Abstract
Background:
Rotator cuff tears (RCTs) are highly prevalent and can have a detrimental effect on the sleep quality of affected patients. However, several studies have shown improvement of sleep after rotator cuff repair (RCR).
Purpose:
To look at the timeline of sleep improvement after RCR in patients with RCTs.
Study Design:
Systematic review; Level of evidence, 3.
Methods:
PubMed, Cochrane, and Google Scholar (pages 1-20) were queried through October 2024. Inclusion criteria consisted of studies that compared the number of patients with sleep disturbances before and after RCR. The compared outcomes consisted of the number of patients with disturbed sleep preoperatively and 3 months, 6 months, and 1 year postoperatively. Sleep disturbance was evaluated either by a patient-reported binary outcome indicating the presence or absence of sleep disturbance or by a validated objective sleep assessment score such as the Pittsburgh Sleep Quality Index or numeric rating scale.
Results:
Nine retrospective studies (based on 8 cohorts), 3 prospective studies, and 1 randomized controlled trial met the inclusion criteria. When studies compared patients with or without sleep disturbances as a binary outcome, a significant improvement in sleep was seen at 3 months (OR = 6.41; 95% CI, 5.01 to 8.22; P < .001), 6 months (OR = 10.64; 95% CI, 7.43 to 15.25; P < .001), and 1 year after RCR (OR = 1.71; 95% CI, 1.41 to 2.09; P < .001). However, when studies looked at the improvement in the sleep assessment scores, improvement in sleep disturbance was seen at 6 months (SMD = 2.97; 95% CI, 1.70 to 4.25; P < .001) and 1 year after RCR (SMD = 0.75; 95% CI, –0.59 to 2.08; P = .27).
Conclusion:
The present study shows that improvement in sleep disturbances in patients with RCTs occurred as early as 3 months after RCR. Future studies looking at the various factors related to the disturbance and improvement of sleep in patients with RCTs are needed.
Studies show that nearly 70% of individuals with shoulder disorders, such as rotator cuff tears (RCTs), experience significant difficulties with sleep, with many reporting pain as the primary cause of sleep disruption. 28 Sleep disturbances are a common yet underappreciated consequence of musculoskeletal disorders, particularly shoulder pathologies. 14 This striking statistic highlights the profound effect shoulder injuries can have beyond physical discomfort. Poor sleep exacerbates the functional limitations caused by shoulder injury, reducing the patient's overall quality of life. 8 The nocturnal pain experienced by these patients often leads to frequent awakenings and difficulty falling back asleep, which ultimately result in fatigue, mood disturbances, and cognitive impairments during the day. 6 These sleep deficits have a cascading effect on physical and mental health, worsening pain sensitivity and delaying recovery.6,19
Among patients with RCTs, sleep disturbances appear particularly severe, with many patients reporting sleep as the most challenging aspect of their condition. 1 Nocturnal pain in patients with rotator cuff pathology not only affects their ability to fall asleep but also causes frequent awakenings throughout the night. 14 This disruption to sleep has been shown to persist even after nonoperative treatments, leaving rotator cuff repair (RCR) as a viable option for many patients. 29 The association between RCTs and sleep disturbances has been the focus of numerous studies. The literature shows considerable variation in the reported prevalence and severity of sleep problems in these patients, with some studies suggesting that sleep quality improves after surgical repair and others showing little to no improvement.15,23 This variability indicates that although surgery is effective in addressing the shoulder's mechanical issues, it may not uniformly resolve the associated sleep problems. This variability may also stem from a lack of uniformity in the way sleep disturbance is considered and measured.
Given the conflicting evidence surrounding the improvement of sleep disturbances after RCR, a clear gap exists in understanding how surgical outcomes translate into sleep benefits. 24 There is a critical need to consolidate these findings to provide clearer guidance for both clinicians and patients. Hence, a meta-analysis is warranted to evaluate the true extent and timeline of improvement in sleep disturbance after RCR.
Methods
Search Strategy
Following the PRISMA guidelines, 20 we searched PubMed, Cochrane, and Google Scholar (pages 1-20) through October 2024 to find articles assessing the improvement in sleep disturbances after RCR. The following keywords and Boolean terms were used: “sleep” and “rotator cuff.” Supplementary articles were added by searching reference lists from articles and Internet searches. One author (M.D.) extracted the data, and another (T.P.) confirmed the choice of the included articles. The process is summarized in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart (Figure 1).
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart for article selection process.
Inclusion criteria consisted of studies that included patients undergoing RCR with reported sleep outcomes both preoperatively and postoperatively. Studies were required to present either binary sleep disturbance data or validated objective measures of sleep quality. Only studies with a minimum follow-up of 3 months were included. There were no restrictions on language. Nevertheless, all of the included articles were in English. Therefore, specific handling for non-English articles was not required. Exclusion criteria consisted of studies not reporting the number of patients with sleep disturbances and studies reporting only the number of patients with postoperative sleep disturbances.
Data Extraction
Eligibility of the included studies was determined by 2 reviewers independently (M.D., T.P.). Sleep disturbance was evaluated either by a patient-reported binary outcome indicating the presence or absence of sleep disturbance or by a validated objective sleep assessment score (numeric rating scale and Pittsburgh Sleep Quality Index, with the latter evaluating sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, sleep medication, and sleep dysfunction). Extracted data consisted of the number of patients with disturbed sleep preoperatively and 3 months, 6 months, and 1 year postoperatively and the continuous sleep scores at the same timepoints.
Risk of Bias Assessment
The ROBINS-I tool was used to assess the risk of bias in these nonrandomized studies by 2 authors independently, 25 excluding studies with a critical risk of bias. As for randomized controlled trials, bias assessment was performed using the Cochrane risk-of-bias tool. Each trial was assessed and recorded as having a high, low, or unclear risk of bias by 2 independent reviewers (M.D. and T.P.).
Statistical Analysis
Review Manager 5.4 (The Cochrane Collaboration, 2020) was implemented for all statistical analyses. Standardized mean difference (SMD) (to account for the heterogeneity of scores used to evaluate sleep) with 95% CI was used for continuous data, whereas odds ratio (OR) was used for dichotomous data. Heterogeneity was evaluated by Q tests and I2 statistics, using a random-effects model in case of considerable heterogeneity (defined by P≤ .05 or I2 > 50%) and a fixed-effect model if P > .05 or I2 < 50%. A statistically significant result was denoted by P < .05.
Results
Characteristics of the Included Studies
Nine retrospective studies (based on 8 cohorts), 3 prospective studies, and 1 randomized controlled trial met the inclusion criteria. ¶ These studies included 2447 patients undergoing RCR. The main characteristics of the included studies are summarized in Table 1.
Characteristics of the Included Studies a
NRS, numeric rating scale; PSQI, Pittsburgh sleep quality index. Dashes indicate data not reported.
The same cohort but different studies.
Binary Analysis
3 Months
Four studies including 904 patients preoperatively and 837 postoperatively reported on the number of patients with disturbed sleep at 3 months. A significant improvement was found in sleep at 3 months after RCR (OR = 6.41; 95% CI, 5.01 to 8.22; P < .001) (Figure 2A).
Forest plots showing the difference in the number of patients with sleep disturbances (A) at 3 months postoperatively, (B) at 6 months postoperatively, (C) between 3 and 6 months postoperatively, (D) at 12 months postoperatively, and (E) between 6 and 12 months postoperatively
6 Months
Six studies including 2170 patients preoperatively and 2080 postoperatively reported on the number of patients with disturbed sleep at 6 months. The studies showed a significant improvement in sleep at 6 months after RCR (OR = 10.64; 95% CI, 7.43 to 15.25, P < .001) (Figure 2B).
3-6 Months
Four studies including 837 patients at 3 months and 814 at 6 months postoperatively reported on the number of patients with disturbed sleep at 3 and 6 months. A significant improvement was found in sleep from 3 months to 6 months after RCR (OR = 1.71; 95% CI, 1.41 to 2.09; P < .001) (Figure 2C).
12 Months
Four studies including 2066 patients preoperatively and 1976 postoperatively reported on the number of patients with disturbed sleep at 12 months. A significant improvement in sleep was noted at 12 months after RCR (OR = 19.95; 95% CI, 13.12 to 30.34; P < .001) (Figure 2D).
6-12 Months
Four studies including 1993 patients at 6 months and 1976 at 12 months postoperatively reported on the number of patients with disturbed sleep at 6 and 12 months. The studies showed a significant improvement in sleep from 6 months to 12 months after RCR (OR = 1.58; 95% CI, 1.39 to 1.81; P < .001) (Figure 2E).
Continuous Analysis
3 Months
Four studies including 193 patients preoperatively and postoperatively reported sleep scores at 3 months. The studies showed no significant improvement in sleep at 3 months after RCR (SMD = 0.32; 95% CI, –0.13 to 0.78, P = .17) (Figure 3A).
Forest plots showing the difference in sleep scores (A) at 3 months postoperatively, (B) at 6 months postoperatively, (C) between 3 and 6 months postoperatively, (D) at 12 months postoperatively, and (E) between 6 and 12 months postoperatively.
6 Months
Seven studies including 1245 patients preoperatively and postoperatively reported sleep scores at 6 months. A significant improvement in sleep was found at 6 months after RCR (SMD = 2.97; 95% CI, 1.70 to 4.25; P < .001) (Figure 3B).
3-6 Months
Four studies including 193 patients at 3 months and 6 months postoperatively reported sleep scores at 3 and 6 months. The studies showed no significant improvement in sleep between 3 and 6 months after RCR (SMD = 0.41; 95% CI, –0.17 to 0.98; P = .16) (Figure 3C).
12 Months
Four studies including 1129 patients preoperatively and postoperatively reported sleep scores at 12 months.
6-12 Months
Two studies including 1020 patients at 6 months and 12 months postoperatively reported sleep scores at 6 and 12 months. No significant improvement in sleep was noted between 6 and 12 months after RCR (SMD = 0.75; 95% CI, –0.59 to 2.08; P = .27) (Figure 3E).
Discussion
Rotator cuff disease is highly prevalent and can have a detrimental effect on the quality of life of affected patients. One of the most common complaints from rotator cuff disease is sleep disturbance due to shoulder pain at night. Several studies have shown improvement in sleep after RCR with a consensus that sleep starts to improve at 6 months postoperatively. # The present meta-analysis showed improvement in sleep as early as 3 months after RCR and continuous improvement up until 1 year postoperatively. However, the continuous analysis showed that sleep started to improve at 6 months and continued to improve until 1 year postoperatively. The improvement in sleep could be even earlier; however, few studies reported about sleep improvement at 6 weeks, which limited additional analysis.
The pathophysiologic process of sleep disturbances in RCT is multifactorial, englobing characteristics of the tear, inflammatory effects of tendon degeneration, and behavioral influences. 8 In fact, conflicting evidence exists about the association between characteristics of the tear and sleep disturbances. Although studies have shown no association,18,22 Gumina et al 12 reported better sleep in patients with small tears compared with patients with large and massive tears. More consistent evidence is available for the inflammatory contribution to sleep disturbances. Higher levels of tumor necrosis factor α and higher peak systolic velocities in the anterior humeral circumflex artery were reported to be associated with sleep disturbances in RCT patients.4,26 As for behavioral factors, studies have reported that sleep position, preoperative narcotic use, mental health, and coping strategies could all contribute to sleep disturbance.13,17,18,22,27
Several studies have shown sleep resolution after RCR. Austin et al 1 were the first to do so, reporting a significant improvement in sleep at 3 months that was maintained at 6 months. 3 Following their study, several other studies reported pain improvement after RCR. ** These studies chose a 6-month threshold for sleep improvement. Nevertheless, as shown in our meta-analysis, sleep improvement could occur as early as 3 months postoperatively. In fact, 45% of the patients included in our analysis stopped having sleep disturbances at 3 months. However, our results showed a difference between the 2 types of analysis that were used. The binary analysis showed improvement at 3 months and continuous improvement up until 1 year, whereas the continuous analysis did not show improvement at 3 months, between 3 and 6 months, and between 6 and 12 months. This difference could be explained by the low number of patients included in these respective continuous analyses and the variability of the scoring systems used compared with the binary analyses. Nevertheless, in our study, the binary resolution of sleep disturbance was considered the primary outcome. This approach was prioritized because it directly reflects the patient's experience and avoids potential overinterpretation of small statistical changes in sleep scores that may not translate into clinically meaningful improvement. The continuous analyses were included as a supporting measure to provide additional detail on the trajectory of improvement across validated scales.
Sleep resolution is important after RCR for several reasons. Zheng et al 29 reported that patients had a higher improvement in patient-reported outcome measures after postoperative sleep normalization. Furthermore, studies have shown that sleep normalization correlated with functional outcomes such as the simple shoulder test and visual analog scale.1,15 Factors that were shown to delay sleep normalization include pre- and postoperative opioid use,1,15 whereas surgical factors including tear size, number of anchors, biceps treatment, and acromioplasty did not correlate with sleep assessment scores postoperatively. 1 Considering the results of our study, we believe that the sleep disturbance after RCR resolves after 3 months postoperatively. However, interventions to help with sleep during these 3 months could be helpful for the patients. Among these interventions, sleep aids have been investigated in the context of RCR. Cho et al 5 reported that zolpidem reduced the need for rescue analgesia after RCR with no associated risk. Similarly, Perez et al 21 reported that melatonin improved sleep quality and functional recovery while reducing opioid use after RCR.
Strengths and Limitations
The present study has several limitations. As a systematic review, findings depend on the variables examined by the studies that met inclusion criteria. Furthermore, the high heterogeneity seen in this analysis could be explained by the multifactorial origin of sleep disturbance and improvement, which could be unique to each person. In addition, a minimal number of studies reported on sleep disturbance beyond 1 year, preventing assessment of continuous improvement at 2 years after RCR. Finally, some of the analyzed outcomes included few studies, making our study underpowered to detect small differences, especially in the continuous analyses.
Conclusion
The present meta-analysis found that sleep in patients with RCTs could improve as soon as 3 months after RCR, continuously improving up to 1 year postoperatively. This study highlights the benefits that RCR has on sleep disturbances seen in patients with RCTs. Future studies are needed to further assess the different factors that might be related to sleep disturbances and improvement in patients with RCTs.
Footnotes
Final revision submitted August 26, 2025; accepted October 6, 2025.
One or more of the authors has declared the following potential conflict of interest or source of funding: A.Z.K. has received research support from Stryker and DePuy and is a paid presenter or speaker for Enovis. J.A.A. receives royalties from Osteocentric Technologies, Enovis, Zimmer-Biomet, Stryker, Globus Medical, Wolters Kluwer, Slack Orthopaedics, and Elsevier; holds stock in Shoulder Jam, Aevumed, Oberd, OTS Medical, Orthobullets, Atreon, and Restore 3D; has received research support from Enovis and Arthrex; and is a board or committee member of American Shoulder and Elbow Society, Mid Atlantic Shoulder and Elbow Society, Shoulder 360, and Pacira. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
