Rotator cuff injury: symptoms, treatment and recovery

The Dudley Group NHS Foundation Trust says a torn rotator cuff can cause pain and weakness in the shoulder. The NHS lists tendonitis, bursitis and impingement as possible causes of pain that is often worse while using the arm or shoulder.

Not every tear hurts. The Dudley leaflet says sometimes injuries that tear the cuff are painful and sometimes they are not, and that up to 40 percent of people may have a mild tear without knowing it. It describes a typical story of a person in late middle age with long-standing shoulder problems who lifts a load or has an injury that tears the tendon, after which they are unable to raise the arm.

Because several shoulder problems cause similar pain, the NHS says not to self-diagnose and to see a GP if you are worried.

The Dudley leaflet says the first goal is to control pain and inflammation. Initial treatment is usually rest and anti-inflammatory medication, with a cortisone injection if you have trouble getting pain under control. The NHS says painkillers such as paracetamol or ibuprofen and heat or cold packs can help you keep moving, and that you should stay active and gently move the shoulder rather than stopping using it completely.

Rehabilitation is usually directed by a physical or occupational therapist. Hands-on treatments and exercises improve range of motion in the shoulder and nearby joints, and later strengthening exercises improve the strength and control of the rotator cuff and shoulder blade muscles. The Dudley leaflet says you may need therapy for six to eight weeks and that most patients are able to get back to their activities with full use of the arm within this time.

Kingston and Richmond NHS Foundation Trust takes a different angle for people with a large tear. It says that once the rotator cuff has torn the tendons do not heal, but that strengthening the large deltoid muscle can help get movement back. Its exercises are done 2 to 3 times a day for 3 to 6 months, starting lying on the back so you are not working against gravity, and it says reducing or stopping smoking will help recovery.

The NHS says the number of physiotherapy sessions depends on the cause. If you are still in pain after sessions end, go back to your GP or refer yourself back to a community musculoskeletal (MSK) service.

The Dudley leaflet says your doctor will ask about your medical history, injury and pain and then examine the shoulder. X-rays will not show tears in the rotator cuff, although a doctor may want a shoulder X-ray to look for bone spurs, loss of joint space or a down-sloping (hooked) acromion, which are associated with tears. An X-ray can also show calcium deposits in the tendon that cause calcific tendonitis.

To confirm a tear, the doctor may ask you to have an ultrasound scan or an MRI scan. The NHS says a health professional will examine you to work out what is causing shoulder pain, and may send you for tests such as an X-ray.

In many areas the NHS says you may be able to get help, such as physiotherapy, from NHS community MSK services without needing a referral from a GP.

The Dudley leaflet says a complete rotator cuff tear will not heal and complete ruptures usually require surgery if your goal is to return the shoulder to optimal function. The exception is elderly patients or patients with other diseases that increase the risks of surgery. Certain types of partial tear may not need surgical repair, and the surgeon will assess how much the tendon is torn and where.

Repair can be an open procedure, a keyhole (arthroscopic) procedure or a combination (mini-open repair). The leaflet says that with both techniques the surgeon will also remove some of the acromion bone to increase the space available for the tendons, and that overall results in respect of healing are the same.

Where the tendon has worn away and cannot hold stitches, a salvage procedure removes the torn tissue and fixes other problems. The leaflet says this may reduce pain but probably will not increase the strength or motion of the shoulder.

Recovery depends on the treatment. The NHS says you usually need to do self-care for 2 weeks before shoulder pain starts to ease, and that it can take 6 months or longer to recover from shoulder pain. The NHS suggests trying shoulder exercises for 6 to 8 weeks to stop pain returning.

After surgery, the Dudley leaflet says most people go home on the day of surgery, though some stay overnight. A sling is generally worn for four to six weeks, most day-to-day activities can start after a few days and driving after 4 to 6 weeks. Active therapy usually starts six weeks after surgery and formal strengthening is delayed until 12 weeks. You will probably need therapy sessions for two to three months, and should expect full recovery to take six to nine months.

The leaflet stresses that getting the shoulder moving early is important, but must be balanced with the need to protect healing tissues, and that you should avoid doing too much, too quickly.

The Dudley leaflet says the rotator cuff tendons have areas of very low blood supply, which makes them vulnerable to degeneration from ageing and helps explain why tears are common later in life. Repeating the same shoulder motions can speed this up, including overhead sports and routine chores such as cleaning windows, washing and waxing cars or painting. Excessive force can then tear weak tendons.

Most patients with a torn rotator cuff are in late middle age, but the leaflet says tears can happen at any age, from overuse or injury. Kingston and Richmond NHS Foundation Trust gives two causes for a large tear: natural ageing wear and tear, and trauma such as a fall.

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone) and the clavicle (collarbone). The upper part of the scapula that forms the roof of the shoulder is called the acromion. The rotator cuff connects the humerus to the scapula and is formed by the tendons of four muscles. Tendons attach muscles to bones, and muscles move the bones by pulling on the tendons.

A bursa, a lubricated sac of tissue, sits between the acromion and the rotator cuff tendons and cuts down on friction so that the two do not grind against each other.

The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you have any of the following, which can be signs of something serious such as a broken or dislocated bone, or a torn or ruptured ligament or tendon.

• Sudden or very bad shoulder pain.

• You cannot move your arm.

• Your arm or shoulder has changed shape or is badly swollen.

• Pins and needles that do not go away, or no feeling in your arm or shoulder.

• Your arm or shoulder is hot or cold to touch.

• The pain started after an injury or accident, like a fall.

• Severe pain in both shoulders, or you feel feverish or unwell.

The NHS says to see a GP if shoulder pain is getting worse or does not improve after 2 weeks, or if it is very difficult to move your arm or shoulder. It also notes physiotherapy is available through the NHS but waiting times can be long, and that you can pay to get physiotherapy privately. In many areas you can refer yourself to a community MSK service.

Some people choose to see a private physiotherapist or orthopaedic shoulder surgeon, particularly for scans or when surgery is being considered. In general terms the same steps apply: examination, ultrasound or MRI to confirm a tear, a trial of physiotherapy for most tears, and surgery for selected complete tears. Ask how follow-up physiotherapy is arranged, as recovery after repair is slow.