What Is the Rotator Cuff?
The rotator cuff is a group of four muscles and their tendons — the supraspinatus, infraspinatus, teres minor and subscapularis — that surround the shoulder joint. Together they hold the head of the humerus (upper arm bone) firmly in the shoulder socket while allowing the wide range of motion the shoulder is capable of. Because the shoulder relies on this soft tissue for stability rather than a deep bony socket like the hip, the rotator cuff does a lot of work, and it’s vulnerable to both gradual wear and sudden injury.
What Causes a Rotator Cuff Tear?
Rotator cuff tears generally fall into two broad categories:
Degenerative tears develop gradually over time as the tendon wears down. This is the most common cause I see, particularly in patients over 40. Reduced blood supply to the tendon as we age, combined with years of repetitive overhead activity — whether from work, sport, or simply daily use — causes the tendon fibres to weaken and fray until they eventually tear. These tears often develop without a specific injury, which is why patients are sometimes surprised to learn they have a significant tear when they can’t recall “doing” anything to it.
Traumatic tears occur suddenly, usually from a fall onto an outstretched arm, a heavy lifting injury, or a shoulder dislocation. These can occur at any age, though they’re more likely to cause a significant tear in a tendon that was already degenerated.
Risk factors that make a tear more likely include:
- Age over 40
- Repetitive overhead activity (tradespeople, painters, throwing athletes, swimmers)
- A previous shoulder injury or dislocation
- Smoking, which reduces blood supply to the tendon
- A family history of rotator cuff problems
Types of Rotator Cuff Tears
Not all tears are the same, and the type of tear significantly influences treatment recommendations:
Partial-thickness tears involve damage to part of the tendon, without a complete break in the fibres. These can sometimes be managed without surgery, particularly if they’re small and symptoms are manageable.
Full-thickness tears involve a complete tear through the tendon, separating it from the bone. These are further classified by size (small, medium, large, massive) and by how much the torn tendon has retracted, both of which affect whether — and how successfully — the tendon can be repaired.
Acute vs chronic tears — a tear that has just occurred behaves very differently to one that has been present for months or years. Chronic tears are more likely to have retracted and undergone fatty degeneration within the muscle, which can reduce the chances of a successful repair the longer surgery is delayed.
Symptoms of a Rotator Cuff Tear
The symptoms of a rotator cuff tear can vary considerably depending on the size and nature of the tear. Common symptoms include:
- Pain when lifting the arm overhead or reaching behind the back
- Weakness when lifting, rotating, or reaching with the arm
- Pain that disturbs sleep, particularly when lying on the affected shoulder
- A cracking, catching or grinding sensation with certain shoulder movements
- In some cases, an inability to lift the arm away from the body at all (suggestive of a large or massive tear)
It’s worth noting that the severity of pain doesn’t always correlate with the size of the tear. Some patients with large tears have relatively mild pain, while others with smaller tears experience significant discomfort. This is one of the reasons imaging is important — the clinical picture alone doesn’t tell the whole story.
How Is a Rotator Cuff Tear Diagnosed?
Diagnosis starts with a thorough clinical history and physical examination, assessing your range of motion, strength, and specific movements that reproduce your symptoms. This is usually followed by imaging to confirm the diagnosis and characterise the tear:
Ultrasound is often the first choice — it’s readily available, cost-effective, and gives good detail on the rotator cuff tendons, particularly in experienced hands.
MRI provides more detailed imaging of the tendon, muscle quality, and surrounding structures, and is particularly useful for surgical planning in larger or more complex tears.
X-rays don’t show the rotator cuff directly (it’s soft tissue) but can be useful to rule out other causes of shoulder pain, such as arthritis or calcific deposits.
Do All Rotator Cuff Tears Need Surgery?
No — this is one of the most common misconceptions I encounter. Not every rotator cuff tear requires surgical repair. The decision depends on several factors:
- Size and pattern of the tear — small and partial tears often respond well to non-surgical treatment
- Your symptoms and functional demands — a tear causing minimal symptoms in a less active patient may be managed differently to the same tear in someone who relies on overhead arm use for work or sport
- Age and activity level
- Whether the tear is acute or chronic — acute traumatic tears, particularly in younger patients, are often better addressed surgically before retraction and muscle changes reduce the chances of a good repair
- Response to initial conservative treatment
Non-Surgical Treatment Options
For appropriate candidates, non-surgical management can be effective and is often worth trialling before considering surgery:
- Physiotherapy focused on strengthening the surrounding shoulder muscles to compensate for the injured tendon, and improving overall shoulder mechanics
- Activity modification to reduce aggravating movements, particularly repetitive overhead activity
- Anti-inflammatory medication for symptom management
- Corticosteroid injections can provide temporary relief of pain and inflammation, though they’re generally used judiciously given potential effects on tendon quality with repeated use
Non-surgical treatment is typically trialled for a period of weeks to a few months. If symptoms persist or worsen despite appropriate conservative management, or if the tear pattern makes it unlikely to improve on its own, surgery may be recommended.
When Is Surgery Recommended?
I generally recommend surgical repair when:
- A tear is causing significant pain or functional limitation that hasn’t responded to a reasonable trial of non-surgical treatment
- The tear is acute and traumatic, particularly in younger, active patients, where early repair gives the best chance of a successful outcome before the tendon retracts
- The tear is large or full-thickness and likely to progress without intervention
- Ongoing weakness is significantly affecting work, sport or daily activities
If surgery is recommended, the goal of rotator cuff repair is to reattach the torn tendon to the bone, relieving pain and restoring shoulder function.
Frequently Asked Questions
Can a rotator cuff tear heal on its own?
A torn tendon does not heal itself the way a muscle strain does, because the torn ends are no longer in contact with each other or with the bone. However, this doesn’t mean surgery is always necessary — many patients manage well long-term without the tear “healing” in the structural sense, by strengthening the surrounding muscles and modifying activity. Whether this is a suitable approach depends on the specific tear and your individual circumstances.
Will a rotator cuff tear get worse if left untreated?
This varies. Some tears remain stable for years, while others gradually enlarge over time, particularly degenerative tears in older patients. This is part of why an accurate diagnosis and ongoing monitoring matters, rather than assuming all tears will inevitably worsen or all will remain stable.
How long can I leave a rotator cuff tear before it becomes irreparable?
There’s no fixed timeframe that applies to everyone, but in general, the longer a full-thickness tear is left, the more likely the tendon is to retract and the muscle to undergo fatty degeneration — both of which make a successful surgical repair less likely. This is one of the reasons I recommend earlier assessment for significant or traumatic tears rather than a prolonged “wait and see” approach.
