The radiological evaluation of rotator cuff degeneration – a narrative review

DOI: 10.70885/hmsj.2026.07.001

Abstract

Background: Fatty infiltration (FI) and muscular atrophy (MA) are key prognostic indicators in rotator cuff pathology, influencing reparability and long-term functional outcomes. Historically assessed using subjective, 2D visual grading systems, these degenerative changes are now better understood as complex, regionally variable, and only partially captured by legacy classifications.Purpose: To critically assess the relevance of traditional 2D classification systems (particularly Goutallier's and Thomazeau's) in the evaluation of rotator cuff muscle quality, in light of recent advances in imaging technologies and quantitative analysis.Results: This narrative review examines the biological and spatial characteristics of FI and MA, their implications for reparability, and the limitations of current visual scoring systems. It outlines the emergence of quantitative imaging methods such as Dixon fat fraction mapping, T2 mapping, 3D volumetric analysis, and AI-assisted segmentation, and evaluates their clinical potential. While these tools offer improved objectivity and reproducibility, widespread adoption is hindered by technological, logistical, and standardization challenges.Conclusion: Traditional classifications remain widely used but show significant reproducibility and accuracy limitations. Quantitative volumetric methods and AI-assisted segmentation offer improved objectivity, though clinical outcome validation and widespread availability remain limited. A unified, standardized approach to muscle quality assessment could enhance surgical decision-making in RC tears.What this study adds to existing knowledge: This review provides a critical and structured appraisal of the limitations of traditional 2D classification systems (Goutallier and Thomazeau), alongside an evaluation of emerging quantitative MRI and AI-based imaging methods for assessing rotator cuff muscle quality.How this study might affect research, practice, or policy: These findings support the development of standardized, automated 3D muscle quality scoring systems that could improve reparability assessment and surgical decision-making in patients with rotator cuff tears.Study design: Narrative reviewLevel of evidence: Level VKeywords: Rotator cuff; Fatty infiltration; Muscle atrophy; Quantitative imaging; MRI; CT; Artificial intelligencehttps://doi.org/10.70885/hmsj.2026.07.001

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