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Rotator cuff tear

«It hurts when I lift my arm and I cannot sleep on that side»

Pain lifting the arm, loss of strength and night pain that wakes you. What a rotator cuff tear is, how it is diagnosed and what the options are.

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Treated by Dr. Ricardo Aveledo, shoulder subspecialist certified by the Royal College of Surgeons. Consultation and surgery in Tenerife · Hospital Quirónsalud View CV

Do any of these sound familiar?

If two or three sound familiar, this fits the picture.

  • Pain lifting the arm, especially above shoulder height
  • Being unable to sleep lying on that side
  • Loss of strength when holding or carrying weight
  • Pain running down the outer side of the arm
  • Clicking or a grating sensation when moving the shoulder
  • Difficulty with everyday tasks: fastening clothes, combing your hair, reaching a shelf

Worth having it assessed soon if you also notice

  • Sudden loss of strength after a fall or a wrench: this may be an acute tear, and those do better the sooner they are assessed.
  • Being unable to hold the arm up when someone lifts it for you.
  • Pain that does not ease at all at night despite painkillers.
The rotator cuff tendons wrap around the head of the humerus and keep it centred as the arm moves. The cross marks where tears most often occur. Clavicle Acromion Rotator cuff Glenoid Humerus
The rotator cuff tendons wrap around the head of the humerus and keep it centred as the arm moves. The cross marks where tears most often occur.

What the rotator cuff is

The rotator cuff is a group of four tendons — supraspinatus, infraspinatus, subscapularis and teres minor — that wrap around the head of the humerus like a closed fist around a ball. Their job is not so much to lift the arm as to keep the head of the humerus centred while the deltoid does the lifting. Without that centring, the shoulder loses efficiency and pain and a sense of giving way appear.

When one of those tendons tears, the balance is lost. Hence the very recognisable pattern: it hurts to lift the arm, strength is missing, and it is worse at night, because lying down removes the effect of gravity that during the day kept the joint decompressed.

Why it tears

There are two different stories behind a cuff tear, and they are not treated the same way:

The degenerative tear is the more common one from the age of 50. The tendon gradually wears, loses its blood supply and eventually gives way, often without any injury to account for it. It comes on gradually, sometimes after a trivial effort that was only the last straw.

The traumatic tear happens after a fall onto the arm, a sudden wrench or a dislocation. It is more common in younger people, the pain and loss of strength are immediate, and here timing does matter: a tendon repaired early is of better quality and less retracted than one that has been torn for months.

The decision to operate or not

Not every rotator cuff tear needs surgery. There are tears visible on MRI in people with no symptoms at all, and there are shoulders that work perfectly well with a torn tendon because the rest of the musculature has learned to compensate.

What is weighed in the consultation is not just the image but the combination of four things: how much strength you have lost, how much it limits your actual life, your age and functional demand, and whether the tear is acute or has been there for years. The same MRI can lead to opposite decisions in two different people.

How the diagnosis is confirmed

  1. 01

    Focused physical examination

    Specific tests for each cuff tendon. In most cases these already indicate which tendon is affected and whether the tear is partial or complete.

  2. 02

    Ultrasound

    Done in the consultation itself, dynamic (the tendon is seen moving) and with no radiation. It is usually enough to confirm the tear and measure it.

  3. 03

    MRI

    When surgery is being considered. It shows the exact size, how far the tendon has retracted and the quality of the muscle, which is what determines whether repair is viable.

What can be done, and in what order

Surgery is not the starting point. It is proposed when it beats not operating, and the reasoning is explained.

First option

Treatment without surgery

This is the starting point for partial tears, for long-standing degenerative tears, and whenever strength is preserved. A great many shoulders are resolved here.

When: Partial tear, preserved strength, or a complete tear in someone with low functional demand on the arm.

What it involves
  • Targeted rehabilitation of the deltoid and the scapular stabilisers, which can compensate for much of the torn tendon's function
  • Temporary modification of activity, without immobilising: a shoulder left still stiffens up
  • Ultrasound-guided injection when pain prevents progress with rehabilitation
  • Scheduled pain relief so you can sleep, which is half the problem
If needed

Arthroscopic repair

The tendon is reattached to the bone arthroscopically, through incisions of less than a centimetre. It is day-case surgery or one night's stay.

When: Complete tear with meaningful loss of strength, acute tear after trauma, or pain that does not improve after several months of properly conducted conservative treatment.

What it involves
  • Bone anchors that hold the tendon in its original position
  • Without opening the joint: less post-operative pain and less stiffness than open surgery
  • In massive irreparable tears, reconstruction techniques with a patch or superior capsule, which avoid the need for a replacement
  • Review at 2 and 4 weeks, with the rehabilitation protocol agreed from day one

How long will this take?

These timings are approximate and correspond to an uncomplicated arthroscopic repair. The tendon takes as long as it takes to heal to the bone, and that cannot be rushed: which is why the first weeks are about protection, even though the pain has already improved. Your own case is planned in the consultation.

  1. Protection First 4 weeks

    Sling for most of the day. Passive movement from the outset to avoid stiffness, but without the tendon working. Pain improves well before the repair has healed, and that is exactly the trap of this phase.

  2. Active movement Weeks 4–12

    Sling off. Movement is regained progressively under your own power, at first without weight. Driving and desk work usually return between weeks six and eight.

  3. Strength Weeks 12–24

    Progressive strengthening. Return to manual work and to most sports without contact or overhead movement.

  4. Full recovery Weeks 24–48

    Overhead sporting movement and heavy lifting. Strength keeps improving up to the one-year mark.

Frequently asked questions

Does a rotator cuff tear heal on its own?

A torn tendon does not reattach itself: a complete tear does not heal spontaneously. What does often happen is that the pain goes and function largely returns, because the surrounding muscles compensate. This is why many tears do not need surgery: the aim of treatment is a shoulder that works and does not hurt, not a perfect MRI.

If I do not have surgery, will the tear get bigger?

Some tears enlarge over time and others stay stable for years. Those at greatest risk of progressing are tears in younger patients, traumatic tears, and tears that are already large. It is one of the factors weighed in the decision, and the reason a young person with an acute tear tends to be repaired sooner.

How long will I be in a sling?

Around four weeks for most of the day after an arthroscopic repair, although passive movement starts straight away so the shoulder does not stiffen. The exact period depends on the size of the tear and the quality of the repaired tendon.

Will I be able to play sport again?

In most cases, yes. Sports without overhead movement resume at around six months, and those that do involve it (tennis, swimming, padel, throwing) at around nine to twelve months. The return is planned progressively, not all at once.

Is it the same as tendinitis?

No. In tendinitis the tendon is inflamed or degenerate but intact; in a tear there is a genuine break in its fibres. They can look very similar in terms of symptoms, which is why the diagnosis is not made on examination alone: ultrasound or MRI is what tells one from the other.

Is the surgery very painful?

The first few days are uncomfortable, particularly at night. Pain relief is prescribed and often a nerve block is given during the operation covering the first hours, which are the worst. Being arthroscopic, post-operative pain is considerably less than with open surgery.

Often confused with

An assessment with Dr. Aveledo

Consultations at Hospital Quirónsalud Tenerife, Vida Puerto de la Cruz and Quirónsalud Santa Cruz.

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