Rotator Cuff Tear: Causes, Symptoms, and Treatment

What Is the Rotator Cuff?

The rotator cuff is a group of four muscles and their attached tendons that surround the shoulder joint, forming a "cuff" of tissue around the ball of the upper arm bone (humeral head). These muscles work together to:

Stabilize the ball within the shoulder socket (glenoid)
Power shoulder rotation and elevation
Allow precise arm positioning for overhead activities

The four rotator cuff muscles:

Supraspinatus: Initiates arm elevation; most commonly torn
Infraspinatus: External rotation of the arm
Teres minor: External rotation and adduction
Subscapularis: Internal rotation; tears can be serious

Types of Rotator Cuff Tears

Partial thickness tear: The tendon is frayed or torn but not completely severed

Full thickness (complete) tear: The tendon is torn all the way through, creating a hole. May be described as small (<1 cm), medium (1–3 cm), large (3–5 cm), or massive (>5 cm)

Acute tear: Result of a sudden traumatic event (fall, lifting injury)

Chronic/degenerative tear: Develops gradually over time due to repeated microtrauma and poor tendon blood supply — common in patients over 60

Causes and Risk Factors

Most rotator cuff tears occur through a combination of degeneration and trauma:

Age: The primary risk factor; the supraspinatus has poor blood supply near its insertion, making it vulnerable to degenerative tearing
Repetitive overhead activities: Swimming, baseball, tennis, painting, carpentry
Acute trauma: Falling on an outstretched arm or lifting a heavy object suddenly
Shoulder impingement: Repeated rubbing of the tendon against the acromion bone can cause wear
Prior shoulder injuries or surgery

Over 50% of people over age 60 have some degree of rotator cuff tear on MRI — many have no pain.

Symptoms

Pain: Typically on the outer side of the shoulder and upper arm, worse with overhead activities and lying on the affected shoulder at night
Weakness: Difficulty raising the arm, lifting objects, or reaching behind the back
Crepitation (crackling): Sensation of grinding or popping with shoulder movement
Reduced range of motion: Stiffness, particularly in overhead reach and external rotation

Night pain is a hallmark — many rotator cuff patients are awakened by shoulder pain when rolling onto the affected side.

Diagnosis

Physical examination tests:

Neer and Hawkins impingement signs
Empty can test (supraspinatus)
External rotation lag sign
Lift-off test and belly-press (subscapularis)
Drop arm test (large/massive tears)

Imaging:

X-ray: Rules out fracture, arthritis; may show superior humeral head migration in large tears
MRI: Gold standard for rotator cuff evaluation — defines tear size, location, tendon quality, and muscle atrophy/fatty infiltration
Ultrasound: Real-time dynamic imaging; operator-dependent but excellent in experienced hands

Treatment

Conservative (Non-Surgical)

Many partial tears and even some full-thickness tears in older, lower-demand patients do well without surgery:

Physical therapy: Periscapular strengthening, rotator cuff strengthening, posture correction
NSAIDs: Anti-inflammatory medications for pain management
Corticosteroid injections: Subacromial space injection can reduce inflammation and pain, facilitating PT

Surgical Treatment (Rotator Cuff Repair)

Surgery is recommended for:

Acute full-thickness tears in young, active patients
Large or massive tears
Failure of conservative treatment after 3–6 months
Significant functional limitation

Arthroscopic rotator cuff repair is the modern standard — small cameras and instruments inserted through tiny portals allow the torn tendon to be reattached to the bone using suture anchors.

Recovery Timeline

Surgery to discharge: Same day (outpatient)
Sling: 4–6 weeks (protects the repair during healing)
Physical therapy: Begins immediately with passive motion, progressing to active strengthening by 3 months
Return to desk work: 4–6 weeks
Return to sport/overhead activities: 4–6 months
Full biological healing of repair: 6–9 months