By Jonathan Cluett, MD 

 Medically reviewed by Miho J. Tanaka, MD

Rotator cuff tears are a common injury of the complex shoulder joint. The shoulder is one of the most amazing joints in the body. The range of motion of your shoulder—the amount of movement at the joint—is greater than in any other joint in the body.

Because of this wide arc of motion, your shoulders are critically important to just about any activity involving the use of the upper extremity. Because of your dependence on the shoulder for many activities, rotator cuff injuries can be frustrating experiences. Learn more about rotator cuff tears, including diagnosis, symptoms, treatments, and rehabilitation.

What Is the Rotator Cuff?

The rotator cuff is the group of four tendons and muscles that surround the shoulder joint. Often confused with other names, the proper word used to describe these muscles and tendons is the rotator cuff. 

When the rotator cuff is injured, it's the tendons that are injured. These tendons connect the rotator cuff muscles to the bone. When the tendons are inflamed or injured, they cannot function properly.

The rotator cuff is not only important with lifting movements of the shoulder, but the muscles and tendons are critical to the normal stability and mechanics of the shoulder. Without a properly functioning rotator cuff, you would expect some limits in normal shoulder function.

Rotator Cuff Tear Symptoms

Pain is the most common symptom of a rotator cuff problem.1 Patients usually complain of pain over the top of the shoulder and arm. In some patients, the pain can descend down the outside of the arm all the way to the elbow.

Shoulder weakness is the other common symptom of a rotator cuff tear.1 Weakness causes difficulty lifting the arm up overhead and difficulty with activities such as reaching, getting dressed, or carrying objects.

Your healthcare provider will try to distinguish between actual weakness as opposed to apparent weakness. Actual weakness means that the muscle is damaged or there is a large tear in the tendon. Essentially, the muscle will not work.

Apparent weakness occurs when pain limits someone's ability to do an activity. While the muscle and tendon are structurally damaged, pain prevents the individual from performing their normal activities.

Rotator cuff tears are incredibly common, especially as you age. They are so common that most people with a torn rotator cuff don't even realize they have a problem.

Most people with a rotator cuff tear have no pain and minimal limitations in function. However, sometimes the tear can cause symptoms, and these individuals may require treatment.

Diagnosis

Shoulder pain is a common complaint that has many causes.2 Because you use your arms for so many common activities, shoulder pain can create significant limitations. For proper treatment, the cause of the problem must be identified.

Many people with shoulder pain may be told by a friend or family member that their symptoms sound like a rotator cuff problem. However, there are other causes of shoulder pain, and without an accurate diagnosis, the treatment may not properly target the actual problem.

Before beginning any treatment plan, be sure you and your healthcare provider or physical therapist understand the source of your pain.

Treatment

Most rotator cuff tears can be treated without surgery. In fact, only a small minority of patients end up undergoing surgical treatment for a rotator cuff tear.1

Non-operative rotator cuff treatments may include:

• Physical therapy for the rotator cuff

• Anti-inflammatory medications

• Cortisone injections

Nonsurgical treatment should be attempted in almost every situation involving a rotator cuff injury. There are some uncommon circumstances when surgical treatment may be recommended immediately following a rotator cuff injury.

However, the vast majority of people will try nonsurgical treatments as the initial treatment. If nonsurgical treatments do not adequately alleviate symptoms or allow for normal function of the shoulder, then a surgical solution may be considered.

Is Surgery Necessary for a Rotator Cuff Tear?

Most rotator cuff tears can be treated non-surgically. However, in some patients, surgery may be recommended as a treatment option. Surgery is performed to repair the torn tendons.

Determining when surgery may be appropriate depends on the type of rotator cuff tear, the patient's activity level, and the treatments that have previously been attempted.1 Even if surgery is the best treatment in some cases to restore normal function in the shoulder, there are some reasons people may opt not to have surgery.

First, many people do not require the full function to do all the activities they want to do. Many people can do their jobs, housework, or even sports with rotator cuff tears.

Second, rehab after surgery can be long and difficult. Many patients have symptoms for six months to a year following surgery.

Rotator Cuff Tear Surgery

There are several surgical options for treatment of a rotator cuff tear.3

The type of rotator cuff surgery you receive may depend on factors including the size and location of your tear, your surgeon's preference, and the activities you want to be able to return to after surgery. Discuss with your healthcare provider which type of surgery he or she recommends for the treatment of your rotator cuff tear.

Traditionally, surgical treatment of a rotator cuff tear was performed by making a large incision over the top of the shoulder and directly viewing the damage to the torn rotator cuff.

More recently, smaller incisions and arthroscopic surgery have been used to identify and repair areas of damage to the rotator cuff without having to make large incisions around the shoulder.

Not every rotator cuff injury is the same, and certain tears may be better managed by one surgical technique than another. Furthermore, different surgeons will have preferences regarding how they can best accomplish the repair of the damaged rotator cuff through various techniques.

If you have questions about your surgeon's preferred technique, it is worthwhile to discuss that prior to surgery.

Rehab After Surgery

Recovering from surgery for a rotator cuff tear is dependent on a patient being able to perform proper rehabilitation and avoid activities that may reinjure the healing tendons.3 Rehab after rotator cuff surgery can vary widely, but, as mentioned earlier, rehab following this surgery can be long and difficult.

Many patients take a year to get back to normal. Some less-invasive surgical procedures can have smaller incisions, but be prepared for a recovery that may be longer than you would want.

Massive Rotator Cuff Tears

A massive rotator cuff tear is just as it sounds—a large tear of the rotator cuff. Some say that a massive rotator cuff tear involves at least two of the four rotator cuff tendons.

Others use the definition that a massive rotator cuff tear is at least 5 centimeters in diameter. There are options for people with massive rotator cuff tears, and many patients can find both pain relief and restored function.4

Non-Surgical Treatments

Even with massive rotator cuff tears, patients can find excellent results with non-surgical treatments. These treatments may include rest, medications, physical therapy, or injections.

Surgery is reserved for the few patients who do not find relief with these simpler treatment options.

Rotator Cuff Debridement

Your surgeon may recommend simply cleaning up inflammation within the shoulder, a technique called a subacromial decompression. This surgery does not repair the torn tendon, but it can remove inflammation that may be the source of pain. This surgery is often combined with a biceps tenodesis to alleviate potential sources of pain in the joint.

Rotator Cuff Repair

A rotator cuff repair is a surgical treatment to repair the torn tendon.3 The surgery is performed under general anesthesia and can either be done through a normal incision or as an arthroscopic repair. The difficulty with surgical repair of a massive rotator cuff tear is that the tendons and muscle may have been damaged beyond the point of repair.

There are two scenarios that generally make a massive rotator cuff tear irreparable. The first is degeneration and damage to the tendon tissue. In these cases, the tendon is often thin, frayed, retracted (pulled back), and weak. Sutures may not hold the tissue, and the normal elasticity of the tendon is lost.

The second scenario is atrophy of the rotator cuff muscle. While the muscle itself was not the initial problem, long-standing rotator cuff tears may lead to a non-functioning muscle.

If the tendon is torn for a long time, the muscle that controls the tendon becomes weak and atrophied. Over time, the normal muscle is replaced by fat, and these changes are not reversible. If the muscle is damaged in this way, a repair is less likely to give good results.

Muscle Transfers

A muscle transfer procedure is performed when the rotator cuff muscles and tendons are not repairable, and the patient is young and active.5

Muscle transfers are usually performed using either the latissimus dorsi or pectoralis muscles. The tendons of these muscles are removed from their normal attachment and reattached to the bone around the shoulder. The muscles then function to replace some of the lost muscle function of the shoulder joint.

Muscle transfers tend to be a good option in young patients with massive rotator cuff tears that cannot be surgically repaired.5 This surgery can have a long rehabilitation.

Furthermore, shoulder function after surgery may be improved, but it is still not entirely normal. Patients undergoing this procedure should have a normal shoulder joint with no signs of arthritis.

Shoulder Replacement Surgery

Shoulder replacement surgery is generally reserved for patients with rotator cuff tear arthropathy, a condition where a massive rotator cuff tear is found in the setting of shoulder arthritis.6

In these situations, a standard shoulder replacement is not the ideal type of implant and can lead to early failures of the replacement. Therefore, special implants, such as a reverse shoulder replacement, are preferred for surgical treatment. These implants are designed for a shoulder joint that has arthritis in addition to rotator cuff insufficiency.

Sources

American Academy of Orthopaedic Surgeons. Rotator cuff tears.

American Academy of Orthopaedic Surgeons. Shoulder pain and common shoulder problems.

American Academy of Orthopaedic Surgeons. Rotator cuff tears: Surgical treatment options.

Lädermann A, Denard PJ, Collin P. Massive rotator cuff tears: Definition and treatment. Int Orthop. 2015;39(12):2403-14. doi:10.1007/s00264-015-2796-5

Oh JH, Park MS, Rhee SM. Treatment strategy for irreparable rotator cuff tears. Clin Orthop Surg. 2018;10(2):119–134. doi:10.4055/cios.2018.10.2.119

American Academy of Orthopaedic Surgeons. Reverse Total Shoulder Replacement.

By Jonathan Cluett, MD
Jonathan Cluett, MD, is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams.