Rotator Cuff Tear

Written by Tele Demetrious, Physiotherapist, BPhysio(Hons)
Reviewed by Brett Harrop, APA Sports Physiotherapist, BPhysio(Hons), MPhysio(Sports Physio)
Updated:

Injuries > Shoulder > Rotator Cuff Tear

(Also known as Torn Rotator Cuff, Rotator Cuff Strain, Supraspinatus Tear, Supraspinatus Strain, Infraspinatus Tear, Infraspinatus Strain)

What is a rotator cuff tear?

A rotator cuff tear is a condition characterised by partial or complete tearing of one or more of the rotator cuff muscles (figure 1).

Rotator Cuff Anatomy

Figure 1 – Relevant Anatomy for a Rotator Cuff Tear (Subscapularis not shown)

The rotator cuff is a group of muscles which originate from the shoulder blade and attach to the upper arm bone (humerus) via the rotator cuff tendons (figure 1). Collectively, the rotator cuff act to provide stability to the shoulder joint and assist with elevation and rotation movements of the shoulder. The 4 muscles of the rotator cuff include:

  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres Minor

During contraction of the rotator cuff muscles, tension is placed through the rotator cuff muscles and tendons. When this tension is excessive due to too much repetition or high force, damage to the rotator cuff may occur. This typically presents as a partial or complete rotator cuff tear and can involve any of the muscles listed above. Of the rotator cuff muscles, the supraspinatus is most commonly affected.


Causes of a rotator cuff tear

Rotator cuff tears often occur suddenly due to a high force going through the muscle and tendon beyond what it can withstand. This may be due to activities such as heavy or awkward lifting, a fall onto an outstretched hand, heavy pushing or pulling, or a forceful throw.

Sometimes a rotator cuff tear may develop over time due to repetitive or prolonged activities placing strain on the rotator cuff. This may cause gradual degeneration and weakening of the rotator cuff predisposing it to further injury. These rotator cuff injuries typically occur due to repetitive lifting, pushing, pulling, use of the arm in front of or away from the body (e.g. housework) or overhead activities and are most common in the older population. In athletes, rotator cuff tears are commonly seen in throwing sports (such as cricket or baseball), swimming, racquet sports (such as tennis), weight lifting or paddling sports (such as kayaking).


Signs and symptoms of a rotator cuff tear

Patients with a rotator cuff tear will often experience a sudden pain or tearing sensation in the shoulder during the provocative activity. In minor cases, patients may be able to continue sport or activity only to have an increase in pain upon resting later (particularly that night or the following morning). In severe cases the pain may be disabling, preventing the patient from performing further activity. Patients with a rotator cuff tear usually experience pain in the front, side or back of the shoulder. Occasionally, pain may radiate into the upper arm, shoulder blade, upper back or neck. The pain associated with this condition is usually experienced as an ache that increases to a sharper pain with activity.

Patients with a rotator cuff tear will usually experience pain or difficulty when elevating the affected arm. Pain may also increase when lifting heavy objects (particularly overhead), using the arm in front of the body, taking the hand behind the body (e.g. doing up a bra), during heavy pushing or pulling or when lying on the affected side.

In patients with a minor rotator cuff tear, little or no symptoms may be present. In these patients, a minor ache may be the only complaint. In severe or chronic cases, muscle wasting and weakness may be evident and night pain (regardless of position) may be present (especially in the case of a complete tear or rupture). This may be severe enough to keep the patient awake at night.


Diagnosis of a rotator cuff tear

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a rotator cuff tear. Further investigations such as an Ultrasound or MRI scan may be required to confirm diagnosis and assess the severity of the tear.


Treatment for a rotator cuff tear

Most minor rotator cuff tears settle well with appropriate physiotherapy. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from any activity that increases their pain until they are symptom free (in severe cases a sling may be required for a number of days). Activities which place large amounts of stress through the rotator cuff should also be minimized, these include: overhead activities, throwing, heavy lifting, pushing or pulling, repetitive or prolonged use of the arm in front of or away from the the body (e.g. housework or driving) and sleeping on the affected side. Resting from aggravating activities ensures that the body can begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.

Ignoring symptoms or adopting a ‘no pain, no gain’ attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with a rotator cuff tear is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.

Patients with a rotator cuff tear should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). This primarily involves resting from aggravating activities (occasionally a sling may be required), regular icing (i.e. 20 minutes every 2 hours) and keeping the arm elevated (i.e. sleeping on the opposite side). Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.

Manual “hands-on” therapy from the physiotherapist such as massage, trigger point releases, joint mobilisation, dry needling, stretches and electrotherapy can hasten healing and assist with improving flexibility, pain and function. This can generally commence once the physiotherapist has indicated it is safe to do so.

Patients with a rotator cuff tear should perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. Exercises to improve scapular posture, stability and strength are a key component of the rehabilitation of a rotator cuff tear. Exercises to improve spinal posture and upper back flexibility are also important, along with a graduated rotator cuff strengthening program (usually involving the use of Resistance Bands). If a rotator cuff tear is not adequately strengthened following injury, a poor outcome is likely. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced. Careful assessment by the physiotherapist to determine which factors have contributed to the development of the condition with subsequent correction of these factors is also important to ensure an optimal outcome.

In the final stages of rehabilitation, a gradual return to activity or sport is indicated as guided by the treating physiotherapist.


Surgery for a rotator cuff tear

In major tears to the rotator cuff, surgical intervention may be required to repair the tear and ensure an optimal outcome. This is then followed by an intensive period of rehabilitation, usually involving an initial period of 3 – 6 weeks in a sling whereby only passive movements are allowed (i.e. the physiotherapist moves the arm with the patient relaxed).

Following this period of rest, a graduated strengthening and flexibility program is indicated over the following months as guided by both the physiotherapist and surgeon. In cases where impingement or bony spurring is contributing to the rotator cuff tear the surgeon may also remove part of the bone to allow the rotator cuff tendon greater freedom of movement (this is known as a subacromial decompression).

Surgery is usually considered in those patients with severe rotator cuff tears, particularly in the following instances:

  • If the patient is under 60 years of age
  • If there is complete tearing of the tendon or muscle
  • If there is failure of conservative management following a period of 6 – 8 weeks of treatment or longer
  • In cases of young and active people, athletes, sportsmen and women
  • If your occupation requires heavy, repetitive or overhead shoulder activities

Prognosis of a rotator cuff tear

With appropriate management, most minor cases of a rotator cuff tear that have not been present for long can usually recover within a few weeks. In chronic cases recovery can be a lengthy process and may take many months to achieve an optimal outcome. Those patients with larger tears to the rotator cuff including complete ruptures that require surgery usually need a period of rehabilitation of 3 – 6 months or longer before returning to full activity.


Contributing factors to the development of a rotator cuff tear

There are several factors which can predispose patients to developing a tear to the rotator cuff. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

  • abnormal biomechanics (eg. poor throwing technique or stroke technique with swimming)
  • neck, upper back and shoulder stiffness
  • muscle imbalances
  • muscle weakness (especially the scapular stabilizers and rotator cuff muscles)
  • muscle tightness
  • poor posture
  • excessive or inappropriate training or activity
  • insufficient recovery periods from training or activity
  • a sudden return to activity following a period of deconditioning
  • inadequate warm-up
  • poor core stability

Physiotherapy for a rotator cuff tear

Physiotherapy treatment is vital to hasten the healing process and ensure an optimal outcome in all patients with this condition. Treatment may comprise:

  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • joint mobilization
  • dry needling
  • ice or heat treatment
  • the use of a sling
  • progressive exercises to improve flexibility and strength (particularly the scapular stabilizers and rotator cuff muscles)
  • hydrotherapy
  • education
  • training and activity modification advice
  • technique correction
  • postural correction
  • anti-inflammatory advice
  • devising and monitoring a return to sport or activity plan

Other intervention for a rotator cuff tear

Despite appropriate physiotherapy management, some patients with this condition do not improve (often developing into chronic rotator cuff tendinopathy). When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may include further investigations such as X-rays, ultrasound, CT scan or MRI, pharmaceutical intervention, corticosteroid injection (sometimes required in the case of secondary bursitis) or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition. Surgery may also be needed to repair the rotator cuff tear in those circumstances mentioned above.


Exercises for a rotator cuff tear

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 – 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.


Initial Exercises

Shoulder Blade Squeezes

Begin this exercise standing or sitting with your back straight. Your chin should be tucked in slightly and your shoulders should be back slightly. Slowly squeeze your shoulder blades together as hard and far as possible provided it does not cause or increase symptoms (figure 2). Hold for 5 seconds and repeat 10 times.

Exercises for a Rotator Cuff Tear - Shoulder Blade Squeezes

Figure 2 – Shoulder Blade Squeezes

Pendular Exercises

Begin leaning forwards with your uninjured forearm supported on a table or bench. Keeping your back straight and your shoulder relaxed, gently swing your injured arm forwards and backwards as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch (figure 3). Repeat 10 times provided the exercise does not cause or increase symptoms. Repeat the exercise swinging your arm side to side provided it is pain free.

Exercises for a Rotator Cuff Tear - Pendular Exercises

Figure 3 – Pendular Exercises (right side)

Pendular Circles

Begin leaning forwards with your uninjured forearm supported on a table or bench. Keeping your back straight and your shoulder relaxed, gently swing your arm in circles clockwise as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch (figure 4). Repeat the exercise swinging your arm counter clockwise. Repeat 10 times in each direction provided the exercise does not cause or increase symptoms.

Exercises for a Rotator Cuff Tear - Pendular Circles

Figure 4 – Pendular Circles (right side)

Foam Roller Stretch

Place a foam roller under your upper back as demonstrated (figure 5). Breathe normally keeping your back and neck relaxed. Hold this position for 15 – 90 seconds provided it is comfortable and does not cause pain. If you do not have a foam roller, you can use a rolled up towel instead provided the exercise is pain free.

Exercises for a Rotator Cuff Tear - Foam Roller Stretch

Figure 5 – Foam Roller Stretch


Intermediate Exercises

Shoulder External Rotation

Begin standing tall, with your neck and back straight, your shoulders should be back slightly. Keeping your elbow tucked into your side and bent to 90 degrees, gently take your hand away from your body as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch (figure 6). Repeat 10 times provided the exercise does not cause or increase symptoms.

External Rotation

Figure 6 – Shoulder External Rotation (right side)

Wall Crawl

Begin standing tall facing a wall. Place your hand on the wall and use your fingers to slowly finger-walk up the wall as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch (figure 7). Repeat 10 times provided the exercise is pain free.

Wall Crawl

Figure 7 – Wall Crawl (left side)

Resistance Band Pull Backs

Begin this exercise in standing or kneeling with your back straight and holding a resistance band as demonstrated (figure 8). Slowly pull your arms backwards, squeezing your shoulder blades together as demonstrated. Hold for 2 seconds and return to the start position. Perform 10 – 30 repetitions provided the exercise does not cause or increase symptoms. Once you can perform 30 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms.

Resistance Band Pull Backs

Figure 8 – Resistance Band Pull Backs

Chariot Pulls

Begin this exercise in standing or kneeling with your back straight and holding a resistance band as demonstrated (figure 9). Keeping your back and elbows straight, slowly pull the band to your hips as demonstrated. Perform 10 – 30 repetitions provided the exercise does not cause or increase symptoms. Once you can perform 30 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms.

Chariot Pulls

Figure 9 – Chariot Pulls

Darts

Begin this exercise lying on your stomach with your arms by your side. Tighten your rhomboids by squeezing your shoulder blades together and slowly lifting your arms and chest off the ground, keeping your neck straight (figure 10). Hold for 2 seconds at the top of the movement and then slowly return to the starting position. Perform 10 – 30 repetitions provided the exercise is pain free. This exercise may be performed with palms facing up or down.

Darts

Figure 10 – Darts

Resistance Band External Rotation

Begin this rotator cuff strengthening exercise standing with your back straight, shoulder blades back slightly and holding a resistance band as demonstrated (figure 11). Keeping your elbow at your side and bent to 90 degrees, slowly move your hand away from your body keeping your shoulder blade still. Perform 10 – 30 repetitions provided the exercise does not cause or increase symptoms. Once you can perform 30 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms.

Resistance Band External Rotation

Figure 11 – Resistance Band External Rotation (left shoulder)

Resistance Band Internal Rotation

Begin this rotator cuff strengthening exercise standing with your back straight, shoulder blades back slightly and holding a resistance band as demonstrated (figure 12). Keeping your elbow at your side and bent to 90 degrees, slowly move your hand towards your body keeping your shoulder blade still. Perform 10 – 30 repetitions provided the exercise does not cause or increase symptoms. Once you can perform 30 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms.

Resistance Band Internal Rotation

Figure 12 – Resistance Band Internal Rotation (right shoulder)


Advanced Exercises

Seated Row

Begin this exercise sitting on a seated row machine with your back and neck straight as demonstrated (figure 13). Slowly pull the handle towards your chest, bringing your elbows backwards and squeezing your shoulder blades together. Perform 10 – 20 repetitions provided the exercise is pain free. Once you can perform 20 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the exercise provided there is no increase in symptoms.

Seated Row

Figure 13 – Seated Row

Resistance Band External Rotation at 90 Degrees

Begin this exercise standing with your back straight, shoulder blades back slightly, arm side elevated to 90 degrees and holding a resistance band as demonstrated (figure 14). Keeping your elbow bent to 90 degrees, slowly move your hand backwards against the resistance band keeping your shoulder blade and elbow still. Perform 10 – 30 repetitions provided the exercise does not cause or increase symptoms. Once you can perform 30 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms.

Resistance Band External Rotation at 90 degrees

Figure 14 – Resistance Band External Rotation at 90 Degrees (left arm)

Resistance Band Internal Rotation at 90 Degrees

Begin this exercise standing with your back straight, shoulder blades back slightly, arm side elevated to 90 degrees and holding a resistance band as demonstrated (figure 15). Keeping your elbow bent to 90 degrees, slowly move your hand down and forwards against the resistance band keeping your shoulder blade and elbow still. Perform 10 – 30 repetitions provided the exercise does not cause or increase symptoms. Once you can perform 30 repetitions consistently without pain, the exercise can be progressed by gradually increasing the resistance of the band provided there is no increase in symptoms.

Resistance Band Internal Rotation at 90 degrees

Figure 15 – Resistance Band Internal Rotation at 90 Degrees (right arm)

Foam Roller Extension

Begin lying on your back on a soft surface such as a bed. Place a foam roller under your upper back, with your arms across your chest as demonstrated (figure 16). Ensure you are comfortable and can fully relax your back and neck (a pillow may be required for comfort). You should feel a mild to moderate stretch without pain. Hold for 15 – 90 seconds provided it is comfortable and does not cause pain, then move the foam roller up or down a few centimetres and repeat along the length of your upper back. This exercise can then be progressed by placing your arms overhead (figure 17), by lying on a harder surface or rolling the foam roller up and down the length of your upper back without pausing.

Foam Roller Extension

Figure 16 – Foam Roller Extension (Arms Across Chest)

Foam Roller Extension Arms Overhead

Figure 17 – Foam Roller Extension (Arms Overhead)


Other Exercises

Abduction with Stick

Begin standing tall with your back and neck straight. Use a broom handle to push your arm to the side and up as far as you can go without pain and provided you feel either nothing, or no more than a mild to moderate stretch (figure 18). Repeat 10 times.

Abduction with Stick

Figure 18 – Abduction with Stick (left side)

Hand Behind Back with Towel

Begin standing tall with your back and neck straight, your shoulders should be back slightly. Using a towel, take your hand behind your back and up your spine as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch (figure 19). Repeat 10 times.

Hand Behind Back with Towel

Figure 19 – Hand Behind Back with Towel (left side)

Arm Across Chest Stretch

Begin standing tall with your back and neck straight. Gently take your arm across your body (using your other arm to take it a little further), as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch (figure 20). Repeat 10 times provided the exercise does not cause or increase symptoms.

Arm Across Chest Stretch

Figure 20 – Arm Across Chest Stretch (right side)


Rehabilitation guide for a rotator cuff tear

The following is a general rehabilitation protocol for a rotator cuff tear (that has not undergone surgical repair). This needs to be tailored to each individual and should be discussed with your treating physiotherapist prior to commencing.

This rehabilitation protocol may also be suitable for some patients who have undergone surgical repair to the rotator cuff following the initial 3 – 6 week period in the sling, but should be discussed with the treating physiotherapist and surgeon prior to commencing.

Progression through this program can vary from several days to many months depending on injury severity and quality of treatment:

  • See your physiotherapist as soon as possible to confirm diagnosis, establish the likely prognosis, identify the contributing factors to injury and begin appropriate treatment.
  • Follow the R.I.C.E regime for the first 48 – 72 hours following injury or when inflammatory signs are present (night-time pain, morning ache / stiffness or pain at rest). This should primarily comprise:
    • Rest from any activity that increases pain (a sling may be required)
    • Ice the sore area for 20 minutes and repeat every 2 hours
    • Elevate the affected arm when lying, by lying with the sore side up (i.e. left side-lying for a right sided rotator cuff tear).
    • Anti-inflammatory medication may be beneficial (discuss this with your doctor and/or pharmacist)
  • Avoid H.A.R.M. during the first 48 – 72 hours following injury or when inflammatory signs are present (night-time pain, morning ache / stiffness or pain at rest) including:
    • Heat (avoid using heat on the injured shoulder, this includes the use of heat packs, hot baths or spas)
    • Alcohol consumption
    • Rigorous Exercise of the affected body part
    • Massage
  • Aim for pain free rehabilitation (i.e. gradually increase strength, flexibility and activity, provided there is no increase in symptoms during activity or upon rest following activity (e.g. upon waking the next morning). This should take place over days to months depending on injury severity).
  • Continue to rest from any activity that increases pain during activity or after activity with rest (i.e. the next night or upon waking the following morning). Especially too much lifting, carrying, pushing, pulling, use of the affected arm in front of the body, overhead activity, lying on the affected side etc. Moderate the force, repetition and duration of activity to ensure there is no increase in symptoms.
  • If using a sling, gradually reduce the period of time you are using this during activity provided there is no increase in symptoms.
  • Maintain optimal posture as much as possible (or as close to optimal posture as possible provided there is no increase in symptoms), particularly when sitting and sleeping. Think tall, squeeze your shoulder blades backwards fully, tuck your chin in  (so your head is over your shoulders and your face is facing straight ahead) then relax a little so you’re not too straight (see figure 21).
  • Begin “Initial Exercises” 72 hours following injury (for those patients who have not undergone surgery) or as instructed by the treating surgeon and physiotherapist (for those who have undergone surgery), provided there is no increase in symptoms. Generally you should begin with one or two “Initial Exercises’ and then add the remaining ‘Initial Exercises’ over a number of days provided there is no increase in symptoms.
  • Heat treatment can usually commence 72 hours following injury provided there is no inflammation (i.e. night-time pain, morning ache/stiffness or pain at rest). Apply a heat pack to the injured area at a comfortable warmth for 20 – 30 minutes before exercises. If inflammation is still present (i.e. night-time pain, morning ache / stiffness or pain at rest) continue to use ice instead of heat.
  • Progress to the “Intermediate Exercises” once the “Initial Exercises” can be performed pain free and to the same extent on the injured side as the non-injured side. Those patients who have undergone surgery should discuss the suitability of these exercises with their treating physiotherapist and surgeon before commencing. Ensure all new exercises do not increase symptoms. The ‘Intermediate Exercises’ should replace the ‘Initial Exercises’. Generally you should begin with one or two “Intermediate Exercises’ and then gradually add the remaining ‘Intermediate Exercises’ over a period of days to weeks provided there is no increase in symptoms.
  • Progress to the “Advanced Exercises” once the “Intermediate Exercises” can be performed pain free and to the same extent on the injured side as the non-injured side. Those patients who have undergone surgery should discuss the suitability of these exercises with their treating physiotherapist and surgeon before commencing. Ensure all new exercises do not increase symptoms. The ‘Advanced Exercises’ should be added to the ‘Intermediate Exercises’. Generally you should begin with one or two “Advanced Exercises’ and then add the remaining ‘Advanced Exercises’ over a period of days to weeks provided there is no increase in symptoms.
  • The “Other Exercises” may be required for some patients who have residual shoulder stiffness. These exercises may be added once the “Advanced Exercises” can be performed pain free for a few days consecutively. Generally you should begin with one of the “Other Exercises” and gradually add the remaining “Other Exercises” over a few days provided there is no increase in symptoms. The “Other Exercises” should generally be continued until they can be performed pain free and to the same extent on the injured side as the uninjured side.
  • Further Shoulder Strengthening Exercises can gradually be added provided they do not cause or increase symptoms.
  • A gradual return to sport and activity can occur once your physiotherapist has advised it is safe to do so and provided there is no increase in symptoms.
  • Ensure your physiotherapist has identified any contributing factors to your injury and appropriate intervention has taken place to address these issues to minimise the likelihood of injury recurrence.

Correct Standing Posture

Figure 21 – Optimal Posture


Physiotherapy Products for a rotator cuff tearPhysiotherapy products for a rotator cuff tear

Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with this condition include:

  1. Slings
  2. Shoulder Supports
  3. Ice Packs or Heat Packs
  4. Sports Tape (for protective taping)
  5. Resistance Band (for strengthening exercises)
  6. Foam Rollers
  7. Spikey Massage Balls (for self massage)
  8. TENS Machines (for pain relief)
  9. Therapeutic Pillows

To purchase physiotherapy products for a rotator cuff tear, click on one of the above links or visit the PhysioAdvisor Shop.


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