Optimal Techniques and Rehabilitation Protocols for Rotator Cuff Repair: A Literature Review

Rotator cuff pathology is present in nearly half the adult population over the age of 50 years and remains a leading cause of shoulder pain and dysfunction. These musculotendinous injuries may be the result of an acute trauma or chronic degeneration. Clinical examination involves inspection, range of motion, and strength assessment with special testing used to isolate the involved rotator cuff muscles. The classification of these injuries involves identification of tear size, thickness, morphology, and the presence of tendon retraction or muscular atrophy to guide clinical management. Magnetic resonance imaging is the primary imaging modality used to define these metrics unless contraindicated in select patients. Nonoperative management is largely reserved for partial thickness tears involving <1 cm full thickness tears. Surgical repair is indicated in the symptomatic patient with >25% of bursal or >50% articular surface involvement and those >1 cm in the sagittal plane. These are often managed with primary repair using single row, double row or transosseous equivalent techniques. In the event of irreparable rotator cuff tears with significant tendon retraction with or without fatty atrophy, partial repair techniques with augmentation, superior capsular reconstruction, and balloon spacers remain salvage options prior to consideration of reverse shoulder arthroplasty. Additionally, there remains debate on optimal postoperative rehabilitation protocol with recent literature supporting early passive mobilization and active range of motion at four to six weeks without compromise of tendon repair integrity that could serve to optimize both glenohumeral motion, accelerated recovery and strength optimization without an increase in re-tear rates. There is currently a lack of high-quality, long-term studies directly comparing surgical techniques and nonsurgical management, especially with follow-up beyond five years to assess durability, re-tear rates, and functional outcomes. This review aims to critically appraise the available evidence to guide optimal rotator cuff repair techniques and postoperative rehabilitation protocols.