BACKGROUND: Partial-thickness rotator cuff tears treated with an isolated bioinductive repair (IBR) in lieu of a completion-and-repair have shown complete healing. This treatment option is afforded by the remaining tendon\'s structural integrity, which is similar to that present in small/medium full-thickness tears (FTTs) when the rotator cable remains intact. This randomized controlled trial (RCT) investigated whether an IBR for small/medium full-thickness tears resulted in superior healing and patient-reported outcomes (PROs) compared with a sutured repair.
METHODS: This prospective, double blinded (patients and outcome assessors), single-center randomized controlled trial enrolled patients ≥18 years with a small/medium (≤2.5 cm) full thickness supraspinatus tear and intact rotator cable. Patients were randomized and blinded to arthroscopic transosseous-equivalent repair (control, n = 30) or IBR (n = 30). The primary outcome was tendon quality on biopsy at 6 months. Secondary outcomes were PROs (American Shoulder and Elbow Surgeons [ASES], Constant-Murley Shoulder [CMS], and pain visual analogue scale scores) and tendon thickness and healing measured via MRI at 6, 12, and 24 months; satisfaction at 12 and 24 months; and time to return to work.
RESULTS: Baseline demographic, tear, and surgical characteristics were comparable between the groups (IBR: mean age, 54.2 years, 14 male; control: mean age, 56.4 years, 16 male). Measured via a 6-month biopsy, highly organized, parallel bundles of collagen, without inflammation, were present in all IBR patients, whereas poorly organized, nonparallel collagen fibers were present in 24/30 (80%) of control patients (P < .0001), with 28/30 having minimal to mild inflammation. The increase in tendon thickness measured via MRI at 6 months from baseline was greater in the IBR group (2.0 mm) than in the control group (0.8 mm) (P < .0001). All IBR patients had 100% healing on MRI at 12 and 24 months. Compared with the control group, the IBR group had higher American Shoulder and Elbow Surgeons and Constant-Murley Shoulder scores at each evaluation, less pain at 6 and 12 months, and greater satisfaction at 12 and 24 months (P < .0003). The IBR group returned to work significantly faster (median 90 days [IQR, 25] vs. median 163.5 days [IQR, 24]; P < .0001) than the control group.
CONCLUSIONS: Compared with a sutured repair, the IBR treatment resulted in superior tendon quality, patient outcomes, satisfaction, and return to work. The IBR enabled a robust healing response evident through MRI and biopsy evaluation, demonstrating superior tendon quality and healing.

BACKGROUND: Healing failure after rotator cuff repair is a challenging problem. Acute, trauma-related tears are considered a separate entity and are often treated surgically. The aim of this study was to identify factors associated with healing failure in previously asymptomatic patients with trauma-related rotator cuff tears treated with early arthroscopic repair.
METHODS: This study included 62 consecutively recruited patients (23% women; median age, 61 years; age range, 42-75 years) with acute symptoms in a previously asymptomatic shoulder and a magnetic resonance imaging-verified full-thickness rotator cuff tear after shoulder trauma. All patients were offered, and underwent, early arthroscopic repair, during which a biopsy specimen was harvested from the supraspinatus tendon and analyzed for signs of degeneration. Of the patients, 57 (92%) completed 1-year follow-up and underwent assessment of repair integrity on magnetic resonance images according to the Sugaya classification. Risk factors for healing failure were investigated using a causal-relation diagram where age, body mass index, tendon degeneration (Bonar score), diabetes mellitus, fatty infiltration (FI), sex, smoking, tear location regarding integrity of the rotator cable, and tear size (number of ruptured tendons and tendon retraction) were included and analyzed.
RESULTS: Healing failure at 1 year was identified in 37% of patients (n = 21). A high degree of FI of the supraspinatus muscle (P = .01), a tear location including disruption of rotator cable integrity (P = .01), and old age (P = .03) were associated with healing failure. Tendon degeneration as determined by histopathology was not associated with healing failure at 1-year follow-up (P = .63).
CONCLUSIONS: Older age, increased FI of the supraspinatus muscle, and a tear including disruption of the rotator cable increased the risk of healing failure after early arthroscopic repair in patients with trauma-related full-thickness rotator cuff tears.

A retear after rotator cuff repair is a common problem; however, there is little information related to the prognosis after a retear. In addition, some patients with retears have satisfactory outcomes, which raises the question of whether a retear leads to a poor prognosis.
To identify radiological factors that influence the prognosis after a retear.
Case-control study; Level of evidence, 3.
A total of 51 patients with retears confirmed by magnetic resonance imaging at 1 year after arthroscopic rotator cuff repair with a minimum follow-up of 24 months were enrolled in this study. Patients were divided into 2 groups according to whether they achieved the minimal clinically important difference for clinical outcome measures. Range of motion and radiological variables, including preoperative and postoperative anteroposterior (AP) and mediolateral (ML) tear sizes, sagittal extent of the retear, acromiohumeral distance (AHD), and degree of fatty degeneration, were analyzed using magnetic resonance imaging.
Overall, 36 patients were allocated to the good prognosis (GP) group and 15 to the poor prognosis (PP) group. The 2 groups had no significant differences in baseline demographics and preoperative radiological parameters. Postoperative range of motion was decreased in the PP group at the last follow-up. The AP and ML retear sizes decreased in both groups after arthroscopic rotator cuff repair, but the retear size was significantly larger in the PP group (both P < .05). The AHD increased in the GP group (P < .001) but decreased in the PP group (P = .230) postoperatively. Logistic regression analysis revealed that postoperative AHD (P = .003), fatty degeneration of the infraspinatus tendon (P = .001), posterior (P = .007) and anterior (P = .025) sagittal extent of the retear, and change in the AP tear size (P = .017) were related to poor outcomes after a retear. However, change in the ML tear size (P = .105) and middle sagittal extent of the retear (P = .878) were not related to a poor prognosis. Also, further analysis showed that posterior (P = .006) and anterior (P = .003) sagittal extent of the retear were related to rotator cable involvement.
An increased AP retear size and decreased AHD were radiological parameters that were associated with poor clinical outcomes after a retear. In particular, patients who had posterior and anterior sagittal extent of the retear, possibly with rotator cable involvement and more severe fatty degeneration of the infraspinatus tendon, showed worse outcomes.

A cross-sectional inter-examiner agreement and reliability study on fresh frozen cadaver shoulders.
Musculoskeletal ultrasound (MSU) is frequently used by physical therapists and radiologists to improve specific diagnosis in rotator cuff related pathology. The evaluation of the rotator cable seems to be important as stabilizing structure when cuff tears occur.
To evaluate the inter-examiner agreement and reliability of MSU of the shoulder to detect rotator cuff-pathology and the involvement of the rotator cable in comparison to \"dissection\".
Physical therapists, a radiologist and an orthopedic surgeon (dissection) investigated 40 fresh frozen cadaver shoulders in order to detect shoulder pathology including rotator cable involvement. Examiners were blinded to each other\'s findings.
We found a strong and significant agreement between the raters: PTs, the radiologist and the dissector in this cadaver study for all rotator cuff, the long head of the biceps pathologies and in detecting abnormalities of the rotator cable. The kappa value was substantial to (almost) perfect agreement for all diagnostic outcome categories.
This study shows that among a limited group of physical therapists, one radiologist and a dissector a strong level of agreement with kappa values from substantial to (almost) perfect in finding subacromial pathology.

The population of Hawai\'i is uniquely connected to the Ocean and to open water sports. Shoulder injuries, particularly those to the rotator cuff, are among the most common injuries sustained to athletes participating in ocean sports such as surfing, paddling, and swimming. In addition, rotator cuff injuries increase in prevalence with advanced age. As a consequence, the number of patients in Hawai\'i who present with an injury to the subscapularis tendon will continue to rise. However, limited research has been done to delineate the involvement of subscapularis injuries in this population. This article covers the anatomy and function of the subscapularis, the epidemiology and classification of tears in this tendon, and the management of tears. The anatomy section will cover innervation, vascular supply and insertional anatomy of the subscapularis tendon. The function of the subscapularis in regards to both stability and motion of the glenohumeral joint will be examined. The focus of the article will then shift to the tears of the subscapularis, starting with an in depth look at the epidemiology and classification of these tears. The article will then cover the different imaging modalities and their utility in regards to subscapularis tears. Finally, the operative and non-operative management and indications for each modality will be discussed in detail.

Anterior cable reconstruction (ACR) using the long head of the biceps tendon (LHBT) was developed to place at the native superior capsule attachment site for large to massive rotator cuff tears (LMRCTs) with anterior cable disruption. In this study, we investigated whether ACR for reinforcement before ARCR prevented retear after arthroscopic rotator cuff repair (ARCR), especially in cases of LMRCTs with anterior cable disruption. A total of 125 patients who underwent arthroscopic rotator cuff repair (ARCR) for LMRCTs were retrospectively enrolled. To assess the benefit of ACR with LHBT, all data were compared with those after ARCR alone. As a result, ACR with LHBT showed satisfactory clinical and radiologic outcomes in comparison with conventional ARCR only technique. ACR with LHBT prevented retear after ARCR and improved the AHD, although There was no difference of clinical outcomes between two groups.

BACKGROUND: This study evaluated the presence of the rotator cable intraoperatively and compared its prevalence according to both patient age and rotator cuff integrity. The study hypothesis was that the cable would be more prevalent in older patients and patients with partial-thickness tears.
METHODS: Patients who were undergoing shoulder arthroscopy and were aged at least 16 years were included in this study, whereas those who had a cuff tear of more than 1 tendon or who had a video with poor visualization of the rotator cuff insertion were excluded. Intraoperative videos were collected, deidentified, and distributed to 7 orthopedic surgeons to define rotator cable and cuff tear characteristics.
RESULTS: A total of 58 arthroscopic videos (average patient age, 46 years; range, 16-75 years) were evaluated. The observers were in the most agreement on identifying the presence of a cable, with a κ coefficient of 0.276. Patients with the rotator cable were significantly older than those without it (mean age, 52.1 years vs. 42.5 years; P = .008), and a positive and significant correlation was found between rotator cable presence and increasing patient age (r = 0.27, P = .04). A significant association was noted between tear degree and cable presence (P = .002). There was no significant association with cable presence in patients with a full-thickness tear.
CONCLUSIONS: In this study, an intraoperative analysis was performed to define the presence of the rotator cable and correlate this with both patient age and rotator cuff integrity. The hypothesis was confirmed in that patients older than 40 years had a significantly higher rotator cable prevalence.

OBJECTIVE: The purpose of this study was to compare clinical and radiological outcomes after arthroscopic repair of two different rotator cuff tear configurations: anterosuperior rotator cuff tear and rotator cuff tears with subscapularis involvement. It was hypothesized that, although both tear configurations would show significant improvement in clinical outcomes after arthroscopic repair, the rotator cuff tears with subscapularis involvement where the anterior rotator cable maintains its integrity would have better clinical outcomes and structural integrity.
METHODS: This study included 226 patients who underwent arthroscopic repair of anterosuperior rotator cuff tears (n = 107, group A) and rotator cuff tears with subscapularis involvement (n = 119, group B). The visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and active range of motion (ROM) were assessed. Modified belly press test was performed to assess the strength of the subscapularis muscle. Cuff integrity was evaluated using magnetic resonance arthrography or computed tomographic arthrography at 6 months after operation.
RESULTS: At 3-year follow-up, the VAS score, SSVs, ASES scores, UCLA shoulder scores, active ROM, and modified belly press test showed significant improvement in both groups (p < 0.001). However, these improvements showed no statistical significance between the two groups. On follow-up radiologic evaluations, no significant difference in re-tear rates between group A (25 of 107, 23.4%) and group B (23 of 119, 19.3%) was observed.
CONCLUSIONS: The presence of anterior cable involvement of the anterosuperior rotator cuff tear did not affect postoperative clinical outcomes and re-tear rate compared to rotator cuff tears with subscapularis involvement where the anterior cable integrity was maintained, although the anterosuperior rotator cuff tear was associated with more significant preoperative supraspinatus fatty infiltration. Therefore, the present study determined that it would not be necessary to differentiate treatment protocols between these patterns.
METHODS: Level III.

UNASSIGNED: Partial articular supraspinatus tendon avulsion (PASTA) lesions are often seen in shoulders of throwing athletes. PASTA lesions in anterior instability are also found in recurrent anterior glenohumeral instability.
UNASSIGNED: To investigate the prevalence and location of rotator cuff tears (RCTs), including PASTA lesions, in shoulders with recurrent anterior instability.
UNASSIGNED: Case series; Level of evidence, 4.
UNASSIGNED: A total of 842 shoulders in 801 patients with recurrent anterior instability (647 men, 154 women; mean age, 24 years; age range, 13-40 years) who underwent arthroscopic surgery at the age of 40 years or younger were enrolled. During surgery, the thickness and the sites of RCTs as well as patient factors associated with RCTs were examined.
UNASSIGNED: RCTs were found in 57 shoulders (7%) in 56 patients. There were 4 shoulders with full-thickness RCTs and 54 shoulders with PASTA lesions. All lesions but 1 involved the anterior border of the supraspinatus (SSP). Participation in high-level athletics and older age at injury were associated with RCTs.
UNASSIGNED: The incidence of RCTs was 7% in shoulders with recurrent anterior instability at age 40 years or younger. Most RCTs were PASTA lesions that involved the anterior border of the SSP.

The rotator cable and rotator interval are among the most recent topics of interest in current shoulder literature. Most of the research has been published in the last two decades and our understanding about the importance of these anatomical structures has improved with biomechanical studies, which changed the pre- and intra-operative approaches of shoulder surgeons to rotator cuff tears in symptomatic patients.The rotator cable is a thick fibrous bundle that carries the applied forces to the rotator cuff like a \'suspension bridge\'. Tears including this weight-bearing bridge result in more symptoms. On the other hand, the rotator interval is more like a protective cover consisting of multiple layers of ligaments and the capsule rather than a single anatomical formation like the rotator cable.Advances in our knowledge about the rotator interval demonstrate that even basic anatomical structures often have greater importance than we may have understood. Misdiagnosis of these two important structures may lead to persistent symptoms.Furthermore, some distinct rotator cuff tear patterns can be associated with concomitant rotator interval injuries because of the anatomical proximity of these two anatomical regions. We summarize these two important structures from the aspect of anatomy, biomechanics, radiology and clinical importance in a review of the literature. Cite this article: EFORT Open Rev 2019;4:56-62. DOI: 10.1302/2058-5241.4.170071.