Rotator cuff tear is partial or full-thickness disruption of one or more of the four muscle-tendon units (supraspinatus, infraspinatus, subscapularis, teres minor) surrounding the shoulder joint. Supraspinatus is the most commonly affected tendon (90%+) because it is subjected to the most mechanical impingement in the subacromial space and the critical zone of the tendon (1 cm proximal to insertion) is an avascular region. Prevalence increases with age: 25-50% asymptomatic tears exist over age 50. Tears can be traumatic (acute fall, sports injury) or degenerative (chronic impingement, tendon degeneration). MRI is the gold standard for diagnosis — tendon gap, retraction degree, and fatty infiltration (Goutallier classification) are evaluated on T2 fat-sat coronal and sagittal sections. In full-thickness tears, tendon continuity is completely lost and fluid communication develops between glenohumeral joint and subacromial bursa. Treatment is planned as conservative or surgical (arthroscopic repair) based on tear size, retraction, muscle quality, and patient functional demands.
Age Range
40-80
Peak Age
55
Gender
Male predominant
Prevalence
Very Common
The pathophysiology of rotator cuff tear is multifactorial combining intrinsic (tendon degeneration) and extrinsic (mechanical impingement) factors. Intrinsic factors: the critical zone of supraspinatus tendon (~1 cm proximal to insertion) is a vascular watershed area predisposed to hypoxic degeneration — arterial perfusion is lowest in this region and decreases further with aging. Collagen (Type I) degeneration, proteoglycan accumulation, and chondroid metaplasia develop in tendon matrix. Extrinsic factors: subacromial impingement — anterior-inferior projection of acromion (Type III hooked acromion), os acromiale, coracoacromial ligament thickening, or acromioclavicular joint osteoarthritis osteophytes mechanically compress supraspinatus tendon. Repetitive overhead movements (athletes, painters) increase this compression. Tear usually begins at the anterior part of supraspinatus tendon (most impingement zone) and progresses posteriorly and medially — may extend to infraspinatus and subscapularis (massive tear). The bright appearance of tendon gap on T2 fat-sat reflects synovial fluid/granulation tissue filling the tear site with free water protons having long T2 relaxation time. Fatty infiltration (Goutallier) represents replacement of muscle fibers with adipose tissue in chronic tear — seen as intramuscular high signal areas on T1 and is irreversible (muscle quality does not improve even after surgical repair). Muscle atrophy is decreased muscle volume and along with fatty infiltration is the most important prognostic determinant.
On T2 fat-sat coronal MRI, complete loss of supraspinatus tendon continuity with hyperintense fluid signal replacing tendon and torn edge showing medial retraction (toward glenoid). This finding is the diagnostic primary MRI finding of full-thickness rotator cuff tear. Retraction degree determines surgical repairability: retraction to or beyond glenoid level indicates poor prognosis.
On coronal T2 fat-sat images, complete loss of supraspinatus tendon continuity with hyperintense fluid signal replacing tendon indicates full-thickness tear. Tear size is measured anteroposteriorly (small <1 cm, medium 1-3 cm, large 3-5 cm, massive >5 cm). Fluid communication between glenohumeral joint and subacromial bursa is pathognomonic for full-thickness tear.
Report Sentence
A full-thickness tear measuring approximately ___ cm in the supraspinatus tendon is seen with tendon stump retraction of ___ cm to glenoid level.
On T1-weighted sagittal-oblique images, fat accumulation in rotator cuff muscles (especially supraspinatus and infraspinatus) is evaluated. Goutallier classification: Grade 0 — normal muscle, no fat; Grade 1 — fat streaks; Grade 2 — muscle>fat; Grade 3 — muscle=fat; Grade 4 — fat>muscle. Grade ≥3 fatty infiltration is irreversible and muscle function does not improve even after surgical repair — poor prognostic indicator.
Report Sentence
Goutallier Grade ___ fatty infiltration is seen in the supraspinatus muscle.
On T2 fat-sat coronal images, focal hyperintense signal increase is seen at the articular (joint side) surface of supraspinatus tendon — partial thickness is affected with intact bursal surface. Articular surface tears are more common than bursal surface tears (3:1 ratio). Partial tear involving >50% of thickness is important for risk of progression to full-thickness tear.
Report Sentence
A partial-thickness tear involving approximately ___% of tendon thickness is seen at the articular surface of the supraspinatus tendon.
On T2 fat-sat axial and coronal images, hyperintense fluid collection in subacromial-subdeltoid bursa is seen. In full-thickness rotator cuff tear, glenohumeral joint fluid passes through tear to bursa — this bursal effusion is an indirect finding of full-thickness tear. Focal bursal fluid may also be seen in partial bursal surface tear. Isolated bursal effusion without rotator cuff tear is also a finding of subacromial bursitis or impingement syndrome.
Report Sentence
Fluid collection in the subacromial-subdeltoid bursa is seen, assessed as associated with rotator cuff tear.
On US, focal thinning, defect, or non-visualized segment is seen in supraspinatus tendon. In full-thickness tear, 'non-visualization' finding — tendon is not seen and hypoechoic/anechoic fluid fills its place. Humeral head cortical surface irregularity and subacromial bursal fluid are accompanying findings. Dynamic assessment allows evaluation of tendon retraction and mobility.
Report Sentence
Focal non-visualization consistent with full-thickness tear and fluid collection replacing tendon is seen in the supraspinatus tendon.
Criteria
Defect at joint side surface of tendon, bursal surface intact
Distinct Features
Most common partial tear type (3:1), >50% thickness progression risk, MR arthrography gold standard
Criteria
Complete tendon continuity loss, AP dimension <1 cm
Distinct Features
Good surgical prognosis, minimal retraction, muscle quality usually preserved
Criteria
AP dimension >5 cm or ≥2 tendon involvement
Distinct Features
Significant retraction, Goutallier ≥3 fatty infiltration common, may be irreparable, reverse shoulder arthroplasty should be considered
Distinguishing Feature
In tendinopathy tendon is thickened with signal increase but no fluid-filled gap; in tear tendon continuity is disrupted with fluid gap present
Distinguishing Feature
Subacromial bursitis characterized by isolated bursal effusion, tendon intact; in tear bursal effusion accompanies tendon gap
Distinguishing Feature
In calcific tendinitis low signal calcification focus within tendon, no tear gap; in tear fluid signal gap present
Urgency
urgentManagement
surgicalBiopsy
Not NeededFollow-up
specialist-referralRotator cuff tear treatment is planned based on tear type, size, retraction degree, muscle quality (Goutallier), and patient age/activity level. Partial tears (<50% thickness) are usually managed conservatively (physiotherapy, subacromial corticosteroid injection). For full-thickness tears in active, young patients, arthroscopic repair is standard treatment. Repairability criteria: retraction <3 cm, Goutallier ≤2, adequate muscle mass. For massive, irreparable tears, reverse total shoulder arthroplasty is performed. In acute traumatic tears, early surgery (within 3-6 weeks) is preferred because delay increases muscle atrophy and fatty infiltration.
Rotator cuff tears require surgical repair especially in active patients. Muscle atrophy and fatty infiltration (Goutallier Grade 3-4) adversely affect surgical outcomes and indicate irreversible changes. Partial tears may be managed conservatively but carry risk of tear progression. Retracted massive tears may require reverse shoulder arthroplasty.