Rotator Cuff Tears Part I: Diagnosis, Nonoperative Management, and Repair of Posterosuperior Tears—An International Expert Consensus Statement

PURPOSE: To establish updated international consensus statements on the diagnosis, nonoperative management, and repair of posterosuperior rotator cuff tears, reflecting new evidence, evolving techniques, and ongoing areas of controversy. METHODS: A consensus process on the treatment of rotator cuff tears was conducted, with 97 shoulder/sports surgeons from 15 countries participating. There were 9 specific subtopics: (1) Diagnosis, (2) Nonoperative Management, (3) Repair of Posterosuperior Tears, (4) Subscapularis Repair, (5) Graft/Patch Augmentation and Superior Capsular Reconstruction, (6) Tendon Transfers, (7) Reverse Total Shoulder Arthroplasty, (8) Revision Surgery, and (9) Rehabilitation, Return to Play, and Follow-up. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Of the 50 consensus statements, 30 achieved strong consensus, 17 achieved consensus, and 3 did not achieve any level of consensus. CONCLUSIONS: Strong consensus was achieved across all diagnostic domains, establishing a standardized approach to history, examination, classification, and imaging. Experts agreed that patient evaluation should emphasize mechanism of injury, tissue quality, and activity level and that rotator cuff tears should be classified by size, tendons involved, thickness, fatty infiltration, and retraction. In nonoperative management, consensus supported an initial trial of rehabilitation and activity modification for most partial or chronic full-thickness tears, whereas nonoperative treatment remains appropriate for older, low-demand, or medically unfit patients with traumatic tears. There was agreement that corticosteroid injections may play a role but that surgery should be delayed several weeks after injection. For posterosuperior cuff repair, the panel agreed that indications include failure of nonoperative management, persistent pain or dysfunction, and traumatic or high-demand tears and that the surgical approach (beach chair or lateral decubitus) and repair construct should be based on surgeon preference and tear pattern. There was consistent agreement on key technical principles including tension-free repair, adequate footprint coverage, and the importance of individualized treatment based on tissue quality and patient goals. LEVEL OF EVIDENCE: Level V, expert opinion.