Rotator cuff tear: Causes, Symptoms, and Treatment

A rotator cuff tear is a common cause of pain and disability among adults. The rotator cuff forms the roof of the shoulder joint and is composed of four muscles and their tendons, which extend from the shoulder blade to the tubercle majus or tubercle minus. These four muscles are:

  • the infraspinatus muscle,
  • the musculus supraspinatus,
  • the subscapular muscle,
  • the musculus teres minor.

The rotator cuff has important functions. It stabilizes the shoulder, is responsible for internal and external rotation, and partly for the lateral spreading of the upper extremity. If a rotator cuff tears, the tendon sheath of these rotators, most frequently the supraspinatus tendon, tears because of its anatomically tight position under the acromion.

Such a tear occurs either as a result of a severe accident, e.g., a fall on an outstretched arm, or as a result of degeneration (wear) of the weakened supraspinatus tendon.

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Symptoms of rotator cuff tearing

Depending on the underlying cause, the symptoms of a rotator cuff tear are different.

The most common symptom is a rotator cuff tear due to wear and tear, i.e., over the years, the tendon mirror becomes thinner due to stress and abrasion, and the natural tendon quality and tear resistance decrease.

Minor injuries, or even without an accident, can ultimately cause the tendon to tear. In such cases, the patient initially feels a lack of strength in the arm during certain movements. For example, the arm can no longer be held at shoulder level or can only be held at shoulder level with great effort. The pain occurs during various movements (see functional shoulder joint examination), which is why the patient usually starts to avoid painful movements. This is known as adopting a relieving posture.

If the rotator cuff tears as a result of an accident, sudden pain occurs. In the case of a total rupture, external rotation or abduction (see functional shoulder joint examination) is not possible or only with difficulty.

Pressure pain in the insertion area of the supraspinatus tendon is typical in both cases (tuberculum majus).

The pain caused by a rotator cuff rupture can radiate beyond the upper arm and into the hand, but the pain is usually concentrated on the shoulder and the lateral upper arm. Often an impingement syndrome is found at the same time.

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Loss of strength in rotator cuff tear

The loss of strength is considered a typical symptom of a torn rotator cuff. In an acute case, this loss of strength occurs immediately, depending on the severity of the rotator cuff tear. At the same time, it also causes immediate pain. If the tear in the rotator cuff is only slightly pronounced, patients sometimes feel only a loss of strength. Otherwise, a complete loss of strength can be assumed to be accompanied by a very pronounced rotator cuff tear.

The loss of strength manifests itself in the movements of the arm. Affected persons find it difficult to lift the arm at the shoulder level. Besides, external rotation or spreading of the arm is difficult or even impossible.

Pain with torn rotator cuffs

In the case of a rotator cuff tear, the acute accident often causes severe pain in the shoulder, which can also move into the surrounding area. Movements in the shoulder are associated with unpleasant pulling pain, which sometimes makes movement impossible. Patients hold their arms in a gentle position in front of the body to avoid stress. At night and when lying on the shoulder, this causes stabbing pain. Especially lifting the arm causes problems. If it is a rotator cuff tear due to occlusion, it is possible that this is not actively perceived with pain and is only noticeable due to the restrictions on movement.

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Diagnosis of a torn rotator cuff

Various examination options are available for the diagnosis of a rotator cuff rupture.

As a rule, a functional shoulder joint examination is started.

Among other things, this examination includes checking the force development of the rotator cuff by lifting the arm sideways (abduction) against resistance, by external rotation (rotation) against resistance with the arm hanging and the elbow bent, and by internal rotation of the arm against resistance.

While the abduction reflects the functionality of the supraspinatus muscle, the functional test, which checks the external rotation against resistance, refers to the teres minor and infraspinatus muscles.

The test of the powerful internal rotation of the arm controls the functionality of the musculus subscapularis.

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In addition to the functional shoulder joint examination, imaging techniques such as

  • X-ray image
  • Sonography (ultrasound)
  • Magnetic resonance imaging of the shoulder (MRT, NMR)

at your disposal.

X-rays cannot directly detect a tear in the rotator cuff because tendons and muscles are part of the soft tissue of the body and are radiolucent to X-rays, i.e., they are not imaged.

However, since the absence of the rotator cuff causes the humeral head to rise below the acromion, observation of this phenomenon is an indirect indication of the presence of a severe rotator cuff tear.

However, small tears do not cause this phenomenon. More importantly, however, an x-ray can reveal concomitant diseases and provide information on the cause of the rotator cuff tear.

An example would be a bony spur under the acromion (subacromial spur = impingement syndrome), which may have torn a hole in the rotator cuff.

The great advantage of sonography is its easy availability and applicability as well as the possibility of dynamic shoulder examination, in that the arm can be moved during the examination. It is, therefore, possible to examine the rotator cuff “at work.” Even small holes in the rotator cuff can be detected by an experienced examiner.

An MRI of the shoulder is increasingly used when a rotator cuff tear is suspected. Tears in the rotator cuff can be reliably detected. Also, the tendon quality and retraction (pulling back of the tendon after the tear) can be assessed well by MRI, which can have direct consequences on the doctor’s therapy recommendation.

A suspected diagnosis can be confirmed by a shoulder joint endoscopy (arthroscopy). Here the extent of the rotator cuff lesion can also be assessed (partial or total rupture) and, if necessary, therapy can be carried out simultaneously (rotator cuff suture = suture of the torn tendon).

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MRI of the shoulder in case of a rotator cuff tear

In the MRI, soft tissue structures, such as tendons and muscles, can be better visualized in comparison to CT and X-ray.

A rotator cuff tear can be seen in the MRI at the point where the continuous structure of the tendon filaments ends abruptly. The radiologist can see edema (fluid) at the corresponding location and also along the rest of the muscle. Depending on the setting of the MRI, the edema may appear light or dark.

m MRI can describe the extent and location of the rotator cuff tear in more detail, and statements can already be made on how to proceed surgically – for example, whether a plastic tendon surgery will be performed. Besides, accompanying problems such as impingement (shoulder tightness) or arthrosis can also be recorded here.

Compared to other examinations, however, MRI of the shoulder is considerably more expensive and also more time-consuming.

How can I detect a rotator cuff tear myself?

In the case of a rotator cuff tear, the tear makes the function of the affected muscle painful or can only be performed to a limited extent. In most cases, the supraspinatus muscle is affected. This muscle is responsible for lifting (abduction) the shoulder. If this muscle tears or tears, lifting the shoulder is only possible with pain. Movements that are often difficult are overhead movements or putting on jackets. With complete and also fresh tears, it may be that the initial lifting of the shoulder is no longer possible. In the case of a rotator cuff tear that has existed for a long time, some patients complain that the entire shoulder becomes stiff over time.

How can one distinguish between injury and wear?

There are two common causes of rotator cuff tears. One is the tear caused by trauma, and the other is wear and tear. Patients in whom wear is the cause of rotator cuff tear tend to be older patients (55 years and older). If the patients indicate that no adequate trauma has occurred, such as a fall or a heavy load, then it is very likely that the rotator cuff tear is due to wear. An ultrasound or MRI examination, which is frequently performed as part of the diagnostic process, can provide a good assessment of the condition of the tendon. If the visible parts, the torn tendon, show signs of thinning and calcification, this indicates a wear process.

Furthermore, the patient’s history of wear-related rotator cuff tear is often conspicuous. The fact that the patient is younger (50 and significantly younger) speaks in favor of a tear caused by an injury. At this age, a closure may already occur – but it is not so pronounced that a tear would occur. If patients report an accident that affects the shoulder and after which corresponding complaints of the shoulder have occurred, then an injury is likely to be the cause of the rotator cuff tear. If arthroscopy, ultrasound, and MRI show that the tendon looks unremarkable and healthy except for the tear, wear, and tear as the cause can be ruled out. In older people who have wear and tear and who suffer an accident, it is probably a combination of both that causes the rotator cuff tear.

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Investigation

About various diagnostic possibilities, some functional tests have already been described to check the functionality of the shoulder joint. Besides, there are further examination options that should be consulted as part of a physical (clinical) examination. This examination usually includes the differentiation of two clinical pictures, the impingement syndrome, and the rupture of the rotator cuff.

The triggering of the so-called painful arc (= painful arc). For this purpose, the arm is passively raised over the side. Between 60 and 120°, the arc passes through a constriction in the case of impingement syndrome, which causes pain when impingement syndrome is present. This examination can thus be used to diagnose symptoms caused by a constriction under the acromion.

If the pain is so severe that the independent movement of the arm is not possible, an anesthetic is injected into the bursa. If the patient is not able to actively move the arm despite the sedative, a rotator cuff tear can be assumed. A pseudoparalysis is when the symptoms are not only related to the loss of function but also resemble paralysis.

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Therapy

Both conservative and surgical treatment measures can be pursued in the context of a rotator cuff rupture. As a rule, conservative therapy usually involves an incomplete rupture of the supraspinatus tendon. If a complete rupture is present, an individual decision is made. As a rule, patients older than 65 years and with tolerable pain are also treated conservatively.

Conservative therapeutic measures can include the following areas:

  • Protection, for example, by immobilization using a thoracic abduction orthosis. This is an aid by which the arm is kept away from the chest at the side. After removal of the orthosis, it is mobilized by physiotherapy.
  • Administration of anti-inflammatory drugs (non-steroidal anti-rheumatic drugs – NSAIDs), such as diclofenac, ibuprofen, indomethacin, or new generation NSAIDs (Cox2 inhibitors), such as Celebrex®.
  • Cryotherapy (cold applications), especially after an accident.
  • Physiotherapeutic, painless movement exercises, including stretching and strengthening exercises to prevent joint stiffness. Training of the remaining musculature
  • Infiltrations (syringe) under the acromion to reduce pain
  • In contrast to surgical therapy, the conservative form of therapy does not allow torn tendon parts to “heal together.” One reason for this is that the torn tendon parts have contracted, and therefore healing is no longer possible. Despite this fact, conservative measures can restore shoulder function to such an extent that normal “everyday use” can be guaranteed.

If such a result does not appear after about three months, you should consider together with your treating doctor whether conservative therapy still promises success or whether surgical measures should be taken. These measures are described below.

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Exercises for torn rotator cuffs

Not every rotator cuff tear is automatically treated surgically. A good option is a conservative treatment, in which physiotherapy and muscle strengthening play an important role. Exercises that are carried out should be discussed with the treating physician or physiotherapist, as the rotator cuff tear can be further aggravated by incorrect execution of the exercises. A first important group of exercises for rotator cuff tears are stretching and loosening exercises. The aim is to loosen the surrounding joints and muscles and make them suitable for everyday use. For loosening the shoulder, circling the arms is a good way to do this. This should be done carefully and evenly, and jerky movements should be avoided. For stretching, it is important that the chest and back are included. To stretch the chest, it is advisable to stretch the arms horizontally while standing. Now both arms in stretched position try to move as far as possible towards the back and then hold for 30 – 60 seconds. You should feel a pull in your chest.

For the upper back and the back shoulder, the following is recommended: Put one arm around the neck from the front and place the hand on the back shoulder. On the other hand, press carefully against the elbow so that the arm continues towards the back. Further stretching exercises can be shown by a physiotherapist. The next important step is to strengthen the muscles. Since the torn parts of the rotator cuff usually do not grow together again, other muscles have to compensate for their task as much as possible, and this has to be learned.

Most of the exercises can be done in physiotherapy on the cable pulley or simply at home with the Theraband. Therabands can be purchased for under $25. It is important to train the inner and outer rotation. The Theraband is placed around a door handle so that you can hold both ends in your hand. To train the outer rotation, you stand with the other shoulder to the door handle. Now hold both ends of the Theraband with your hand, the shoulder to be trained. The elbow is placed on the side of the body and bent by 90° so that the forearm is pointing horizontally forward. Now pull the Theraband outwards and backward with your hand, thereby pulling the Theraband outwards and backward. It is important that the elbow remains attached to the body. This can be done in three passes with 15-20 repetitions. For the other arm, it is done the same way; only you have to turn around.

To train the inner rotation, stand to the side of the door handle again. This time you stand with the shoulder to be trained towards the door and hold the Theraband with your hand, the shoulder to be trained. Again, the elbow is bent 90° and stays on the body. This time, the forearm is rotated towards the abdomen, as if you wanted to grab the abdomen. There are three passes with 15 – 20 repetitions each. To train the other shoulder, you have to turn around accordingly. An additional good exercise, which trains the outer rotation and shoulder lifter, is as follows. The Theraband is held with stretched and applied arm at the hip of the opposite side. With the side to be trained, the tensed Theraband is held at the end and pulled evenly upwards and outwards with a stretched arm. Thereby the arm makes a slight curve. Then the arm is moved back slowly and evenly. This exercise can be done for each arm in three passes with 10 – 15 repetitions each. It is important that you do not continue with the exercise in case of pain, but first consult your doctor or physiotherapist.

A fourth helpful exercise to strengthen the shoulder muscles is to keep the arms horizontal and stretched out in front of the body, approximately shoulder width. With both hands, the Theraband is held taut. Now both arms are stretched evenly and pulled back so that you have the feeling that the shoulder blades are touching each other. This exercise can be done in three passes with 10-15 repetitions each. Another group of exercises that strengthens the muscles is the support exercises. Here you can lie down in the forearm support. You lie on your belly, then put your forearms lengthwise underneath you on the floor and lift your belly, bottom, and knees so that you only touch the floor with your forearms and your toes. Try to keep this position as long as possible. You can also do something similar in the push-up position. Here you push yourself off the floor with your hands a bit wider than shoulder-width and try to hold this position. In both exercises, the body tension must be maintained by tensing the stomach, back, and bottom. For all exercises, it is essential that they are discussed with the doctor or physiotherapist in charge, as each patient may have individual complicating factors.

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(Kinesio)-taping for torn rotator cuffs

Taping the shoulder in the case of a rotator cuff tear can be helpful and alleviate discomfort. The aim is to transfer the load that the affected tendon would otherwise have to bear. Furthermore, circulation is to be improved, and pain reduced. The tapes can be glued in different ways. There are different methods and views behind this. But the basic method is the same as that used for taping the shoulder impingement.

Surgical treatment

Indication criteria concerning surgical treatment of a rotator cuff rupture are, for example:

  • Severe pain
  • Age (< 65 years) in combination with professional or sports activities
  • Rupture of the rotator cuff on the dominant arm, i.e., usually the right arm.
  • Resistance to therapy or degenerative / wear-related changes in the shoulder joint.

Surgical therapy differentiates between incomplete and complete rupture concerning the surgical intervention. Whether arthroscopic or open surgery is/can be performed depends on the size of the rupture. The smaller the rupture, the better it can be treated within the scope of an arthroscopy of the shoulder joint. Larger tears can usually only be cleaned arthroscopically, and the pain can be relieved by endoscopic subacromial decompression (ESD). Various procedures are available, such as acromioplasty, according to Neer or excision of the tendon area. Suturing the supraspinatus tendon is also conceivable, for example, in the case of a transverse tear of the rotator cuff. In this case, one speaks of a so-called transosseous suture, i.e., a future that is to be sutured through the bone at the place where it originally tore. There are various possibilities for anchoring this procedure:

  • Screw anchors, which are either made of titanium or bioresorbable (= self-dissolving) material. All procedures require postoperative treatment.
  • Transosseous sutures, i.e., the thread is pulled through the bone, which is sutured using special suture and knotting techniques (e.g., Mason – Ellen technique).
  • After-treatment of rotator cuff tear

The follow-up treatment of a rotator cuff tear is highly dependent on the patient, the type of treatment, and the size of the tear. If it is a small tear that does not require surgery, physiotherapy is usually followed. In addition to muscle building with the exercises mentioned above, the priority is to heal the tear. In the first weeks, it is advisable to take it easy. Additionally, cold applications, acupuncture, and also pain injections into the tendon area are helpful. However, this is particularly useful in the first few weeks to reduce the pain of the accident or the inflammation. In the case of fresh ruptures, only passive movement is allowed for the first six weeks.

In the case of larger ruptures and during operations, the surgeon draws up a follow-up treatment plan which is passed on to the physiotherapist. After an operation, it is assumed that the tendon suture is only stable again after approx. Six weeks. The arm must usually be held in a kind of abduction bandage for this time. Exactly how long this bandage must be worn depends strongly on the condition of the tendon and how well it heals. During the first four weeks, the arm may only be moved passively and only in limited angular degrees. From the 4th week onwards, movement may be mostly assistive (supported by the therapist), and from the 6th week onwards, cautious active movement is allowed. Movements against resistance should take place from week seven at the earliest. Exercises with weight should not be performed during the first two months.

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Which tendon is most frequently affected?

The rotator cuff consists of a total of 4 muscles: the infraspinatus, supraspinatus, subscapular, and minor teres. If the rotator cuff is torn, the tendon of the supraspinatus muscle is most frequently affected. The reason for this is the anatomical position of the tendon. The tendon runs directly between the acromion and the head of the humerus. As soon as there is a small narrowing of this space, the tendon can be affected. Since this is very often the case in the context of inflammation of the bursa, injuries, or degenerative changes, the tendon of the supraspinatus muscle is considered to be very susceptible to irritation, which results in a tear. Classically, a rupture of the supraspinatus tendon can be detected by an abduction inhibition of the arm. The function of this muscle, namely the abduction or abduction of the arm in the shoulder joint, is not maintained in the event of a tear.

Can a rotator cuff tear heal by itself?

Without conservative or surgical measures, self-healing of a rotator cuff tear is unlikely. To regain full functionality and load capacity, torn parts are surgically reunited. With purely conservative therapy, this goal of reunification can no longer be achieved, so that movement and load restrictions may remain.

If a tear in the rotator cuff is left to itself, only symptoms such as pain can be reduced. A restriction of movement or a loss of strength will remain, as the torn parts will not rejoin on their own. Effectively, pain may be reduced over time without therapeutic measures – but the arm and shoulder joint will have to lose functionality and mobility.

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How long will I be off sick or unable to work with a torn rotator cuff?

The length of a sick note or incapacity to work depends on the severity of the tear, the type of therapy, and, to a large extent, the profession.

As a rule, the torn rotator cuff is treated surgically to restore functionality and load completely. This means that the arm must first be immobilized 4-6 weeks after the operation. In most cases, physiotherapy is already started during this time to avoid stiffening due to immobilization. This may be followed by several weeks of rehabilitation.

Depending on whether the affected person only has to work in an office with minimal strain on the shoulder and arm or is employed in physically active professions such as construction workers or artisans, the duration of the sick leave or incapacity to work varies. For purely office jobs, it amounts to 2-3 weeks. Since a torn tendon can take up to 4 months to heal completely, a sick note or incapacity to work is issued for 3-4 months for physically demanding jobs.

Duration of a torn rotator cuff

A rotator cuff tear can occur in the very short term due to trauma, but also due to long-term damage lasting for years. Initially, only a small tear may occur, which continues to tear over several weeks until it becomes painful and causes problems. After a tear, it can be assumed that no matter whether surgery or conservative treatment, six weeks must be planned during which no active movement at all may be performed. Only after six weeks may you slowly start moving again. But even then, no heavy work may be carried out or heavyweights lifted. Some patients are fit for use again after 3-4 months. Others have complaints and pain for years and are not fully functional. What they have in common, however, is that sports and jobs that put a strain on the shoulder may only be fully functional again after about six months. And even then, it is essential to consult with the patient if pain occurs.

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