Rotator Cuff Tear

What is a Rotator Cuff Tear?

The rotator cuff is a group of four muscles and their associated tendons that surround the shoulder joint, keeping the head of your upper arm bone (humerus) firmly within the shallow socket of the shoulder (glenoid). These four muscles — the supraspinatus, infraspinatus, teres minor, and subscapularis — work together to provide shoulder stability and enable a wide range of arm movements including lifting, rotating, and reaching overhead.

A rotator cuff tear occurs when one or more of these tendons partially or completely detach from the head of the humerus. Tears can range from a small partial-thickness fraying to a full-thickness complete rupture where the tendon separates entirely from the bone. In severe cases, massive tears may involve two or more tendons simultaneously.

Types of Rotator Cuff Tears

• Partial Tear: The tendon is damaged but not completely severed. The tendon frays or is partially worn through, though it still remains attached to the bone.
• Full-Thickness (Complete) Tear: The tendon is torn all the way through, creating a hole or detaching it entirely from the humeral head. This is the most common type requiring surgical intervention.
• Acute Tear: Caused by a sudden traumatic injury such as a fall, heavy lifting, or a forceful pulling movement.
• Degenerative Tear: Develops gradually over time due to repetitive overhead activities, reduced blood supply to the tendon with age, or bone spurs that wear down the tendon.
• Massive Tear: Involves two or more tendons, often requiring more complex surgical reconstruction techniques.

Causes and Risk Factors

Rotator cuff tears can develop from acute trauma or gradual degeneration. Common causes include:

• Acute injury from a fall onto an outstretched arm or direct blow to the shoulder
• Repetitive overhead movements in sports (swimming, tennis, cricket, baseball) or certain occupations (painting, carpentry)
• Age-related tendon degeneration — tears are significantly more common in people over 40
• Bone spurs (subacromial impingement) that repeatedly abrade the tendon
• Poor blood supply to the tendon’s critical zone near its insertion
• Heavy lifting or sudden forceful pulling

Symptoms

Rotator cuff tears can present differently depending on the severity and whether the tear is acute or degenerative. Common symptoms include:

• Deep, aching pain in the shoulder, often worse at night or when lying on the affected side
• Weakness when lifting the arm, particularly above shoulder height
• Difficulty reaching behind the back or overhead
• A clicking, crackling, or catching sensation when moving the shoulder
• Restricted range of motion
• In acute tears, sudden severe pain and immediate loss of strength

Diagnosis

Accurate diagnosis begins with a thorough clinical examination. Your orthopaedic surgeon will assess shoulder strength, range of motion, and perform specific provocative tests to identify which tendons are involved. Imaging investigations typically include:

• X-ray: To rule out bony pathology such as fractures, arthritis, or bone spurs.
• Ultrasound: A dynamic, cost-effective tool for visualising tendon tears and assessing their size in real time.
• MRI (Magnetic Resonance Imaging): The gold standard for evaluating the extent, size, and location of the tear, as well as assessing muscle quality and degree of retraction — all of which influence surgical planning.

Non-Surgical Treatment

Not all rotator cuff tears require surgery. Many patients — particularly those with partial tears, older patients with lower functional demands, or those with significant medical comorbidities — can be managed effectively with conservative treatment:

• Rest and activity modification to avoid aggravating movements
• Anti-inflammatory medications (NSAIDs) to reduce pain and swelling
• Corticosteroid injections into the subacromial space to provide targeted pain relief
• Physiotherapy to strengthen the surrounding shoulder muscles and restore range of motion

Conservative management is typically trialled for at least 3–6 months. Surgery is recommended when symptoms persist despite adequate non-surgical treatment, or when the tear is large, acute, or in an active younger patient.

Rotator Cuff Repair Surgery

Surgical repair of the rotator cuff aims to reattach the torn tendon back to its footprint on the humeral head, restoring shoulder strength, stability, and function. Surgery is most commonly performed arthroscopically, though open or mini-open techniques may be employed in select cases.

Arthroscopic Rotator Cuff Repair

Arthroscopic repair is the preferred approach for the majority of rotator cuff tears. The procedure is minimally invasive, performed through small keyhole incisions, and offers several advantages over traditional open surgery including reduced post-operative pain, faster recovery, and lower risk of infection.

The procedure is performed under general anaesthesia, usually with the addition of a regional nerve block (interscalene block) to minimise post-operative pain. The patient is typically positioned either in the beach chair position or lateral decubitus position.

Step-by-Step Surgical Process

1. Anaesthesia and Positioning: General anaesthesia is administered. A nerve block is placed for post-operative pain control. The patient is positioned appropriately and the shoulder is carefully prepared and draped.
2. Portal Placement: Small incisions (portals) of approximately 5mm are made around the shoulder joint. A camera (arthroscope) is inserted through the posterior portal, with additional working portals placed anteriorly and laterally.
3. Joint Inspection: The surgeon performs a thorough examination of the entire glenohumeral joint and subacromial space, assessing the biceps tendon, labrum, articular cartilage, and the extent of the rotator cuff tear.
4. Subacromial Decompression (Acromioplasty): If bone spurs are contributing to impingement, they are carefully removed using a motorised shaver and burr to create more space for the repaired tendon.
5. Tendon Preparation: The torn tendon edges are debrided and freshened. The footprint on the humeral head is also prepared by removing soft tissue and lightly abrading the bone surface to promote healing.
6. Suture Anchor Insertion: Small titanium or bioabsorbable suture anchors (pre-loaded with strong sutures) are inserted directly into the bone at the tendon’s footprint. The number and position of anchors depend on the size and configuration of the tear.
7. Tendon Repair: Sutures from the anchors are carefully passed through the tendon using specialised instruments, and tied securely to pull the tendon back down to the bone. Modern double-row and transosseous-equivalent repair constructs maximise the tendon footprint contact area and enhance healing.
8. Additional Procedures: If indicated, biceps tenodesis (re-anchoring a damaged long head of biceps tendon) or treatment of labral tears may be performed at the same time.
9. Wound Closure: The portals are closed with sutures or steri-strips and a sterile dressing is applied. The arm is placed in a sling.

Open and Mini-Open Repair

In cases of large or massive tears with significant tendon retraction, an open or mini-open approach may be necessary. This involves a larger incision over the shoulder, allowing the surgeon direct visualisation and access to perform more extensive reconstruction, including tendon mobilisation techniques or patch augmentation where required.

Risks and Complications

Rotator cuff repair surgery is generally safe, but as with any surgical procedure, potential risks include:

• Infection at the surgical site
• Bleeding or haematoma formation
• Nerve or blood vessel injury (rare)
• Stiffness or frozen shoulder (adhesive capsulitis)
• Re-tear of the repaired tendon — the risk increases with tear size, patient age, and tissue quality
• Failure of the repair to heal (non-healing is more common in massive or chronic tears)
• Anaesthetic complications
• Deep vein thrombosis (rare in upper limb surgery)

Your surgeon will discuss these risks with you in detail during your pre-operative consultation.

Recovery and Rehabilitation

Recovery from rotator cuff repair requires patience and commitment to a structured rehabilitation programme. Tendon-to-bone healing is a biological process that takes time, and the repair must be protected during this critical period.

Phase 1: Protection (Weeks 0–6)

The arm is kept in a sling at all times during this phase. Passive range of motion exercises (performed by a physiotherapist) begin within the first 1–2 weeks to prevent stiffness, while avoiding any active use of the repaired muscles. Pendulum exercises and gentle elbow, wrist, and hand movements are encouraged to maintain circulation.

Phase 2: Active-Assisted and Active Range of Motion (Weeks 6–12)

The sling is gradually weaned. Active-assisted exercises are introduced, progressing to active range of motion as pain and strength allow. The focus is on restoring shoulder mobility while continuing to protect the healing tendon.

Phase 3: Strengthening (Weeks 12–20)

Progressive resistance exercises commence once adequate range of motion is achieved. Rotator cuff and periscapular strengthening exercises are the cornerstone of this phase, targeting the repaired muscles as well as the surrounding stabilisers.

Phase 4: Functional Return (Months 5–12)

Sport-specific and occupation-specific activities are gradually reintroduced. Return to overhead sports or heavy manual work typically occurs between 6 and 12 months, depending on the size of the tear and the quality of healing. Full recovery can take up to 12 months for larger repairs.

Expected Outcomes

The vast majority of patients experience significant improvement in pain, strength, and function following rotator cuff repair. Success rates for small to medium tears are excellent, with studies reporting greater than 85–90% patient satisfaction. Larger tears carry a higher risk of re-tear and may have a more guarded prognosis, though most patients still achieve meaningful functional improvement. Early surgery for acute tears — before muscle atrophy and tendon retraction occur — is associated with the best outcomes.

When to Seek Surgical Consultation

You should consider seeing an orthopaedic surgeon if you experience:

• Persistent shoulder pain lasting more than 6 weeks despite rest and analgesia
• Significant weakness preventing normal daily activities or work
• An acute injury resulting in immediate severe pain and loss of shoulder function
• Failure to improve with physiotherapy and injections

At Principle Orthopaedics, our specialist shoulder surgeons will conduct a comprehensive assessment and develop a personalised treatment plan to get you back to the activities you love as safely and efficiently as possible.