Rotator Cuff Tears and Arthroscopic Rotator Cuff Repair

 

The rotator cuff is a group of four tendons that surround the shoulder joint. These tendons help lift and rotate the arm while keeping the ball of the shoulder centred within the socket. A rotator cuff tear occurs when one or more of these tendons partially or completely separates from its attachment to the upper arm bone. Some tears develop gradually through age-related degeneration, while others occur suddenly after a fall, lifting injury, shoulder dislocation or other trauma.

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Rotator cuff tears are common, but not every tear causes symptoms and not every tear requires surgery. Treatment depends on the type of tear, the patient’s symptoms, the quality of the tendon and muscle, and the physical demands placed on the shoulder.

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What does the rotator cuff do?

The four rotator cuff muscles are the supraspinatus, infraspinatus, subscapularis and teres minor. They work together to:

• Lift the arm;

• Rotate the shoulder;

• Control the position of the humeral head;

• Maintain shoulder stability during movement; and

• Allow coordinated overhead use of the arm.

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The supraspinatus is the tendon most commonly torn. Larger tears may extend into the infraspinatus or subscapularis and can cause more substantial weakness.

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What causes a rotator cuff tear?

Rotator cuff tears can be traumatic or degenerative.

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Traumatic rotator cuff tears

• A traumatic tear may occur following:

• A fall onto the arm;

• A sudden lifting or pulling injury;

• A shoulder dislocation;

• A sporting injury; or

• A forceful movement against resistance.

Traumatic tears often cause sudden pain, a snapping sensation and immediate weakness. They are more common in younger patients than purely degenerative tears, although a traumatic event can also extend a pre-existing age-related tear.

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Degenerative rotator cuff tears

Many rotator cuff tears develop gradually as the tendon changes with age. Repetitive overhead activity, heavy manual work, smoking, reduced tendon blood supply and the natural ageing process may contribute.

Degenerative tears may begin as a partial-thickness injury and gradually enlarge. Some patients have little pain initially, while others develop progressive night pain, weakness and difficulty using the arm.

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Partial and full-thickness tears

A partial-thickness tear affects only part of the tendon, while a full-thickness tear extends through the entire tendon and may retract away from the bone. Tears can also vary in size, chronicity, cause, number of tendons involved and whether they remain repairable. Although tear size is important, treatment also depends on tendon mobility, muscle quality, fatty change, arthritis, symptoms, age and the functional demands placed on the shoulder.

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Symptoms of a rotator cuff tear

Common symptoms include:

• Pain when lifting or lowering the arm;

• Pain reaching overhead or behind the back;

• Night pain, particularly when lying on the affected shoulder;

• Weakness when lifting or rotating the arm;

• Difficulty dressing, washing or reaching into a cupboard;

• Reduced ability to work, exercise or play sport;

• Clicking or catching within the shoulder; and

• Sudden inability to lift the arm after an injury.

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Pain commonly travels down the outer aspect of the upper arm but usually does not extend into the hand.

Some rotator cuff tears cause little or no pain. Other patients may have severe pain despite having a relatively small tear. The size of a tear and the severity of pain do not always correlate.

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How is a rotator cuff tear diagnosed?

Diagnosis begins with a history of the injury, the onset of pain and the activities that have become difficult.

The examination assesses:

• Active and passive shoulder movement;

• Strength of the individual rotator cuff tendons;

• Pain during elevation and rotation;

• Signs of shoulder stiffness;

• Biceps tendon symptoms;

• Shoulder stability; and

• Whether symptoms may be arising from the neck.

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X-rays

The rotator cuff tendons are not visible on a standard X-ray, but X-rays remain important because they show the rest of the shoulder. They can identify arthritis, calcification, previous fractures, changes in bone shape and features associated with a longstanding massive tear.

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Ultrasound

Ultrasound can be a useful quick screening test for a rotator cuff tear and can assess the biceps tendon dynamically. However, it is generally not sufficient on its own for surgical decision-making, as the accuracy depends heavily on the operator and it provides less information about the overall tear pattern and tissue quality.

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MRI

MRI is the gold-standard investigation when planning treatment for a rotator cuff tear. It shows which tendons are involved, the size and pattern of the tear, the degree of tendon retraction, muscle wasting and fatty change, associated biceps or cartilage problems, and whether the tear is likely to be repairable.

Preparing for your appointment

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Ideally, you should have at least a shoulder X-ray and MRI available before your appointment. However, these investigations can also be arranged at the time of your first consultation if required.

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Does every rotator cuff tear require surgery?

No. Many patients improve without surgery, particularly when the tear is small or degenerative and the main symptom is pain rather than profound weakness.

• Non-operative treatment may include:

• Modification of painful activities;

• Simple pain relief or anti-inflammatory medication when medically appropriate;

• Physiotherapy to restore movement and strengthen the remaining shoulder muscles;

• Carefully considered corticosteroid injection.

​Non-surgical treatment can improve pain and function in many patients. However, it does not reattach a completely torn tendon to the bone. Some tears may enlarge over time, with progression of muscle wasting and fatty change. This does not occur in every patient, but it is relevant when deciding whether continued observation remains appropriate. 

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Cortisone injections can provide short-term pain relief, but if you have a rotator cuff tear that may require repair, it is best to be assessed before proceeding. Injections given close to surgery, particularly within the preceding month, have been associated with a small increase in infection risk and may affect the timing of surgery.

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Repeated corticosteroid injections should be approached cautiously. The 2025 AAOS guideline notes that multiple injections may compromise tendon integrity and potentially affect a later repair. 

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When should rotator cuff repair be considered?

The decision to proceed with surgery is complex, as no two patients or rotator cuff tears are the same. Treatment is personalised according to your circumstances, the condition of the shoulder, and the size, pattern, retraction and tissue quality of the tear. In general, surgery may be considered after failed non-operative treatment, following an acute traumatic tear, for larger or retracted tears, or when pain, weakness and loss of function are significantly affecting quality of life.

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Recent acute tears associated with marked weakness generally warrant early specialist assessment. Delay can sometimes allow the tendon to retract and the muscle to deteriorate, although the appropriate timing of surgery depends on the tear and the patient.

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What is arthroscopic rotator cuff repair?

Most repairable rotator cuff tears can be treated arthroscopically using keyhole surgery.

A camera is introduced into the shoulder through a small incision. The joint and the space above the rotator cuff are examined, and associated problems are treated where appropriate.​

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The inflammation (burisitis) is removed and downsloping bone spurs (enthesiophytes) are burred away with special arthroscopic instruments to create space for the repair

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The torn tendon is released from scar tissue and mobilised back towards its attachment. The bone surface is prepared, and small anchors containing strong sutures are inserted into the humeral head. The sutures secure the tendon back onto the bone so that biological healing can occur.

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The aim is not simply to place stitches into the tendon. The operation creates the conditions for the tendon to heal back to the bone over several months.

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What else may be treated during surgery?

Rotator cuff tears are sometimes associated with other shoulder problems.

Depending on the findings, surgery may also include:

• Treatment of an inflamed or unstable biceps tendon;

• Biceps tenodesis or tenotomy;

• Removal of inflamed bursal tissue;

• Limited acromial reshaping where clinically appropriate;

• Treatment of an acromioclavicular joint problem;

• Release of scar tissue in a stiff shoulder; or

• Repair of an associated subscapularis tear.

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These additional procedures are not automatically required in every patient. They are selected according to the symptoms, imaging and findings at arthroscopy.

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Small and medium rotator cuff tears

Small and medium tears are often mobile and can usually be restored to their normal attachment without excessive tension. When the tendon heals, patients generally experience meaningful improvement in pain, strength and shoulder function. Evidence reviewed in the current AAOS guideline indicates that healed repairs have better patient-reported and functional outcomes than unhealed repairs or physiotherapy alone.

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Large and massive rotator cuff tears

Large tears may involve several tendons and can be associated with tendon retraction, scarring and muscle deterioration. Many remain repairable but may require more extensive tendon mobilisation, multiple anchors and a slower rehabilitation program. In some cases, only a partial repair is safely achievable. Healing rates are generally lower with larger tears and poorer tendon or muscle quality, although patients may still experience meaningful improvement in pain and function even if complete healing does not occur.

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Irreparable rotator cuff tears

Occasionally, a longstanding tear cannot be brought back to the bone without excessive tension, or the muscle has developed advanced atrophy and fatty change.

Treatment depends on the patient’s age, arthritis, remaining movement and principal symptoms.

Options for the treatment of a irreparable rotator cuff tear may include:

• Physiotherapy (anterior deltoid protocol) and activity modification;

• Biceps surgery and arthroscopic debridement for pain relief;

• Tendon transfer in selected younger patients;

• Other reconstructive procedures in selected cases; or

• Reverse shoulder replacement when there is an irreparable tear associated with substantial loss of function or shoulder arthritis. This has revolutionised the treatment outcomes of irreparable cuff tears in recent decades.

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The best option depends on whether the principal problem is pain, weakness, loss of elevation, arthritis or a combination of these.

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Results of rotator cuff repair

Most appropriately selected patients experience substantial improvement in pain and shoulder function after rotator cuff repair.

The result depends on:

• The size and chronicity of the tear;

• Tendon and muscle quality;

• The patient’s age and general health;

• Smoking and metabolic health;

• Whether the repair heals;

• The presence of shoulder arthritis or stiffness; and

• Participation in rehabilitation.

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Repair does not restore a tendon to its original biological state, and a recurrent tear can occur. The risk is greater in larger, longstanding tears and where tissue quality is poor. Improvement is gradual. Patients commonly notice meaningful progress by four to six months, but strength, endurance and comfort can continue to improve for 12 months or longer.

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Recovery after rotator cuff repair

Rehabilitation must balance two competing priorities: protecting the tendon while it heals and preventing excessive shoulder stiffness. The exact program varies according to the size of the tear, quality of the repair and any additional procedures.​ A typical recovery includes:

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• First six weeks: The arm is protected in a sling. Elbow, wrist and hand movement is encouraged. Shoulder exercises are passive or assisted. The repaired arm must not be used for lifting, pushing, pulling or supporting body weight. Desk-based work may be possible if the arm remains protected.

• ​Six to twelve weeks: The sling is gradually discontinued and active shoulder movement begins. The focus is on restoring controlled movement rather than strength. Heavy lifting remains restricted. Driving may resume once the sling is off and the shoulder can be controlled safely.

• ​Three months: Strengthening usually begins at approximately three months. Resistance is introduced gradually to avoid placing excessive stress on the healing repair.

• ​Four to six months: Use of the arm for everyday activities becomes more normal. Light gym work and gradual work conditioning may begin. Heavier work, overhead activity and sport are introduced progressively.

• Six months and beyond: ​Many patients return to heavier work and recreational activities at approximately six months. Recovery from large or massive tears may take longer. Strength and endurance can continue to improve for 12 to 18 months.

 

Return to work

Return to work depends on the physical demands of the job. Administrative or computer-based duties may be possible within several weeks if the shoulder can remain protected. Light physical duties are introduced as active movement improves. Heavy manual work, repetitive overhead activity and forceful lifting usually require around six months and may take longer after a large repair. A graduated return is generally safer than immediately resuming unrestricted duties.

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Risks of rotator cuff repair

Rotator cuff repair is generally safe, but no operation is without risk.

Potential risks include:

• Infection;

• Bleeding or haematoma;

• Shoulder stiffness;

• Persistent pain;

• Failure of the tendon to heal;

• Recurrent tearing;

• Weakness despite repair;

• Injury to nearby nerves or blood vessels;

• Problems associated with the biceps tendon or anchors;

• Blood clots;

• Anaesthetic complications; and

• The need for further treatment or surgery.

• The most significant practical risks are stiffness and failure of tendon healing. Careful surgical technique, protection of the repair and adherence to rehabilitation help reduce these risks but cannot eliminate them.

 

When should you seek specialist assessment?

Assessment is reasonable when shoulder pain is affecting your quality of life, you develop weakness, or symptoms begin after an injury. The aim is not simply to confirm the diagnosis, but to determine the most appropriate treatment, whether surgical or non-surgical.

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Preparing for your first appointment

To get the most from your first appointment, it is helpful to have recent shoulder X-rays and an MRI scan available, together with the imaging reports and the actual images where possible. These investigations help assess the shoulder joint, the size and location of the tear, tendon retraction, muscle quality and any associated biceps, cartilage or arthritic changes.

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You should not delay making an appointment if imaging has not yet been arranged. The appropriate investigations can be organised after your history and examination.