Does a rotator cuff tear always need surgery?

What is the rotator cuff?

The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint. They keep the ball of the upper arm centred in the shallow socket and help lift and rotate the arm. The supraspinatus tendon, at the top of the shoulder, is the one most often affected.

A tear can be partial, affecting part of the tendon's thickness, or full-thickness, going all the way through. Tears can result from a sudden injury such as a fall, or develop gradually as tendons change with age.

Is a tear on the scan always the cause of pain?

Not necessarily. In a Finnish population study of 602 adults aged 41 to 76 who had MRI of both shoulders between 2023 and 2024, rotator cuff abnormalities were found in 98.7 per cent of participants 1. Abnormalities were present in 96 per cent of shoulders without symptoms and 98 per cent of shoulders with symptoms 1.

This means a scan finding needs to be interpreted together with symptoms and examination. A tear may be an incidental finding rather than the reason for pain, which helps explain why many people improve without having the tear repaired.

How does physiotherapy compare with surgery?

A randomised trial compared three treatments for non-traumatic supraspinatus tears in 180 shoulders of people over 55: physiotherapy alone, a procedure to shave bone under the shoulder tip plus physiotherapy, and tendon repair plus the same procedure and physiotherapy 2. At one year, the Constant shoulder scores were 74.1, 77.2 and 77.9 respectively, with no statistically significant difference between groups 2.

The authors concluded that conservative treatment should be considered first for this type of tear. Longer-term follow-up and individual factors, such as tear size, tendon quality and activity demands, still influence decisions.

What does rotator cuff rehabilitation involve?

Rehabilitation usually starts with advice on managing pain and adjusting activities that aggravate the shoulder, followed by progressive exercises. These strengthen the remaining rotator cuff and the muscles that control the shoulder blade, improve range of movement and build the ability to lift and reach overhead.

Exercises progress gradually over several weeks to months. Some discomfort during exercise is acceptable if it settles afterwards. Pain relief such as simple analgesics or, in some cases, an injection may help people take part in exercise.

When is surgery more likely to be recommended?

Surgery is more often considered for acute tears caused by a clear injury, particularly with sudden loss of strength, for younger and physically active people, for large tears where the tendon may retract and become harder to repair over time, and for people whose pain and function do not improve after a good course of rehabilitation.

An orthopaedic surgeon weighs tear size, muscle quality on imaging, age, general health and the person's goals when discussing repair.

What does recovery look like with physiotherapy alone?

With a structured programme, many people notice gradual improvements in pain and function over several weeks. Early stages focus on reducing pain and improving movement, followed by progressive strengthening of the rotator cuff and shoulder blade muscles.

Exercises are usually done at home several times a week, with periodic review by a physiotherapist. If pain and weakness remain significant after a good course of rehabilitation, surgical opinion can be sought.

What are the warning signs that need quick assessment?

Sudden inability to lift the arm after a fall or a heavy lift, a shoulder that looks out of place, severe pain with fever or redness, or numbness and weakness spreading down the arm should be assessed promptly.

Early assessment matters for acute traumatic tears because delaying repair of some large tears can make surgery less successful.

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