Prevalence, risk factors, and outcomes of rotator cuff injuries. A comprehensive analysis

Nº de DOI: 10.34896/RSI.2025.39.40.001

AUTHORS

1. Alan Leonel Quiñónez Plaza. General Practitioner. Attached to Private Clinics in Ecuador. Graduate of the State University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0001-2028-7438
2. Juan Carlos Serrano Alvarez. General Practitioner. Attached to Private Clinics in Ecuador. Graduate of the University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0008-5584-0142
3. Erick Lauriel Romero Anchundia. General Practitioner. Attached to the Luis Moscoso Basic Hospital. Graduate of the University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0004-1081-4080
4. Luis Adrián Crespo Vélez. General Practitioner and Master’s Degree in Health Institution Management. Attached to the Quito No. 1 Specialty Hospital of the National Police. Graduate of the Catholic University of Cuenca. (Quito-Ecuador). https://orcid.org/0000-0002-5571-5914
5. Fernando Javier Mafla Camacho. General Practitioner. Attached to Alfa Hospital. Graduate of UTE University. (Ibarra-Ecuador). https://orcid.org/0009-0002-0709-9464

SUMMARY

This comprehensive analysis aims to elucidate the global prevalence patterns, identify key risk factors, and evaluate the clinical outcomes associated with rotator cuff injuries, thereby providing a detailed understanding essential for improving prevention, diagnosis, and treatment methodologies within diverse populations.

KEY WORDS

Rotator cuff injuries, shoulder pathology, epidemiology, risk factors, overuse injuries, tendinopathy, full-thickness tears, biomechanics.

RESUMEN

Esta revisión sintetiza la evidencia actual sobre la prevalencia global, los factores de riesgo y los resultados clínicos de las lesiones del manguito rotador, con el objetivo de apoyar mejores estrategias de prevención, diagnóstico y tratamiento en poblaciones diversas.

PALABRAS CLAVE

Lesiones del manguito rotador, trastornos del hombro, epidemiología, factores de riesgo, lesiones por sobreuso, tendinopatía, desgarros del manguito rotador, biomecánica.

INTRODUCTION

Rotator cuff injuries represent a prevalent musculoskeletal condition that significantly impacts individuals across diverse populations worldwide, posing considerable challenges to both patients and healthcare systems. These injuries, encompassing a spectrum from tendinopathy to full-thickness tears, are recognized for their substantial contribution to shoulder pain and functional impairment, particularly among athletes, manual laborers, and aging populations. The prevalence of rotator cuff injuries varies considerably depending on demographic factors such as age, with a marked increase in incidence among middle-aged and elderly individuals, and is influenced by gender, occupation, and geographic or ethnic differences that suggest underlying genetic or environmental contributions. Numerous intrinsic factors—including anatomical variations, genetic predispositions, and degenerative changes—interact with extrinsic risk factors such as repetitive overhead activities, strenuous physical work, and sports participation, which further elevate the risk of injury. Comorbidities like diabetes mellitus and smoking have also been implicated in the development and poor healing outcomes of rotator cuff pathologies, complicating prognosis. Despite the high prevalence, questions remain regarding optimal management strategies, as outcomes vary based on injury severity, patient characteristics, and treatment modalities—ranging from conservative approaches to surgical repair—with some individuals experiencing recurrent injuries or suboptimal functional recovery.

OBJECTIVE

Clarify global prevalence patterns, identify key risk factors, and evaluate clinical outcomes associated with rotator cuff injuries, thereby providing detailed insights essential for improving prevention, diagnosis, and treatment methodologies across diverse populations.

METHODOLOGY

This narrative review was conducted to synthesize current evidence on the global prevalence, risk factors, and clinical outcomes associated with rotator cuff (RC) injuries across diverse populations. A comprehensive literature search was performed using PubMed, Scopus, Web of Science, and Google Scholar, covering studies published between 1990 and 2024 to incorporate both foundational and contemporary research.

Search terms included combinations of: “rotator cuff injury,” “shoulder tendinopathy,” “rotator cuff tear,” “partial-thickness tear,” “full-thickness tear,” “epidemiology,” “prevalence,” “risk factors,” “overhead activities,” “repetitive motion,” “tendon degeneration,” “diabetes,” “smoking,” “clinical outcomes,” “prognosis,” and “treatment effectiveness.” Reference lists of relevant systematic reviews and cohort studies were manually screened to identify additional sources.

Inclusion criteria were:

1. Peer-reviewed studies reporting RC prevalence, incidence, or risk factors.
2. Research addressing intrinsic, extrinsic, or comorbidity-related contributors to RC pathology.
3. Studies evaluating functional outcomes, recurrence risk, or prognosis following RC injury.
4. English-language publications with clear methodology.

Exclusion criteria included:

1. Case reports, small case series, and studies lacking methodological detail.
2. Research not specifically focused on rotator cuff pathology (e.g., general shoulder pain without imaging confirmation).
3. Articles centered exclusively on surgical techniques without outcome analysis.

Extracted data were organized into thematic domains: (1) global and demographic prevalence patterns, (2) intrinsic anatomical and genetic factors, (3) extrinsic occupational and activity-related contributors, (4) comorbidity influences, and (5) short- and long-term clinical outcomes. Due to heterogeneity in study designs and outcome measures, a meta-analysis was not feasible. A narrative synthesis approach was employed to integrate findings, identify major determinants of RC injury risk, and highlight evidence gaps relevant to prevention and management.

RESULTS

Prevalence of Rotator Cuff Injuries:

What is the global prevalence of rotator cuff injuries in various populations?

The prevalence of rotator cuff injuries demonstrates considerable variability across different populations, highlighting the complex interplay between demographic, occupational, and recreational factors. Among athletes, rotator cuff (RC) pathology stands out as a significant cause of pain and functional limitation, affecting individuals regardless of their age, type of sport, or competitive level¹. This widespread impact in athletic populations is often attributed to repetitive overhead activities and high physical demands, which can accelerate degenerative processes and increase susceptibility to injury. In contrast, studies focusing on the general population estimate the prevalence of rotator cuff tears to be between 5% and 39%, indicating a substantial disease burden that extends beyond those engaged in sports². This broad range reflects differences in study methodologies, diagnostic criteria, and the inclusion of asymptomatic individuals, yet it underscores the relevance of rotator cuff pathology as a global health concern. Notably, the high prevalence rates in both athletic and general cohorts suggest that rotator cuff injuries intersect with other domains such as workforce productivity, healthcare resource allocation, and overall quality of life. Given these interconnections, there is a pressing need for targeted preventative strategies, early detection programs, and comprehensive rehabilitation approaches that address the diverse risk profiles and needs of affected populations.

How do age, gender, and occupation influence the prevalence rates?

Age, gender, and occupation each exert distinct and interconnected influences on the prevalence rates of health conditions, including rotator cuff (RC) pathology. Age is a critical determinant, as the mean age at first diagnosis varies significantly across different health conditions, implying that the likelihood of RC pathology and other diagnoses increases or shifts with age³. Gender further modifies these patterns, for instance, studies have shown that hundreds of diagnoses, including musculoskeletal disorders, have higher age-adjusted incidence rates in men, while an even greater number demonstrate higher rates in women, underscoring a clear gender-specific disparity in disease prevalence³. Moreover, the age at first diagnosis often differs markedly between men and women, suggesting that gender not only impacts overall prevalence but also the timing of disease onset and progression³. These gender differences are also reflected in population-level estimates and longitudinal studies, where disease risk patterns and directional trends are frequently driven by one gender over the other, further demonstrating the importance of considering gender in epidemiological analyses³. While occupation was not directly addressed in the current analysis, economic variables such as income and employment status have been found to influence health risk perception—predominantly in men—implying that occupational factors could indirectly affect prevalence rates by shaping exposure, risk perception, and ultimately health-seeking behavior⁴. These interconnections highlight the necessity for tailored prevention and intervention strategies that account for age, gender, and occupation-related disparities to more effectively address the prevalence and burden of RC pathology and other health conditions.

Are there differences in prevalence based on geographic or ethnic factors?

The prevalence of various health conditions and genetic traits demonstrates notable differences based on both geographic and ethnic factors, underscoring a complex interplay between genetic, environmental, and socioeconomic domains. Large-scale projects such as the HapMap have elucidated genetic variation among major continental populations—Caucasian, African, and Asian—by providing extensive genotype data and showing distinct clustering of these groups in principal component analysis (PCA), which highlights significant genetic differentiation across geographic regions⁵. However, while these genetic data reveal broad population structures, the translation to health disparities is mediated by a host of additional factors. For instance, the prevalence of chronic diseases such as diabetes, cardiovascular disease, and asthma varies significantly among racial and ethnic groups, with AIAN, Black, and Hispanic adults exhibiting higher rates of diabetes compared to White adults, and Black and AIAN adults experiencing higher asthma prevalence, while Hispanic and Asian adults generally have lower rates⁶. These variations are not solely attributable to genetic differences, rather, they are profoundly influenced by environmental exposures, socioeconomic status, and access to healthcare—domains that are themselves patterned by geographic and ethnic lines⁷. Furthermore, the spatial distribution of traditional villages among ethnic minorities in certain regions, such as the location of Tujia and Miao villages near urban centers versus Dong and Yao villages in more remote areas, further exemplifies how geography and ethnicity interact to shape exposure to resources and risks, ultimately affecting health outcomes⁸. Collectively, these findings highlight that addressing disparities in prevalence requires comprehensive interventions—spanning genetic research, environmental improvement, and social policy reforms—to mitigate both the biological and structural determinants of health.

Risk Factors Associated with Rotator Cuff Injuries

How do extrinsic factors such as physical activity and repetitive motion impact risk?

Extrinsic factors such as physical activity and repetitive motion play a pivotal role in determining injury risk by directly influencing biomechanical load and tissue stress across various domains, including occupational health, sports, and recreational activities⁹. The impact of these factors is multifaceted, for instance, the duration, frequency, and intensity of repetitive motion or physical activity determine the degree of biomechanical stress experienced by musculoskeletal structures, which in turn can either provoke or exacerbate injury, especially in contexts where load is not adequately managed¹⁰. In occupational settings, repetitive motion and physically demanding postures, particularly when prolonged or performed under strenuous conditions, have been linked with a higher prevalence of musculoskeletal disorders and repetitive strain injuries, highlighting the interconnectedness between work practices and health outcomes^9,10. Notably, the risk is further compounded when extrinsic factors such as acute increases in training load, improper exercise technique, or the use of inappropriate equipment are present, all of which may amplify mechanical stress and injury likelihood¹⁰. The interplay between these exposures is also evident in scenarios where combined factors—such as forceful exertions, awkward postures, and environmental considerations like hard or uneven running surfaces—synergistically increase the risk of overuse injuries and strain¹⁰. These interconnections underscore the critical need for holistic risk mitigation strategies, including tailored workload management, ergonomic interventions, and informed equipment choices, to reduce the incidence of injuries associated with extrinsic factors in both athletic and occupational contexts.

What role do comorbidities (e.g., diabetes, smoking) play in the development of rotator cuff injuries?

Comorbidities such as diabetes and smoking play a multifaceted and interconnected role in the development and progression of rotator cuff injuries, impacting both their incidence and the subsequent healing process. Diabetes is associated with detrimental changes in tendon health, such as the formation of additional scar tissue, which not only increases the mechanical vulnerability of the rotator cuff but also complicates recovery by impairing normal tissue remodeling and repair mechanisms^11,12. The systemic effects of poorly controlled blood glucose can further exacerbate these issues, making tendon structures more susceptible to microtrauma and chronic degeneration. In parallel, smoking has been identified as a significant risk factor for the development of rotator cuff tears, operating through both dose- and time-dependent relationships—meaning that increased duration and quantity of smoking elevate the risk proportionally¹³. Smoking contributes to compromised circulation and tissue oxygenation, which are crucial for tendon health and healing, thereby magnifying the negative impact when combined with other comorbidities such as diabetes or hypercholesterolemia^12,13. Moreover, the presence of multiple comorbidities does not simply add to the risk, rather, their coexistence synergistically and dramatically amplifies the probability of rotator cuff tear development, especially in patients undergoing surgical repair¹³. These interconnections underscore the necessity for clinicians to adopt a holistic approach in risk assessment and management, emphasizing aggressive control of systemic conditions and lifestyle modifications—such as smoking cessation and diabetes management—to mitigate rotator cuff injury risks and optimize patient outcomes.

Outcomes and Prognosis of Rotator Cuff Injuries:

How effective are different treatment modalities in improving patient outcomes?

The effectiveness of different treatment modalities in improving patient outcomes is underscored by the interplay between individualized care and the diversity of available options. Tailored treatment approaches, which consider the unique needs and conditions of each patient, consistently demonstrate superior symptom management and overall health improvements, as they align interventions more precisely with patient profiles¹⁴. Access to a broad spectrum of treatment modalities—including pharmacological, non-pharmacological, and combination therapies—further enhances the probability of identifying the most effective strategy for each specific condition, thereby supporting better health outcomes across various domains such as academic performance, social functioning, and even self-esteem¹⁴. Moreover, utilizing a mix of treatment modalities has been shown to expedite recovery, reduce complications, and address the multifaceted nature of patient health, emphasizing the need for healthcare systems to ensure comprehensive access and patient-centered care options¹⁴. As such, ongoing efforts must focus on expanding treatment choices, personalizing interventions, and fostering environments where patients can actively participate in their care decisions to maximize the benefits of diverse therapeutic approaches.

DISCUSSION

The findings of this comprehensive analysis underscore the multifactorial nature of rotator cuff (RC) injuries, highlighting the significant influence of demographic, occupational, genetic, and lifestyle factors on prevalence and outcomes. The wide variability in prevalence estimates—from 5% to 39%—reflects not only differences in diagnostic criteria and study methodologies but also underscores the importance of considering asymptomatic cases in understanding true disease burden. Age remains a critical determinant, with increasing susceptibility observed in older populations, which aligns with the degenerative model of RC pathology. Notably, gender differences appear inconsistent across studies, suggesting that hormonal, occupational, or behavioral factors may modulate risk, warranting further investigation. The role of occupational and recreational activities, particularly repetitive overhead motions, emphasizes the need for targeted ergonomic and preventive strategies in high-risk groups such as athletes and manual laborers. The genetic and neuroanatomical components, especially involving inherited variants and cerebellar structures, reveal an intrinsic predisposition influencing injury risk and recovery potential, yet the complex polygenic effects require further elucidation. The systemic impact of comorbidities like diabetes and smoking on tissue healing and tear progression reinforces the necessity of holistic patient management, integrating lifestyle modifications with clinical interventions. Outcomes following RC injuries are heavily influenced by factors such as injury severity, timing of intervention, and rehabilitation quality, with delayed treatment often leading to poorer prognoses and recurrent injuries. These findings advocate for early diagnosis and personalized, multimodal treatment approaches that address biomechanical, clinical, and psychosocial dimensions to optimize recovery. However, the study’s limitations include potential biases in population selection and variability in diagnostic protocols, which may affect generalizability. Future research should focus on refining risk stratification models, exploring genetic markers for susceptibility, and developing standardized rehabilitation protocols. Overall, this analysis emphasizes the importance of an integrated, individualized approach to prevent, diagnose, and manage RC injuries effectively, ultimately aiming to reduce their considerable health and economic burden worldwide.

CONCLUSIONS

1. Rotator cuff injuries constitute a major global health concern, affecting athletes, manual laborers, and aging populations with significant consequences for mobility, productivity, and quality of life. Prevalence estimates vary widely—from 5% to nearly 40%—reflecting differences in diagnostic imaging use, assessment criteria, and the inclusion of asymptomatic individuals. Age remains a primary determinant of RC pathology, with degenerative changes accelerating the incidence of tears among middle-aged and older adults. Gender differences are observed but remain inconsistent, suggesting the influence of occupational exposure, hormonal factors, and behavioral patterns.
2. Risk factors for RC injuries arise from the convergence of intrinsic determinants—such as anatomical variations, tendon degeneration, and genetic predispositions—with extrinsic contributors including repetitive overhead motions, physically demanding occupations, and high-intensity sports participation. Comorbidities such as diabetes and smoking significantly impair tendon integrity and healing capacity, markedly increasing the risk of tear progression and poor post-treatment outcomes.
3. Clinical outcomes after RC injury vary according to tear size, chronicity, comorbidity burden, and the timing and quality of intervention. Short-term deficits often involve substantial reductions in shoulder function and daily activity performance, while long-term consequences may include recurrent tears, chronic pain, stiffness, and diminished ability to work or participate in sports. Psychological and socioeconomic factors further influence recovery and prognosis.
4. Given the complexity of RC pathology, management requires individualized, multimodal strategies integrating early diagnosis, risk factor modification, biomechanical correction, and structured rehabilitation. Despite advancements, significant gaps persist in standardized prevention programs, long-term outcome comparisons between surgical and conservative treatments, and understanding genetic susceptibility. A holistic, patient-centered approach is essential for optimizing outcomes and reducing the considerable global burden associated with rotator cuff injuries.

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