- Also known as
- Cuff tear, supraspinatus tear
- Most common in
- Adults over 50
- manual workers
- overhead athletes
- First-line imaging
- Shoulder ultrasound
- Treatment
- Physiotherapy or arthroscopic repair
What a rotator cuff tear is.
The rotator cuff is a group of four small but critical tendons — supraspinatus, infraspinatus, subscapularis and teres minor — that wrap around the head of the humerus (the ball of the ball-and-socket joint) and provide the fine, coordinated movement of the shoulder. The deltoid muscle is the powerhouse; the cuff is the steering.
A rotator cuff tear is a structural disruption of one or more of these tendons. It may be:
- Partial-thickness — the tendon is frayed and incompletely torn through its substance. The most common version is articular-sided partial tearing of the supraspinatus.
- Full-thickness — the tendon has torn all the way through, but the tear remains small to medium in size.
- Massive — the tear involves two or more tendons, or measures more than 5 cm in diameter, and may be associated with retraction, fatty infiltration of the muscle, and proximal migration of the humeral head.
Tears can be degenerative (the slow, age-related attritional process that accounts for the majority of cases seen in clinic) or traumatic (a single inciting event, often a fall onto the outstretched arm or a sudden lifting injury).
How common is it?
Cuff disease is one of the most common musculoskeletal conditions seen in adult orthopaedic practice. Population studies suggest full-thickness rotator cuff tears are present in approximately 20–25% of adults over the age of 60, and the prevalence rises with each decade.1 Many of these tears are asymptomatic — present on imaging but causing no pain or weakness. An important point follows from this: the presence of a tear on imaging does not, by itself, indicate the need for surgery.
Causes and risk factors.
Most rotator cuff tears develop over years and are best thought of as a tendon failure rather than a single injury event. The underlying biology involves cumulative load, age-related collagen change, reduced tendon vascularity, and (in many patients) a degree of mechanical compression beneath the acromion.
Well-recognised risk factors include:
- Age — the strongest single predictor; cuff tears are uncommon under 40 and increasingly common from the late 50s onward.
- Repetitive overhead loading — manual trades (carpentry, painting, scaffolding), recreational sports (tennis, swimming, throwing), and occupations involving lifting at or above shoulder height.
- Smoking — reduces tendon vascularity and is associated with larger tears and poorer healing after repair.
- Diabetes — accelerates tendon disease and reduces healing rates.
- Family history — there is a meaningful genetic component to cuff tendinopathy and tearing.
- Previous shoulder injury — particularly anterior dislocation in patients over 40, which can produce a traumatic cuff tear.
Symptoms.
The classical presentation of a rotator cuff tear is a triad of pain, weakness, and difficulty with overhead movement. In practice, the pattern varies with the size of the tear, the duration of symptoms, and the patient's activity level.
Pain
- Felt over the outside of the upper arm, often radiating down toward the deltoid insertion.
- Worse at night — patients describe being unable to lie on the affected side and being woken from sleep.
- Worse on reaching, particularly above shoulder height (washing hair, reaching into a high cupboard, putting on a seatbelt).
Weakness
- Loss of strength on lifting the arm out to the side or in front.
- Difficulty holding the arm up — "I can lift it, but I can't keep it there."
- In larger tears: an inability to actively elevate the arm at all (pseudoparalysis).
Loss of function
- Difficulty with dressing, grooming, and overhead reaching.
- Difficulty carrying weight at the side (the cuff tendons also act as humeral head depressors).
- In younger patients: loss of overhead sport (serving, throwing, swimming).
How Dr Coory diagnoses a rotator cuff tear.
Clinical examination
The diagnosis begins with the history, but is confirmed in the examination room. Dr Coory uses a structured examination that includes:
- Inspection — for muscle wasting (the spinati fossae empty out in chronic large tears).
- Active and passive range of motion — a true cuff tear preserves passive range; loss of passive motion suggests a different diagnosis (frozen shoulder, arthritis).
- Strength testing — the Jobe (empty can) test for supraspinatus, external rotation lag for infraspinatus, the belly-press and lift-off tests for subscapularis.
- Impingement signs — Neer and Hawkins-Kennedy — useful but non-specific.
- Cervical spine examination — many shoulders that look like cuff tears are actually referred neck pain.
Imaging
Plain radiographs are taken in every patient with shoulder pain. They cannot show the cuff, but they exclude alternative diagnoses (arthritis, calcific deposits, AC joint pathology, occult fracture) and show secondary signs of chronic massive tearing (proximal humeral migration, "rounding" of the greater tuberosity).
Shoulder ultrasound is the first-line imaging investigation for the rotator cuff in Australia. It is sensitive and specific in trained hands, provides a dynamic assessment, and is inexpensive. On the Sunshine Coast, Dr Coory works with a small group of musculoskeletal radiologists whose ultrasound reports he trusts.
MRI is obtained for every patient before their first consultation with Dr Coory. It is essential for an accurate diagnosis and a clear plan on the day. MRI assesses tear size, retraction, tendon quality, muscle atrophy and fatty infiltration, and is the single best test for predicting whether a cuff is repairable. If you do not already have an MRI when you are referred, Dr Coory's team will arrange one before your appointment.
Non-operative treatment.
For most patients with partial-thickness or small full-thickness tears, the first treatment is non-operative. The evidence is reasonably clear that a structured physiotherapy programme reduces pain and improves function in the majority of patients with cuff disease, even when the tendon does not heal.2
- Activity modification — temporarily avoiding the provoking overhead positions.
- Targeted physiotherapy — emphasising scapular control, posterior cuff strengthening, and progressive loading; a programme of 8–12 weeks is reasonable.
- Analgesia and anti-inflammatories — for short-term symptom relief.
- Subacromial corticosteroid injection — can be useful diagnostically and therapeutically, particularly in patients with a strong inflammatory component. Repeated injections are best avoided where surgery is contemplated, as they reduce tendon healing rates.
When surgery is considered.
The decision to operate is made jointly between patient and surgeon. The main considerations are:
- Failure of non-operative care — persistent pain or weakness after 3–6 months of well-conducted physiotherapy.
- Acute traumatic tear in a younger patient — these tears have the best healing potential and benefit from early repair (within weeks rather than months).
- Functional demand — a tradesperson, an athlete, or anyone for whom the affected shoulder is their dominant working tool.
- Tendon quality on MRI — repairable tendons are not retracted past the glenoid rim and have minimal fatty infiltration. Tendons with Goutallier grade 3 or 4 fatty change are unlikely to heal even if technically repaired.
Where repair is not appropriate or the cuff is irreparable, options include continued physiotherapy, debridement and biceps tenodesis, superior capsule reconstruction, tendon transfer, and (in the arthritic shoulder) reverse total shoulder replacement.
Surgical option: arthroscopic rotator cuff repair.
The contemporary repair is performed entirely arthroscopically (keyhole) under general anaesthesia with a regional nerve block. Through several 5 mm portals, the torn tendon is mobilised, the footprint on the greater tuberosity is prepared, and the tendon is re-attached using small titanium or absorbable suture anchors — most commonly in a double-row or suture-bridge configuration.
Where the biology of healing is in doubt — a re-tear of a previous repair, a chronic tear in an older patient, a smoker, or a diabetic — Dr Coory may augment the repair with a bio-inductive collagen implant. The decision is individualised and discussed in detail.
Read about arthroscopic rotator cuff repair
Recovery timeline.
Weeks 0–6
- Sling worn continuously, including overnight.
- Pendulum exercises and passive elevation by the physiotherapist.
- No driving until the sling is off (about week 6).
Weeks 6–12
- Sling removed. Active-assisted range of motion progressing to active range.
- Light desk work usually possible from week 2–3, depending on the role.
- Light manual work from week 6, no overhead loading.
Months 3–6
- Strengthening begins. Posterior cuff and scapular control first; deltoid and pectoralis second.
- Return to driving and most manual work.
Months 6–12
- Return to overhead sport and heavy manual work.
- Strength continues to improve at 12 months and beyond.
Frequently asked questions.
Can a rotator cuff tear heal on its own?
Once the cuff tendon has fully torn, it does not knit back together on its own. Many people, however, live well with a small full-thickness tear because the surrounding cuff muscles compensate. The decision to repair is based on pain, function, tear size, tendon quality and your goals — not the MRI alone.
How urgent is rotator cuff repair?
Acute traumatic full-thickness tears, particularly in younger patients, are best repaired within several weeks before the tendon retracts and the muscle atrophies. Chronic degenerative tears are less time-critical, and the decision can be made deliberately after a trial of non-operative care.
Does physiotherapy work for a torn rotator cuff?
For partial tears and many small full-thickness tears, structured physiotherapy is effective at reducing pain and restoring function — even though the tendon does not heal. A typical programme runs for 8–12 weeks and emphasises scapular control and posterior cuff strength.
What is the recovery time after rotator cuff repair?
Sling for 4–6 weeks, no driving for 6 weeks, return to a desk job at 2–4 weeks, return to manual work at 4–6 months, return to overhead sport at 6 months. Final strength continues to improve out to a year.
How do I know if I have a rotator cuff tear?
The classical features are pain on the outside of the shoulder, weakness on lifting the arm above shoulder height, and pain at night that wakes you from sleep. Diagnosis requires a careful examination and imaging — ultrasound is a sensitive first-line test on the Sunshine Coast; MRI is reserved for surgical planning.
Will I need a shoulder replacement?
A shoulder replacement is only considered when the cuff cannot be repaired and the joint has developed arthritis as a result (cuff tear arthropathy). The reverse total shoulder replacement was specifically designed for this situation.
References.
- Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19(1):116–120.
- Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2013;22(10):1371–1379.
- Australian Orthopaedic Association National Joint Replacement Registry. Shoulder Arthroplasty Annual Report. Adelaide: AOA; 2024. Available from: aoanjrr.sahmri.com.