Rotator Cuff Injuries

Clinically, the pattern I look for is weakness that is out of proportion to pain, particularly with resisted testing of a specific tendon, plus a story of sudden loss of strength or chronic overhead aggravation. Classic signs include a positive drop-arm test, weakness on external rotation against resistance, or difficulty lifting the arm overhead without hitching the shoulder blade. Clinical tests are imperfect, so imaging such as ultrasound or MRI is the definitive answer when a tear would change management.

Many tears can become pain-free and functional without surgery, even if the tendon itself does not structurally knit back together. The MOON Shoulder Group work led by Kuhn and colleagues (JSES 2013) found that roughly 75% of patients with atraumatic full-thickness tears avoided surgery at 2 years after a structured exercise programme. Long-term data is more nuanced. Moosmayer and colleagues followed small to medium tears for 10 years (JBJS 2019) and reported that tendon repair produced modestly better pain and function scores than physiotherapy alone, though both groups still did reasonably well. The honest message: many atraumatic tears can be managed without surgery and stay functional, but structural repair may offer an edge at long follow-up in the right candidate. Traumatic tears in younger, active patients are a different conversation and I refer on promptly when indicated.

A few things stack up at night. Lying on the affected side compresses the supraspinatus and the subacromial bursa, the shoulder loses the gravitational unloading it had during the day, and local blood flow to an already compromised tendon drops. I usually have patients sleep on the unaffected side with the sore arm supported forward on a pillow, or on their back with a small towel roll behind the scapula. For most people this settles night pain meaningfully within a couple of weeks, though it rarely disappears overnight.

Full recovery after arthroscopic rotator cuff repair generally takes 6 to 12 months, not the 6 weeks patients often expect. Typical milestones, in line with the American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation after arthroscopic rotator cuff repair (Thigpen and colleagues, J Shoulder Elbow Surg 2016), are: an early period of relative immobilisation with protected passive range only to protect the repair, restoration of active range of motion, progressive strengthening generally introduced around 12 weeks, and a staged return to higher demand activity over the following months. Re-tear rates in the literature range widely depending on tear size and patient factors, which is why graded loading matters.

Often yes, with modifications. Completely resting a painful tendon tends to lead to further deconditioning. Research from Littlewood and Lewis supports progressive loading as a core treatment. Early on I usually cut overhead pressing, upright rows, and behind-the-neck movements, and keep loaded work below shoulder height with rotator cuff isometrics and scapular work added. As symptoms settle and strength returns, I progressively reintroduce overhead loading.

MRI is sensitive but the bigger issue is the reverse: scans often show tears in people with no symptoms at all. A 2014 systematic review by Teunis and colleagues found rotator cuff abnormalities on imaging in roughly 10% of asymptomatic shoulders at age 20, rising past 60% over age 80. That is why I treat the patient, not the scan. If an MRI finding does not match your clinical picture, it should not automatically drive a surgical decision.

Tendinopathy and partial tears often improve with appropriate loading, activity modification, and time, but unlike a bone, a structurally torn tendon does not reliably knit back together. What research does show is that pain and function can improve substantially even when the tear itself persists, because you are retraining the surrounding cuff and scapular stabilisers to share load. Leaving symptoms entirely untreated tends to lead to compensation patterns and secondary stiffness.

Painless weakness after a fall or sudden pull on the arm is a finding I take seriously. It can indicate a full-thickness traumatic rotator cuff tear, especially in patients under 65 who suddenly cannot lift the arm to shoulder level. Evidence suggests earlier surgical opinion in this subgroup improves outcomes, as the tendon retracts and the muscle fatty infiltrates over months. In that situation I will refer for imaging and orthopaedic review quickly rather than watch and wait.