Overview
The rotator cuff is four tendons — supraspinatus, infraspinatus, subscapularis and teres minor — that wrap the ball of the shoulder and hold it centered in the socket while the larger muscles move the arm. A tear is a split or detachment of one of those tendons, most often the supraspinatus, where it attaches to the top of the humerus. Tears are graded by depth (partial-thickness or full-thickness) and by size, and that grading drives almost every treatment decision that follows.
Two patients with the same MRI can need very different care. A 28-year-old pitcher with a partial articular-sided tear and a 62-year-old tennis player with a full-thickness tear that has been slowly enlarging for years are both “rotator cuff tears,” and only one of them is likely to need surgery soon. The sections below cover how Dr. O'Donnell tells those situations apart and what each one means for returning to the sport or overhead work that caused the problem.
Common Symptoms
- Pain on the outside of the upper arm, often felt a few inches below the shoulder rather than in the joint itself
- Night pain, especially lying on the affected side — the symptom that most reliably brings patients in
- Weakness lifting the arm to the side or turning it outward; difficulty with overhead reaching, serving, throwing, or putting on a jacket
- A catching or crackling sensation with overhead motion
- With a large acute tear, sudden inability to lift the arm after a fall or a heavy pull
Pain alone is a poor guide to tear size. Many people with painful shoulders have an intact cuff and an inflamed bursa (see shoulder impingement & bursitis), while some large chronic tears cause surprisingly little pain and present only as weakness. Stiffness that limits passive motion points more toward frozen shoulder or arthritis than toward the cuff.
Causes & Risk Factors
Rotator cuff tears fall into two groups. Acute tears follow a specific event — a fall onto an outstretched arm, a hard landing on the shoulder in skiing or cycling, catching a heavy object, or a shoulder dislocation in a patient over 40. Degenerative tears develop over years as the tendon's blood supply and collagen quality decline, and they become common after 50 whether or not the person is active. Repetitive overhead work in sport or on the job (tennis, swimming, baseball, painting, carpentry) accelerates the process, as does a hooked acromion that rubs the tendon from above. Smoking and a family history of cuff disease are independent risk factors.
How It Is Diagnosed
The diagnosis starts with the exam. Dr. O'Donnell tests each tendon individually: the empty-can and drop-arm tests for supraspinatus, resisted external rotation at the side for infraspinatus, and the belly-press and lift-off tests for subscapularis. Weakness on a specific test localizes the tear before any imaging is ordered; pain without weakness usually means the tendon is intact.
X-rays are taken at the first visit. They do not show the tendon, but they show what surrounds it — acromial shape, bone spurs, calcific deposits, arthritis, and in long-standing large tears an upward migration of the humeral head that changes the surgical plan. MRI is the definitive test and is ordered when the exam suggests a tear, when symptoms have not settled after six to eight weeks of appropriate treatment, or when an acute injury has caused sudden weakness. It shows tear thickness, size, which tendons are involved, how far the tendon has retracted, and the condition of the muscle behind it. Out-of-town patients can upload existing MRI images through mymedicalimages.com for review before traveling.
Treatment Options
Non-operative care
Most partial-thickness tears and many small degenerative full-thickness tears are treated without surgery, and the results are good. The program has three parts: a short period of activity modification to reduce inflammation, a physical therapy course focused on restoring motion and then strengthening the intact cuff and the muscles that control the shoulder blade, and, when pain is blocking progress, a corticosteroid injection into the subacromial space. Dr. O'Donnell places injections under ultrasound guidance so the medication reaches the bursa. Most patients treated this way feel meaningfully better within 6 to 12 weeks.
When surgery is recommended
Surgery is advised when the tear is acute and full-thickness in an active patient, when a full-thickness tear is causing weakness that has not responded to therapy, or when serial imaging shows a tear enlarging. Tendon that has retracted and muscle that has turned to fat do not recover once they are advanced, which is why a full-thickness tear in a patient under 65 is usually repaired sooner rather than later. The procedure is an arthroscopic rotator cuff repair: the torn edge is mobilized and anchored back to bone through small portals, and the acromion is smoothed if it is contributing. Selected tears are augmented with a biologic patch or a marrow-stimulation technique to improve healing. For massive, irreparable tears with arthritis, a reverse shoulder replacement restores overhead function in a way that repair cannot.
Recovery & What to Expect
After repair the tendon has to heal to bone before it can be loaded, and that healing time sets the timeline. Dr. O'Donnell's rehabilitation protocol is criteria-based — each phase is entered when the previous goals are met, not simply on elapsed time.
| Phase | Timing | What happens |
|---|---|---|
| Maximum protection | Weeks 0–6 | Sling with an abduction pillow at all times except hygiene and exercises. Passive motion only, with a goal of about 120° of forward elevation by week 6. No lifting, pushing or pulling. |
| Active motion | Weeks 6–12 | Sling weaned. Active-assisted then active motion in all planes; scapular strengthening; light cuff isometrics late in the phase. Lifting limited to 1–2 lb. |
| Strengthening | Weeks 12–18 | Resistance-band external and internal rotation, deltoid and periscapular strengthening, endurance work. Advance when strength reaches 70–80% of the other side. |
| Return to activity | Months 4–6 | Plyometrics, sport- or job-specific program, interval throwing or overhead program where indicated. Return to sport is typically around 6 months, surgeon-cleared. |
Desk work is usually possible within one to two weeks, driving once the sling is off and motion is comfortable (about 6 weeks), and heavy manual work at 4 to 6 months. Larger tears, revision repairs and poor tissue quality are progressed more slowly. The full protocol is available as a PDF: Rotator Cuff Repair rehabilitation protocol. Patients treated non-operatively follow the rotator cuff tendinitis protocol.
Frequently Asked Questions
Can a rotator cuff tear heal on its own?
A torn tendon does not reattach to bone by itself, so a full-thickness tear will not close. What can happen is that the shoulder becomes pain-free and strong enough for everyday use through therapy, because the remaining cuff and the shoulder-blade muscles compensate. Partial tears can stabilize and stop causing symptoms. Whether a tear that stays open matters depends on your age, activity and tear size, which is why small degenerative tears in older patients are often watched, while full-thickness tears in active patients under 65 are usually repaired.
How do I know if my shoulder pain is a rotator cuff tear or just bursitis?
Bursitis and tendinitis cause pain with overhead reaching but the arm stays strong when tested. A tear produces weakness on specific tests — for example, difficulty holding the arm out to the side against light resistance. Night pain occurs with both. The exam usually separates them; an MRI is ordered when the exam suggests a tear or when pain has not improved after six to eight weeks of treatment.
Do I need an MRI before my first appointment?
No. Dr. O'Donnell examines the shoulder and takes X-rays at the first visit, and orders an MRI when the exam calls for it. If you already have an MRI, bring the disc or upload the images through mymedicalimages.com so they can be reviewed before you arrive.
How long does rotator cuff surgery take, and will I stay overnight?
Arthroscopic repair takes roughly one to two hours depending on tear size. It is performed as an outpatient procedure at Bayside Surgery Center in Coconut Grove under a nerve block plus general anesthesia, and patients go home the same day with the arm in a sling.
How long will I be in a sling?
Four to six weeks, including while sleeping. The sling protects the repair while the tendon heals to bone. Passive motion exercises begin in the first week so the shoulder does not stiffen.
When can I drive, work and play sport again after repair?
Most patients return to desk work within one to two weeks and drive once the sling is discontinued at about six weeks. Strengthening starts at three months. Return to overhead sport, tennis, golf or heavy manual work is typically around six months, once strength and motion are symmetric and Dr. O'Donnell has cleared you.
This page is for general education and is not a substitute for a medical evaluation. Treatment recommendations depend on your individual diagnosis and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.