Rotator cuff tear: symptoms, treatment and recovery

A torn cuff typically causes pain and weakness in the shoulder. People describe difficulty lifting the arm, especially above shoulder height, a catching sensation as they move, and pain when lying on the affected side at night. After a sudden injury you may find you cannot lift the arm at all, whereas after a slow-onset tear the main complaint is often gradual loss of strength and sleep disturbed by aching.

Pain does not always match the size of the tear, and neck problems can refer pain to the shoulder. Arthritis UK notes that tingling in the hand or arm alongside shoulder pain is more likely to come from the neck. If shoulder pain follows an injury, comes on very suddenly, or arrives with a change in shape of the shoulder, severe swelling, numbness, or fever, NHS advice is to get urgent medical help, because these can be signs of a broken or dislocated bone or a torn tendon or ligament.

The first goal is to control pain and inflammation. Initial care is usually rest from aggravating activity plus pain relief such as paracetamol or anti-inflammatory tablets, with a cortisone (steroid) injection sometimes offered if pain is hard to control. A physiotherapist or occupational therapist then directs a rehabilitation programme: hands-on treatment and exercises to restore movement first, followed by strengthening of the rotator cuff and shoulder blade muscles. The Dudley leaflet says you may need therapy for six to eight weeks and that most people are able to get back to activities with full use of the arm in that time.

Surgery is a different path. According to the same leaflet, a complete tear will not heal, so complete ruptures usually need surgery if the goal is to return the shoulder to optimal function, with the exception of older patients or those with other illnesses that raise surgical risk. Certain partial tears may not need repair at all, and the surgeon will want to work out how much of the tendon is torn and where before recommending an operation.

Repair can be done as open surgery, keyhole (arthroscopic) surgery, or a combination known as mini-open repair. The leaflet says healing results overall are the same with the different techniques, and that the choice is the surgeon's based on examination and tests. Some of the acromion bone is usually trimmed to create more room for the tendons (decompression). Where the tendon has simply worn away and cannot hold stitches, removing the torn tissue and treating other problems in the shoulder may still reduce pain, though it will probably not restore strength.

The NHS shoulder pain advice applies while you are waiting to be seen or having physiotherapy. It says you can usually do things to ease shoulder pain yourself, that you usually need to do them for 2 weeks before pain starts to ease, and that it can take 6 months or longer to recover from shoulder pain.

Its suggestions are to stay active and gently move your shoulder, try shoulder exercises for 6 to 8 weeks to stop pain returning, stand up straight with your shoulders down and gently back, rest your arm on a cushion in your lap, and use pain relief such as paracetamol and ibuprofen, or heat and cold packs, so you can keep moving. A pack of frozen peas wrapped in a tea towel can be used for up to 20 minutes, 3 times a day, or a hot water bottle wrapped in a tea towel for up to 20 minutes, 2 to 3 times a day.

The NHS says not to completely stop using your shoulder, which can stop it getting better, and not to make up your own strenuous exercises or use heavy gym equipment. It says to get medical help if shoulder pain does not start feeling better after 2 weeks.

Most patients go home on the day of surgery, although some stay overnight. A sling is generally worn for four to six weeks to protect the repair, and most day-to-day activities can restart after a few days. Driving is described as possible after 4 to 6 weeks. Rehabilitation is slow: expect to attend therapy sessions for two to three months, and full recovery to take six to nine months.

Getting the shoulder moving early matters, but it has to be balanced against protecting healing tissue. Treatment starts with gentle range-of-motion exercises and moves gradually towards active stretching and strengthening, with active therapy usually starting about six weeks after surgery and formal strengthening delayed until around 12 weeks. Doing too much too soon is the main risk to the repair, so follow your surgeon's timetable rather than how the shoulder feels.

• Sling: generally four to six weeks after repair.

• Active exercises: usually start about six weeks after surgery.

• Strengthening: formal work is delayed until around 12 weeks.

• Full recovery: six to nine months is the figure given in the Dudley leaflet.

Assessment starts with questions about your medical history, how the pain began and what it stops you doing, followed by a hands-on examination of the shoulder. A GP, a first-contact physiotherapist or an NHS community musculoskeletal (MSK) service may do this. The NHS says that in many areas you can refer yourself to community MSK services for help such as physiotherapy without seeing a GP first.

An ordinary X-ray cannot show a rotator cuff tear because tendons do not appear on it. It is still sometimes requested, because it can reveal bone spurs, loss of joint space, a hooked acromion, or calcium deposits in the tendon (calcific tendonitis), all of which are linked with cuff problems. To confirm a tear, an ultrasound scan or an MRI scan may be arranged. Ultrasound is quick and can be done by a trained sonographer or clinician, while MRI shows the whole joint in more detail.

Scan results should always be read alongside symptoms. A report describing a small or partial tear in an older adult with a stiff, achy shoulder may not change the plan, which will still be exercise first.

The Dudley Group NHS leaflet explains that parts of the rotator cuff tendons have a very poor blood supply. Tissue with less blood supply repairs and maintains itself more slowly, which makes these areas vulnerable to age-related degeneration. Tears often begin in those weakened zones, which helps explain why the problem is so common later in life.

Repeating the same shoulder movements can speed up that wear. The leaflet gives overhead athletes as an example, but also everyday jobs such as cleaning windows, washing and waxing cars or painting, all of which can fatigue the cuff through overuse. A tendon that is already degenerate can then give way with a single event, for example lifting a heavy load or catching yourself in a fall.

Younger people can also tear the cuff, usually after a clear injury such as a heavy fall or a forceful pull on the arm. In that situation the tendon was often healthy beforehand, which can change the conversation about timing of surgery, so it is worth telling the clinician exactly how the injury happened.

• Gradual wear on an already weakened tendon is the most common pattern.

• Repeated overhead or lifting work can bring it on sooner.

• A sudden injury, such as a fall onto the arm, can tear a healthy or a degenerate tendon.

• Other shoulder problems, including bone spurs under the acromion, are found alongside many tears.

The shoulder joins three bones: the shoulder blade (scapula), the upper arm bone (humerus) and the collarbone (clavicle). Sitting over the joint like a sleeve is the rotator cuff, formed from the tendons of four muscles called the supraspinatus, infraspinatus, teres minor and subscapularis. Tendons are the cords that attach muscle to bone, so when these muscles contract they pull on the tendons and help to lift and rotate the arm. A fluid-filled sac called a bursa sits between the bony roof of the shoulder (the acromion) and the tendons, reducing friction as the two move past each other.

A tear means that part of a tendon has come away from, or frayed through at, its attachment on the upper arm bone. Tears are described as partial when the tendon is damaged but still in continuity, and complete (full thickness) when the damage goes right through. That distinction matters, because it shapes what treatment is likely to be suggested.

Not every painful shoulder with a tear on the scan is painful because of the tear. Arthritis UK points out that a torn rotator cuff is more common in people over 40, while an NHS hospital leaflet notes that many people carry a mild tear without symptoms. For that reason clinicians usually combine the story, the examination and the scan rather than relying on imaging alone.

The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you have any of the following. It says these can be signs of something serious, like a broken or dislocated bone, or a torn (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.

On the NHS the usual route is a GP or MSK service assessment, a trial of physiotherapy, imaging if the picture is unclear, and referral to a shoulder surgeon if symptoms persist or the tear is large. The NHS notes that physiotherapy is available but that waiting times can be long, and that you can pay to get physiotherapy privately.

A private consultation can shorten the wait for assessment and imaging, and some people choose it when pain is disrupting work or sleep. The clinical thinking is the same either way: exercise-based care first for most tears, and surgery reserved for complete tears, major loss of function or failure to improve. It is reasonable to ask a surgeon what the realistic expected gain is for your tear, how long rehabilitation will take, and what the alternatives are. Services and waiting times vary by area, so confirm the current position with the provider.