Rotator cuff tears are a common musculoskeletal condition, and arthroscopic rotator cuff repair is a standard surgical treatment for symptomatic full‑thickness tears. Postoperative tendon healing and functional recovery are influenced by multiple factors, and the design of rehabilitation protocols plays a central role in outcomes. This review systematically examined the literature on the application of musculoskeletal ultrasound to monitor tendon and muscle status after rotator cuff repair and to inform rehabilitation decision‑making.
Postoperative rehabilitation must balance protection of the repair to promote tendon‑to‑bone healing against early mobilization to prevent stiffness, muscle atrophy, and adhesions. Traditional time‑based protocols apply fixed milestones for initiating active movement and progressing load, but they neglect substantial inter‑individual variability in tear size, tissue quality, healing trajectory, and patient factors such as age and preoperative muscle condition. Reported retear rates vary widely (15%–21% on average, up to 94% for massive tears), and although retears negatively affect recovery, some patients still achieve acceptable function despite structural failure. This heterogeneity supports a movement toward precision rehabilitation tailored to individual tissue healing status rather than a one‑size‑fits‑all timetable.
Musculoskeletal ultrasound offers several practical advantages for postoperative assessment: it is non‑invasive, available at the bedside, permits dynamic imaging, and allows repeated, quantitative follow‑up. Advances such as high‑frequency transducers, panoramic imaging, and elastography enable improved visualization of tendon structure and quantification of biomechanical properties. Compared with MRI, ultrasound avoids metal‑related artifacts and is more amenable to serial monitoring in the clinic or rehabilitation setting. Elastography parameters such as shear wave velocity (SWV) and elastic modulus have been used in both preoperative prediction and postoperative monitoring of tendon healing.
Prior reviews have largely summarized sonographic appearances and diagnostic utility of ultrasound versus MRI, or the use of ultrasound to detect complications. Although clinical studies have shown correlations between ultrasound elastography scores and muscle strength or function, and demonstrated that ultrasound metrics change with recovery, few reviews have focused specifically on whether and how ultrasound parameters have been translated into concrete rehabilitation decisions (for example, timing of active movement initiation, adjustment of exercise intensity, or criteria for return to sport). This systematic review aimed to map the evidence that links ultrasound monitoring metrics to rehabilitation management after rotator cuff repair.
The core question driving this review was: which ultrasound parameters, at what postoperative time points, and in what ways have been used to inform adjustments of rehabilitation protocols after rotator cuff repair? The review sought to synthesize available evidence to support ultrasound‑informed precision rehabilitation and to identify gaps for future research.
The review followed PRISMA 2020 guidelines and the protocol was registered with PROSPERO (registration number CRD420261418165). Searches were performed in PubMed, China National Knowledge Infrastructure (CNKI), and Wanfang Data for the period January 2020 to April 2026, with language restricted to English and Chinese. Eligible original studies included patients who had undergone rotator cuff repair and used musculoskeletal ultrasound (including gray‑scale ultrasound, elastography, or similar techniques) to evaluate tendons or shoulder muscles, reporting at least one parameter related to rehabilitation decision‑making or functional outcomes. The completed PRISMA checklist and supporting information were provided in the article's supplementary files.
Eleven studies met inclusion criteria. The most frequently reported ultrasound parameters were shear wave velocity (SWV), cross‑sectional area (CSA), and echo intensity (EI). Across the included studies, SWV demonstrated a progressive increase after surgery; the available evidence indicated an overall increase of approximately 22% to 25% between one week and 12 months postoperatively. An abnormally elevated SWV in the early postoperative period was associated in the included reports with an increased risk of retear, suggesting that clinicians might adopt a more conservative rehabilitation strategy in patients with such findings.
Tendon stiffness measured at approximately 12 weeks after surgery was reported in some studies to independently predict long‑term return‑to‑sport outcomes. Muscle parameters also provided clinically relevant information: changes in CSA and EI correlated positively with shoulder function scores, and combining CSA and EI measures helped to identify patients experiencing rehabilitation bottlenecks. The review synthesized these relationships and mapped them to potential rehabilitation decisions, including initiation of active movement, adjustment of exercise loads, and prognosis for return to sport.
The collated evidence supports the concept that musculoskeletal ultrasound, especially elastography‑derived metrics like SWV, can provide objective, repeatable information about tendon healing and muscle status that is relevant to postoperative rehabilitation planning. SWV's progressive increase over time may serve as a reference trajectory for judging healing progress; early deviations from expected patterns (notably elevated SWV) were linked with higher retear risk in the available literature. Muscle imaging using CSA and EI complemented tendon assessment by correlating with functional recovery and flagging patients with limited progress.
Despite promising signals, the review emphasizes important limitations in the current evidence base. Included studies varied in design, measurement protocols, timing of assessments, and outcome definitions. The review highlights the absence of randomized controlled trials directly comparing ultrasound‑informed rehabilitation strategies with conventional time‑based protocols, and it notes the need for standardized measurement techniques and clinically applicable reference values for ultrasound parameters. Without such standardization and prospective comparative trials, recommendations for altering rehabilitation solely on the basis of ultrasound remain provisional.
Musculoskeletal ultrasound parameters—most notably SWV, along with CSA and EI—are associated with key rehabilitation decisions after rotator cuff repair: timing of active movement initiation, exercise load adjustment, prognosis for return to sport, and identification of retear risk. SWV appears particularly promising as an objective monitoring metric. The review calls for randomized controlled trials to determine whether ultrasound‑guided rehabilitation improves outcomes compared with traditional time‑based regimens and for the establishment of standardized protocols and reference values to enable clinical application.