Rotator Cuff Tendinopathy and Tears

Symptoms

• Pain on the outside of the upper arm, especially when lifting the arm overhead
• Pain at night or when lying on the shoulder
• Pain reaching behind the back or into a back pocket
• Weakness lifting the arm (more suggestive of a tear)

Causes and who gets it

Overhead sports (swimming, volleyball, tennis, throwing, pickleball overheads) and overhead work overload the cuff. Tendon degeneration increases with age, and many people over 50 have tears on imaging without symptoms. A fall on an outstretched arm can cause an acute tear.

How it is diagnosed

A clinician checks motion, strength, and pain with specific tests. X-ray can show bone spurs or arthritis. Ultrasound or MRI shows tendinopathy and tears when the result will change treatment.

Treatment

• Modify overhead activity for a period, without complete rest
• Physical therapy focused on rotator cuff and shoulder blade strength is the core treatment for tendinopathy
• A corticosteroid injection may help calm pain enough to do rehab
• Many degenerative tears do well with rehabilitation
• Acute traumatic tears with weakness, especially in younger active people, are often referred for early surgical opinion

Recovery time

Tendinopathy often improves over 6 to 12 weeks of consistent rehab, sometimes longer. Recovery after rotator cuff repair usually takes 6 to 12 months.

When to see a doctor

• Sudden weakness lifting the arm after a fall or injury
• You cannot lift the arm at all
• A shoulder that looks out of place
• Night pain or weakness that is not improving after several weeks
• Pain with fever, or a red, hot shoulder

Clinical pearls

• Painful arc, Hawkins, and Neer suggest subacromial pain; empty can or full can and drop arm help evaluate supraspinatus
• External rotation lag sign and hornblower sign suggest posterosuperior cuff tears; lift-off and belly press assess subscapularis
• An acute traumatic full-thickness tear with weakness in an active patient merits prompt imaging and surgical referral
• Rule out cervical radiculopathy, adhesive capsulitis (loss of passive external rotation), and glenohumeral arthritis
• Exercise therapy performs as well as subacromial decompression surgery for subacromial pain in multiple trials