Background: Massive irreparable rotator cuff tears (MIRCTs) represent a complex clinical challenge, resulting in pain, pseudoparalysis, and functional disability. Over the past century, their surgical management has undergone significant evolution, from early open repairs to sophisticated reconstructive and joint replacement strategies. Methods: A historical narrative review was conducted, informed by a systematic search of PubMed/MEDLINE, Embase, and landmark texts. Major surgical innovations–open repair, tendon transfers, debridement, superior capsular reconstruction (SCR), subacromial spacers, and reverse shoulder arthroplasty (RSA)–were examined in the context of their development and impact. Results: Open repairs offered limited success for chronic MIRCTs. Subacromial decompression and debridement provided symptom relief in low-demand patients. Tendon transfers and graft interpositions emerged as joint-preserving strategies in select cases. RSA transformed management by reliably restoring function in pseudoparalysis and cuff tear arthropathy. Contemporary techniques such as SCR and biologic augmentation aim to preserve native anatomy, but outcomes remain inconsistent. Discussion: MIRCT management has progressed from salvage repairs to a diverse toolkit of joint-preserving and reconstructive options. No single strategy is universally superior, underscoring the need for patient-specific approaches. Ongoing comparative trials and surgical consensus efforts are critical to optimising care.

Suprascapular nerve block (SSNB) is a recognized treatment for chronic shoulder pain, including pain from rotator cuff tears. While it is purported that image-guided SSNB improve injection accuracy over landmark-guided techniques, the impact on clinical outcomes remains unclear. This systematic review compared image-guided vs. landmark-guided SSNB in patients with rotator cuff tears, evaluating efficacy, pain relief, functional improvement, complications, and duration of relief. We searched PubMed, MEDLINE, Cochrane Library, Embase, and CINAHL (inception to April 2025) for prospective or retrospective studies comparing image-guided (ultrasound, fluoroscopy, computed tomography, or arthroscopic) to landmark-guided SSNB. Two reviewers independently screened titles/abstracts and full texts, with discrepancies resolved by consensus. Data on pain outcomes, functional scores, complications, and duration of pain relief were extracted. Risk of bias was assessed for each study. Thirty studies were included, comprising 25 randomized controlled trials, 2 nonrandomized prospective studies, and 3 retrospective studies, totaling 2,205 patients. Both image-guided and landmark-guided techniques significantly reduced pain and improved shoulder function, with pain reduction typically ranging from 3.2 to 5.5 points on a 0-10 visual analog scale at 48 hours postoperatively. There was no consistent evidence indicating superior clinical outcomes with image-guided techniques in terms of pain relief, functional improvement, complication rates, or duration of analgesia. Both image-guided and landmark-guided SSNB techniques provide effective pain relief and functional improvement in patients with rotator cuff-related shoulder pain. Despite potential procedural advantages of image guidance, such as reduced needle repositioning and higher first-attempt success rates, these benefits did not translate into consistently superior clinical outcomes. This systematic review suggests landmark-guided SSNB offer similar outcomes to image-guided techniques, with implications for resource and expertise availability.

Background: Rotator cuff (RC) repairs heal unreliably, particularly in chronic disease. The molecular mechanisms underlying failed repair remain poorly understood. While individual studies have examined protein expression in diseased RC tissue, no synthesis has investigated these findings across various disease stages. This systematic review explores the stage-specific protein expression of human RC degeneration using immunohistochemistry. Methods: Following PRISMA guidelines, MEDLINE, Embase, and Cochrane Library were systematically searched to September 2025 for human studies that use immunohistochemistry to evaluate protein expression in intraoperative RC tendon or muscle biopsies. Study quality was appraised with Joanna Briggs Institute (JBI) tools. No meta-analysis was performed due to heterogeneity. Results: Forty-seven studies were included. Despite methodological heterogeneity, convergent molecular patterns emerged within disease stages. Partial and small tears demonstrated hypoxic-inflammatory-apoptotic signatures (HIF-1α, BNip3, IL-6, IL-1β, MMP-1/3/9) with preserved regenerative markers (Ki67, CD34), suggesting reparative potential. Medium tears exhibited sustained angiogenic activity (VEGF) and emerging adipogenic drift (PPARγ, C/EBPα). Large and massive tears showed depletion of anabolic factors (TGF-β1, BMP-5), M2-macrophage predominance (CD206, CD163), and fibrofatty infiltration. Patient comorbidities (diabetes, vitamin D deficiency, smoking) amplified inflammatory and adipogenic signatures. Conclusions: Cross-sectional human immunohistochemical evidence infers a stage-associated molecular trajectory: inflammatory-hypoxic stress with retained reparative capacity at earlier disease stages to fibrotic–adipogenic failure at later stages. This molecular framework may support future approaches to surgical decision-making and precision therapies.

Myofascial pain syndrome (MFPS) causes chronic shoulder pain. Supraspinatus and infraspinatus, rotator cuff muscles innervated by the suprascapular nerve, are commonly affected. Intramuscular botulinum neurotoxin (BoNT) injections near motor points (i.e. , visible nerve branch entry sites used as a proxy for motor endplates) are an effective treatment for such pain. However, current techniques limit accessibility. This study aimed to develop a patient‐specific, landmark‐guided technique for BoNT delivery into supraspinatus and infraspinatus using scapular dimensions. Ten pairs of cadaveric shoulders ( n = 20) were dissected to identify supraspinatus and infraspinatus motor points. Distances from scapular landmarks to these motor points were measured in two axes. These distances were correlated with scapular dimensions (height, spine length, width) using linear regression. Patient‐specific predictive formulae were derived. For validation, landmark‐guided methylene blue dye injections were performed on four additional shoulders using calculated coordinates. For supraspinatus, motor points were predicted using deltoid tubercle and root of the scapular spine ( r = 0.58–0.64, p = 0.0016–0.021). For infraspinatus, root of the scapular spine and lateral acromion were used ( r = 0.46–0.60, p = 0.0054–0.0500). In all validation specimens, injected dye accurately reached the motor points. This study provides a validated, patient‐specific, landmark‐guided technique for BoNT delivery into the rotator cuff, offering an approach for accessible analgesia.

Arthroscopic suprascapular nerve (SSN) decompression is an increasingly adopted treatment for SSN entrapment. It involves lateral-to-medial dissection to reach the suprascapular notch, placing adjacent neurovasculature at risk. Despite this, anatomical guidelines for safe dissection in this complex region remain limited. This study aimed to provide anatomical guidance for patient-specific arthroscopic SSN decompression. Twenty cadaveric shoulders from 10 cadavers were dissected. Distances from SSN and suprascapular artery (SSA) to the lateral insertion of the superior transverse scapular ligament (STSL) were measured. Distances from the lateral STSL to lateral acromion and acromioclavicular (AC) joint were recorded and correlated with measured scapular dimensions (height, spine length, and width). The SSN and SSA were 7.0 ± 2.7 mm (range: 2.6-11.8 mm) and 4.2 ± 2.5 mm (1.4-9.5 mm) medial to the lateral STSL, respectively. The lateral STSL was 7.7 ± 1.0 cm (6.2-9.2 cm) from the lateral acromion and 4.5 ± 0.6 cm (3.1-5.5 cm) from AC joint, both distances significantly correlating with scapular dimensions (r = 0.45-0.77; P < .001 to P = .047). The SSA and SSN may lie as close as 1.4 mm and 2.6 mm from the lateral STSL, defining a “lateral danger zone” at the suprascapular notch. The data suggest blunt dissection may cautiously be performed up to 3.0 cm medial to the AC joint and 6.0 cm medial to the lateral acromion. Factoring individual scapular dimensions may further refine patient-specific operative reference distances. These findings may enhance pre-operative planning, surgical training, and intraoperative safety.

Purpose: Diagnosis of compartment syndrome remains challenging, as intracompartmental pressure (ICP) monitoring measures mechanical pressure rather than tissue perfusion. Near-infrared spectroscopy (NIRS) enables non-invasive, continuous assessment of tissue oxygen saturation (StO ₂ ), potentially identifying ischemia earlier. However, its diagnostic accuracy remains uncertain. Methods: Following PRISMA-ScR guidelines, PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and WHO-ICTRP were searched to April 2025 for studies evaluating NIRS in acute (ACS) or chronic exertional (CECS) compartment syndrome. Data on diagnostic accuracy, device protocols, and patient characteristics were extracted. Studies reporting comparable StO ₂ data in CECS and controls were pooled using a random-effects meta-analysis. Results: Twenty-three studies ( n = 1000) were included. In ACS, some demonstrated strong correlation with perfusion pressure and post-fasciotomy StO ₂ recovery, while others found poor agreement with ICP or no diagnostic discrimination. There was heterogeneity in device type, patient demographics (particularly skin pigmentation), and protocols. In CECS, pooled analysis showed lower baseline StO ₂ (mean difference − 3.4%, 95% CI − 6.2 to − 0.7) and greater exercise-induced deoxygenation (+ 15.0%, 95% CI 0.4–29.7) versus controls. Conclusion: NIRS provides a physiologically relevant but technically variable indicator of compartmental perfusion, which may complement, but not replace, ICP monitoring for compartment syndrome. The results presented are hypothesis-generating and require prospective trials with standardised protocols, inclusive calibration, and prospective validation before clinical adoption of NIRS.