Degenerative Rotator Cuff Tear
1. Introduction
The shoulder joint is a ball and socket joint and can move in many different directions. The shoulder joint is supported by the rotator cuff. The rotator cuff is group of four muscles, that support and stabilise the shoulder (1). These muscles often work harder when we lift our arm overhead or perform certain tasks. It is therefore normal that over time, these structures demonstrate some normal, age-associated changes. A rotator cuff tear can result in pain, weakness and difficulty using the affected shoulder (3,4). It is worth noting that studies have shown that some people have evidence of a rotator cuff tear and have no pain, loss of movement or disability (5). It is also worth noting that 80% of patients with a rotator cuff tear improve well with non-surgical treatment such as exercise, physiotherapy, and medication (4).
Frequently Asked Questions
- A rotator cuff tear is a common cause of shoulder pain. It is where one of the tendons that insert into the shoulder joint is damaged or torn.
- Common.
- Rotator cuff related shoulder pain, including muscle strains or a tear, account for 65% of all cases (1).
- Shoulder pain is the third most common musculoskeletal condition after low back pain and osteoarthritis (1).
- No.
- However, a rotator cuff tear can result in pain, and may affect your ability to use your arm freely (2).
- A rotator cuff tear is not a sign of a more serious medical condition.
- It is worth noting that many people who demonstrate changes to the rotator cuff on scans are pain-free and function perfectly normally (2).
There are two main causes of a rotator cuff tear:
- (i) Degenerative: Most rotator cuff tears occur because of normal, age-associated changes to the strength of the tendons that may lead to a tear over time.
- (ii) Traumatic: A traumatic rotator cuff tear can occur following an injury, such as a fall or by lifting a heavy load.
As most rotator cuff tears are degenerative, it is more common in those over the age of 50 (2).
People who regularly work overhead or lift heavy items may be at risk of a traumatic tear (2, 3).
Common symptoms of a rotator cuff tear include:
- Reduced range of movement of the affected shoulder.
- Pain or weakness when you try to use the affected arm overhead.
- Pain that may be worse at night when you lay on the affected shoulder.
- A feeling of instability, or apprehension when using the arm in certain positions (3).
Once a diagnosis has been confirmed, there are several things you may be able to do to help manage your symptoms:
- Reduce or modify activities that cause or increase your pain.
- Specific exercises to help mobilise and strengthen the shoulder.
- Take any prescribed pain relief as recommended by your healthcare professional.
- Heat or ice packs may be soothing for some people (3, 4).
- 80% of people with a rotator cuff tear who are managed without surgery improve well (1, 10, 11).
- Recovery through physio will typically take between 2-4 months.
- A small percentage of patients with persistent symptoms, or those who have sustained a significant tear involving other structures may require a rotator cuff repair procedure (9).
- Recovery from a rotator cuff repair can take 6-9 months and further physiotherapy is vital (12).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
The severity of symptoms varies depending on the location and size of the rotator cuff tear. However, some of the more commonly reported symptoms include:
- Reduced range of movement of the shoulder, particularly overhead.
- Pain or weakness when trying to use the affected arm.
- Discomfort when laying on the affected side at night (4, 5, 6).
3. Causes
A rotator cuff tear can occur due to the normal, age-related changes to the tendons of these muscles. This is a process that, to some extent, affects us all and is not associated with pain, disability, or function (4, 5). However, in some people, degenerative changes to the rotator cuff can occur secondary to these age-related changes. The actual tear may not happen after any specific incident but slowly develop over time (6).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing a rotator cuff tear. It does not mean everyone with these risk factors will develop symptoms:
- Age – as most rotator cuff tears occur due to the degenerative process, people over the age of 50 are at higher risk (3,4) However, traumatic tears are more likely to occur in the young, especially those aged under 40.
- Occupational factors – traumatic rotator cuff tears may be more likely to occur in those involved in regular lifting or overhead activities such as plasterers, electricians, and builders.
- Gender – females may be at greater risk than males (2,3,7).
5. Prevalence
In the general population, shoulder pain is the third most common cause of musculoskeletal pain (1). It is estimated that 65% of patients with shoulder pain have some dysfunction of the rotator cuff, including a tear of the muscle or tendons (2).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified health care professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis. Your physiotherapist or doctor may perform certain tests of your shoulder to determine whether there is pain, weakness or stiffness contributing to your symptoms.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent re-assessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRI or ultrasound may be required to determine the size and extent of the rotator cuff tear.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your rotator cuff tear. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
Research is very clear that most patients with a rotator cuff tear improve well with rehabilitation, activity modification and strengthening exercises. There may be subgroups of patients (such as overhead athletes) who may require more intensive treatment, but overall, most people improve well with rehabilitation (4, 9, 10).
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing rotator cuff injury. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Degenerative Rotator Cuff Tear
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This initial programme focuses on early, gentle mobilisation of the shoulder and neck. The aim is to promote normal movement of the shoulder and begin some low-level isometric (static) muscle contractions.
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Once your pain has settled to more manageable levels, you can progress to more challenging exercises that aim to strengthen the muscles around your shoulders, upper-mid back and neck. These may be performed once daily, or every other day, like you would if you were going to a gym or health club.
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The goal of the advanced rehabilitation plan is to continue to build further strength in the muscles around the neck, shoulders and mid-back and develop further control of movement and overhead activity. These exercises, as they are more demanding, should be performed 3-4 times per week, to enable regular rest days.
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10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain reliving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.
11. Other Treatment Options
In people with severe cases, or where there are progressive or worsening symptoms (such as weakness, subluxation, or dislocation), surgery may be indicated. Patients with severe or disabling pain may also be helped with an injection which may be recommended prior to surgery (10). The principal goal of surgery for a rotator cuff tear is to attempt to repair the tissue. However, final outcomes from surgery vary (10, 11) and recovery time frames can be slow and unpredictable (12).
References
- Sambandam SN, Khanna V, Gul A, Mounasamy V. Rotator cuff tears: An evidence based approach. World J Orthop. 2015;6(11):902-918. Published 2015 Dec 18. doi:10.5312/wjo.v6.i11.902.
- Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23:1913–1921
- Mathiasen R, Hogrefe C. Evaluation and Management of Rotator Cuff Tears: a Primary Care Perspective. Curr Rev Musculoskelet Med. 2018;11(1):72-76. doi:10.1007/s12178-018-9471-6
- Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: a systematic overview of current evidence. PLoS One. 2017;12(6):e0178621. doi: 10.1371/journal.pone.0178621
- Eric H. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systemic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964–978. doi: 10.1136/bjsports-2012-091066.
- Rees JL, Kulkarni R, Rangan A, et al. Shoulder Pain Diagnosis, Treatment and Referral Guidelines for Primary, Community and Intermediate Care. Shoulder & Elbow. 2021;13(1):1–17. https://doi.org/10.1177/1758573220984471
- Guyer C. Shoulder. In: Waterbrook A, editor. Sports medicine for the emergency physician: a practical handbook. Cambridge University Press; 2016
- Ma, Q., Sun, C., Gao, H., et al. (2022). The combined utilization of predictors seems more suitable to diagnose and predict rotator cuff tears. BMC Musculoskeletal Disorders, 23, 1013. https://doi.org/10.1186/s12891-022-05986-3
- Aly AR, Rajasekaran S, Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med. 2015;49(16):1042–1049. doi: 10.1136/bjsports-2014-093573.
- Page MJ, Green S, McBain B, Surace SJ, Deitch J, Lyttle N, Mrocki MA, Buchbinder R. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016;10:CD012224
- Kukkonen, J., Joukainen, A., Lehtinen, J., et al. (2021). Treatment of Nontraumatic Rotator Cuff Tears: A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up. Journal of Shoulder and Elbow Surgery, 30(2), 245–254. https://doi.org/10.1016/j.jse.2020.06.018
- Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL, Harrell F, Holloway BG, Jones GL, Ma CB, Marx RG, McCarty EC, Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf BR, Wright RW, MOON Shoulder Group 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. J Shoulder Elb Surg. 2016;25(8):1303–1311. doi: 10.1016/j.jse.2016.04.030
Other Conditions in
Shoulders, Long Term Conditions, Orthopaedics
Whiplash Disorders
An injury which typically occurs following a road traffic collision, often affecting the soft tissues of the neck.
Thoracic Outlet Syndrome
A condition presenting with pain in the arm as a result of compression of structures around the neck/shoulder.
Shoulder Osteoarthritis (OA)
Age and activity related changes to the joints of the shoulder which can lead to pain and stiffness.
Shoulder Impingement
Shoulder impingement is an umbrella term used to describe a variety of conditions that can cause pain in the shoulder.
Shoulder Dislocation
An injury in which your upper arm bone ‘pops out’ of the cup-shaped socket of your shoulder blade.
Rotator Cuff Tendinopathy
Pain and weakness affecting the shoulder and limiting function.
Frozen Shoulder
An insidious (no clear cause), painful/stiff condition of the shoulder persisting for more than 3 months.
Clavicle Fracture
Calcific Tendinopathy
A rare condition causing pain and loss of free movement in tendons and joints.
Biceps Tendinopathy
A tendon-related issue affecting the long bicep tenon at the front of the shoulder.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Acute Torticollis
Sometimes referred to as “wry neck”, this is a condition causing muscle spasms and associated neck pain.
Acromioclavicular Joint Injury
Injury to a small joint at the end of the collar bone (clavicle)/top of your shoulder.