The Impact of Psychosocial Factors on Pain and Functional Outcomes After Rotator Cuff Repair: A Systematic Review.

Introduction: Outcomes after rotator cuff repair are commonly evaluated in terms of structural healing and surgical technique. However, psychological factors may also influence patients' experience of pain and functional recovery. Increasing attention has therefore been directed toward the potential role of preoperative psychological distress in shaping postoperative outcomes. In this review we aimed to systematically review the available evidence examining whether psychological factors present before surgery are associated with postoperative pain and functional outcomes following rotator cuff repair. Methods: This systematic review was conducted in accordance with PRISMA guidelines and prospectively registered in PROSPERO (CRD420251132190; 28/08/2025). A structured literature review was performed using MEDLINE, Embase and PsycINFO, from database inception to March 6, 2026, for studies evaluating preoperative psychological variables in relation to postoperative pain and functional outcomes. Eligible study designs included randomized controlled trials, non-randomized trials, and observational cohort studies; however, only observational cohort studies met the final inclusion criteria. Risk of bias was assessed using the ROBINS-I tool, and methodological quality was appraised using the Newcastle-Ottawa Scale. Results: Ten observational studies were included. Across these studies, higher levels of depression, anxiety, pain catastrophizing, poorer emotional well-being, negative affect, and broader psychological distress were frequently associated with worse postoperative pain intensity and lower functional outcome scores. The reported associations were generally small-to-moderate strength and varied across cohorts. Some findings suggested potential interaction between psychological vulnerability and biological predisposition, including variation in Catechol-O-Methyltransferase (COMT) genotype. Importantly, elevated preoperative psychological distress did not preclude meaningful postoperative improvement, and several studies reported parallel improvements in psychological symptoms and physical recovery over time. Discussion: The available evidence indicates that recovery after rotator cuff repair cannot be explained solely by structural or surgical factors. Psychological health appears to influence how patients experience and report postoperative pain and function. However, the observed relationships are not uniform, and the evidence base is limited by observational design, methodological heterogeneity, and variability in outcome measurement. While preoperative psychological assessment may have clinical value, further prospective and interventional research is required to clarify its impact on surgical outcomes. Conclusions: Preoperative psychological distress is associated with postoperative pain and functional outcomes after rotator cuff repair, although it does not determine recovery in isolation. Psychological factors likely represent one component of a broader multifactorial recovery process. Future studies should explore whether targeted psychological interventions can improve postoperative pain trajectories and functional recovery.