is common. Cadaveric studies, as well as imaging studies, on symptomatic and asymptomatic individuals over age 60 years, reveal full-thickness tear prevalence of at least 10%, and sometimes up to 40%. When partial-thickness tears are included, the percentages can rise by 5% to 20%. These studies show that prevalence is proportional to age, and that geographic variation also exists.

What is not well understood is why only a percentage of these patients are symptomatic, and why only a small percentage (likely <5%) each year require surgery.

Surgical Issues

Conservative vs. Surgical Treatment

There are no well accepted, published guidelines as to which patients with rotator cuff disease require surgery. A recent meta-analysis of surgical indications in clinical outcome studies of rotator cuff repair (86 papers) found that 52% described failure of non-operative treatment as a basis for surgery. Only 26% described the duration of non-operative therapy, and 31% referred to limitations in activities of daily living.

A Level IV review demonstrated that age and gender should not influence surgical decisions, and that it may be appropriate to operate on acute tears. There is a general lack of agreement in surgical decision-making amongst surveyed orthopaedic surgeons.

Surgical Timing

Delays in orthopaedic consultation and surgical wait lists can impact a patient’s clinical situation. It is estimated that 25% of patients presenting with rotator cuff tears are unable to work because of their symptoms, and that of those working, productivity is diminished by 20%. Pain tends to decrease while waiting for surgery, but strength, range of motion, function, and health status do not improve.

Open vs. Arthroscopic Repair

Once the decision to operate on a rotator cuff tear has been made, further issues then arise. The choice of open or arthroscopic repair is primarily influenced by surgeon preference and training. To date, there is no evidence demonstrating a clear benefit of one form of treatment over the other.

A significant problem when interpreting the published evidence is finding studies of sufficient quality to draw meaningful conclusions. A meta-analysis comparing arthroscopic and mini-open cuff repair found only five papers that were Level I-III with >1 year follow-up and used one of four validated outcome tools. The conclusions drawn were that there was no difference in outcome or complication rates.

A Level IV study of 96 patients acknowledged a learning curve for arthroscopic cuff repair, and found trends toward better patient satisfaction and Simple Shoulder Test scores in the arthroscopic group. Tear site and the Simple Shoulder Test had no correlation.

Multiple smaller studies, with results that do not reach statistical significance, have been published. These papers have the potential to confuse the surgeon who is trying to investigate this topic.

Single vs. Double Bundle

The anatomic footprint of the rotator cuff tendon insertions has created another source of debate. Fixation technique has been studied, with investigators proposing that restoration of the footprint and increased contact pressure at the repair site would improve surgical outcomes. Laboratory data support this hypothesis, with double row techniques increasing contact area, contact pressure, load-to-failure, cyclic displacement, and gap formation.8-12 Healed rotator cuff repairs have been shown to result in improved postoperative function.13

Clinical studies have not been as conclusive. Postoperative MRI has, in some studies, shown improved healing with double row techniques,14 but this has not been the case in all studies. No clinical studies have demonstrated a clear benefit of double row techniques for small and medium tears (<3 cm). Large and massive tears may benefit from these techniques (>3 cm), but this is not yet conclusive.

Double row techniques are, therefore, appealing both anatomically and biomechanically, but until sufficient Level I evidence exists, the added surgical difficulty, implant cost, and surgical time are difficult to justify.

Repair Augmentation

A challenge to rotator cuff surgeons is to improve healing rates for surgical repairs, and to make irreparable tears repairable. Cuff augmentation has been investigated for both of these issues. This is especially true for large and massive tears that have reported failure rates of 50%.15 Multiple devices, varying in tissue type, strain, stiffness, and suture failure load have been used with varying success. Further studies are needed before conclusions can be drawn on the success of these augments. Newly developed biologics may also play a role in improving healing and reparability, but concerns regarding inflammatory responses have been raised.16


Rotator cuff disease remains a common and challenging entity for orthopaedic surgeons, and evidence-based treatment guidelines continue to evolve. Further review of non-operative and surgical management is justified. Advances in surgical techniques and development of biologics will be areas of further investigation.


  1. Reilly P., Macleod I., Macfarlane R., Windley J. & Emery R.J.H., Dead men and radiologists don’t lie: a review of cadaveric and radiological studies of rotator cuff tear prevalence, Ann R Coll Surg Engl, 2006; 88: 116-21
  2. Vitale, M.G., Krant, J.J., Gelijns A.C., Heitjan D.F., Arons R.R., Bigliani L.U. & Flatow E.L., Geographic Variations in the Rates of Operative Procedures Involving the Shoulder, Including Total Shoulder Replacement, Humeral Head Replacement, and Rotator Cuff Repair, JBJS(A), 1999; 81-A(6): 763-72
  3. Marx R.G., Koulouvaris P., Chu S.K. & Levy B.A., Indications for Surgery in Clinical Outcome Studies of Rotator Cuff Repair, CORR, 2009; 467(2): 450-56
  4. Oh L.S., Wolf B.R., Hall M.P., Levy B.A. & Marx, R.G., Indications for Rotator Cuff Repair: A Systematic Review, CORR, 2007; 455: 52-63
  5. Dunn W.R., Schackman B.R., Walsh C., Lyman S., Jones E.C., Warren R.F., & Marx R.G., Variation in Orthopaedic Surgeons’ Perceptions About the Indications for Rotator Cuff Surgery, JBJS(A), 2005; 87-A(9): 1978-84
  6. Morse K., Davis A.D., Afra R., Kaye E.K., Schepsis A. & Voloshin I., Clinical Sports Medicine Update: Arthroscopic Versus Mini-open Rotator Cuff Repair: A Comprehensive Review and Meta-analysis, Am J Sports Med, 2008; 36: 1824-8
  7. Buess E., Steuber K-U. & Waibl B., Open Versus Arthroscopic Rotator Cuff Repair: A Comparative View of 96 Cases, Arthroscopy, 2005; 21(5): 597-604
  8. Tuoheti Y., Itoi E., Yamamoto N., Seki N., Abe H., Minagawa H., Okada K. & Shimada Y., Contact Area, Contact Pressure, and Pressure Patterns of the Tendon-Bone Interface After Rotator Cuff Repair Am J Sports Med, 2005; 33: 1869-74
  9. Apreleva M., Ozbaydar M., Fitzgibbons P.G. & Warner J.J.P., Rotator Cuff Tears: The Effect of the Reconstruction Method on Three-Dimensional Repair Site Area, Arthroscopy, 2002; 18 (5): 519-26
  10. Waltrip R.L., Zheng N., Dugas J.R. & Andrews J.R., Rotator Cuff Repair: A Biomechanical Comparison of Three Techniques, Am J Sports Med, 2003; 31: 493-7
  11. Park M.C., Cadet E.R., Levine W.N., Bigliani L.U. & Ahmad C.S., Tendon-to-Bone Pressure Distributions at a Repaired Rotator Cuff Footprint Using Transosseous Suture and Suture Anchor Fixation Techniques, Am J Sports Med, 2005; 33: 1154-9
  12. Mazzocca A.D., Millett P.J., Guanche C.A., Santangelo S.A. & Arciero R.A., Arthroscopic Single-Row Versus Double-Row Suture Anchor Rotator Cuff Repair, Am J Sports Med, 2005; 33: 1861-8
  13. Sugaya H., Maeda K., Matsuki K. & Moriishi J., Repair Integrity and Functional Outcome After Arthroscopic Double-Row Rotator Cuff Repair. A Prospective Outcome Study, JBJS(A), 2007; 89: 953-60
  14. Sugaya H., Maeda K., Matsuki K. & Moriishi J., Functional and Structural Outcome After Arthroscopic Full-Thickness Rotator Cuff Repair: Single-Row Versus Dual-Row Fixation, Arthroscopy, 2005;21: 1307-16
  15. Harryman D.T., Mack L.A., Wang K.Y., Jackins S.E., Richardson M.L. & Matsen F.A., Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff, JBJS(A), 1991;73: 982-89
  16. Iannotti J.P., Codsi M.J., Kwon Y.W., Derwin K., Ciccone J. & Brems J.J., Porcine Small Intestine Submucosa Augmentation of Surgical Repair of Chronic Two-Tendon Rotator Cuff Tears. A Randomized, Controlled Trial, JBJS(A), 2006;88:1238-44

Reprinted with permission from the Fall 2010 issue of COA Bulletin