The Rotator Cuff Healing Index — and what we do when the biology is against us.

The problem.

Rotator cuff repair does not always heal. The published structural failure rate — meaning a defect at the repair site on follow-up imaging — sits at roughly 11% for small isolated supraspinatus tears, climbs into the 20–40% range for medium tears, and reaches 40–90% in massive multi-tendon tears with significant retraction or fatty atrophy.¹ The operation itself — the suture configuration, the anchor choice, the construct — matters. But the single most powerful predictor of whether the repair will hold is not the surgery. It is the biology of the cuff that is being sewn back to the bone, and the host biology of the patient it sits in.

The Rotator Cuff Healing Index (ROHI), published by Kwon and colleagues from Seoul in the American Journal of Sports Medicine in 2019, is the most useful attempt I have seen at structuring that biology into a score a surgeon can act on.²

What the ROHI captures.

The score combines six parameters, drawn from a multivariable analysis of healed versus unhealed repairs. Each parameter is independently associated with structural failure on post-operative imaging. The maximum total is 15 points.

1. Age over 70 (+2). Older tendons are less metabolically active and heal more slowly. The cellular turnover that bridges tendon to bone falls with each decade. The Kwon cut-off is binary: the risk lift sits at the 70-year boundary.
2. AP tear size over 2.5 cm (+2). Larger AP gaps mean more tendon being brought back to a footprint of the same size, under more tension. 2.5 cm is the published inflection point.
3. Tendon retraction (0–4). The distance the tendon has retracted from its footprint. The only graded parameter: under 1 cm scores 0, 1–2 cm scores 1, 2–3 cm scores 2, and 3 cm or more scores 4. Retraction carries the heaviest single-parameter weight in the score, because tension at the repair site is the dominant biomechanical enemy of healing.
4. Goutallier grade of infraspinatus ≥ 2 (+3). Fat in the infraspinatus belly is the histological end-state of disuse and chronicity. Goutallier 2 or above signals that the muscle is no longer pulling its weight as a couple force, and predicts poor structural healing.³
5. Bone mineral density T-score ≤ −2.5 (+2). The repair sits at the bone-tendon interface. Osteoporotic bone provides poor anchor purchase and a poor biological scaffold for the healing tendon to integrate into.
6. High level of work or activity (+2). Heavy manual labour, overhead trades and overhead sport all load the repair before it has healed. The Kwon score is the rare clinical tool that explicitly recognises that what the patient does for a living matters as much as what their MRI shows.

The score is not patient-friendly in the sense the Oxford Shoulder Score is. It requires an MRI report with explicit Goutallier grading and tendon-retraction measurement, and ideally a recent DEXA. Most of those values appear in your radiology report or are determined at consultation.

Blog Insights

Calculate the ROHI.

Use the interactive calculator below. Pick the option that matches each parameter from your MRI report and (if available) your DEXA scan. Your total ROHI score and the band it falls in will update as you go.

What we actually do when the ROHI is high.

A high ROHI does not mean "do not operate." It means the operation is not the whole answer. The healing chassis around the operation has to be optimised. There are three layers of intervention, and a thoughtful practice attacks all three.

1. Patient-level optimisation, before the operation.

• Smoking cessation. The strongest modifiable predictor of cuff healing failure. Smoking impairs microvascular perfusion at the tendon-bone interface and inhibits collagen cross-linking. A meaningful interval of cessation before surgery (typically ≥ 4 weeks; longer is better) measurably changes the odds. This is not a moral conversation; it is a biological one.⁴
• Vitamin D optimisation. Low serum 25-OH vitamin D is over-represented in unhealed cuff repairs and is associated with worse tendon-bone integration in animal and clinical work. Check it. If low, treat it — cheap, fast, well-tolerated.⁵
• Glycaemic control. Poorly controlled diabetes thickens the tendon's collagen architecture and impairs the inflammatory phase of healing. If HbA1c is above target, optimise before booking.
• Bone mineral density. If the DEXA shows osteopaenia or osteoporosis, treat. Repair construct purchase depends on the bone the anchor sits in.
• Weight, sleep, alcohol. The unglamorous fundamentals. Each one independently shifts the biology.

2. At the operation.

• Construct. A double-row suture-bridge construct distributes tension across a larger footprint than a single-row repair, and biomechanically reproduces the native footprint more faithfully. The healing-rate advantage in larger tears is consistent.⁶
• Patch augmentation. A dermal allograft patch (e.g. Conexa, ArthroFlex) placed over a high-risk repair acts as a biological scaffold and a mechanical reinforcement — reducing strain at the repair site while host cells colonise the matrix.⁷ In a truly massive irreparable tear, a bridging patch can replace tendon that simply will not reach footprint.
• Bone marrow aspirate concentrate (BMAC). Harvested from the iliac crest or proximal humerus and delivered to the repair site, BMAC introduces mesenchymal stromal cells, growth factors and platelets into a biologically depleted environment. Evidence is strongest in long-term healing rates and in revision settings.⁸
• Platelet-rich plasma (PRP). Mixed published evidence, but a reasonable adjunct in selected cases — the biology is sound and the cost-risk profile is low.
• Anchor strategy. All-suture or biocomposite anchors that integrate with bone over time, with multiple points of fixation in cases where pull-out is the risk.

3. After the operation.

• Longer sling time. A high-ROHI repair gets six weeks of strict sling immobilisation, not four. The tendon is given a longer protected window in which the early biology can hold.
• Delayed strengthening. Active-assisted range from week six; active range from week eight; strengthening deferred to twelve weeks rather than ten. Return to overhead loading shifted from four to six months post-op.
• Repeat imaging at six months. Not a test the patient asks for — a test the surgeon does to know whether the construct is holding and whether to escalate post-op physiotherapy.
• Honest conversation about expectations. A high-ROHI repair is more likely to fail than a low-ROHI one. Hiding that risk does not serve the patient. Naming it allows shared decision-making about whether to proceed at all, and structures the post-operative review around it.

The point underneath the score.

The ROHI is useful because it is uncomfortable. It forces the surgeon to acknowledge before the operation what the post-operative MRI is going to show six months later. The instinct in shoulder surgery is to focus on the surgical construct — the new anchor, the new suture configuration, the latest patch — because the operation is the part the surgeon controls. The biology is harder, slower, less photogenic. It is also where most of the variance in outcome lives.

A repair that does not heal is not necessarily a failed operation. Many cuffs that fail on MRI nonetheless give the patient pain relief and acceptable function, because the deltoid compensates and the repair has bought the soft-tissue scaffold time to remodel. But the patient sitting in the chair is asking for a repair that heals. The job is to make that more likely — not just to perform the surgery.

This is what good rotator cuff practice looks like: structured risk assessment before the operation, biological augmentation at the operation, and a protocol after the operation that matches the risk. The ROHI is a way to make that explicit.

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Related reading on this site

• Rotator cuff tear — the condition page
• Arthroscopic rotator cuff repair — the procedure page
• Biology of rotator cuff repair (companion essay)
• Tendon retraction in chronic cuff tears
• Oxford Shoulder Score — track your shoulder over time

References

1. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219–224.
2. Kwon J, Kim SH, Lee YH, Kim TI, Oh JH. The Rotator Cuff Healing Index: A New Scoring System to Predict Rotator Cuff Repair Failure in Patients With Large or Massive Tears. Am J Sports Med. 2019;47(1):173–180.
3. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;(304):78–83.
4. Mallon WJ, Misamore G, Snead DS, Denton P. The impact of preoperative smoking habits on the results of rotator cuff repair. J Shoulder Elbow Surg. 2004;13(2):129–132.
5. Cancienne JM, Brockmeier SF, Rodeo SA, Werner BC. Hypovitaminosis D as a risk factor for rotator cuff repair failure. Am J Sports Med. 2020;48(13):3325–3331.
6. Millett PJ, Warth RJ, Dornan GJ, Lee JT, Spiegl UJ. Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2014;23(4):586–597.
7. Barber FA, Burns JP, Deutsch A, Labbe MR, Litchfield RB. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012;28(1):8–15.
8. Hernigou P, Flouzat Lachaniette CH, Delambre J, et al. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study. Int Orthop. 2014;38(9):1811–1818.
9. Rotator Cuff Healing Index (RoHI) Scoring System — reference summary. ShoulderDoc.co.uk.