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Shoulder Conditions

Rotator Cuff Tearing

Rotator Cuff Tears: Causes, Symptoms and Treatment Options

Rotator cuff tears are a common cause of shoulder pain, weakness, and loss of function. The rotator cuff plays a vital role in stabilising the shoulder joint while allowing controlled and coordinated movement. When one or more of these tendons becomes damaged or torn, normal shoulder mechanics are disrupted, often leading to pain, reduced strength, and difficulty performing everyday activities.
Rotator cuff tears may occur suddenly following an injury or develop gradually over time due to tendon degeneration.
Understanding the cause and size of the tear is essential when determining the most appropriate treatment.

What Is the Rotator Cuff and Why Is It Important?

The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint. These muscles originate from the shoulder blade (scapula) and attach to the head of the upper arm bone (humerus).
The primary functions of the rotator cuff are to:
  • Keep the humeral head centred within the glenoid socket during movement
  • Initiate and control shoulder motion, particularly lifting and rotation
  • Subscapularis – at the front of the shoulder – rotates the arm inwards and behind the back
  • Supraspinatus – at the top of the shoulder – helps to lift the arm upwards
  • Infraspinatus and teres minor – at the back of the shoulder – rotates the arm outwards
Damage to any of these tendons can affect shoulder stability, strength, and overall function.
It is important to know that ‘Rotator cuff tearing’ refers to fraying or tearing of the tendon part itself, not the muscle, and the tear occurs right at the point of connection of the tendon to the bone.
Tears are described by the amount of damage and by how long they take to form
  • Partial – an area of fraying and splitting but where the tendon remans connected to the bone.
  • Full – when the tendon fully tears off the bone
Immediately or Slowly
An immediate rotator cuff tear (called acute) occurs following a sudden significant injury to the shoulder. Common causes include a fall, a shoulder dislocation, or a sudden force applied to the arm. Typical symptoms may include:
  • Severe shoulder pain
  • Loss of strength
  • Difficulty lifting the arm
More commonly, rotator cuff tears develop slowly and gradually over time due to tendon degeneration. This is called a chronic tear. There does not need to be a specific injury to the arm for these to occur, and are common with advancing age. Symptoms may begin subtly and worsen progressively, sometimes becoming noticeable after a relatively minor incident such as lifting something too heavy or a simple fall.
  • Severe shoulder pain
  • Loss of strength
  • Difficulty lifting the arm

Common symptoms include:

  • Pain over the side of the shoulder, sometimes spreading towards the elbow
  • Weakness with lifting or overhead activities
  • Night pain that interferes with sleep – one of the most common reasons people seek treatment

Severe symptoms occur with very large tears

  • Inabililty to raise the arm at all
  • Inability to rotate the arm to the side
  • Development of secondary damage (arthritis) to the ball and socket part of the shoulder joint

Cause of Rotator Tearing

Rotator cuff tearing typically develops due to a combination of internal tendon damage and mechanical factors.
The older a person is, the more likely internal damage (degeneration) is occurring.

Internal Tendon Damage

As part of the natural ageing process, tendons gradually lose water content and elasticity. This reduces their ability to recover from repetitive micro-trauma associated with daily activities, work, or sport. Over time, cumulative damage weakens the tendon, paticularly in the rotator cuff at the point where it connects to bone where blood flow is poor, making it more vulnerable to tearing, even with relatively low loads.

Mechanical Factors

This can be a sudden injury to the shoulder and can damage any of the 4 tendons.
The most commonly torn tendon, the supraspinatus tendon, can be also more slowly damaged due to pressure from a bone spur above it coupled with overuse.
The tendon passes through a relatively narrow space between the humeral head below and the acromion above it, where the spur grows. With repeated overhead movement or ongoing heavy physical strain, or in many people simply with the passage of years of normal living, the spur grows and enlarges putting pressure on the supraspinatus tendon below causing it to fray and eventually tear.

This process is progressive over years : Spur formation and impingement 🡪 ‘tendinosis’ (weakening) of the tendon 🡪 partial tear 🡪 full tear.

Bursitis is almost always present in people whose rotator cuff is deteriorating or torn, and is a consequence of the tear, the spur, or both. It is worse with higher activity levels and is a major cause of pain.

How are Rotator Cuff Tears Diagnosed?

1

A tear is suspected by the type of pain felt, the type of injury experienced (if there was one) and by any restriction in movement or strength.

2

When examined medically, specific tests will show up painful positions or patterns of weakness.

3

Confirmatory imaging tests are useful such as an ultrasound (which can sometimes be inaccurate) or MRI scan (more accurate). Not every patient requires an MRI.

Do All Rotator Cuff Tears Require Surgery?

Not all rotator cuff tears require surgical treatment.
Studies have shown that many people, particularly over the age of 60, have rotator cuff tears of different sizes without experiencing any symptoms. They are due to degeneration of the tendon and develop slowly.
If symptoms, examination findings, and imaging are consistent with rotator cuff disease, treatment directed towards the rotator cuff can be helpful. This can be with non-surgical strategies or operative repair.
Treatment decisions are guided by factors such as:
  • Severity of pain and weakness
  • Impact on functions of daily life
  • Tear size and pattern
  • Tear onset – acute or chronic (sudden or slow onset)
  • Tendon and muscle quality
  • Patient age
  • Individual activity demands and goals
Remember pain around the shoulder region can come from other areas such as spreading down from the neck or another structure in the shoulder, and the rotator cuff tear itself may not be actually causing the pain being felt.

Non-Surgical Treatment Options for Rotator Cuff Tears

For many people with rotator cuff issues, treatment begins with non-operative management. A significant proportion of patients experience meaningful improvement without surgery.
Non-surgical options may include:
  • Activity modification
  • Physiotherapy focused on shoulder mechanics and strength
  • Ice or heat packs
  • Analgesics and Anti-inflammatory medication
  • Corticosteroid injections to reduce inflammation in selected cases
  • Biologic injections, such as platelet-rich plasma (PRP), in specific situations
While these treatments do not repair the torn tendon, they can reduce symptoms and improve shoulder function.

Rotator Cuff Repair Surgery

  • Surgery may be recommended in anyone, of any age if medically fit, when symptoms persist after a period of appropriate non-operative treatment.
  • Surgery may also be recommended instead of non-operative treatment in cases of acute tears in active people causing limited movement.
Rotator cuff tears do not heal. If present they may increase in size. If very large, they may become impossible to repair and result in permanent pain, weakness and/or the development of arthiritis. As such full thickness tears, particularly if large in size or involving multiple tendons, are on most occasions best repaired early before they increase in size.
Rotator cuff repair is most commonly performed using a minimally invasive arthroscopic technique. During surgery, the torn tendon is reattached to the bone using sutures and anchors.
Additional associated problems or contributing to pain such as bone spurs, acromioclavicular (AC) joint arthritis, or biceps tendon pathology can be addressed at the same time.
In summary
  • Surgery is more likely to be needed in the younger the patient, the more sudden the tear, larger or full thickness tear size and the greater the weakness and limitation to movement.
  • Non-operative treatment is preferred for the older age group, long-standing tears, partial or smaller sized tears and good movement range.

Individualised Care With Dr Richard Dallalana

Rotator cuff tears vary widely between individuals and many factors need to be considered to direct best treatment. A thorough assessment is required to individualise treatment recommendations based on your shoulder damage, lifestyle, and functional goals, Decisions are evidence-based and appropriate for your specific situation.

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