Rotator Cuff Disorders
Summary
Rotator cuff disorders encompass a spectrum from tendinopathy and impingement to partial and complete tears. They are the most common cause of shoulder pain in adults, particularly those over 40. The rotator cuff comprises four muscles (SITS: Supraspinatus, Infraspinatus, Teres minor, Subscapularis) that stabilise the glenohumeral joint. Supraspinatus is most commonly affected. Presentation includes pain with overhead activities and weakness. Treatment depends on pathology and patient factors — most patients respond to physiotherapy, with surgery reserved for acute traumatic tears or refractory cases.
Key Facts
- Definition: Spectrum from tendinopathy to complete rotator cuff tear
- Prevalence: Increases with age — present in >50% of people over 60 (often asymptomatic)
- Most Affected: Supraspinatus tendon
- Classic Symptom: Pain with overhead activities; night pain; weakness
- Key Investigation: USS (first-line for tears); MRI for surgical planning
- Treatment: Physiotherapy mainstay; surgery for acute tears or refractory cases
Clinical Pearls
"SITS" Mnemonic: Supraspinatus, Infraspinatus, Teres minor, Subscapularis. Supraspinatus is the most commonly torn (abducts the arm initially).
Degenerative Tears Are Common and Often Asymptomatic: MRI studies show >50% of people over 60 have rotator cuff tears — most are asymptomatic. Don't assume an imaging finding explains all shoulder pain.
Physiotherapy Works: Even for complete tears, structured physiotherapy improves outcomes in many patients. Surgery is not always needed.
Why This Matters Clinically
Rotator cuff disorders are extremely common in primary care. Understanding the clinical assessment, appropriate use of imaging, and role of physiotherapy versus surgery helps avoid unnecessary intervention and optimise patient outcomes.
Incidence & Prevalence
- Prevalence: Increases with age; >50% of people over 60 have tears (often asymptomatic)
- Symptomatic Tears: 20-30% of those with imaging-confirmed tears
- Most Common in: 40-70 years; higher in dominant arm
Demographics
| Factor | Details |
|---|---|
| Age | Increases with age; peak 40-70 years |
| Sex | Male slightly more common |
| Occupation | Higher in overhead workers (painters, builders) |
| Sport | Swimming, tennis, baseball |
Risk Factors
| Risk Factor | Notes |
|---|---|
| Age >40 | Strong — degenerative changes |
| Overhead occupation/sport | Repetitive microtrauma |
| Smoking | Impairs tendon healing |
| Diabetes | Increases risk of tendinopathy and poor healing |
| Hypercholesterolaemia | Associated with tendon degeneration |
| Previous shoulder injury | Increases tear risk |
| Dominant arm | More affected |
Mechanism
Degenerative (Most Common):
Step 1: Chronic Microtrauma
- Repetitive overhead movements
- Compression in subacromial space ("impingement")
Step 2: Tendinopathy
- Hypovascularity of supraspinatus tendon
- Inability to repair microdamage
Step 3: Partial → Full Thickness Tear
- Progressive collagen degeneration
- Tear propagation over time
Traumatic (Less Common):
- Acute injury (fall, dislocation) in younger patients
- Sudden avulsion or tear
Anatomy (SITS Muscles)
| Muscle | Insertion | Function | Nerve |
|---|---|---|---|
| Supraspinatus | Greater tuberosity (top) | Initiates abduction | Suprascapular |
| Infraspinatus | Greater tuberosity (middle) | External rotation | Suprascapular |
| Teres Minor | Greater tuberosity (lower) | External rotation | Axillary |
| Subscapularis | Lesser tuberosity | Internal rotation | Subscapular |
Classification
By Tear Size:
- Small: <1cm
- Medium: 1-3cm
- Large: 3-5cm
- Massive: >5cm or ≥2 tendons
By Tear Depth:
- Tendinopathy (no tear)
- Partial-thickness tear
- Full-thickness tear
Symptoms
Typical Presentation:
Acute Traumatic:
Signs
Red Flags
[!CAUTION] Red Flags — Suggest serious or urgent pathology:
- Pseudoparalysis (complete inability to elevate arm) — massive tear
- Acute traumatic tear in young patient — consider urgent repair
- Worsening night pain + weight loss — consider malignancy
- Fever + shoulder pain — septic arthritis
- Axillary mass — Pancoast tumour
Structured Approach
Look:
- Muscle wasting (supraspinatus, infraspinatus fossa)
- Deformity, swelling
- Compare both sides
Feel:
- Tenderness (AC joint, greater tuberosity, biceps)
- Subacromial tenderness
Move:
- Active and passive ROM (compare)
- Assess strength (abduction, external/internal rotation)
Special Tests
| Test | Technique | Positive Finding | Tests For |
|---|---|---|---|
| Neer Test | Passively flex shoulder with scapula fixed | Pain = impingement | Subacromial impingement |
| Hawkins-Kennedy | Flex shoulder 90°, internally rotate | Pain | Subacromial impingement |
| Jobe Test (Empty Can) | Abduct 90°, 30° forward, thumbs down, resist | Weakness/pain | Supraspinatus tear |
| External Rotation Lag | Passively position; ask to maintain | Drops into IR | Infraspinatus/teres minor tear |
| Lift-Off Test | Hand behind back, push away | Cannot lift off | Subscapularis tear |
| Belly Press Test | Push belly with hand, elbow forward | Weakness | Subscapularis |
| Drop Arm Test | Slowly lower arm from 90° abduction | Drops suddenly | Large rotator cuff tear |
First-Line
| Test | Purpose | Notes |
|---|---|---|
| X-ray | Exclude other pathology (OA, fracture, calcification) | Does not show soft tissue tears |
| Ultrasound | First-line for suspected tear | 90% sensitive for full-thickness tears; operator-dependent |
Further Imaging
| Modality | When | Notes |
|---|---|---|
| MRI | Surgical planning; unclear USS; full-extent assessment | Gold standard for soft tissue detail |
| MRA (Arthrogram) | If partial tear suspected or detailed labral assessment | More invasive |
Diagnostic Injection
Subacromial Injection (Diagnostic/Therapeutic):
- Lidocaine ± corticosteroid injected into subacromial space
- If injection relieves pain and improves strength → impingement (not large tear)
- If weakness persists despite pain relief → suggests true rotator cuff tear
Management Algorithm
ROTATOR CUFF DISORDER MANAGEMENT
↓
┌─────────────────────────────────────────────────────┐
│ CONSERVATIVE (First-Line for Most) │
│ │
│ PHYSIOTHERAPY (Essential): │
│ • Strengthening (rotator cuff, deltoid, periscapular)│
│ • Range of motion exercises │
│ • Scapular stabilisation │
│ • 6-12 weeks minimum before assessing │
│ │
│ ANALGESIA: │
│ • Paracetamol, NSAIDs (short-term) │
│ • Avoid opioids long-term │
│ │
│ INJECTION: │
│ • Subacromial corticosteroid (US-guided preferred) │
│ • Short-term benefit; limit to 2-3 injections │
│ • Diagnostic value (differentiates impingement) │
│ │
│ ACTIVITY MODIFICATION: │
│ • Avoid aggravating activities temporarily │
└─────────────────────────────────────────────────────┘
↓
SURGERY CONSIDERATIONS
↓
┌─────────────────────────────────────────────────────┐
│ INDICATIONS FOR SURGERY: │
│ • Acute traumatic full-thickness tear (young, active)│
│ • Failed 3-6 months of conservative treatment │
│ • Full-thickness tear with significant weakness │
│ • Repairable tear at risk of progression │
│ │
│ PROCEDURES: │
│ • Arthroscopic rotator cuff repair (most common) │
│ • Open repair (large/revision cases) │
│ • Subacromial decompression (rarely done alone now) │
│ • Superior capsular reconstruction (massive tear) │
│ • Reverse total shoulder arthroplasty (irreparable, │
│ elderly with rotator cuff arthropathy) │
└─────────────────────────────────────────────────────┘
Rehabilitation Post-Surgery
- Sling immobilisation (4-6 weeks)
- Progressive passive → active ROM
- Strengthening (6-12 weeks onwards)
- Full recovery: 6-12 months
Disease-Related
| Complication | Notes |
|---|---|
| Tear progression | Partial → full thickness; small → large |
| Rotator cuff arthropathy | Secondary OA from chronic massive tears |
| Adhesive capsulitis | "Frozen shoulder" can coexist or develop |
| Muscle atrophy/fatty infiltration | Chronic tears lead to irreversible muscle changes |
Treatment-Related
| Complication | Treatment |
|---|---|
| Steroid injection | Fat pad atrophy, tendon weakening, infection (rare) |
| Surgery | Re-tear (10-30%), stiffness, infection, nerve injury |
Natural History
Many asymptomatic tears remain stable over years. However, symptomatic full-thickness tears tend to enlarge over time, with progressive fatty infiltration of muscle.
Outcomes with Treatment
| Variable | Outcome |
|---|---|
| Conservative (physiotherapy) | 60-80% improvement without surgery |
| Surgical repair (small-medium) | 85-95% healing; good function |
| Surgical repair (large-massive) | 60-80% healing; higher re-tear rate |
| Post-surgery function | Most regain good pain relief and function |
Prognostic Factors
Good Prognosis:
- Small tear
- Young patient
- Short symptom duration
- No fatty infiltration
- Non-smoker
- Compliance with rehabilitation
Poor Prognosis:
- Massive tear
- Advanced fatty infiltration
- Muscle atrophy
- Older age
- Smoking
- Diabetes
Key Guidelines
-
BESS/BOA Guidance on Subacromial Shoulder Pain — Supports physiotherapy first; questions value of subacromial decompression surgery alone.
-
NICE Guidance — Supports structured physiotherapy; injection as adjunct.
Landmark Trials
CSAW Trial (2018) — Subacromial decompression surgery
- RCT comparing surgery vs sham surgery vs no surgery for impingement
- Key finding: No benefit of surgical decompression over sham or conservative care
- Clinical Impact: Reduced use of subacromial decompression alone
UKUFF Trial (2015) — Rotator cuff repair
- RCT on surgical repair of rotator cuff tears
- Key finding: Surgery may benefit patients with full-thickness tears
- Clinical Impact: Supports selective surgical intervention
Evidence Strength
| Intervention | Level | Key Evidence |
|---|---|---|
| Physiotherapy | 1a | Systematic reviews |
| Corticosteroid injection | 1a | Short-term benefit only |
| Subacromial decompression alone | 1b | CSAW trial — no benefit |
| Rotator cuff repair | 1b | UKUFF, cohort studies |
What is a Rotator Cuff Disorder?
The rotator cuff is a group of four muscles and tendons that surround your shoulder joint, keeping it stable and allowing you to lift and rotate your arm. These tendons can become irritated (tendinopathy), partially torn, or completely torn, causing pain and weakness.
Why does it matter?
Rotator cuff problems are very common, especially as we get older. They can cause significant pain and affect daily activities like dressing, reaching, or sleeping. The good news is that most people improve with exercises and don't need surgery.
How is it treated?
-
Physiotherapy (most important): Specific exercises to strengthen the shoulder muscles and improve movement. This takes time (6-12 weeks) but is very effective.
-
Pain relief: Anti-inflammatory tablets or gel. Avoid relying on strong painkillers long-term.
-
Injection: A steroid injection into the shoulder can help reduce pain and allow you to do your exercises more effectively. It's usually a temporary fix.
-
Surgery: Only needed if:
- You have a sudden tear from an injury (especially if you're young and active)
- Exercises haven't helped after several months
- You have significant weakness
What to expect
- Many people with rotator cuff tears on scans have no pain at all
- Finding a tear on a scan doesn't always mean you need surgery
- Physiotherapy takes time — give it at least 6-12 weeks
- If surgery is needed, recovery takes 6-12 months with rehabilitation
When to seek help
See a doctor if:
- You have sudden severe shoulder pain after an injury
- You can't lift your arm at all
- Pain wakes you at night and isn't improving
- Weakness is preventing you from doing daily activities
Key Guidelines
- British Elbow & Shoulder Society. Subacromial Shoulder Pain. 2021.
Key Trials
-
Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329-338. PMID: 29169668
-
Carr AJ, Cooper CD, Campbell MK, et al. Clinical effectiveness and cost-effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a pragmatic, multicentre, randomised controlled trial. Health Technol Assess. 2015;19(80):1-218. PMID: 26463717
-
Moosmayer S, Smith HJ, Tariq R, Larmo A. Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study. J Bone Joint Surg Br. 2009;91(9):1207-1211. PMID: 19721048
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