Rotator cuff tear

What is a rotator cuff tear?

Your rotator cuff is made up of four muscles and their tendons, wrapping around your shoulder to hold the top of your arm bone securely in its socket and letting you lift and rotate your arm. A tear happens when one of these tendons is damaged or pulls away from the bone, either partly or completely.

What are the symptoms of a rotator cuff tear?

Not every tear causes symptoms: some people have a tear and don't know it. When symptoms do appear, they commonly include:

• pain around the shoulder that can spread into the upper arm, and that's typically worse at night or when you lie on that side
• pain when reaching away from your body or behind your back
• weakness when lifting, lowering or rotating your arm, or trouble raising it above shoulder height
• clicking, popping or a crackling feeling when you move your shoulder
• struggling to lift objects the way you used to.

How it feels often depends on how the tear happened. A sudden tear, from a fall or similar injury, usually causes intense, immediate pain and weakness. A tear that's developed gradually through wear and tear may start as a mild ache that eases with over-the-counter painkillers, then slowly worsen as time goes on, until painkillers stop helping.

What causes a rotator cuff tear, and who is at risk?

There are two broad causes: a sudden, traumatic injury, such as a fall onto an outstretched arm or a heavy, jerky lift, or a gradual, degenerative tear that develops from years of wear on the tendon.

Degenerative tears are far more common and are linked to bone spurs rubbing on the tendon, a naturally reduced blood supply to the area as you age, and repeated overhead or overuse movements, even from everyday tasks like cleaning windows or decorating.

Around 9 in 10 rotator cuff tears involve one particular tendon, the supraspinatus. Things that raise your chance of a tear include:

• getting older, with risk increasing noticeably from your 40s onwards and most tears occurring in people over 60
• a family history of shoulder problems, suggesting a possible genetic link
• smoking and poor posture
• jobs involving repetitive overhead work, such as carpentry, decorating, or mechanics
• sports that stress the shoulder, including baseball, tennis, rowing and weightlifting.

Your dominant arm is more often affected. If one shoulder already has a wear-related tear, the other shoulder is also somewhat more likely to develop one over time, even before it starts hurting.

Are there different types of rotator cuff tear?

Tears are generally described by how much of the tendon is affected:

• a partial (incomplete) tear, where the tendon is frayed or thinned but still attached to the bone, so you may still be able to use your shoulder fairly normally
• a complete (full-thickness) tear, where the tendon fully separates from the bone, leaving a hole or gap, and usually causing more noticeable pain and weakness.

How is a rotator cuff tear diagnosed?

Your doctor will examine your shoulder, checking how far you can move it, your strength, and which positions bring on pain. Several hands-on tests can point towards a tear, such as asking you to resist pressure while your arm is held in specific positions (sometimes called the empty can, full can or lift-off tests).

You'll usually also have imaging. An X-ray can't show a soft tissue tear directly, but it helps rule out arthritis, fractures and bone spurs, and can reveal a hooked shoulder bone (acromion) or calcium deposits that might be contributing. An ultrasound or MRI scan is then used to confirm the tear itself and help your doctor plan the right treatment.

How is a rotator cuff tear treated?

A torn rotator cuff won't heal by itself and tends to get bigger over time, but that doesn't automatically mean you need an operation. If your tear happened suddenly through an injury and you're under about 70, early surgical repair is often recommended, since outcomes tend to be better the sooner it's fixed. If your tear has developed gradually through wear and tear, non-surgical treatment is usually tried first.

Non-surgical treatment

• resting the arm, sometimes in a sling, and adjusting activities that aggravate it
• painkillers and anti-inflammatory medicines to ease pain and swelling
• a steroid (cortisone) injection into the shoulder, which may be repeated two or three times, spaced at least three months apart
• physiotherapy, building from gentle stretching to strengthening exercises, often continuing for several months and sometimes up to a year.

This approach works well for many people: around 8 in 10 people with a partial tear improve without surgery, though the full benefit can take as long as 12 months to come through.

Surgical treatment

Surgery is generally considered where the tendon is fully torn, where non-surgical treatment hasn't helped enough, or if your job or sport places heavy demands on your shoulder.

Most repairs are done arthroscopically (through small keyhole cuts using a camera), using stitches and small anchors to fix the tendon back to the bone. This is usually a day case done under general anaesthetic, often combined with a local nerve block to help with pain afterwards. Open surgery, using a larger cut, is sometimes needed instead.

For a partial tear, the surgeon may just need to trim away the damaged, frayed section rather than fully reattach it. For some larger or long-standing tears where the tendon has worn away too much to stitch back, options include removing the damaged tissue to ease pain (without restoring full strength), a tendon transfer from elsewhere in the shoulder, or a shoulder replacement.

Surgery has a good success rate. Around 9 in 10 people notice a real improvement in pain, movement and function. In the remaining cases, the tendon doesn't fully heal back to the bone, leaving ongoing pain, stiffness or weakness.

As with any operation, there are risks, including bleeding, infection, nerve damage and stiffness. The repair can also fail or re-tear later, which is more likely with larger original tears, in smokers, and in people over 65.

Afterwards, you'll wear a sling for around 4 to 6 weeks to protect the repair while physiotherapy begins, and you won't be able to drive during this time. Most people can return to light daily activities within weeks, but going back to work generally takes at least 3 months, and contact sports or heavy manual work may take around 6 months. Full recovery, including regaining strength, is gradual and can take anywhere from around 6 months to a year or longer.

When should I see a doctor?

See a doctor if you have shoulder pain or weakness that doesn't settle, especially if it:

• is constant, or wakes you at night or stops you sleeping
• comes with redness, swelling or tenderness around the shoulder joint
• makes it hard to lift your arm or carry out everyday tasks
• follows a fall, jerking movement, or other injury to the shoulder.

It's worth getting it checked even if the pain is mild, since a rotator cuff tear won't heal on its own and can lead to further problems, such as a stiff (frozen) shoulder or arthritis, if it's left untreated for a long time.