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The rotator cuff is a group of tough, flexible fibres (tendons) and muscles in the shoulder. Rotator cuff disorders occur when tissues in the shoulder get irritated or damaged. Rotator cuff disorders include:
The shoulder is a joint with three main bones: the upper arm bone (humerus), the collarbone (clavicle), and the shoulder blade (scapula). The bones are held together by muscles, tendons, and ligaments. The rotator cuff keeps the upper arm bone in the shoulder socket and lets you raise and twist your arm.
The shoulder is a ball-and-socket joint. The ball at the top of the upper arm bone fits into the socket of the shoulder blade. This socket is shallow, which lets you move your arm in a wide range of motion. But it also means that the muscles and tendons of the rotator cuff have to work hard to hold the bones in place. As a result, they are easy to injure and are prone to wear and tear.
Most rotator cuff disorders are caused by a combination of:
It takes great force to tear a healthy rotator cuff tendon. This can happen during sports, a crash, or a severe fall. But even a simple movement like lifting a suitcase can cause a rotator cuff tear in an older adult or someone whose shoulder is already damaged.
Symptoms of a rotator cuff disorder include pain and weakness in the shoulder. Most often, the pain is on the side and front of the upper arm and shoulder. It may hurt or be impossible to do everyday things, such as comb your hair, tuck in your shirt, or reach for something. You may have pain during the night and trouble sleeping.
To diagnose a rotator cuff disorder, doctors ask about any shoulder injuries or past shoulder pain. They also do a physical examination to see how well the shoulder works and to find painful areas or activities. Moving your arm in certain ways can help a doctor learn about the condition of the rotator cuff.
You may have an X-ray to check the bones of the shoulder. If the diagnosis is still unclear, the doctor may order an imaging test, such as an MRI or an ultrasound.
It is important to treat a rotator cuff problem. Without treatment, your shoulder may get weaker and you may not be able to lift up your arm.
For most rotator cuff disorders, doctors recommend these steps first:
The doctor may also suggest physiotherapy. Physiotherapy can reduce pain and help make your shoulder stronger and more flexible. In physiotherapy, you learn exercises to stretch and strengthen your shoulder. After you learn the exercises, you can do them at home.
It is important to give treatment time to work. It may take from a couple of weeks to several months to get good results.
If other treatments don't help, your doctor may give you shots of steroid medicine in the shoulder. The shots probably don't cure rotator cuff disorders. But they can help relieve pain and inflammation so you are able to do exercises to strengthen the shoulder. The shots may also help your doctor find out if your shoulder pain is from your rotator cuff. If a steroid shot near the rotator cuff relieves your pain, even if the pain comes back later, it means the rotator cuff—not some other shoulder problem—is causing the pain.
Most rotator cuff disorders aren't treated with surgery. But doctors may do surgery if a rotator cuff tendon is torn or if several months of other treatments have not helped.
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In a rotator cuff disorder, tendons that make up the rotator cuff get squeezed and rub against bone. They become damaged and irritated. This causes bleeding and inflammation. The tendons can develop scar tissue, which is not as strong and flexible as normal tendon tissue. Over time, the tendons get weaker and less flexible. Eventually, they can tear.
Normal wear and tear and overuse cause most rotator cuff problems.
A rotator cuff disorder causes pain and weakness in your shoulder. It may be uncomfortable or impossible to do everyday activities, such as combing your hair, tucking in your shirt, or reaching above your head.
Most often, you will feel the pain on the side and front of your upper arm and shoulder. You may have pain during the night and have trouble sleeping on that side. Pain is almost always worse when you make overhead movements.
Because of the pain, you may try not to use your arm. And that can cause even more weakness and stiffness in the shoulder.
The amount of pain usually depends on how much damage there is:
Sometimes the pain isn't directly related to the amount of damage. For example, your rotator cuff may have minor damage, but strength and the loss of range of motion may be severe because it's too painful to move in certain ways. This is especially true if you normally make a lot of overhead movements.
In tendinitis (inflammation in the tendon), the pain usually starts gradually, over the side of the shoulder and the upper arm.
Over time, the pain may get worse or you may have constant pain. In some cases, this is because you actually have one or more small tendon tears.
Some people also have tendinitis in other parts of the shoulder. And some people have neck pain from using other muscles to help move the shoulder.
The most common symptoms of a tear are:
Symptoms of a sudden, severe tear include:
You can have a complete tear without symptoms, especially if you are an older adult who is not very active.
In rare cases, shoulder pain may be a sign of a more serious problem with your heart or lungs.
The rotator cuff is a group of four tendons. These tendons connect the main muscles of the shoulder to the upper arm. The tendons and muscles stabilize the shoulder joint so you can raise and rotate your arm. Every time you raise your arm above your head, the upper tendon glides under the upper end of your shoulder blade.
Sometimes the shoulder blade is rough or abnormally shaped and rubs or scrapes the tendon. Over time, this can cause tiny tears and bleeding. When these tears heal, the scar tissue is weaker and less flexible than normal tendon, so the whole rotator cuff gets weaker. The weaker the tendon becomes, the greater its chances of tearing.
Without treatment, this cycle of inflammation, wear and tear, and limited use can lead to other shoulder problems, such as stiffness or frozen shoulder. Activities that require repeated overhead arm movements can lead to problems like bursitis and tendinitis.
Here are the things that can gradually lead to rotator cuff problems. They often occur together or overlap:
It takes tremendous force to tear a healthy rotator cuff tendon. This may happen while you are playing sports or during a crash or a severe fall.
In older, less active adults, even simple movements such as lifting a suitcase can cause a tear.
Things that may increase the risk of rotator cuff disorders include:
As the rotator cuff and the shoulder weaken, the risk for a partial or complete tear increases.
Call 911 or other emergency services immediately if shoulder or arm pain occurs with chest pain or other symptoms of a heart attack, such as shortness of breath and nausea.
Call your doctor immediately if you have an injury to your shoulder and:
Call your doctor if:
Watchful waiting is a period of time during which you and your doctor observe your symptoms or condition without using medical treatment. A watchful waiting period may vary from a few days to weeks or possibly months. Watchful waiting is not appropriate if:
Your family doctor or general practitioner can diagnose and manage rotator cuff disorders. For emergency treatment for a rotator cuff injury or severe symptoms, you may see an emergency medicine specialist.
For treatment, you may be referred to a specialist, such as:
To diagnose a rotator cuff disorder, your doctor will ask about your injury or shoulder pain history and will do a physical examination to see how your shoulder is working.
If your symptoms and examination show that you may have a complete rotator cuff tear, you may have one or more of these tests to confirm the diagnosis:
Your age, job, and activity level are considered when your doctor is deciding about further testing. For example, if you are a competitive athlete or have a job that requires frequent overhead activity, you may need further testing sooner than a relatively inactive older adult. A more complete diagnosis is important if you are likely to continue activities that may further damage your shoulder.
Treatment of rotator cuff disorders should begin soon after an injury or soon after symptoms develop, to give you the best chance of restoring flexibility and strength to your shoulder. Without treatment, inflammation and tears can build up, causing pain, weakness, and loss of function.
Treatment depends on your symptoms, age, and activity level, and on whether your symptoms appear to be related to a rotator cuff injury.
Most rotator cuff disorders are treated without surgery. Your treatment may include:
If symptoms don't improve after a few months of non-surgical treatment, you and your doctor may consider testing (such as X-rays or an MRI) to find out if you have a rotator cuff tear.
Or your doctor may give you a corticosteroid shot.
Surgery often is used to repair a torn rotator cuff in a healthy young person, because good results are more likely if there is little or no evidence of degeneration or impingement.
People who have advanced rotator cuff disorders and tendons that are tough, stringy (fibrous), and stiff usually respond less well to surgery. Surgery may successfully repair the tear, but it can't repair all the damage caused by age or degeneration.
But surgery may be considered if:
For more information, see Surgery.
Recovery from a rotator cuff disorder varies with each person. Your physiotherapy and home exercise program should continue until your shoulder is as strong and flexible as possible. Some treatments for rotator cuff disorders can last up to a year. Most people can return to their previous activities after several weeks of rehabilitation.
Experts have differing opinions about treating rotator cuff tears.
The long-term changes that occur in and around the shoulder joint because of everyday wear and tear cannot be totally prevented. But you may be able to prevent some rotator cuff problems if you:
Home treatment is often the first treatment for a rotator cuff problem. Treatment can help relieve the discomfort and keep the problem from getting worse.
People respond to heat and ice differently. Use whichever one makes you feel better. In some cases, heat feels good for a while but may make pain and stiffness worse after 1 to 2 hours. For a sudden injury, don't use heat for the first 48 hours.
At first, ice helps relieve pain and reduce swelling. Try applying ice to your shoulder for the first 48 hours after discomfort begins:
After 2 to 3 days, start moving your shoulder with the aid of moist heat:
Eventually, your doctor may want you to do more to stretch and strengthen your shoulder. For exercises you can do at home (with your doctor's approval), see:
Medicines don't heal rotator cuff disorders. They help with pain and inflammation. This allows you to start exercises to stretch and gradually strengthen the shoulder, which reduces the risk of stiffness or a frozen shoulder.
Be safe with medicines. Read and follow all instructions on the label.
Surgery may be considered if:
Surgery typically is used to repair a torn rotator cuff in a healthy young person, because good results are more likely if there is little or no evidence of other problems. People who have advanced rotator cuff disorders and tendons that are tough, stringy (fibrous), and stiff usually respond less well to surgery. Surgery may successfully repair the tear, but it can't repair all the damage caused by age or degeneration.
If surgery isn't done right away, repair of a large tear may not be as successful. But it still usually relieves pain and restores enough strength for you to do routine, non-strenuous activities.
After surgery, a program of physical rehabilitation (rehab) is very important. You may not do as well after surgery if you aren't willing or able to commit to completing a challenging physical rehab program.
Shoulder surgery for rotator cuff disorders usually involves one or more of the following:
These procedures may be done arthroscopically, by traditional open surgery, or by a combination of the two approaches.
Sometimes a rotator cuff tear is so severe that it can't be fixed in the usual ways. If this happens in a younger person, the doctor may suggest moving another tendon to substitute for the torn tendon. In an older person, the doctor may suggest a special shoulder replacement.
The success of surgery for rotator cuff tears depends on many things, such as:
A physiotherapy and rehabilitation (rehab) program usually involves exercises to stretch and gradually strengthen the shoulder. Some physiotherapists may use other techniques, such as massage or ultrasound, to relieve pain and reduce muscle spasms.
This program of treatment may be used without surgery or as part of recovery after surgery. It can reduce pain in the soft tissues (such as the muscles, ligaments, and tendons), improve function, and build muscle strength.
Common difficulties with rehab programs include:
Although completing a rehab program may be hard, a successful outcome after surgery depends on your commitment to treatment. If you follow your physiotherapy plan closely and get help when you need it, you are more likely to restore shoulder strength and movement.
Exercises for rotator cuff disorders include:
Experts are studying a new treatment for chronic calcifying tendinitis of the rotator cuff. The treatment uses sound waves to create shock waves that destroy calcium deposits in the rotator cuff tendons. This is called extracorporeal shock wave therapy. Some studies show pain relief and increased range of motion. But more studies are needed to see whether these results can be duplicated and to measure long-term results.footnote 1
Other treatments being studied include:
CitationsGeorge L, et al. (2002). Plasma folate levels and risk of spontaneous abortion. JAMA, 288(15): 1867–1873.Other Works ConsultedAmerican Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2010). Impingement syndrome. In JF Sarwark, ed., Essentials of Musculoskeletal Care, 4th ed., pp. 295–300. Rosemont, IL: American Academy of Orthopaedic Surgeons.Bannuru RR, et al. (2014). High-energy extracorporeal shock-wave therapy for treating chronic calcific tendinitis of the shoulder: A systematic review. Annals of Internal Medicine, 160(8): 542–549. DOI: 10.7326/M13-1982. Accessed September 3, 2014.Lin KC, et al. (2010). Rotator cuff: 1. Impingement lesions in adult and adolescent athletes. In JC DeLee et al., eds., DeLee and Drez's Orthopaedic Sports Medicine, Principles and Practice, 3rd ed., vol. 1, pp. 986–1015. Philadelphia: Saunders Elsevier.Wiesel BB, Carroll RM (2010). The shoulder. In SW Wiesel, JN Delahay, eds., Essentials of Orthopedic Surgery, 4th ed., pp. 323–351. New York: Springer.
Adaptation Date: 10/28/2020
Adapted By: Alberta Health Services
Adaptation Reviewed By: Alberta Health Services
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