Rotator cuff tear: causes and surgery options— full professional article

What is the rotator cuff?

The rotator cuff is a sleeve of four tendons (supraspinatus, infraspinatus, teres minor, and subscapularis) that wrap around the head of the humerus (upper arm bone). Together they power shoulder movement, keep the joint stable, and maintain normal shoulder mechanics.

What is a rotator cuff tear?

A rotator cuff tear is a disruption of the tendon fibers where they attach to the bone at the top of the humerus. Tears may be partial-thickness or full-thickness. In a partial tear, some fibers remain attached at the footprint.

Full-thickness tears are graded by size (small, medium, large, or massive), based on how far the tendon has pulled back from its footprint.

A rotator cuff tear often causes significant pain, including night pain that disturbs sleep, difficulty lifting the arm overhead, and, in severe cases, an inability to actively raise the arm at all.

What causes a rotator cuff tear?

Rotator cuff tears may be traumatic (from an injury) or degenerative (from tendon wear and progressive fiber failure over time).

Shoulder impingement, in which the tendons are repeatedly crowded and compressed under the acromion, also contributes to rotator cuff damage.

What is shoulder impingement?

Impingement is a mechanical narrowing of the space between the humeral head and the acromion, which squeezes the rotator cuff tendons in the subacromial space. This repeated compression leads to tendon irritation and inflammation, and over time can progress to a tear.

Contributing factors include a weak rotator cuff, poor shoulder movement patterns, and sometimes the shape of the acromion (a hooked acromion).

Typical symptoms include pain when lifting or rotating the arm, often with night pain.

How is shoulder impingement treated?

The first line of treatment is non-operative: physiotherapy to strengthen the rotator cuff and the muscles that stabilize the shoulder blade, activity modification, and sometimes a subacromial corticosteroid injection to calm inflammation and allow effective rehabilitation.

If conservative care does not help, arthroscopic subacromial decompression (acromioplasty) may be considered to create more space and relieve the impingement.

How is a rotator cuff tear treated?

Non-operative options include structured physiotherapy and injections (corticosteroid, or biologics such as PRP in selected cases).

Non-operative care suits patients with mild symptoms, those at high surgical risk, and those who prefer to avoid surgery.

The operative treatment is usually an arthroscopic or mini-open repair to reattach the tendon to the bone, when the symptoms and tear pattern warrant surgery and the risks are acceptable.

Rehabilitation after surgery follows staged goals: first protected passive and then active range of motion, followed by gradual strengthening of the rotator cuff and shoulder-blade muscles. Sling use, lifting limits, and return-to-work timelines depend on the size of the tear, the quality of the tissue, the tension of the repair, and any additional procedures performed.

Fatty infiltration of the muscle on imaging (for example, Goutallier-type changes) points to a less favorable environment for healing and may influence whether repair is realistic or whether alternative strategies are better.

What happens if a rotator cuff tear is left untreated?

Beyond pain and weakness, an untreated tear can grow over time as the muscles pull the retracted tendon further from the bone. A long-standing massive tear can become irreparable, with fatty degeneration of the muscle.

Advanced dysfunction can look like pseudoparalysis, an inability to actively raise the arm without help, although this is not a true nerve palsy.

Large, chronic tears can also speed up arthritis in the shoulder joint, a condition known as cuff tear arthropathy.

How are massive tears and cuff tear arthropathy treated?

A massive, irreparable tear or end-stage cuff tear arthropathy may require a reverse total shoulder replacement. In this design, the ball and socket of the joint are swapped compared with a standard anatomic shoulder replacement, which lets the deltoid muscle lift the arm even when the rotator cuff can no longer work.

The reversed mechanics stop the humeral component from riding up and give the deltoid a better mechanical advantage to actively raise the arm.