Rotator Cuff Tear

What the rotator cuff does

The rotator cuff is a group of four muscles and their tendons:

Together they keep the ball of the humerus centered in the shallow socket of the shoulder blade. A torn tendon weakens this control, causing pain and weakness.

Types of tears

• Partial-thickness: the tendon is frayed but not torn through.
• Full-thickness: a hole goes through the tendon; it may be small or massive (involving two or more tendons).
• Degenerative: most common; from gradual wear, reduced blood supply and bone spurs. Many people over 60 have tears without symptoms.
• Acute: from a fall on an outstretched arm, lifting something heavy, or shoulder dislocation.

Causes and risk factors

• age over 40, increasing sharply after 60
• repetitive overhead work or sport (painting, construction, swimming, tennis, baseball)
• shoulder impingement and bone spurs
• smoking (reduces tendon blood supply and healing)
• family history
• falls and shoulder dislocations
• high cholesterol and diabetes

Symptoms

• dull, deep ache in the outer shoulder and upper arm
• pain at night, especially lying on the affected side
• pain lifting or lowering the arm, especially between shoulder and head height
• weakness when lifting or rotating the arm
• crackling (crepitus) with movement
• with acute tears: a sudden tearing sensation and immediate weakness

Severity of pain does not always match tear size; some large tears cause little pain.

Rotator cuff tear vs other shoulder problems

Diagnosis

• Examination: range of motion, strength tests for each tendon (empty can test, external rotation strength, lift-off and belly-press tests), and the drop-arm test for large tears.
• X-rays: bone spurs, arthritis, and in large chronic tears, the humeral head riding up.
• Ultrasound: accurate for full-thickness tears, quick and inexpensive.
• MRI: shows tear size, tendon retraction and muscle quality (fatty degeneration), which help predict repair success.

Treatment

Non-surgical treatment

Effective for many degenerative tears, particularly in people over 60:

• activity modification: avoid repetitive overhead lifting that provokes pain
• physical therapy: stretching, then strengthening the remaining rotator cuff, deltoid and shoulder blade muscles; programs typically last 6 to 12 weeks
• NSAIDs or acetaminophen, following the label
• corticosteroid injection into the space above the cuff for short-term pain relief; limited number because steroids may weaken tendons

About three-quarters of people with chronic degenerative tears improve with physical therapy.

Surgery

Considered for:

• acute, traumatic tears, especially in people under 65; repair within a few weeks gives the best results
• full-thickness tears in active people with significant weakness
• persistent pain and weakness after 3 to 6 months of physical therapy

Options:

• Arthroscopic rotator cuff repair: reattaching the tendon to bone with anchors through small incisions
• Debridement and subacromial decompression for some partial tears
• Tendon transfer or superior capsular reconstruction for irreparable massive tears
• Reverse shoulder replacement for massive tears with arthritis (cuff tear arthropathy)

Recovery after surgery

Re-tears are more common with large tears, older age, smoking and poor tendon quality.

Complications

• progression of tear size
• muscle weakness and wasting
• frozen shoulder
• cuff tear arthropathy (arthritis from a large tear)
• surgical complications: re-tear, stiffness, infection

Prevention

• strengthen the rotator cuff and shoulder blade muscles
• use good technique and take breaks in overhead work
• avoid smoking
• treat shoulder pain early

Frequently asked questions

What does a torn rotator cuff feel like?

It usually causes a deep ache in the outer shoulder, pain at night and when lying on that side, pain lifting the arm, and weakness raising or rotating the arm. An acute tear may cause a sudden tearing sensation and immediate weakness.

Can a rotator cuff tear heal without surgery?

A torn tendon does not heal back to the bone on its own, but many people, especially with degenerative tears, regain good function and pain relief with physical therapy that strengthens the surrounding muscles. Surgery is recommended for some tears.

How long does rotator cuff surgery recovery take?

Expect a sling for 4 to 6 weeks, physical therapy for several months, and a return to most activities by 4 to 6 months. Full strength can take up to a year, depending on the tear size and your age and health.

What is the difference between a partial and full rotator cuff tear?

A partial tear damages the tendon without going all the way through. A full-thickness tear creates a hole through the tendon or detaches it from the bone. Partial tears usually respond to physical therapy; full tears more often need surgery in active people.

Will a rotator cuff tear get worse?

Some do. Degenerative tears can enlarge over time, especially larger, symptomatic tears. Monitoring symptoms and strength, and repeat imaging if symptoms change, helps decide whether and when to repair.