Przejdź do treściCan ultrasound and elastography replace the calendar as the main guide for rehabilitation progression after rotator cuff repair? A recent systematic review found interesting associations between ultrasound-derived measures and tendon healing, function and return to activity. It also shows how far the field remains from validated decision thresholds that are ready for routine clinical use.
Polish version · For Doctors and Physiotherapists
Why is this study interesting?
Rehabilitation after rotator cuff repair has to balance protection of the repair with gradual restoration of motion and strength. Protocols based only on time do not account for tendon quality, tear size or individual healing rates. Ultrasound is repeatable, dynamic and widely accessible, while shear-wave elastography can describe mechanical properties of tissue. The clinically relevant question is not simply whether an imaging measure correlates with outcome, but whether changing rehabilitation according to that measure improves patient outcomes.
Question and methodology
Shi, Bao and Li conducted a PRISMA-compliant systematic review with a protocol registered in PROSPERO. They searched PubMed and two Chinese databases, CNKI and Wanfang, for studies published from January 2020 through April 2026. Eligible studies involved patients after surgical rotator cuff repair and related grayscale ultrasound, Doppler or elastographic findings to rehabilitation decisions or functional outcomes.
Eleven studies including 673 patients were synthesised: six prospective cohorts, three retrospective cohorts, one case series and one randomised trial. Individual studies included 39 to 95 patients. Nine of the eleven studies were therefore cohort studies, and most of the key inferences came from observed associations rather than direct comparisons of rehabilitation strategies.
Main findings
Shear-wave velocity in the tendon
In normally healing supraspinatus tendons, shear-wave velocity, used as an indirect measure of stiffness, was approximately 6.2–6.3 m/s at one week, about 7.5 m/s at six months and 7.7–7.8 m/s at one year. This represented an increase of roughly 22–25% over 12 months.
Higher early values were associated with a greater retear risk in one cohort. Tendon stiffness measured at 12 weeks was also correlated with later return to work or sport, with a reported correlation coefficient of 0.49. This is a moderate prognostic signal, not evidence that adjusting load according to that parameter improves outcomes.
Muscle cross-sectional area and echogenicity
Changes in muscle cross-sectional area and echogenicity were associated with shoulder function. In one study, correlations with the Constant score were 0.633 and 0.693 respectively. Confidence intervals were not reported, however, and these associations do not constitute validated criteria for starting active movement, increasing resistance or introducing electrical stimulation.
Clinical interpretation for an orthopaedic surgeon
The review supports the use of ultrasound as a tool for observing healing biology and for generating hypotheses about more individualised rehabilitation. It does not support a simple rule such as “the elastography value crossed a threshold, therefore loading can be increased”. The review itself acknowledges that quantitative thresholds remain limited and unvalidated.
A value around 7.5 m/s at six months was presented as a potential reference point, but it depends on the ultrasound system, probe, measurement angle, tendon tension, limb position and protocol. It cannot be treated as a universal safety threshold.
Limitations
- only one of the 11 studies was randomised;
- small samples, ranging from 39 to 95 patients, with 673 participants in total;
- substantial heterogeneity in ultrasound techniques, time points and measured parameters;
- no shared prospectively validated threshold for changing rehabilitation load;
- some correlations were reported without confidence intervals;
- the search was limited to three databases and English- and Chinese-language publications;
- two reports by Maloof and colleagues each included 50 patients and may represent sequential analyses of the same or partly overlapping cohort;
- the review did not directly compare imaging-guided rehabilitation with a well-conducted clinical rehabilitation protocol.
What could change practice?
At present, the most defensible use is systematic documentation of the repaired tendon and muscle parameters in centres with a reproducible protocol. An unusual appearance may prompt closer clinical review, reassessment of loading or additional imaging. It should not independently determine a return-to-sport date.
A practice-changing study would need to randomise patients to a rehabilitation protocol modified according to standardised ultrasound measurements versus a protocol based on time, operative findings and functional assessment. Patient-important outcomes should include retear, pain, function, stiffness, return to work or sport and adverse events.
What does the review not prove?
It does not prove that elastography improves rehabilitation outcomes, that one shear-wave velocity is safe for every repaired tendon, or that a normal ultrasound can replace clinical examination. It also does not show that time-based protocols should be abandoned. The review is a useful map of a developing field, not a ready-made rehabilitation algorithm.
Source
Shi Y, Bao Y, Li C. Application of musculoskeletal ultrasound in postoperative rehabilitation assessment and monitoring after rotator cuff repair: a systematic review. PLoS One. 2026;21(9):e0357622. Published 8 September 2026. DOI: 10.1371/journal.pone.0357622. PubMed. Full text.
Content prepared by: Tomasz Poboży - orthopaedic surgeon.