INTRODUCTION
Rotator cuff tears are among the most prevalent musculoskeletal disorders, affecting up to 30% of individuals older than 60 years and 20% of the general population [1]. These injuries range from acute traumatic tears in younger, active individuals to degenerative tears resulting from chronic wear and tear in older adults [2]. Regardless of aetiology, rotator cuff tears are a major source of pain, functional impairment, and reduced quality of life, highlighting the need for effective treatment in orthopaedic practice [1].
For patients unresponsive to conservative management—including physical therapy, corticosteroid injections, and activity modification—arthroscopic rotator cuff repair (ARCR) is the gold standard surgical intervention [3]. ARCR aims to restore function, relieve pain, and prevent tendon degeneration. However, the role of acromioplasty, which involves removal of part of the acromion to address subacromial impingement, remains a matter of controversy.
Traditionally, acromioplasty was thought to expand the subacromial space, reduce mechanical compression on the repaired tendon, and enhance healing [4]. Despite these theoretical benefits, recent advances in arthroscopic techniques that minimise subacromial compression have led to increasing scepticism about its necessity [5,6]. Indeed, recent surgical trends show a shift away from routine acromioplasty, reflecting evolving perspectives on its true clinical value.
The evidence regarding acromioplasty remains conflicting. Some studies suggest that it improves functional outcomes and lowers re-tear rates [7-9], while others report no significant benefits in pain relief or tendon integrity over ARCR alone [10,11]. This inconsistency has fuelled ongoing debate among clinicians regarding the routine use of this approach. Prior systematic reviews and meta-analyses have attempted to address this issue; however, many were limited by non-randomised studies, small sample sizes, or heterogeneous patient populations [12,13]. Furthermore, no recent synthesis has incorporated the growing body of high-quality randomized controlled trials (RCTs) published in the last decade, leaving a gap in the current evidence base.
This meta-analysis seeks to fill this gap by synthesising data from six recent RCTs evaluating the efficacy of acromioplasty in ARCR. Specifically, we compare functional outcomes, pain relief, and re-tear rates between ARCR with and without acromioplasty. By providing a comprehensive, up-to-date assessment, this study aims to clarify the role of acromioplasty in rotator cuff repair and inform evidence-based surgical decision-making.
METHODS
This study did not involve human participants or identifiable data; therefore, institutional review board approval and informed consent were not required.
Study Design and Search Strategy
This meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to ensure methodological rigour and transparency. A comprehensive search was conducted across four electronic databases—PubMed, Embase, Cochrane Library, and Scopus—to identify relevant studies published between January 2011 and December 2023. The search strategy incorporated a combination of Medical Subject Headings (MeSH) terms and free-text keywords, including “rotator cuff tear,” “acromioplasty,” “subacromial decompression,” “arthroscopic repair,” “functional outcomes,” and “randomised controlled trial.” Boolean operators (AND, OR, NOT) were applied to refine search results. For example: (“rotator cuff tear” OR “rotator cuff injury”) AND (“acromioplasty” OR “subacromial decompression”) AND (“arthroscopic repair”) AND (“randomised controlled trial”). The search was limited to English-language studies involving human subjects. Additionally, reference lists of included studies and relevant systematic reviews were manually screened to identify additional eligible trials.
Inclusion and Exclusion Criteria
The inclusion criteria were as follows: (1) RCT comparing ARCR with and without acromioplasty; (2) patients with full-thickness rotator cuff tears confirmed via imaging (e.g., magnetic resonance imaging or ultrasound); (3) Intervention: ARCR with acromioplasty (ARCR-A); (4) Comparison: ARCR without acromioplasty (ARCR); (5) outcomes: Studies reporting at least one of the following—functional outcomes (e.g., American Shoulder and Elbow Surgeons [ASES], Western Ontario Rotator Cuff [WORC], University of California, Los Angeles [UCLA] scores), pain levels (e.g., visual analog scale [VAS]), or re-tear rates (confirmed by imaging or clinical assessment); (6) publication timeline: 2011–2023. Exclusion criteria were as follows: (1) non- RCT studies (e.g., observational studies, case reports); (2) Studies investigating partial-thickness rotator cuff tears or using open/mini-open surgical techniques; (3) Animal or cadaveric studies; (4) Studies lacking sufficient data for meta-analysis (e.g., missing means, standard deviations, or effect sizes).
Study Selection and Data Extraction
The study selection process was conducted in two phases. Initially, two independent reviewers (MB and KM) screened study titles and abstracts to identify potentially relevant articles. Full texts of eligible studies were then assessed using the predefined inclusion criteria. Disagreements between reviewers were resolved through consensus or consultation with a third investigator.
Data extraction was performed independently by two reviewers using a standardised form. Extracted data included (1) study characteristics (author, year, country, sample size, follow-up duration); (2) patient demographics (mean age, sex distribution); (3) intervention details (surgical technique, acromioplasty method); (4) outcome measures (functional scores, pain scores, re-tear rates); and (5) Statistical data (means, standard deviations, confidence intervals, P-values). Among the included RCTs, the acromioplasty technique varied slightly, with some studies performing lateral acromion resection and others including anterior acromioplasty. Tendon repair methods also differed, ranging from single-row to double-row suture anchor constructs. Fixation devices, portal placement, and surgeon experience were not consistently reported. These variations may contribute to clinical heterogeneity and were considered during analysis and interpretation. All extracted data were cross verified to ensure accuracy and consistency (Table 1).
Risk of Bias Assessment
The methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool for randomized controlled trials. This tool evaluates six domains: (1) random sequence generation (selection bias); (2) allocation concealment (selection bias); (3) blinding of participants and personnel (performance bias); (4) blinding of outcome assessment (detection bias); (5) incomplete outcome data (attrition bias); and (6) Selective reporting (reporting bias). Each domain was rated as low risk, high risk, or unclear risk of bias. The overall risk of bias for each study was then summarized (Table 2).
Primary Outcomes
The primary outcomes assessed in this meta-analysis included (1) functional outcomes: Measured using the ASES score, WORC index, and UCLA Shoulder Score; (2) pain scores: assessed using the VAS; and (3) re-tear rates: reported as binary outcomes based on imaging or clinical assessment.
Statistical Analysis
All statistical analyses were conducted using Review Manager (RevMan) Version 5.4 (The Cochrane Collaboration). For continuous outcomes (e.g., ASES, WORC, and VAS), results were reported as mean differences (MDs) with 95% CIs. For dichotomous outcomes (e.g., re-tear rates), results were expressed as risk ratios (RRs) with 95% CIs. A random-effects model was used to account for heterogeneity across studies. Heterogeneity was assessed using the I² statistic: I²<25%: low heterogeneity, I²=25%–50%: moderate heterogeneity, I²>50%: high heterogeneity. Sensitivity analyses were conducted after excluding studies with a high risk of bias or outliers to assess the robustness of results. Publication bias was evaluated using funnel plots, examining symmetry to detect potential reporting biases (Figs. 1-4).
RESULTS
A total of six RCTs were included in this meta-analysis, comprising 574 patients who underwent ARCR with or without acromioplasty. The sample sizes across studies ranged from 25 to 60 participants per group, with follow-up durations between 2 to 7.5 years. The mean patient age range across studies was 55 to 60 years (Table 1). Primary outcome measures were functional scores (ASES, WORC index, and UCLA score), pain scores (VAS), and re-tear rates assessed via imaging or clinical evaluation (Fig. 5).
The methodological quality of the included studies was evaluated using the Cochrane Risk of Bias Tool. Most trials demonstrated low risk in random sequence generation and allocation concealment, ensuring proper randomisation. However, three studies did not specify blinding of outcome assessors, introducing a potential risk of detection bias, particularly for subjective outcomes like functional scores and pain ratings. Attrition bias was noted in several trials due to incomplete imaging follow-up for re-tear assessment (Table 2).
The pooled analysis revealed modest improvements in functional outcomes in the acromioplasty (ARCR-A) group compared to the non-acromioplasty (ARCR) group. ASES scores: ARCR-A: MD=39.71 (95% CI, 36.32 to 43.10; P<0.00001), ARCR: MD=36.78 (95% CI, 33.35 to 40.21; P<0.00001). UCLA scores: ARCR-A: MD=9.96 (95% CI, 3.18 to 16.74; P=0.004). ARCR: MD=7.79 (95% CI, 3.23 to 12.35; P=0.0008). Although statistically significant, these improvements did not exceed the minimal clinically important difference (MCID), suggesting that the functional gains may not translate into a perceptible benefit for most patients (Fig. 6). Pain relief was not significantly different between groups. VAS: MD=–0.12 (95% CI, –0.45 to 0.21; P=0.48), re-tear rates were also comparable: RR=1.12 (95% CI, 0.85 to 1.48; P=0.42). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment indicated high certainty for ASES outcomes in the ARCR group, with moderate certainty for ASES in the ARCR-A group and for UCLA scores. Funnel plot analyses revealed no significant publication bias across outcome measures (Figs. 1-4).
DISCUSSION
This meta-analysis confirms that acromioplasty provides only modest functional benefits without significant improvements in pain relief or re-tear rates. The improvement in functional scores observed in patients undergoing acromioplasty was statistically significant but did not exceed the MCID—emphasizing that these gains may not translate into meaningful clinical improvement for most patients [3-5]. Given that both groups demonstrated functional recovery, the necessity of acromioplasty as a routine adjunct to ARCR is questionable. This finding underscores the importance of distinguishing between statistical significance and clinical relevance—an especially critical issue when interpreting PROMs. Patients with preoperative symptoms of subacromial impingement or certain anatomical variants may experience some benefit from acromioplasty; however, across the broader ARCR population, the incremental value appears limited [6,7].
The lack of a pain-relieving effect is clinically notable, as postoperative discomfort remains a key determinant of patient satisfaction. Pain in rotator cuff pathology is multifactorial, involving tendon degeneration, muscle atrophy, synovial inflammation, and neural sensitization [8,9]. The results suggest that resecting part of the acromion does not meaningfully address these pain generators, reinforcing the notion that acromioplasty may offer little added value in standard ARCR [10,11]. Re-tear rates were also similar between the ARCR and ARCR-A groups, challenging the long-standing theory that acromioplasty improves tendon healing by reducing mechanical compression [12,13]. Instead, the findings support the idea that healing is primarily influenced by tissue biology, quality of fixation, and rehabilitation protocols. Without clear evidence of impingement, acromioplasty should not be presumed to offer structural protection.
Importantly, the lack of assessor blinding in half of the included RCTs introduces some risk of detection bias, particularly for subjective outcomes such as VAS and functional scores. This methodological limitation warrants cautious interpretation, even though the pooled evidence remains robust [15,16]. Despite its historical popularity, routine acromioplasty may increase operative time, carry risks (e.g., deltoid injury, bleeding), and add to procedural costs without corresponding patient benefit. Thus, surgeons should make case-by-case decisions, prioritizing anatomical findings and symptom profiles [17,18]. Certain subgroups—particularly patients with type III acromion or symptomatic impingement unresponsive to conservative treatment—may still benefit from targeted acromioplasty. Identifying such high-yield populations is essential for individualized care [19,20].
In conclusion, this study provides contemporary, high-certainty evidence suggesting that acromioplasty should not be performed routinely during ARCR. Its use should be guided by patient-specific anatomical and clinical indicators rather than tradition or default practice. Future research should focus on refining these selection criteria and evaluating long-term outcomes of acromion-preserving repair strategies.
CONCLUSIONS
Acromioplasty modestly enhances functional outcomes but does not significantly improve pain or re-tear rates. These findings support a selective, rather than routine, approach to acromioplasty in ARCR. Surgeons should weigh the risks, benefits, and operative complexity before incorporating acromioplasty into their standard rotator cuff repair procedures. A more conservative approach may be warranted in cases without mechanical impingement. However, acromioplasty may still be appropriate in patients with type III acromion morphology, symptomatic subacromial impingement, or those unresponsive to conservative management. Future research should focus on refining these selection criteria to guide individualized surgical decisions.
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