What are rotator cuff tears?
Rotator cuff pathology refers to any disease, injury, or dysfunction affecting the rotator cuff. The rotator cuff is a group of four muscles and their tendons that wrap around the ball shaped humeral head to stabilise the shoulder and allow lifting and rotation of the arm. The four muscles and their tendons that make up the rotator cuff are supraspinatus, infraspinatus, teres minor and subscapularis.
There is a broad spectrum of problems involving the rotator cuff, ranging from mild inflammation to complete tendon tears.
Causes
The causes of rotator cuff tears are usually a mix of degenerative (wear-and-tear or ageing) and traumatic (injury-related) factors.
Degeneration of the rotator cuff tendons occurs with aging as there is a reduced blood supply and collagen breakdown. Activities which involve repetitive overhead movements can put excessive strain on tendons leading to a tear. Narrowing of the subacromial space (under the acromion) from spurs, osteophytes or the shape of the acromion can also lead to tendon compression. Calcific deposits within tendons are another possible factor which may contribute to a tear. Weakness of the scapular stabiliser or rotator cuff musles can lead to abnormal stress on the tendons.
Traumatic causes can be a sudden fall on an outstretched arm, heavy lifting or forceful shoulder movement. Shoulder dislocation may also tear the rotator cuff especially in older patients.
Symptoms
The common symptoms include :
- Pain
Dull, aching pain in the shoulder (often felt in the upper arm, not just at the joint)
Worsens with overhead or behind-the-back movements
Night pain, especially when lying on the affected side - Weakness
Difficulty lifting the arm away from the body
Trouble with activities like combing hair, dressing, or reaching overhead
Reduced strength in rotation movements (internal or external rotation) - Limited range of motion
Stiffness or reduced mobility in the shoulder
Painful arc: pain when lifting the arm between ~60°–120° (common in impingement)
- Mechanical symptoms
Clicking, catching, or crepitus (grating sound) with movement
Feeling of instability in severe tears
- Functional limitations
Difficulty performing overhead sports or work activities
Trouble with everyday tasks like lifting objects, carrying groceries, or reaching into a cabinet
Diagnosis
Your surgeon will have a discussion with you about the history of your shoulder issues including the pain patterns, functional limitations and onset. There will also be a physical examination and review of your imaging.
The physical examination will include inspection and palpation, range of motion and specific tests which help to determine the pathology.
Imaging
Your GP should have already arranged an Xray and Ultrasound before your visit. Your surgeon may additionally order an MRI depending on what has been determined from your other images.
Treatment
Conservative (non-operative)
This is the first-line management for most cases of rotator cuff pathology, especially tendonitis, impingement, and partial tears. The goals are to reduce pain, restore function, and prevent progression. Conservative treatment includes activity modification, pain management and physiotherapy. There are some additional options including ultrasound therapy or TENs as well as PRP injections which are still under research and not widely used. Weight control, health diet and general overall health measures such as smoking cessation result in better tendon health
Surgical Treatment
Surgical treatment of rotator cuff tears is considered when conservative measures fail (usually after 3–6 months) or in cases of large or acute traumatic tears with significant functional loss.
The indications for surgery include :
- Persistent pain and dysfunction despite conservative treatment.
- Acute traumatic full-thickness tear (especially in younger/active patients).
- Large or progressive tears.
- Significant weakness or loss of shoulder function.
- Associated structural issues (e.g., impingement, bony spurs).
Most surgical options are performed by a minimally invasive technique where small key-hole incisions are made in the shoulder. A camera (or arthroscope) is inserted into the shoulder and then soft tissue shavers and ultrasonic wands are used to remove inflamed tissue, bone spurs or frayed tendons. This is called an arthroscopic debridement and subacromial decompression and is indicated for impingement syndrome or partial tears. For more extensive tendon tears the tendon is reattached to the humeral head using sutures and anchors.
Some tears may not be repairable and may require tendon transfer surgery or graft tissue to stabilise the humeral head.
For massive irreparable tears where the cuff is not functioning and there may also be arthritis, prosthetic replacment of the shoulder with a reverse shoulder replacement may be indicated.
Recovery
When can I return to daily activities?
This depends on the activity, the exact nature of your surgery and your progress with your rehabilitation.
Most people can:
- Return to office or light duties (no use of the arm at chest height or above, no repetitive duties, no heavy lifting) at 10-14 days. Sling should be worn when using a computer / doing admin work
- Walking for exercise from 3 weeks
- Driving – approximately 4-6 weeks, 15-30 minutes as you feel safe and confident. When you are no longer using the sling and have full control of the vehicle. No truck driving until 4 months
- No heavy lifting particularly above chest height for 6 months
When can I participate in leisure activities?
Your ability to start these will be dependent on the range of movement and strength that you have in your shoulder following the operation. Please discuss activities in which you may be interested with your physiotherapist or surgeon.
Start with short sessions, involving little effort and gradually increase. General examples are:
- Cycling – 4 to 6 weeks
- Jogging – 12 weeks
- Swimming – gentle breast-stroke 12 weeks, freestyle variable timeframe (minimum 4 months)
- Light sports/racquet sports using non-operated arm – 10 weeks
- Racquet sports using operated arm / Golf – 4 to 6 months
- Contact or collision sports which includes horse riding, soccer, martial arts, football and rock climbing – 6 to 9 months