Rotator cuff surgery and semantics

Abstract

The imprecise definition of terms used to describe pathological diagnosis in clinical medicine can lead to imprecise treatment concepts and inaccurate recording of outcomes. In this article, we explore the meaning of common terms applied to the pathology of the rotator cuff, and demonstrate how the imprecise use of words entails a risk of leading to a poor definition of the clinical condition being treated. We suggest improvements in the accuracy of the definition of what constitutes the rotator cuff. We suggest the use of ‘defect’ to describe the most common presentation of a degenerative lesion of the rotator cuff, rather than perpetuate the use of the term ‘tear’, which has a different, injurious aetiology. We suggest that the term ‘repair’ should be reserved for the condition in which an acutely injured tendon (with a ‘tear’) can be expected to heal, using the correct definition of the term ‘to heal’. We recommend reserving the use of the term ‘healed’ for the condition of an acute lesion of the rotator cuff (a ‘tear’) to which the histological process of regenerating a near-normal enthesis can be reasonably applied. We further suggest that degenerative lesions (‘defects’) of the rotator cuff, which do not have the biological capacity to heal in the true sense when brought back to bone, should be described as having ‘closure’ of the defect.

Cite this article: Bone Jt Open 2025;6(11):1475–1478.

Introduction

Superior compartment shoulder pain (frequently referred to as subacromial pain) is a common condition, and not infrequently a defect in one or more of the rotator cuff tendons may be associated with symptoms.¹ Surgical restoration of tendon-to-bone integrity has been thought to improve function and in numerous publications, postoperative pain reduction has been reported.^2-4 However, improvement in symptoms has also often been seen despite incomplete healing or only partial restoration of tendons to bone: it appears that surgery is often successful in achieving pain reduction but less reliable for the restoration of tendon-bone integrity.^5-8 Apparently, therefore, factors other than tendon defects contribute to subacromial pain, but the pathomechanisms have not been clearly identified.^9-11 There appears to be a lack of precision in current descriptions and definitions of the associated factors and treatment methods, which may be an obstacle to clear communication of relevant concepts. As indicated in a study by Zadro et al,¹² the persistence of imprecise terms and terminology may lead to the imprecise development of concepts and thereby inadvertently exclude avenues worth pursuing, while others with less biological value continue to be followed. We illustrate the importance of this with some examples.

Rotator cuff: what is it?

Several studies and recommendations have related size of tendon defects to the outcome of surgical procedures.^13-15 Apart from the fact that humans come in different sizes, reflected also in the shoulder, a rotator cuff defect can engage one or several tendons, and the consequences are not only a function of size, but rather of which tendons and, more importantly, which region of the tendon structure is affected. Some studies on rotator cuff surgery report on tendon repairs without detailed description of specific anatomical (and, by inference, different ‘functional’) areas. Since different parts of the rotator cuff have different importance for shoulder function, it seems relevant and of value to describe in detail the specific region that is affected and treated in order to allow direct and accurate comparisons of outcomes. For example, a traumatic but limited rupture of the anterior supraspinatus rotator cable and rotator interval has a very different presentation, functional implication, and prognosis compared with a degenerate, complete, and full-thickness defect in the crescent region of the same tendon, which spares the anterior pillar. Yet both are often conflated in reports of so-called ‘supraspinatus tears’.^16,17 Collin et al¹⁸ published a system for description of the location of a tendon defect, and although relatively simple it enables a more detailed comprehension of which anatomical parts of the rotator cuff are affected. Ranebo et al⁹ used a radiological method, and on sagittal MRI views divided the cuff into sectors with the same purpose. Pouliart et al¹⁹ described a persuasive concept of the functional architecture of the rotator cuff, with emphasis on the rotator interval, and suggested that so-called ‘rotator cuff’ lesions are essentially capsular lesions with associated tendon defects.

Rotator cuff tear

A tear (noun, from an Indo-European stem shared by the Latin, derein, ‘flay’) is a hole created as a result of tearing, the condition of a structure after having being disrupted forcefully (as in ‘flayed’). The verb ‘to tear’ describes the process by which an object or structure is disrupted: it is defined as ‘to pull’ or ‘be pulled apart,’ or ‘to pull pieces off’ as with a violent force from the site of origin. Neither of these uses seem appropriate to describe a defect in the rotator cuff, since there is substantial and growing evidence to demonstrate that, in most instances, and certainly in asymptomatic cuff defects, the tendon lesion is the consequence of a predetermined, slow, degenerative (apoptotic) process, as a result of which there is loss of tissue, which creates a defect.^20-24 A defect is defined as a fault in a structure or object that causes the structure or object not to function in the expected manner. The defect can become larger due to forceful disruption (i.e. trauma) inflicted on an already degenerate and weak rotator cuff tendon. This is sometimes called an ‘acute-on-chronic tear’.¹⁷ Here, the acute progression (a true ‘tear’) and the chronic degenerative defect are considered together under the same label (‘the tear’). However, different regions of the acute-on-chronic lesion have very different biological (healing) potentials: conflating the two aetiologies leads to errors of judgement about the potential for reduction to a healthy bone recipient, and healing potential. If different origins of rotator cuff defects are brought together under one heading, it may obscure the many other reasons that are important to comprehending the true nature of the problem and its solutions. It seems reasonable to suggest that the term ‘defect’ should be used for all faults in the rotator cuff, and only those created through forceful disruption should be labelled as a ‘tear’. This more precise description is intended to guide the clinician to seek different reasons for the symptoms and behaviour of individual rotator cuff defects, and treatment options can then be discussed in terms of restoration, replacement with or without augmentation of tissue (degenerative fault – a ‘defect’, with poor intrinsic healing potential), or repair (traumatic defect – a ‘tear’, with greater intrinsic healing potential).

Rotator cuff repair

A ‘repair’ (noun) is the state or condition of an object or structure which, having been broken, faulty, or deficient, has been restored to a good condition: a functional state. The verb ‘to repair’ describes the activity by which the damaged or dysfunctional object or structure is restored with the intention of optimizing function. The implication is that this will prompt the search for a treatment method that can restore the injured structure close to the pre-injured state. The literature is replete with reports describing that the tendon healing (see below) failure rate after an attempted ‘repair’ is extremely high, even though patients often seem to benefit from reduced pain.^7,8,13 Even if the defect is closed (or simply covered) this does not necessarily mean that the related musculotendinous unit is functional. Most, if not all, studies on rotator cuff surgery focus on the tendon, the tendon insertion, and technical aspects of the surgical procedure. The condition of the muscle, the contractile part which provides the actual function, is less often considered, and yet is fundamentally decisive for the functional outcome.²⁵ Consequently, the term ‘repair’ might be misleading since, in a long-standing lesion (an apoptotic defect), even an apparently successful surgical closure of the defect can fail to restore function to the shoulder. We suggest a more accurate terminology might be ‘closure of the defect’.

Tendon healing

Healing (when used as a noun) is defined as the process of improving or becoming sound or healthy again, or (when used as an adjective) helping to make someone or something well again. The implication is the restoration of a tissue that is close to the original in structure, form, and function. No surgical procedure has yet replicated the subtle lamination of a native osteotendinous enthesis: the goal of bringing the tendon edge or surface into close approximation to a bone surface is the production of a strong, organized scar – which does not have the same biomechanical behaviour of tendon or capsular ligament.²⁶ A tendon affected by programmed cell death cannot ‘heal’ in this sense, by definition, even if the surgical procedure brings the tendon stump back to its original insertion at the footprint on the greater tuberosity.⁷ Healing by scar formation is a hoped-for outcome: the more organized the scar the better, and if a smooth bursal surface layer of tissue results, then a new gliding surface under the acromion may reduce preoperative symptoms. A typical scenario is the abovementioned ‘acute-on-chronic’ lesion. Most often this means a previous, asymptomatic, degenerative tear of the supraspinatus tendon, but with the rotator cable still more or less intact.^16,17 A new trauma can result in a rupture of one of the cable attachment regions, including the rotator interval with further extension into a previously intact and functioning infraspinatus or subscapularis tendon. If this extension is diagnosed early, a successful repair may result in subsequent healing of the new lesion.²⁷ From anatomical and functional points of view, this would be a partial repair.

Summary

The power (accuracy and meaning) of words cannot be underestimated: if the rotator cuff structures, lesions, treatment methods, and results are not described with precision, this may prevent complete understanding of the extensive published research, and in the worst case even result in unwarranted treatment.¹² We suggest the word ‘tear’ should be reserved to describe fresh traumatic injuries with a potential for healing (in the strict application of this term) and ‘repair’ used only for tendons and muscles that are sufficiently preserved to have a biological potential which leads to a predictable restoration of near-normal function once repaired. Consequently, the word ‘defect’ should be used for a tendon lesion due to apoptosis, which cannot be repaired (in the strict sense of this term) or heal (likewise); however, a defect may be reduced in extent or covered by using one of a large number of techniques, and contribute to better outcomes with an interposed although non-functional soft-tissue coverage, and a gliding surface that may provide reduced symptoms. If these terms are more accurately applied, we suggest that comprehension of the available literature, establishment of necessary research strategies, and assessment of clinical outcomes will be more specific and sensitive, and hence more helpful to the future clinician in discussing management options with patients.

Take home message

- Accurate use of terminology in rotator cuff disease and its management will likely improve the quality of data relating to diagnosis and treatment.

- Improved accuracy of definitions of rotator cuff disease will enhance the quality of informed consent in shared decision-making when considering and evaluating options and potential outcomes of treatment.