---
title: "Musculoskeletal ultrasound to guide rehabilitation after rotator cuff repair: systematic review fi"
id: "plos-one-22-application-of-musculoskeletal-ultrasound-in-postoperative-rehabilitation"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-22-application-of-musculoskeletal-ultrasound-in-postoperative-rehabilitation"
content_type: "clinical_feed_article"
specialty: "Radiology"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357622"
published_at: "2026-09-08T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Musculoskeletal ultrasound to guide rehabilitation after rotator cuff repair: systematic review fi
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-22-application-of-musculoskeletal-ultrasound-in-postoperative-rehabilitation
- **Specialty:** [Radiology](https://medichelpline.com/clinical-feed/radiology.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357622)
- **Published At:** 2026-09-08T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This systematic review synthesized studies from January 2020 to April 2026 on the use of **musculoskeletal ultrasound** to monitor healing and inform rehabilitation after arthroscopic rotator cuff repair. - Eleven original studies met inclusion criteria; commonly reported ultrasound parameters included **shear wave velocity (SWV)**, cross-sectional area (CSA), and echo intensity (EI). - SWV showed a progressive postoperative increase; pooled evidence across studies reported approximately a 22%–25% rise from one week to 12 months after surgery. - An abnormally elevated early postoperative SWV was associated with higher risk of **retear**, indicating potential value in prompting more conservative rehabilitation in such patients. - Tendon stiffness measured at 12 weeks post-op independently predicted long-term return-to-sport outcomes in the studies that reported this relationship. - Muscle metrics (CSA and EI) changed alongside recovery and correlated positively with shoulder function scores; combined assessment of CSA and EI helped identify patients with rehabilitation bottlenecks. - Authors conclude that ultrasound parameters are linked to key rehabilitation decisions: timing of active movement initiation, exercise load adjustment, prognosis for return to sport, and retear risk identification. - The review highlights **SWV** as a particularly promising objective monitoring metric but notes that standardized measurement protocols, clinically applicable reference values, and randomized controlled trials comparing ultrasound‑informed versus time‑based rehabilitation are lacking. - The review was registered with PROSPERO and followed PRISMA 2020 reporting standards. Funding sources and competing interest statements were reported; no conflicts declared.
## Clinical Analysis & Structured Key Points
Application of musculoskeletal ultrasound in postoperative rehabilitation assessment and monitoring after rotator cuff repair: A systematic review | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Background The development of rehabilitation protocols after rotator cuff repair has long lacked objective benchmarks. Traditional time‑based regimens are limited by considerable inter‑individual variability and an increased risk of re‑tear. Musculoskeletal ultrasound allows dynamic assessment of tendon healing and muscle morphology, yet evidence for directly linking its use to rehabilitation decisions remains scarce. Objective To systematically synthesize the evidence on the use of musculoskeletal ultrasound monitoring to inform rehabilitation decision‑making after rotator cuff repair. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta‑Analyses (PRISMA) guidelines, we searched PubMed, China National Knowledge Infrastructure (CNKI), and Wanfang Data from January 2020 to April 2026. Original studies were included if they involved patients who had undergone rotator cuff repair, used musculoskeletal ultrasound (including gray‑scale ultrasound, elastography, etc.) to evaluate the rotator cuff tendons or shoulder muscles, and reported at least one parameter related to rehabilitation decision-making or functional outcomes. Results Eleven studies were included. Shear wave velocity (SWV), cross‑sectional area (CSA), and echo intensity (EI) were the most frequently reported ultrasound parameters. Available evidence indicated that SWV increased progressively after surgery, with an overall increase of approximately 22% to 25% from one week to 12 months postoperatively. This dynamic trajectory may serve as a reference baseline for judging rehabilitation progress. An abnormally elevated SWV in the early postoperative period was associated with an increased risk of re‑tear, suggesting that a more conservative rehabilitation strategy should be adopted. Tendon stiffness measured at 12 weeks after surgery independently predicted long‑term return to sport. Regarding muscle parameters, changes in CSA and EI were positively correlated with shoulder function scores, and the combination of these two parameters effectively identified patients with rehabilitation bottlenecks . Conclusion Musculoskeletal ultrasound parameters are associated with the initiation of active movement, adjustment of exercise load, prediction of return‑to‑sport prognosis, and identification of retear risk. Among these, SWV shows particular promise as an objective monitoring parameter for supporting rehabilitation assessment after rotator cuff repair. Future randomized controlled trials are needed to determine whether ultrasound-informed assessment can improve rehabilitation outcomes compared with traditional time-based regimens, and to establish standardized measurement protocols and clinically applicable reference values. Key findings of this review are summarized in S1 File. Citation: Shi Y, Bao Y, Li C (2026) Application of musculoskeletal ultrasound in postoperative rehabilitation assessment and monitoring after rotator cuff repair: A systematic review. PLoS One 21(9): e0357622. https://doi.org/10.1371/journal.pone.0357622 Editor: Wencai Liu, Shanghai Jiaotong University: Shanghai Jiao Tong University, CHINA Received: June 11, 2026; Accepted: August 19, 2026; Published: September 8, 2026 Copyright: © 2026 Shi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the paper and its Supporting Information files. Funding: This work was supported by the Scientific Research Fund Project for Teachers of the Department of Education of Yunnan Province (Grant No. 2026J0026), the Yunnan University Medical Research Foundation (Grant No. YDYXJJ2024-0036), and the Yunnan Fundamental Research Projects (Grant No. 202601AT070147). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors declare no conflict of interest. 1 Introduction Rotator cuff tear is one of the most common musculoskeletal disorders [ 1 ]. Arthroscopic rotator cuff repair is currently the mainstream surgical treatment for symptomatic full-thickness tears, as it effectively improves shoulder function and reduces pain [ 2 ]. Nevertheless, postoperative healing of the repaired tendon and functional recovery are influenced by multiple factors [ 3 ], and the design of the rehabilitation protocol is a key determinant of postoperative outcomes [ 4 ]. 1.1 Rehabilitation challenges after rotator cuff repair: Limitations of traditional time‑driven protocols Rehabilitation after rotator cuff repair must balance two conflicting needs: sufficient immobilization to protect the repair interface and promote tendon-to-bone healing, and early mobilization to prevent joint stiffness, muscle atrophy, and adhesion formation. Postoperative shoulder stiffness is a common complication, closely associated with insufficient rehabilitation training and excessive immobilization [ 5 ]. Meanwhile, the reported retear rate after rotator cuff repair ranges from 15% to 21%, and can reach as high as 94% in cases of massive tears [ 6 ]. A number of systematic reviews and meta-analyses have shown that although retears have a negative effect on functional recovery, the effect size is modest and does not reach the threshold for clinical significance. This means that some patients may still achieve acceptable functional outcomes despite a retear — a finding that suggests postoperative rehabilitation decisions should not be informed solely by the goal of “absolute prevention of retears.” This observation is supported by the evidence from Holtedahl et al. [ 7 ]. In addition, age, tear size, fatty infiltration, muscle atrophy, and the appropriateness of the postoperative rehabilitation protocol have all been identified as significant risk factors for retear [ 8 ]. Traditional “one-size-fits-all” protocols that rely on fixed time points neglect the substantial inter-individual variability in tear characteristics, tissue quality, and healing trajectory. There is a clear need to shift toward a precision rehabilitation model based on the patient’s individual tissue healing status. 1.2 Technical advantages of musculoskeletal ultrasound: non‑invasive, bedside, dynamic, and quantifiable assessment of tendon healing and muscle morphology Musculoskeletal ultrasound is a non-invasive, real-time, and reproducible imaging modality that has recently demonstrated distinct advantages in the postoperative assessment of rotator cuff repair [ 9 , 10 ]. Advances in high-frequency transducers have enabled clearer visualization of fine tendon structures, panoramic imaging allows larger-scale structural assessment, and the introduction of elastography makes it possible to quantitatively evaluate the biomechanical properties of tendons and muscles [ 11 ]. Compared with magnetic resonance imaging, musculoskeletal ultrasound offers several practical benefits, including bedside applicability, dynamic imaging capability, and repeatable follow-up [ 12 ]. It also avoids artifacts caused by metal implants, making it particularly suitable for postoperative rehabilitation monitoring [ 13 ]. Musculoskeletal ultrasound can be used not only for the differential diagnosis of rotator cuff tears but also for assessing surgical outcomes and supporting rehabilitation monitoring at different postoperative stages [ 11 ]. In recent years, ultrasound elastography has also seen important progress in the preoperative evaluation of rotator cuff tears. Zhang et al. (2024) analyzed 106 patients who underwent arthroscopic rotator cuff repair and found that preoperative shear wave velocity (SWV) and elastic modulus were positively correlated with the Constant score at one year postoperatively. The combination of these two parameters predicted postoperative retear with an area under the curve (AUC) of 0.95 and a sensitivity of 91.70%, indicating that preoperative ultrasound parameters can effectively predict long-term functional outcomes and retear risk [ 14 ]. 1.3 Research gap: existing reviews focus on diagnosis or treatment; none have systematically synthesized the evidence linking ultrasound monitoring with rehabilitation-related decisions In recent years, the application of musculoskeletal ultrasound in rehabilitation after rotator cuff repair has gradually shifted from “structural assessment” to “functional monitoring.” Existing reviews have systematically summarized the normal sonographic appearances of the postoperative rotator cuff and common complications [ 15 ], and others have compared the use of ultrasound versus MRI in the postoperative setting [ 13 ]. In addition, clinical studies have confirmed that postoperative strain elastography scores are significantly correlated with muscle strength and function [ 16 ], that musculoskeletal ultrasound combined with shear wave elastography can assess tendon healing status after surgery for different tear types [ 17 ], and that changes in ultrasound parameters are positively correlated with shoulder function recovery [ 18 ]. However, most of these studies remain at the level of monitoring; they have not systematically summarized how ultrasound parameters can be directly translated into rehabilitation decisions (e.g., when to initiate active movement, how to adjust load intensity, or how to predict prognosis). In other words, although a large number of studies have used musculoskeletal ultrasound to monitor postoperative rehabilitation, a systematic review specifically focusing on how musculoskeletal ultrasound monitoring may inform rehabilitation decision-making after rotator cuff repair is still lacking. 1.4 Study objective Accordingly, the aim of this systematic review is to systematically search and synthesize the available literature to answer the following core question: which ultrasound parameters, at what postoperative time points, and in what manner have been used to inform adjustments of rehabilitation protocols after rotator cuff repair? By systematically mapping the evidence linking ultrasound parameters to rehabilitation decisions, this review seeks to provide clinicians with evidence‑based support for ultrasound‑informed precision rehabilitation, to identify key gaps in the current evidence base, and to offer directions for future research. 2 Methods This systematic review was designed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‑Analyses (PRISMA) 2020 statement [ 19 ]. The study protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews). The completed PRISMA 2020 checklist is provided in S1 Checklist. 2.1 Registered The protocol for this systematic review was registered with the PROSPERO International Prospective Register of Systematic Reviews (registration number: CRD420261418165). 2.2 Search strategy Searches were conducted in three electronic databases: PubMed, China National Knowledge Infrastructure (CNKI), and Wanfang Data Knowledge Service Platform. The search period covered January 2020 to April 2026, and the language was restricted to English and Chinese. For PubMed, the following search string was used: (“rotator cuff repair” AND (ultrasound OR elastography) AND (rehabilitation OR decision)). For the Chinese databases, the search strings were adapted accordingly: CNKI: SU=(’肩袖’ + ‘冈上肌’) * (’修复’ + ‘修补’ + ‘关节镜’) * (’超声’ + ‘肌骨超声’ + ‘弹性成像’) * (’康复’ + ‘术后’ + ‘功能恢复’ + ‘训练’); Wanfang Data: (主题:(肩袖) OR 主题:(冈上肌)) AND (主题:(修复) OR 主题:(修补) OR 主题:(关节镜)) AND (主题:(超声) OR 主题:(肌骨超声) OR 主题:(弹性成像)) AND (主题:(康复) OR 主题:(功能恢复) OR 主题:(术后) OR 主题:(训练)). The complete electronic search strategies are provided in S2 File . 2.3 Inclusion and exclusion criteria The inclusion and exclusion criteria were defined according to the PICOS framework as follows. 2.3.1 Inclusion criteria. (1) Population: Patients who underwent arthroscopic or open rotator cuff repair, regardless of tear type (full‑thickness or partial‑thickness) or tear size. (2) Intervention/Exposure: Assessment using musculoskeletal ultrasound, including but not limited to gray‑scale ultrasound, Doppler ultrasound, shear wave elastography (SWE), and real‑time tissue elastography (RTE). (3) Outcomes: A clear association between ultrasound parameters and either rehabilitation decision‑making (e.g., timing of initiation or progression of active movement, load intensity adjustment, return‑to‑sport determination, retear risk warning) or functional outcomes (e.g., Constant score, ASES score, range of motion, muscle strength). (4) Study type: Randomized controlled trials, prospective or retrospective cohort studies, case‑control studies, or case series (with a sample size of ≥10 patients). (5) Publication period: January 2020 to April 2026. (6) Language: English or Chinese. 2.3.2 Exclusion criteria. (1) Patients with rotator cuff tears who did not undergo surgical repair (e.g., studies on conservative treatment). (2) Patients who underwent concurrent shoulder procedures (e.g., Bankart repair, shoulder arthroplasty, biceps tenodesis). (3) Studies that used only MRI or CT for assessment without performing ultrasound examination. (4) Studies that reported ultrasound parameters without any form of association with rehabilitation decisions or functional outcomes. (5) Studies with ineligible study types: case reports (sample size < 10), reviews, editorials, commentaries, conference abstracts, animal experiments, or in vitro studies. 2.4 Literature screening and data extraction Literature screening was performed following the process recommended by the PRISMA 2020 guideline. Duplicate records were first removed using reference management software (NoteExpress). Two investigators independently screened the titles and abstracts against the inclusion criteria and excluded records that clearly did not meet the criteria. Full texts of the potentially eligible articles were then retrieved and independently assessed by the two investigators to make the final decision on inclusion. Data extraction was also performed independently by the two investigators using a pre‑designed data extraction form. The extracted information included (1) basic study characteristics (first author, year of publication, study design); (2) participant characteristics (sample size, tear type and size, postoperative follow‑up time points); (3) musculoskeletal ultrasound parameters (ultrasound device, parameter types: cross‑sectional area, echo intensity, shear wave velocity, strain ratio, etc.); (4) rehabilitation decision‑related information; and (5) level of evidence. After extraction, the two investigators cross‑checked the data to ensure accuracy. Disagreements between reviewers were resolved through discussion, with a third reviewer consulted when necessary. All screening decisions were reached by consensus; however, formal inter-rater agreement statistics (e.g., Cohen's kappa) were not calculated. The characteristics of included studies are summarized in Table 1 . Download: PNG larger image TIFF original image Table 1. Methodological characteristics of included studies. LOE, level of evidence, graded according to the Oxford Centre for Evidence-Based Medicine (CEBM) levels of evidence. https://doi.org/10.1371/journal.pone.0357622.t001 2.5 Risk of bias assessment The methodological quality (risk of bias) of the included studies was independently assessed by two reviewers. The assessment tool was selected according to the study design. For the single randomized controlled trial, the Cochrane Risk of Bias tool version 2 (RoB 2) was used, evaluating bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selective reporting of results. For the nine cohort studies, the Risk of Bias in Non-randomized Studies of Interventions tool version 1 (ROBINS-I) was applied, assessing bias due to confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and selective reporting of results. For the one case series, the JBI Critical Appraisal Checklist for Case Series was used. Each study was rated as having either “low risk of bias,” “moderate risk of bias,” “high risk of bias,” or “some concerns.” The two reviewers independently performed the assessment and then cross-checked their results. Disagreements were resolved through discussion, with a third reviewer consulted when necessary. For the single randomized controlled trial included in this review, the Cochrane Risk of Bias tool version 2 (RoB 2) was used; the trial (He et al., 2021) was judged to have low risk of bias across all domains. For the case series included in this review (Liu et al., 2022), the JBI Critical Appraisal Checklist for Case Series was used; the study was judged to have moderate risk of bias. 3 Results 3.1 Study selection The study selection process was reported following the PRISMA 2020 guidelines. The initial search yielded 278 records: 126 from PubMed, 52 from CNKI, and 100 from Wanfang Data. After removing duplicates using NoteExpress, 268 records remained. Screening by title and abstract excluded 221 records, leaving 47 articles for full‑text assessment. Based on the inclusion and exclusion criteria, 36 articles were excluded after full‑text review. Consequently, 11 studies were included in this systematic review. The screening process and its results are presented in a PRISMA flow diagram Figure 1 . Download: PNG larger image TIFF original image Fig 1. PRISMA 2020 flow diagram of study selection process. https://doi.org/10.1371/journal.pone.0357622.g001 3.2 Characteristics of included studies The 11 included studies were published between January 2020 and April 2026. In terms of study design, there were six prospective cohort studies, three retrospective cohort studies, one case series, and one randomized controlled trial. Sample sizes ranged from 39 to 95 patients, with a total of 673 participants across the included studies. Postoperative assessment time points ranged from one week to 12 months, with one month, three months, and six months being the most common evaluation points. In terms of ultrasound parameters, six studies focused on tendon parameters (mainly SWV), four studies examined muscle parameters (CSA and EI), and one study reported both types of parameters. Regarding the association with rehabilitation decisions, three studies explored the relationship between ultrasound parameters and the initiation or progression of active movement, seven investigated retear risk warning, four involved prognostic prediction of return to sport, seven addressed load intensity adjustment, and three covered rehabilitation bottleneck identification. 3.3 Summary of ultrasound parameters The included studies primarily reported two categories of ultrasound parameters: muscle morphology parameters (e.g., cross‑sectional area [CSA] of the supraspinatus muscle, used to assess muscle atrophy) and tendon structural parameters (e.g., tendon thickness [TH], shear wave velocity [SWV], used to assess tendon healing quality). A detailed summary of ultrasound equipment and technical specifications is provided in S1 Table . 3.3.1 Tendon parameters. Six studies reported shear wave velocity (SWV) of the supraspinatus tendon. In normally healed tendons, SWV was approximate
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