Low-tension rotator cuff repair for retracted tears: Balancing mechanical relaxation and footprint coverage

Retear after arthroscopic rotator cuff repair remains a major concern, especially in large, chronic, retracted tears. Although anatomic footprint restoration is preferred, forced lateralization may increase repair tension, compromising fixation mechanics and tendon perfusion. This systematized narrative review synthesizes clinical, biomechanical, cadaveric, and technical evidence on repair tension, footprint coverage, medialization, margin convergence, interval slide procedures, and partial functional repair. A structured PubMed/MEDLINE search was supplemented by targeted publisher searches and citation chaining through April 2026. Evidence suggests that repair tension is measurable, reflects tear severity and imaging risk factors, and may be associated with poorer cuff integrity and reduced tendon microvascular flow. Recent Level III comparative evidence favors tension-reducing repair at 24 months, but measurement methods and thresholds do not support a universal strategy. Complete anatomic repair remains the goal when achievable under acceptable tension. In retracted tears, a tension-aware approach may support selective mobilization, margin convergence, limited medialization, or functional partial repair rather than forced high-tension repair. Medialization refers to bone-bed location, whereas functional partial repair is defined by a planned residual tendon defect. This review proposes a decision framework and provisional tension-aware categories, emphasizing individualized surgical judgment and prospective comparative studies.