The Geometric Classification of Rotator Cuff Tears: A System Linking Tear Pattern to Treatment and Prognosis

(A) A type 1, crescent-shaped tear is short and wide with a medial-to-lateral length (L) less than the anterior-to-posterior width (W). (B) Crescent tears can usually be repaired with a direct tendon end–to–bone technique. (IS, infraspinatus; SS, supraspinatus.)

(A) The maximum medial-to-lateral length (L) of the tear is measured on T2-weighted coronal oblique MRI views by use of the scale printed on the MRI scan. (B) If no lateral stump of cuff is present, measurement is made to the apex of the tuberosity. (C) The partial-thickness portion of a tear is not used in measurements.

(A) The maximum anterior-to-posterior width (W) of a tear is measured on T2-weighted sagittal oblique MRI views using the scale printed on the MRI scan. (B) In a massive tear, if no anterior tissue is present, the shortest tangential line from the superior coracoid to the humeral head is used to approximate the location of the rotator interval. Measurement is made to this point. (C) The partial-thickness portion of a tear is not used in measurements.

Tendon edges are characterized on MRI as (A) blunt, (B) tapered, or (C) wispy. Measurements are made as depicted.

Type 1, crescent-shaped tear. The maximum medial-to-lateral length (L) measured on the T2-weighted coronal MRI images is less than or equal to the maximum anterior-to-posterior width (W) measured on the T2-weighted sagittal MRI images, and the length is less than 2 cm (L ≤W, L <2 cm).

Clinical example of a type 1, crescent-shaped tear on MRI with maximum coronal length (left) less than maximum sagittal width (right).

(A) Type 2, longitudinal tear. This U-shaped longitudinal tear is long and narrow. The medial-to-lateral length (L) is greater than the anterior-to-posterior width (W). (B, C) Longitudinal tears can usually be repaired with a side-to-side/margin convergence technique along with lateral suture anchors. (IS, infraspinatus; SS, supraspinatus.)

(A) Type 2, longitudinal tear. This L-shaped tear is long and narrow. The length (L) is greater than the width (W). (B, C) L-shaped tears can usually be repaired with a side-to-side/margin convergence technique along with lateral suture anchors. (IS, infraspinatus; SS, supraspinatus; RI, rotator interval; Sub, subscapularis; CHL, coracohumeral ligament.)

Type 2, longitudinal tear. The maximum length (L) measured on the T2-weighted coronal images is greater than the maximum width (W) measured on the T2-weighted sagittal images, and the width is less than 2 cm (L >W, W <2 cm).

Clinical example of a type 2, longitudinal tear on MRI with maximal coronal length (left) greater than sagittal width (right).

(A) Type 3, massive contracted tears are long and wide. Direct end-to-bone or side-to-side repairs are not possible. Interval slides are often required. (B) Anterior and posterior releases are made. (C) After release, there is improved tissue mobility. (D) The supraspinatus can then be repaired to the bone bed. (E) The posterior defect is closed with side-to-side sutures. (IS, infraspinatus; SS, supraspinatus; Sub, subscapularis; CHL, coracohumeral ligament.)

Type 3, massive contracted tear. Both the maximum length (L) measured on coronal MRI scans and the maximum width (W) measured on sagittal MRI scans are greater than or equal to 2 cm.

Clinical example of a type 3, massive contracted tear on MRI with maximum coronal length (left) and maximal sagittal length (right) both greater than 2 cm.

Radiograph of type 4, rotator cuff arthropathy. There is end-stage degeneration of the glenohumeral joint and articulation of the humeral head with the acromion.

Treatment algorithm for rotator cuff tears.

MRI scans showing fatty degeneration of greater than 75%. (A) T2-weighted coronal image with greater than 75% fatty degeneration of infraspinatus (arrow). (B) T1-weighted sagittal image with greater than 75% fatty degeneration of infraspinatus (arrow).