Rotator Cuff Injuries

The rotator cuff is a group of four muscles and their tendons that work together to help move and stabilise the shoulder. Because these tendons are involved in many everyday movements — from reaching overhead and lifting objects to exercise and sport — they can be affected by a range of injuries and conditions.

Rotator cuff problems can develop gradually through changes in the tendon over time, or occur more suddenly following an injury. Symptoms can include shoulder pain, weakness, reduced movement and difficulty with activities such as reaching overhead, lifting, dressing or sleeping on the affected side.

In this guide, we’ll look at the different types of rotator cuff injuries, why they occur, common symptoms, how they are assessed and the treatment and rehabilitation options available.

What Is the Rotator Cuff?

Rotator cuff anatomy showing the supraspinatus, infraspinatus, teres minor and subscapularis muscles and tendons

The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint. Together, they help keep the head of the humerus (upper arm bone) centred within the shallow socket of the shoulder while also contributing to movement of the arm.

The four rotator cuff muscles are the supraspinatus, infraspinatus, teres minor and subscapularis. Each has a slightly different role, but together they are particularly important for controlling rotation of the shoulder and providing stability as the arm moves.

The tendons of these muscles attach around the head of the humerus, forming a cuff-like structure — which is where the name “rotator cuff” comes from. These tendons can be affected by age-related changes, repetitive loading or injury, leading to conditions ranging from tendinopathy to partial or full-thickness tears.

Types of Rotator Cuff Injuries

Rotator cuff injuries can affect the muscles themselves, but more commonly involve the tendons that attach the rotator cuff muscles to the humerus. These conditions exist on a spectrum, from changes within the tendon to partial or complete tears.

Importantly, changes seen on imaging do not always correspond directly with pain. Rotator cuff tendon changes and even tears can be present in people who have no shoulder symptoms, particularly as we get older. For this reason, imaging findings need to be considered alongside a person’s symptoms, strength, movement and clinical assessment.

Rotator Cuff Tendinopathy

Rotator cuff tendinopathy describes changes within one or more of the rotator cuff tendons. Symptoms commonly develop gradually and may include pain with lifting, reaching overhead or repeated use of the arm.

Partial-Thickness Rotator Cuff Tear

A partial-thickness tear affects only part of the thickness of the tendon. Some tendon fibres are disrupted, but the tendon has not torn completely through.

Full-Thickness Rotator Cuff Tear

A full-thickness tear extends through the entire thickness of the tendon. These tears vary considerably in size and may develop gradually over time or occur more suddenly following an injury.

What Causes Rotator Cuff Injuries?

Rotator cuff injuries do not always have a single cause. In many people, changes develop gradually as the tendons are repeatedly loaded over time. In others, symptoms may begin more suddenly following an injury, such as a fall, lifting a heavy object or a forceful movement of the arm.

Age-related changes within the rotator cuff tendons are also common. As we get older, the structure and capacity of the tendons can change, which may make them more susceptible to irritation or tearing. However, these changes do not necessarily cause pain, and rotator cuff tears can also be found in people without shoulder symptoms.

Factors that may contribute to rotator cuff problems include repetitive overhead activity, sudden increases in training or workload, heavy or unfamiliar lifting, previous shoulder injury, and age-related tendon changes. Sports and occupations involving frequent overhead movement can place greater demands on the rotator cuff, but this does not mean these activities should necessarily be avoided.

The important point is that rotator cuff pain is often multifactorial. Assessment therefore considers not only the tendon itself, but also a person’s symptoms, strength, shoulder movement, activity levels and the demands they place on their shoulder.

Symptoms of a Rotator Cuff Injury

Symptoms of a rotator cuff injury can vary considerably depending on the tendon involved, the nature of the injury and the individual. Some people experience significant pain and loss of function, while others may have structural changes or even a tear without noticeable symptoms.

Common symptoms can include pain around the shoulder or upper arm, particularly when lifting or reaching overhead. Pain may also be felt when reaching behind the back, lifting objects away from the body or performing repeated movements of the arm.

Some people notice weakness or reduced strength, especially when lifting the arm or rotating the shoulder. Everyday activities such as putting on a shirt, reaching into a cupboard, carrying shopping or participating in sport may become more difficult.

Night pain is also common. Lying on the affected shoulder can be uncomfortable, and shoulder pain may sometimes disturb sleep.

Other symptoms may include:

Pain with lifting or reaching overhead
Pain around the outer shoulder or upper arm
Weakness when lifting or rotating the arm
Reduced or painful shoulder movement
Difficulty reaching behind the back
Pain when lying on the affected side
Difficulty with work, exercise or sporting activities

Importantly, the severity of symptoms does not always reflect the extent of changes seen on imaging. Rotator cuff abnormalities are relatively common in people without shoulder pain, particularly with increasing age. For this reason, symptoms are best interpreted alongside strength, movement, function and clinical assessment, rather than relying on an ultrasound or MRI finding alone.

How Are Rotator Cuff Injuries Diagnosed

Assessment of a rotator cuff injury usually begins with a discussion about how the symptoms started, which movements or activities aggravate the shoulder, and how the problem is affecting everyday activities, work, exercise or sport.

A physical examination may assess shoulder movement, strength and function. Specific movements and resisted tests can help determine which structures may be contributing to the symptoms, although no single clinical test can diagnose a rotator cuff injury in isolation.

Imaging is not always required. In many cases, the combination of a person’s symptoms and clinical examination provides enough information to begin appropriate management.

When imaging is indicated, ultrasound or MRI may be used to assess the rotator cuff tendons and identify changes such as tendinopathy or partial- or full-thickness tears. X-rays do not show the rotator cuff tendons directly but may sometimes be useful for assessing the bones and joints of the shoulder.

Importantly, imaging findings need to be interpreted in context. Rotator cuff tendon changes and tears become increasingly common with age and can be present in people who have no shoulder pain. A scan result therefore does not necessarily explain a person’s symptoms on its own.

Treatment for Rotator Cuff Injuries

Treatment for a rotator cuff injury depends on the type of injury, the severity of symptoms and how the shoulder is affecting a person’s everyday activities. For many rotator cuff problems, particularly those that develop gradually, treatment begins with a non-surgical approach.

In the early stages, this may involve temporarily modifying activities that significantly aggravate the shoulder while continuing to use the arm within comfortable limits. Complete rest is generally not necessary, and maintaining appropriate movement can help prevent unnecessary loss of strength and function.

Exercise and rehabilitation are important components of treatment. A rehabilitation program may include exercises to improve shoulder movement, gradually strengthen the rotator cuff and surrounding muscles, and increase the shoulder’s ability to tolerate the demands of work, exercise and sport.

Pain-relieving medication or anti-inflammatory medication may sometimes be considered in consultation with a GP or pharmacist. In some circumstances, corticosteroid injections may also be considered for short-term symptom relief, although these do not address the underlying capacity of the shoulder and are not appropriate for everyone.

Most importantly, treatment should be guided by symptoms and function rather than imaging findings alone. Even when a scan identifies a rotator cuff tear, surgery is not automatically required. Many people with rotator cuff-related shoulder pain can improve with appropriate education, activity modification and progressive rehabilitation.

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