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My second finding for technology was Dynamometry. Dynamometers are used by physicians, physical therapists, and athletic trainers to figure out the amount of muscle force produced by specific muscle groups in order to guide strengthening programs for injury prevention and rehabilitation. There are two types:

1. Hand-held: Hand-held dynamometry (HHD) is where the tester wears a hand-held force sensor as the patient exerts a force against it, so they can measure the force production. This is helpful in the sports medicine and injury prevention field because it is portable and easy to use. From using HHD, studies have shown that professional baseball pitchers who have a decreased pre-season external rotation (ER) strength are associated with in-season throwing injuries requiring surgical intervention.

2. Fixed-frame: Fixed frame dynamometry is used as an alternative to HHD to expand to larger, lower body muscle groups. The patient applies force to a fixed frame device to record force output in real time under a variety of different conditions.

The HHD would be more valuable for a rotator cuff tear since the fixed-frame is used for larger muscle groups. Using dynamometer technology can help to predict how much force the shoulder is exerting to provide information that an athlete can use to prevent a rotator cuff injury.

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Technology Used in the Prevention and Treatment of Shoulder and Elbow Injuries in the Overhead Athlete

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To review the current technology available for the prevention and treatment of shoulder and elbow injuries in the overhead athlete. Shoulder and elbow injuries are common in recreational and high-level overhead athletes. Injury prevention in these…

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I chose to explore the technology that can aid in the treatment of rotator cuff injuries. My first finding was kinesiology tape, which is used to help manage pain and dysfunction in athletes. Some benefits are increased blood flow to the affected area, improved mechanical stabilization, and improved proprioception. In patients with subacromial impingement syndrome, kinesiotaping of the scapula seems to help with scapular motion and muscle performance, especially in baseball players, where this injury is common. Subacromial impingement can actually lead to a rotator cuff tear, so reducing that risk can also reduce the risk of a full tear.

# data[].attributes.attachment_link.title
Technology Used in the Prevention and Treatment of Shoulder and Elbow Injuries in the Overhead Athlete

# data[].attributes.attachment_link.description
To review the current technology available for the prevention and treatment of shoulder and elbow injuries in the overhead athlete. Shoulder and elbow injuries are common in recreational and high-level overhead athletes. Injury prevention in these…

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Tele-rehabilitation for Rotator Cuff Injuries 

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Tele-rehabilitation for Rotator Cuff Injuries 

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To evaluate the effectiveness of virtual reality-based rehabilitation compared to conventional rehabilitation methods in improving shoulder functions, range of motion (ROM), strength, and pain relief in patients recovering from rotator cuff repair. To assess the impact of virtual reality–based rehabilitation on rehabilitation adherence and patient satisfaction in postoperative rotator cuff repair recovery.

Methods

A systematic literature search of PubMed, Cochrane Library, Dimensions AI, and Google Scholar was performed from inception to February 14, 2025. Studies involving patients who underwent rotator cuff repair and comparing virtual reality (VR)-based rehabilitation with standard physical therapy were included. Data were extracted and synthesized. Meta-analysis was conducted for outcomes reported by multiple studies, and risk of bias was assessed with the Cochrane Risk of Bias 2.0 tool.

Results

Of 599 screened records, 6 studies (n ≈ 332 patients) met the inclusion criteria. There was no statistically significant difference between VR-based and conventional rehabilitation in reducing perceived pain and improving patient-reported functional outcomes. Importantly, VR-based therapy led to significantly greater improvement in shoulder abduction ROM than conventional rehabilitation. However, gains in shoulder flexion and external rotation were not significantly different between groups. Patient adherence and satisfaction varied with rehabilitation modality: home-based digital programs tended to improve adherence, while satisfaction depended on individual preferences for supervision.

Conclusion

VR-based rehabilitation is a feasible alternative or adjunct to traditional physiotherapy after rotator cuff repair. It yields postoperative outcomes (pain relief, functional improvement, and strength recovery) comparable to standard rehabilitation, with a clear advantage in enhancing shoulder abduction ROM. Digital rehabilitation may improve patient compliance through greater engagement and accessibility, although integration of periodic clinician interaction may be necessary to maximize patient satisfaction. These findings support incorporating digital health technology into postoperative shoulder rehab protocols, tailored to individual patient needs.

Alhossan, A. (n.d.). Https://www.sciencedirect.com/science/article/abs/pii/S1047847720300046?via=ihub. https://www.med.upenn.edu/pmi/events/https-www-sciencedirect-com-science-article-abs-pii-s1047847720300046-via-3dihub

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Rotator cuff tears are a common cause of shoulder pain, especially among seniors. Aging, combined with the natural wear and tear of shoulder muscles and tendons, causes many seniors to experience discomfort and limited mobility over time. But the good news is there are various treatment options available to address the condition effectively.

Here, we explore the causes, symptoms, and treatment options for rotator cuff tears in seniors, including how expert care can help improve outcomes and restore mobility.

What Causes a Rotator Cuff Tear in Seniors?

The following factors often contribute to the condition in seniors:

Degeneration and Weakened Tendons: Reduced blood supply with age weakens tendons, reducing the body’s ability to repair wear and tear.

Repetitive Overuse: Overhead motions from activities like painting, construction work, or even certain sports can stress the tendons over time.

Bone Spurs: Bone growths in the shoulder can create friction and damage the tendons.

Sudden trauma, such as a fall, can also result in rotator cuff injuries, though this is less common in seniors.

Symptoms of Rotator Cuff Tears

Rotator cuff injuries can develop gradually or result suddenly from a traumatic injury. Not all rotator cuff tears cause obvious symptoms, but you might experience a deep, dull ache or a sharp, stabbing pain in your shoulder.

Common symptoms of a rotator cuff tear include:

Persistent pain in the front or side of the shoulder

Pain, weakness, or difficulty rotating, raising, or lowering the arm

Pain increasing during overhead movements or while resting

Weakness or difficulty lifting items

A crackling or popping sound/sensation during shoulder movement

If left untreated, rotator cuff tears can worsen, so an accurate diagnosis and timely intervention are crucial.

How Rotator Cuff Tears Are Diagnosed

A healthcare provider will evaluate your symptoms and perform a physical examination to assess the shoulder’s mobility and strength. Other methods may be used to diagnose the injury, such as X-ray, MRI, and ultrasound.

Early diagnosis allows you to explore both surgical and non-surgical treatments and choose what works best for your needs.

Non-Surgical Rotator Cuff Tear Treatments for Seniors

Non-surgical approaches are often the first line of treatment, especially for mild-to-moderate tears. Although rotator cuff tears do not heal on their own without surgery, these non-surgical treatments for rotator cuff injuries can alleviate pain and improve shoulder function without requiring invasive procedures.

Rest and Activity Modification

Limiting shoulder movement, especially avoiding repetitive overhead activity, gives the shoulder a chance to heal. A shoulder sling may also be recommended to reduce strain.

Cold Therapy

Applying ice packs to the affected area can reduce inflammation and numb localized pain.

Physical Therapy

Strengthening the shoulder muscles can improve functionality and decrease pain. A trained physical therapist will guide you through stretches and strengthening exercises to enhance shoulder function, improve mobility, and prevent further damage.

Medication for Pain Relief

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can help minimize swelling and discomfort. For chronic or severe pain, corticosteroid injections may be administered to provide temporary relief.

Platelet-Rich Plasma (PRP) Therapy

PRP therapy involves injecting a patient’s own plasma, enriched with platelets, to promote healing and reduce swelling in the injured area. Commonly used in sports medicine, it helps treat various conditions, including tendon injuries, by accelerating recovery naturally and safely.

Non-surgical methods can successfully manage many cases, but it may take up to a year for the condition to improve. However, for those who do not see improvement may require surgical treatment.

When is Surgery Necessary?

Surgical treatment may become necessary when conservative therapies fail to improve symptoms or in the case of severe tears. Indications for surgery include considerable pain, poor arm mobility, or injuries that impact daily life or work. Many seniors opt for surgical repair to regain strength and functionality.

Surgical Treatment for Rotator Cuff Tears in Elderly Patients

There are a range of surgical procedures to treat rotator cuff injuries. Your surgeon will discuss the best option for you based on the severity of your injury, symptoms, lifestyle, and overall health. Options include:

Arthroscopic Surgery: A minimally invasive procedure in which a tiny camera and surgical tools are used to repair damaged tissue or remove bone spurs through small incisions.

Mini-Open Surgery: A hybrid approach that combines arthroscopy for joint evaluation with open techniques for tendon repair.

Open Surgical Repair: Traditional surgery used for large or complicated tears, involving direct access to the shoulder through a larger incision.

Nwachukwu, J. (2025, March 21). Understanding rotator cuff tear treatments for seniors. Personalized Orthopedics of the Palm Beaches. https://www.popb.md/2025/03/28/understanding-rotator-cuff-tear-treatments-for-seniors/

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 Special Populations, Technology and Public Health #2

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 Special Populations, Technology and Public Health #2

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Over recent years, many technological advancements have been made in rotator cuff surgeries to make them less invasive and promote better recovery for those who undergo them. One advancement revolves around biological augmentation. Platelet-rich plasma cells and stem cells are injected to enhance the healing environment for rotator cuff repairs. This can promote tissue regeneration and tissue healing, while also showing signs that they can help prevent potential future re-tears. Like many other surgeries now, they are using the assistance of robots to help with precision, and rotator cuff surgeries are no different. Robotic-assisted surgery offers more accuracy to the surgeons when dealing with complex tears, and can help the surgeons avoid critical structures in the shoulder where the tissues may be undamaged. This may improve the outcome of complex tears, and with fewer unnecessary movements being done, shoulder recovery is much more manageable and potentially quicker.

The Latest Trends in Rotator Cuff Surgery: Colorado Sports Medicine & Orthopaedics: Orthopaedics. Cosportsmedicine.com. Published 2025. https://www.cosportsmedicine.com/blog/the-latest-trends-in-rotator-cuff-surgery/?bp=45335

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Special Populations, Technology and Public Health #1

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Special Populations, Technology and Public Health #1

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A major population of people who suffer from rotator cuff injury is athletes. Sports involving overhead movements, such as basketball, football, and volleyball, can all cause some form of injury. Weightlifting can also cause a sudden injury, as well as things like falls, collisions, or direct blows. Although these injuries are quick to be noticed, they are not the most common type of rotator cuff injury. Degenerative rotator cuff tears are by far more common, and they are seen in another population, which is those over 60. A major reason for rotator cuff injury is a lack of blood supply to the muscles and tendons of the shoulder. As you age, the blood supply to the rotator cuff lessens, thus making it harder to recover from a light tear. Degenerative rotator cuff tears happen over time, so they're harder to detect when it is a slight tear, hence why they appear more often, and typically over a long period of time.

Wheeler T. What Is a Rotator Cuff Tear? WebMD. Published August 28, 2022. https://www.webmd.com/pain-management/rotator-cuff-tear

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Platelet-Rich Plasma injections (PRP) are a minimally invasive treatment for musculoskeletal injuries that are a fantastic option for patients who have chronic inflammation and patients who are post surgery. PRP injections take the patients own blood, use a centrifuge to extract the platelets and inject it into the injured site. This has been proven to stimulate healing properties by injecting a concentrated source of the patients own growth factors, it promotes angiogenesis which creates new blood vessel formations, allowing inflammation to decrease thus promoting healing. This has immense relevance to technological health, because it represents a shift and understanding towards regenerative medicine.

Citation:

The Clinical Efficacy of Platelet-Rich Plasma Injection Therapy versus Different Control Groups for Chronic Low Back Pain: A Network Meta-Analysis of Randomized Controlled Trials. Journal of Pain Research. 2024;Volume 17:1077-1089. Accessed: 21 November 2025

doi:https://doi.org/10.2147/jpr.s444189

# data[].attributes.attachment_link.title
The Clinical Efficacy of Platelet-Rich Plasma Injection Therapy versus Different Control Groups for Chronic Low Back Pain: A Network Meta-Analysis of Randomized Controlled Trials

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Low back pain is one of the main causes of disability in the world. Although regenerative medicine may represent breakthroughs in the management of low back pain, its use remains controversial. Therefore, we conducted a meta-analysis to evaluate the…

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People who have jobs that require repetitive overhead lifting have a significantly higher chance of developing a rotator cuff injury. This is due to repetitive micro and macro trauma to the rotator cuff, while not allowing proper time to heal. Continuous and cumulative micro-traumas to a rotator cuff can result in chronic inflammation and tendinopathy. Lifting objects repeatedly overhead impinges (compresses) the supraspinatus tendon, which is what causes the chronic inflammation, and tendinosis.

This is highly relevant to public health, as it highlights the risks associated with continuous overhead lifting and hopefully promotes safety measures for employees to be implemented.

Citation:

Work-Related Risk Factors for Rotator Cuff Syndrome in a Prospective Study of Manufacturing and Healthcare Workers. Human Factors: The Journal of the Human Factors and Ergonomics Society. Published online June 20, 202, Accessed November 20, 2025. https://doi.org/10.1177/00187208211022122

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. Author manuscript; available in PMC: 2024 May 1.

Abstract

Objective

This prospective study assessed the risk of developing rotator cuff syndrome (RCS) with separate or specific combinations of biomechanical exposures measures, controlling for individual confounders.

Background

Compared to other musculoskeletal disorders, rates of work-related shoulder musculoskeletal disorders have been declining more slowly.

Method

We conducted up to two years of individual, annual assessments of covariates, exposures, and health outcomes for 393 U.S. manufacturing and healthcare workers without RCS at baseline. Task-level biomechanical exposures assessed exposure to forceful exertions (level, exertion rates, duty cycles), vibration, and upper arm postures (flexion, abduction). Hazard ratios (HR) were calculated with Cox proportional hazard models.

Results

We observed 39 incident RCS cases in 694 person-years (incidence rate = 5.62 per 100 person-years). Adjusting for confounders, we found increased risk of incident RCS associated with forceful hand exertions per minute for three upper arm posture tertiles: flexion ≥ 45° (≥ 28.2%-time, HR = 1.11, CI [1.01, 1.22]), abduction ≥ 30° (11.9-21.2%-time, HR = 1.18, CI [1.04, 1.34]), and abduction > 60° (≥ 4.8%-time, HR = 1.16, CI [1.04, 1.29]). We failed to observe statistically significant effects for other interactions or any separate measures of biomechanical exposure.

Conclusion

This study highlights the importance of assessing combinations of exposure to forceful repetition and upper arm elevation when developing interventions for preventing RCS.

Application

Based on these results, interventions that reduce exposure to forceful repetition (i.e., lower force levels and/or slower exertion rates) may reduce the risk of RCS, especially when upper arm elevation cannot be avoided.

Keywords: shoulder pain, ergonomics, occupational diseases, musculoskeletal diseases, rotator cuff tendinopathy, rotator cuff syndrome, work-related factors, posture, repetition, incidence

Précis:

We examined associations between biomechanical exposures at work and incident rotator cuff syndrome (RCS). Increased risk of incident RCS was associated with interactions between forceful repetition and upper arm elevation variables. This study highlights the importance of reducing exposure to forceful repetition, especially when upper arm elevation cannot be avoided.

INTRODUCTION

From 1999-2013, in the U.S. State of Washington alone, the total direct cost (medical and indemnity) of lost-time rotator cuff syndrome (RCS) workers' compensation claims was $1.5 billion, representing 8 million lost work days ( Marcum & Adams, 2017). While musculoskeletal disorder (MSD) rates have been declining, rates of RCS and other work-related shoulder MSDs have been declining more slowly ( Bureau of Labor Statistics, 2019; Marcum & Adams, 2017). Although the etiology of work-related RCS is multifactorial, our understanding of what causes RCS is still evolving ( Seitz et al., 2011); it is clear that work-related biomechanical exposures are important risk factors ( Bernard, 1997; Seidler et al., 2020; Seitz et al., 2011; van Der Molen et al., 2017).

One obstacle to reducing the burden of shoulder MSDs is our limited understanding of modifiable, biomechanical risk factors, including combinations of exposure to: upper arm elevation, high repetition, static shoulder postures, forceful exertion, hand-arm vibration. Based on several review articles ( Bernard, 1997; Mayer et al., 2012; Seidler et al., 2020; van Der Molen et al., 2017), there is agreement that risk factors for shoulder MSDs include: 1) upper arm elevation and 2) a combination of exposure to repeated or sustained upper arm elevation and other biomechanical factors (e.g., repetition, force). The evidence is weaker that high repetition or static shoulder postures are independent risk factors ( Bernard, 1997; Mayer et al., 2012). In contrast to other upper extremity MSDs, for shoulder MSDs there is weaker evidence that forceful exertion ( Dalbøge et al., 2018; Mayer et al., 2012; Seidler et al., 2020; Thygesen et al., 2016) is an independent risk factor and little indication that vibration is an independent risk factor. Combinations of biomechanical exposures as risk factors for shoulder MSDs are not well characterized. The Danish job exposure matrix (JEM) "shoulder load" variable is the most commonly reported measure of combined exposure associated with shoulder MSD risk ( Dalbøge et al., 2014, 2018; Svendsen et al., 2013). The Danish JEM shoulder load variable is categorical with three-levels (high, medium, and low) and refers to separate or combined exposures to three measures - forceful exertion rating, upper-arm elevation above 90° (hours/day), and repetitive work (hours/day). Recently, Gallagher and colleagues have proposed that forceful repetition could be an important biomechanical risk factor for any MSD based on their research applying fatigue failure theory to understand cumulative soft tissue damage involved in MSDs ( Gallagher & Schall Jr, 2017; Gallagher et al., 2018). Among fourteen articles included in a 2020 systematic review ( Seidler et al., 2020), two cross-sectional studies ( Frost et al., 2002; Silverstein et al., 2008) and zero longitudinal studies analyzed specific combinations of biomechanical exposures.

More high-quality, longitudinal epidemiology studies of clinically assessed shoulder MSDs designed to detect quantitative exposure-response relationships are still needed ( Bernard, 1997; Mayer et al., 2012). This research project is one of ten high-quality, field-based MSD cohort studies funded by the U.S. National Institute for Occupational Safety and Health (NIOSH) ( Garg & Marrass, 2014) to examine associations between biomechanical work exposures and work-related MSDs. To address methodological limitations of previous epidemiologic MSD studies, the study methods for these cohorts (Upper Limb Musculoskeletal Disorder Consortium) all included: 1) using a prospective study design; 2) using quantitative, task-based exposure measures that included computer-assisted posture analysis; 3) using case definitions based on self-reported symptoms and clinical examinations; and 4) controlling for confounding by personal characteristics, psychosocial exposures, and other work factors. The current study of RCS was conducted to quantify exposure-response relationships between risk of developing RCS when controlling for personal, work environment, and dissimilar biomechanical confounders (different primary domains). Specifically, our aim was to quantify dose-response associations between incident RCS using: 1) separate measures of biomechanical exposure to forceful exertion, repetition, vibration, and upper arm elevation; and 2) specific combinations of those biomechanical exposure variables. We expected that dose-response patterns for the risk of developing RCS would be stronger for combinations of exposures, especially when upper arm elevation was combined with higher exposure to other biomechanical exposure variables.

METHODS

In this study, we analyzed data from the NIOSH cohort study of work-related upper limb MSDs. The analyses presented in this paper are specific to incident RCS. Study cohort and data collection methods for the overall study have been described more fully in prior publications that focused on hand/wrist exposures and carpal tunnel syndrome ( Burt et al., 2011; Burt et al., 2013; Wurzelbacher et al., 2010). We briefly summarized the study population and methods below and provide detailed descriptions of methods specific to studying RCS. This research complied with the American Psychological Association Code of Ethics and was approved by the NIOSH Institutional Review Board. Informed consent was obtained from each participant.

Study participants and procedures

Participants

For this prospective cohort study, shoulder symptom and clinical exam data were available for 485 participants from a cohort of manufacturing (Heavy Duty Truck Manufacturing, Motor Vehicle Gasoline Engine and Engine Parts Manufacturing) and healthcare (General Medical and Surgical Hospital) workers recruited from three research sites. All study participants were full-time workers and had at least three months work experience ( Burt et al., 2011). We excluded participants with missing health outcome variables or who met the case definition criteria for RCS at baseline; participants with missing health outcome follow-up data were lost to follow-up.

Data collection

From 2002-2005, complete, individual on-site assessments were conducted at baseline and annually for up to two years to administer questionnaires, conduct biomechanical exposure assessments, videotape all job tasks, and perform clinical assessments ( Burt et al., 2013). Our investigators used a questionnaire to collect information on personal characteristics, health history, work history, work environment (including psychosocial factors such as job strain) ( Hurrell Jr & McLaney, 1988; Karasek et al., 1998; McNair et al., 1971; Radloff, 1977), physical activities outside of work, and musculoskeletal symptoms (neck, hand, wrist, elbow, shoulder) ( Kuorinka et al., 1987). Trained analysts (e.g., ergonomists, industrial hygienists) conducted biomechanical exposure assessments that included force ratings and determining vibration exposure (yes/no) by job task ( Borg, 1982). Each job task, as defined by Bao and colleagues (2009), was video recorded at 30 frames/s from two angles (17 minutes for single task jobs and 12 minutes per task for multi-task jobs). Usually, the cameras were positioned at right angles to each other to allow clear views of the subject's sagittal and transverse planes. Biomechanical exposures were also reassessed after baseline site visits every six months if an individual participant changed job titles, production lines, or departments ( Burt et al., 2013).

Laboratory exposure analysis

Detailed time study

Repetition rates and duty cycles of total exertion and forceful exertions (grip force ≥ 40N or pinch force ≥ 10N) were extracted by conducting a detailed time study using the Multimedia Video Task Analysis™ system ( Yen & Radwin, 1995), as described by Wurzelbacher et al. (2010).

Posture analyses

The computer-assisted, video-based method we used to conduct upper extremity posture analysis for this study was based on a video frame sampling protocol similar to the one developed by Bao et al. (2006). The methods for selecting random sets of non-overlapping, one-minute video segments are presented in more detail in the online Appendix ( Burt et al., 2011; Burt et al., 2006). First, 75 randomly selected still frames were analyzed for each single task job (fifteen frames from five, non-overlapping, one-minute video segments), while 45 still frames were analyzed from each task for multiple task jobs (fifteen frames from three, non-overlapping, one-minute video segments per task for multiple task jobs) ( Appendix, Supplemental Figure 1). While the number of frames used to characterize each task was shorter for a multiple task job, there were more total frames used to characterize their workday. This aligns with methods used by researchers in a similar prospective cohort study that used individual, task-level exposure assessment methods ( Bao et al., 2007). The sampling strategy was appropriate for this study because 1) the tasks were clearly distinguishable, 2) major tasks tended to differ in exposure, 3) we could accurately estimate task proportions, 4) task transitions were irregular, and 5) task durations were available prior to sampling ( Mathiassen et al., 2003). We analyzed upper arm posture angles for each still frame and each arm using two visual analog scales accompanied by two scales depicting the full range of joint articulation for upper arm-trunk angles in two planes of motion - sagittal (60° extension-180° flexion) and frontal (75° adduction-180° abduction). Two screenshots of the program's interface for rating upper arm flexion/extension and upper arm abduction are presented in Supplemental Figure 2 ( Appendix). Among three analysts who analyzed 315 frames from five tasks, interrater reliability based on Shrout/Fleiss intraclass correlation coefficients (ICC) were good (> 0.70) for all upper arm rating scales (right flexion/extension ICC = 0.84, CI [0.86, 0.81]; left flexion/extension ICC = 0.82, CI [0.84, 0.79]; right abduction ICC = 0.72, CI [0.76, 0.67]; left abduction ICC = 0.74, CI [0.77, 0.70] ( Burt et al., 2006). For each posture variable, we calculated percent time per task based on the proportion of still frames where the posture angle was within a given range (e.g. ≥ 45°). For example, we calculated percent time ≥ 45° flexion by dividing the number of frames where the upper arm was flexed ≥ 45° by total number of sampled frames. Time weighted averages (TWAs) were used to estimate percent time per shift spent in upper arm flexion or abduction, using several sets of overlapping cut-points based on the literature ( Bao et al., 2007; Silverstein et al., 2008).

Job-level exposures

We used three methods to calculate job-level exposures ( Burt et al., 2011; Burt et al., 2013; Wurzelbacher et al., 2010): 1) TWAs of mean values using percent time spent in each task, 2) peak values among all tasks, and 3) a weighted sum of percent time using percent time spent in each task. For several participants with changes in exposure six months between annual visits (years 0.5 or 1.5), the means or maximums of the two previous values were used to calculate lagged exposure values at the next annual visit (e.g., we used the mean of exposure values from year 0 and year 0.5 for mean exposure up to year 1). Study team members who collected and analyzed exposure data were blinded to information collected for the health assessment or determination of outcome status and vice versa.

Outcome

To diagnose work-related RCS (also called rotator cuff tendinosis, tendinopathy, or disease; subacromial pain syndrome), physical therapists conducted clinical examinations of both arms and hands on all participants at baseline with annual follow-up for up to two years. Our case definition for dominant arm RCS case included a combination of 1) shoulder pain during a clinical examination induced by at least one provocative test ( Sluiter et al., 2001)]; and 2) meeting both self-reported shoulder symptom criteria: a) in the past twelve months, they experienced any shoulder symptoms, and b) any shoulder pain in the past seven days ( Supplemental Figure 3). Prevalent cases - met all case criteria at baseline - were excluded (censored) from the analyses for this study. Participants who met only criteria #1 or #2 were included in the study.

Statistical analysis

Univariate and multivariable Cox proportional hazard models were used to analyze the incidence of RCS. The models were stratified within the Cox model by year of follow up (years 1 and 2). Baseline values (year 0) were used for the demographic and psychosocial variables.

Missing exposure variable values were replaced with the first non-missing value from a previous visit. The final exposure variables used in the analysis represent a lag of one year. The final exposure variables were analyzed as continuous and categorical variables (tertiles/thirds). To improve model stability, tertile cut-points were determined using baseline values among cases.

Shoulder pain in the last seven days at baseline was the only demographic, psychosocial, or biomechanical characteristic excluded as a potential confounder because it is on the causal pathway between exposure and RCS. Based on subject matter knowledge, we included all other demographic/psychosocial factors in this study based on their potential to be a confounder between biomechanical exposures and RCS. Likewise, we considered biomechanical exposures with different primary domains could be confounded by other biomechanical exposures. The selection of confounders for the multivariate models began by selecting potential demographic, psychosocial, and exposure variables associated with time to event in univariate models with p < 0.20. A form of backward elimination was used to determine the confounders for each model ( Harris-Adamson et al., 2015). All potential confounders were entered in a model and were retained if their removal resulted in a change of 10% or more in the regression coefficient of the exposure variable of interest. Potential confounders were tested in order from largest to smallest univariate p-value. To avoid overfitting the models for a given exposure variable, exposure variables in the same primary domain (force, repetition, duty cycle, vibration, and posture) were not considered as a confounder. We reduced multivariable model instability attributed to highly skewed distribution of forceful repetition values by using a categorical form of forceful repetition rate (median split). Otherwise, only continuous exposure variables were used in the selection of confounders.

Interactions between the categorical posture variables and continuous, non-posture exposure variables were tested in multivariable models to determine if the effect of a non-posture exposure variable varied by categories of a posture variable. The main effects of one categorical and one continuous variable as well as their interaction were included in a model. We used the final multivariable models for the non-posture exposure variables to analyze interactions.

We used SAS® (Release 9.4, SAS Institute, Inc., Cary, North Carolina) to conduct all calculations. The assumptions of the Cox proportional hazard model were tested in univariate models.

RESULTS

Cohort description

We excluded 34 participants from the longitudinal analyses who met the case definition criteria for RCS at baseline, resulting in 451 eligible cohort participants. We lost 58 participants due to lack of health outcome follow-up data, leaving 393 workers in the cohort ( Table 1, Supplemental Figure 4). We observed 39 incident cases of RCS in 694 person-years (incidence rate = 5.62 per 100 person-years, 95% CI 4.12, 7.69). Baseline demographic, medical history, and psychosocial characteristics are presented by case status in Table 1 and descriptive results for baseline biomechanical exposures are presented in Table 2. Compared to non-cases, incident cases were older (difference in means = 5.3 years, CI [1.8, 8.8]), were more likely to have a BMI ≥ 30 kg/m2 (X ² = 5.1, p = .02), had a higher BMI (difference in means = 2.3kg/m2, CI [0.2, 4.4]), and fewer had completed high school (X ² = 6.0, p = .01). Mean years worked at employer for the cohort was 9.9 (SD = 8.1) and was not meaningfully different for cases compared to non-cases. Compared to non-cases, the 77 participants who had shoulder pain at baseline, but were not classified as a prevalent case, were more likely to become an incident case eventually (p < .001). No significant baseline comparisons were observed for any psychosocial factor measured. Exposures at baseline were not significantly different when stratified by baseline symptom status (data not shown).

Table 1.

Characteristic

Total
(N=393)*

Incident cases
(N=39)

Non-cases
(N=354)*

Incident
case
vs.
Non-
case

N

%

N

%

N

%

p-value

Mean

SD

Mean

SD

Mean

SD

BMI (kg/m ²)

29.6

6.3

31.6

7.1

29.6

6.3

0.06

Table 2.

Incident Cases (N=39)

Non-cases (N=354)

Incident case vs.
Non-case
(P-value†)

Exposure Variables

N

Mean

Std Dev

Min

Max

N

Mean

Std Dev

Min

Max

Non-posture exposure variables

TWA forceful repetition ratet‡(/min)

39

4.83

6.00

0.00

30.60

348

3.1

4.2

0.0

22.2

0.09†

Forceful duty cycle‡(%Time)

39

16.6

17.3

0.0

69.7

348

14.2

17.9

0.0

100.0

0.42

Upper arm posture variables (%Time)

Potential confounders

The twelve potential confounders (p < .20) are presented in Table 3 in ascending order by p-value. Age in years (HR = 1.05, CI [1.02, 1.08], p < .01), body mass index (BMI, HR = 1.05, CI [1.00, 1.10], p = .04), and TWA forceful repetition rate (HR =1.06, CI [1.00, 1.13], p = .04) were all significantly associated with increased incidence of RCS. To improve model stability, we controlled for forceful repetition rate using a two category model with a cut-point at the median, 2.8 repetitions per minute (HR =1.70, CI [0.87, 3.31], p = .12). Having at least a high school education was associated with a significant decrease in incident RCS (HR = 0.27, CI [0.10, 0.75], p < .001). Participants who had shoulder pain at baseline, but did not meet the RCS case definition, had an increased risk of developing RCS (HR = 3.91, CI [2.01, 7.63], p < .001). Univariable results for are presented in Supplemental Table 1 for demographic and psychosocial covariates where p ≥ .20, and Supplemental Table 2 for biomechanical univariable.

Table 3.

Variable type

Characteristic or exposure variable description

Hazard
Ratio

95% CI

p-value

code†

Demog/Psychosocial

Site (1,2, or 3)$

0.05

e

RCS risk associated with biomechanical exposures

Survival analysis results for adjusted models of the association between biomechanical exposures are presented in Table 4. Five variables were confounders in > 69% of models - Site (1, 2, or 3), forceful repetition rate category, supervisor support, age (years), and BMI (kg/m ²). For most results by tertile, associations were attenuated toward the null in the highest tertile. We failed to observe any meaningful associations of increased risk of RCS among the single biomechanical exposures by tertile ( Table 4) and linear (trend) effects ( Supplemental Table 2). It appears that there may have been a difference in risk by tertile for forceful repetition rate (p = .06), where the second tertile was less hazardous than the first or third tertiles. Any risk associated with forceful repetition rate was unlikely to be linear (linear effect: HR = 1.06, CI [0.98, 1.14]). For linear effects, adjusted results did not vary substantially compared to unadjusted hazard ratios ( Supplemental Table 2).

Table 4.

Exposure variables

Cases
(N)

Tertiles among cases

HR

95% CI

p-value

Confounders†
(codes a-k)

Non-posture exposure variable domains

Upper arm posture variables (% Time)

Figure 1 presents hazard ratios for interactions between tertiles of upper arm flexion and abduction posture exposures (% time) and analyst rated force (charts A-D), total repetition rate (charts E-H), and forceful repetition rate (charts I-L). When working with the upper arm abducted ≥ 30° for 12%-time to 21%-time, each unit increase in total repetition rate and forceful repetition rate was associated with a statistically significant increased risk of incident RCS (total repetition: HR = 1.11 , CI [1.04, 1.34]; forceful repetition: HR = 1.18 , CI [1.04, 1.34]) . Forceful repetition was also associated with increased risk of RCS when working with the upper arm abducted ≥ 60° for ≥ 5%-time (HR = 1.16 , CI [1.04, 1.29]) or flexed ≥ 45° for ≥ 29%-time (HR = 1.11 , CI [1.01, 1.22]). Overall, significant interactions between posture variables and biomechanical variables from other domains were rare; we found no significant increased risk of RCS for interactions between upper arm posture tertiles and force ratings, duty cycle, or vibration exposure measures. Numeric interaction results for all variables are available in Supplemental Tables 3- 6.

Figure 1.

Biomechanical exposure and risk of rotator cuff tendinosis: Cox proportional hazard ratios (dots) and 95% confidence intervals (grey vertical lines) for interactions between tertiles of all posture exposures (% Time) and (A-D) TWA forceful exertion ratings by analysts (Borg scale) (open dots); (E-H) total repetition (solid grey dots); and, (I-L) forceful repetition (black dots). All charts are presented on a log scale with a dashed lined to mark HR=1.0 along the y-axis.

δAnalyst Rated Force models main effect was HR = 0.60, CI [0.23,1.59], adjusted for: age (years), forceful element repetition rate (TWA) - median split, site (N=3), and supervisor support; None of the force differences by tertile were statistically significant, the P-value range was .25-1.00; €Total repetition main effect was HR = 1.00, CI [0.97, 1.04], adjusted for age (years), education - at least high school, BMI, site (N=3), supervisor support, years worked at employer, job strain ratio (pd/dl), mental demands, and female; ¶ Forceful repetition main effect was HR = 1.06, CI [0.98, 1.14], adjusted for BMI (kg/m2),site (N=3), supervisor support, job strain ratio; *p-value < .05; †p-value = .08 for differences between forceful repetition categories.

DISCUSSION

The prevalence and incidence of clinically assessed RCS in our study of 393 manufacturing and healthcare workers were consistent with other work-related shoulder MSDs studies ( Bodin et al., 2012; Hegmann et al., 2014; Herin et al., 2012; Miranda et al., 2008; Silverstein et al., 2008). In this cohort, we found significant increased risk of incident RCS for interactions between forceful repetition and three of four upper arm elevation variables. Imprecise, monotonic increases were observed for both repetition variables for upper arm postures ≥ 45° flexion and ≥ 60° abduction but were attenuated in the High tertile for abduction ≥ 30°.

Forceful, repetitive work combined with upper arm elevation

Positive associations with incident RCS for forceful repetition rate alone approached statistically significance (p < .10), but when combined with Medium or High upper arm elevation exposure groups the risk increased and was statistically significant. In general, as upper arm elevation angles increased, participants could spend less time in those postures (lower tertile cut-points) without increasing their risk of developing RCS for each unit increase in forceful repetition rate. Working with upper abduction ≥ 60° for as little as 5%-time was associated with increased risk when combined with forceful, repetitive work. Although these results were consistent with two cross-sectional studies ( Frost et al., 2002; Silverstein et al., 2008), most similar studies included in recent systematic reviews have not included a specific measure of forceful repetition ( Dalbøge et al., 2014; Mayer et al., 2012; van Der Molen et al., 2017). The Danish JEM lacks a forceful repetition component; their shoulder load variable includes forceful exertion rating, upper-arm elevation above 90° (hours/day), and repetitive work (hours/day). Despite the differences between our forceful repetition variable and the Danish JEM shoulder load variable (includes upper arm elevation > 90°), our results for exposure to forceful repetition and interactions with our posture variables seem consistent with the Danish results for combinations of exposures ( Dalbøge et al., 2014, 2018; Svendsen et al., 2013). Our results also may support recent work conducted by Gallagher and colleagues who hypothesize that cumulative damage to musculoskeletal soft tissues can be explained by applying fatigue failure theory to understand cumulative soft tissue damage involved in MSDs ( Gallagher & Schall Jr, 2017; Gallagher et al., 2018). If true, forceful repetition could be an important biomechanical risk factor for any MSD, including RCS. More research is needed in this area; however, our results may support their hypothesis ( Gallagher & Schall Jr, 2017; Gallagher et al., 2018).

Exposure to upper arm elevation

In contrast to this study, other studies have demonstrated that working with extreme upper arm postures (e.g., ≥ 60°) is a risk factor for shoulder MSDs - especially ≥ 90° ( Bernard, 1997; Dalbøge et al., 2014; Mayer et al., 2012; Seidler et al., 2020; Svendsen et al., 2013). We propose that the lack of positive findings for extreme upper arm postures in this study may be attributed to three factors: (1) Healthy worker survival bias may be a limitation of our study that could account for the unexpected upper arm elevation results; we will discuss this topic in the Limitations section. (2) Compared to most large, Scandinavian registry studies ( Dalbøge et al., 2014, 2018, 2019; Svendsen et al., 2013), where exposures are accumulated across a minimum of five years up to a person's working lifetime, our follow-up time was limited to two years ( Dalbøge et al., 2014, 2018; Svendsen et al., 2013). At low exposure magnitudes, it may take many years of cumulative exposure to increase risk. This is consistent with a recent meta-analysis that calculated risk of developing specific shoulder diseases by calculating cumulative exposures for a number of studies and then conducting a meta-analysis that found an increase in risk after 1000 cumulative hours of work above shoulder level ( Seidler et al., 2020). In contrast, recent analyses by Dalbøge et al (2018, 2019) found that compared to people who worked above shoulder level for no more 2.25 min/day, the risk of developing one of several rotator cuff related shoulder diagnoses was elevated when a person's cumulative exposure was at least 2.25 min/day for 1 year working above shoulder level ( Dalbøge et al., 2019). (3) Due to sparse numbers of cases per tertile, our analysis was sensitive to relatively minor differences in category cut-points. For example, in early analyses we found a significant association between spending ≥ 4.3%-time in ≥ 90° flexion; however, after the cut-point was changed to 3.5%-time to improve model stability, the association was no longer significant.

Limitations

A lack of statistical power, our simple method of characterizing shoulder posture, and potential bias due to healthy worker survivor bias ( Picciotto et al., 2013) are the three main limitations of this study. (1) As mentioned above, sometimes relatively small changes in the tertile cut-points had a substantial effect on our results due sparse numbers of cases per group. Despite a relatively large sample size, the number of RCS cases was relatively small. It is possible that some of our results were not statistically significant and unstable due to inadequate power. For example, our power to detect a HR of 2.0 between the middle tertile exposure group compared to low group, with an alpha level of .05 was 33% for flexion ≥ 45° flexion. For each unit change in forceful repetition rate at an alpha level of .05, our power was 81% to detect a HR of 1.12; for middle tertile exposure group compared to the low group our power was 81% to detect a HR 3.0, but only 43% to detect HR 2.0 for the same group comparison. Despite this limitation, we found statistically significant, meaningful results for interactions between forceful repetition and three of four posture variables. (2) Our upper arm flexion and abduction measures may have overly simplified shoulder loading. Even using the most sophisticated methods available today (e.g., three-dimensional kinematics using imaging, motion capture, digital human models, multibody kinematics optimization), the three bones, four joints, and seventeen muscles help make the shoulder anatomically complex, highly mobile, and challenging to model the joint and muscle loads ( Blache et al., 2019; Chopp-Hurley & Dickerson, 2015; Dickerson et al., 2020). Superior humeral head translation (e.g., shoulder shrug), or other scapulothoracic motions were not measured in this study. By assessing two-dimensional upper arm posture angles, we were unable to measure the effects of other shoulder positions on the kinematic loads at the shoulder. Scapulothoracic motions affect rotator cuff muscle demands and, depending on the upper arm elevation angles, can increase or decrease subacromial space ( Chopp-Hurley & Dickerson, 2015). Humeral elevation seems to be along the causal pathway to rotator cuff damage ( Dickerson et al., 2020). (3) Healthy worker survival bias occurs when healthy workers are lost disproportionately from highly exposed groups due to employment termination ( Applebaum et al., 2011; Picciotto et al., 2013; Stayner et al., 2003). For many of our analyses, we observed attenuation or decline of risk for the highest exposure group. This pattern has been observed in other studies of MSDs and is often attributed to healthy worker survival bias ( Applebaum et al., 2011; Picciotto et al., 2013; Stayner et al., 2003). Among the 58 participants lost to follow-up, 17 left the study because they left employment, but only one person listed shoulder pain as a reason for leaving employment. Among the 41 other participants who left the study, seven reported shoulder pain at baseline. Also, at baseline, the mean and median time at current job for this cohort were 6.9 and 4.0 years. Although tenure at current employer, current job, and in current occupation were not different between cases and non-cases, all values were relatively high. It is possible that these relatively long tenure employees are less vulnerable to developing work-related MSDs that might lead someone to change jobs. When years of tenure met our criteria, we did control for it as a confounder. In Table 4, the footnotes for confounder code g can be used to find the four models that retained the variable.

Conclusions

This study highlights the importance of assessing forceful repetition and upper arm elevation as risk factors when developing JEMs and interventions for preventing RCS. Based on these results, interventions that reduce exposure to forceful repetition (i.e., lower force levels and/or slower exertion rates) may reduce the risk of RCS, especially when upper arm elevation cannot be avoided. Likewise, when forceful and repetitive work cannot be eliminated, limiting time spent with upper arms elevated ≥ 30° abduction and ≥ 45° flexion may reduce risk of RCS.

Supplementary Material

Key points:

This study found increased risk of incident RCS for interactions between forceful hand exertions per minute and all ranges of upper arm postures.

This study highlights the importance of assessing combinations of exposure to forceful repetition and upper arm elevation variables when conducting ergonomic assessments and designing interventions to prevent RCS.

Lowering forceful exertion levels, slowing exertion rates, or a combination of both job modifications may reduce the risk of RCS, especially when upper arm elevation is also a concern.

Acknowledgements

This research was supported by intramural funds, awarded as part of a competitive process within the U.S. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. We would like to acknowledge contributions to many current and former NIOSH staff or contractors whose contributions to this study at various stages over the last twenty years have been invaluable (in alphabetical order): Steve Allee, James Deddens, Bill Ehling, Lawrence J. Fine, TJ Lentz, Jean Geiman, Kim Jenkins, Denise Giglio, Chip Lehman, Donna Pfirman, Diane Papes, Avima Ruder, Diane Wormus, and Yan Yin. The authors would also like to acknowledge the contributions of Stephen Bao for consultation on exposure assessment and for reviewing the manuscript; Carisa Harris Adamson, Candice Johnson, and Kaitlin Kelly-Reif for consultation on epidemiology methods and interpretation; Brian Lowe and Andreas M. Neophytou for reviewing the manuscript. We also thank the employees, management and union representatives at participating worksites.

Disclaimer

Note: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.

Biography

Alysha R. Meyers is a research epidemiologist in the Field Research Branch and the Center for Workers' Compensation Studies, within the Division of Field Studies and Engineering at the National Institute for Occupational Safety and Health. She earned her Ph.D. in Occupational and Environmental Health from University of Iowa in 2010.

Steven J. Wurzelbacher, is the director of the Center for Workers' Compensation Studies and a research health scientist team lead in the Field Research Branch, within the Division of Field Studies and Engineering at the National Institute for Occupational Safety and Health. He earned his Ph.D. in Occupational Safety and Ergonomics from University of Cincinnati in 2006.

Edward F Krieg is a research statistician in the Field Research Branch and Center for Workers' Compensation Studies within the Division of Field Studies and Engineering at the National Institute for Occupational Safety and Health. He earned his Ph.D in Psychology from Tulane University in 1986.

Jessica G. Ramsey, is an industrial hygiene team lead within the Division of Field Studies and Engineering, National Institute for Occupational Safety and Health. She earned her M.S. in Industrial Hygiene from University of Cincinnati in 2002.

Kenneth Crombie is a supervisory industrial hygienist within the Office of Regulatory Affairs, U.S. Food and Drug Administration. He earned his M.S. in Industrial Hygiene/Occupational Ergonomics from University of Massachusetts - Lowell in 1999.

Annette L. Christianson is a research associate within the Department of Environmental and Public Health Sciences at the University of Cincinnati and was formerly a Statistician at the National Institute for Occupational Safety and Health. She earned her M.S. in Statistics from University of Cincinnati in 2004.

Lian Luo is a programmer at ATTAIN, LLC. He earned his Bachelor of Engineering (Chemical Engineering) from Zhejiang University in 1988

Susan Burt is the former chief of Ergonomics Research Activity within IWSB/DSHEFS/NIOSH. She earned her Doctor of Science in Environmental Health/Occupational Health from Harvard University School of Public Health in 1999.

Footnotes

We have no known conflicts to disclose.

REFERENCES

1. Bureau of Labor Statistics. (2019). Nonfatal cases involving days away from work: selected characteristics by special combinations, All U.S., All workers, Private industry, (2011-2017) [Custom tabulation by body park for musculoskeletal disorders]. [Google Scholar]

2. Burt S, Crombie K, Luo L, Gordon J, & Deddens J (2006). A new computer-assisted method for posture analysis of the upper limb (poster) 16th World Congress on Ergonomics (IEA2006), Maastricht, The Netherlands. [Google Scholar]

Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials

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Work-related risk factors for rotator cuff syndrome in a prospective study of manufacturing and healthcare workers

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This prospective study assessed the risk of developing rotator cuff syndrome (RCS) with separate or specific combinations of biomechanical exposures measures, controlling for individual confounders. Compared to other musculoskeletal disorders, rates ...

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Participating in various exercises post-rotator cuff surgery can aid the shoulder in regaining its proper strength and mobility. Working with a physical therapist is a fantastic way of building the shoulder up, even without surgery. There are numerous techniques and exercises one can do in their daily lives to help with rotator cuff injury. A physical therapist can teach mobility exercises, such as body weight movements like pushing off a wall, or work with resistance bands. Techniques like properly lifting objects or sleeping position tweaks can all help reduce pain. Utilizing such exercises and movements in daily life helps prolong the health of the shoulder and can minimize recovery time. Working with a physical therapist can ultimately empower individuals to rebuild strength safely and support long-term shoulder health.

Exercises and Physical Therapy for Rotator Cuff Tear. WebMD. https://www.webmd.com/pain-management/physical-therapy-rotator-cuff-tear

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One potential lifestyle change for improving the health of your shoulder from rotator cuff injury is promoting recovery through nutrition. Tendons are predominantly made up of protein collagens, and without enough nutrients, their recovery can slow down. Ensuring you eat enough vitamin C for enzyme regulation and protein for stimulating tendon growth can help promote repair and recovery in the tendons. Recovery also means reducing inflammation, so supplements like fish oils have been shown to do that, on top of subsequently reducing pain. Performing exercises for the rotator cuffs in order to strengthen the muscles is also a worthwhile change for helping a rotator cuff injury. Exercises like the pendulum swing and stretches like internal rotation stretches and crossover arm stretches all help with the mobility of the shoulder, and allow the shoulder to be strengthened in hopes of preventing future injury.

Mehta Y, DO, Physiatrist. 3 Little-Known Ways to Help Your Rotator Cuff Heal Faster | Sports-health. www.sports-health.com. https://www.sports-health.com/blog/3-little-known-ways-help-your-rotator-cuff-heal-faster

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Modify Your Exercise Routine

Returning to fitness does not mean immediately resuming your regular exercise routine or training at your previous intensity. Instead, it is crucial to modify your workouts to suit your injury and gradually progress back to your pre-injury fitness level.

Start by incorporating low-impact exercises that prevent excessive strain on the shoulder joint. Swimming, stationary biking, and walking are excellent choices to improve cardiovascular fitness while minimizing shoulder stress. Additionally, exercises that target other muscle groups can be integrated to maintain overall strength and fitness.

Gradually Introduce Resistance Training

As your shoulder continues to heal and gain strength, you can gradually reintroduce resistance training exercises to your routine. However, it is crucial to start with light weights and focus on proper form and technique. Gradually increase the weight and intensity over time, recognizing any signs of pain or discomfort that may signal overexertion. Consulting with a trainer or physical therapist to develop a customized program tailored to your specific recovery needs is highly beneficial during this phase.

Focus on Shoulder Stability Exercises

To prevent future re-injury and enhance shoulder stability, incorporating specific exercises targeting the rotator cuff muscles is essential. These exercises typically involve isotonic and isometric movements to improve muscle control and stability.

Isotonic exercises work by contracting and lengthening the muscles, such as external and internal rotations of the shoulder with resistance bands. Isometric exercises, on the other hand, involve holding a static position, like the “wall push” exercise, where you gently press your hands against a wall for 30 seconds.

Listen to Your Body

Throughout your recovery journey, it is crucial to listen to your body and be mindful of any discomfort or pain. Pushing through pain or ignoring warning signs can lead to further injury. Gradually increase the intensity and duration of your workouts, paying attention to how your shoulder responds. If you experience any pain or discomfort that persists beyond normal muscle soreness, it is crucial to consult with a medical professional to avoid exacerbating your injury.

Summary

Returning to fitness after a rotator cuff injury requires patience, diligence, and a well-thought-out plan. By allowing adequate rest, focusing on rehabilitation exercises, modifying your fitness routine, and gradually reintroducing resistance training, you can safely and effectively recover your shoulder strength and regain your fitness. Remember to listen to your body and consult with professionals throughout the process to ensure a successful return to an active, healthy lifestyle.

Ong, B. (2023, November 3). Returning to fitness after a rotator cuff injury: Best practices -. https://ongortho.com/2023/11/returning-to-fitness-after-a-rotator-cuff-injury-best-practices/

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The role Nutrition and joint health can play in Rotator Cuff Injury recovery

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The role Nutrition and joint health can play in Rotator Cuff Injury recovery

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Recovering from a rotator cuff injury isn’t just about rest and rehab—what you eat matters, too. The right nutrition helps reduce inflammation, repair damaged tissues, and strengthen joints to prevent future injuries. If you're healing from a rotator cuff tear or shoulder surgery, fueling your body with the right nutrients can accelerate recovery and improve your results.

Key Nutrients for Rotator Cuff Healing

Your body needs the right building blocks to repair damaged tendons and restore joint function. These essential nutrients can support a faster and stronger recovery:

Protein: Crucial for muscle and tendon repair. Lean meats, fish, eggs, and plant-based sources like lentils and quinoa help rebuild damaged tissues.

Omega-3 Fatty Acids: Found in salmon, flaxseeds, and walnuts, omega-3s reduce inflammation and promote joint lubrication.

Vitamin C: Supports collagen production, essential for tendon healing. Citrus fruits, bell peppers, and strawberries are great sources.

Calcium & Vitamin D: Strengthen bones and support joint health. Dairy products, leafy greens, and fortified foods provide calcium, while sunlight exposure and fatty fish help with vitamin D intake.

Zinc & Magnesium: Aid tissue repair and reduce muscle cramps. Nuts, seeds, and whole grains are excellent sources.

Anti-Inflammatory Foods to Reduce Pain and Swelling

Chronic inflammation can delay healing and prolong discomfort. Adding these anti-inflammatory foods to your diet can speed up recovery:

Berries: Packed with antioxidants that combat oxidative stress and support tissue repair.

Leafy Greens: Spinach, kale, and Swiss chard provide powerful anti-inflammatory nutrients.

Turmeric: Contains curcumin, a natural anti-inflammatory compound.

Ginger: Helps reduce pain and swelling in injured joints.

Hydration and Joint Health

Staying hydrated is often overlooked but is essential for joint recovery. Water helps transport nutrients to injured tissues and keeps joints lubricated. Aim for at least eight glasses of water per day, and include hydrating foods like cucumbers and watermelon.

Supplements for Rotator Cuff Recovery

Certain supplements can enhance healing and reduce inflammation, with collagen peptides trending recently.

Collagen Peptides: Improve tendon elasticity and support tissue regeneration. More studies are needed to determine the effectiveness of peptides in healing.

Glucosamine & Chondroitin: Promote cartilage health and joint function.

Bromelain: A natural enzyme that reduces swelling and speeds up healing.

Turmeric: Research indicates that curcumin supplements may be as effective as non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen in reducing arthritis pain, with fewer side effects.

Maximizing Recovery Through Diet and Rehabilitation

Lifestyle choices play a crucial role in shoulder health, as diet and overall wellness directly impact pain and recovery. While nutrition supports healing, it’s most effective when combined with a structured rehab program. Strength exercises, physical therapy, and proper rest—alongside a nutrient-rich diet—can accelerate recovery and restore strength.

By focusing on proper nutrition, staying hydrated, and following your orthopedic specialist’s treatment plan, you can optimize healing and regain shoulder function more effectively.

shah, anup. (2025, March 5). The role of Nutrition and joint health in rotator cuff injury recovery. Picture of Anup Shah, MD, MBA, FAAOS. https://www.orthoshah.com/blog/the-role-of-nutrition-and-joint-health-in-rotator-cuff-injury-recovery/?bp=45178

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A physical therapist would be helpful when deciding on an exercise plan to strengthen your shoulder. They can examine you so that they know which muscles are weaker, and that you should focus on. They can then teach you how to properly perform an exercise that they recommend. Physical therapists will often recommend a mixture of some stretching exercises and strength exercises. Some examples are:

Stretching:

1. Stretching the back of your shoulder

2. Hand up your back stretch

3. Pendulum exercises

4. Wall stretches

Strength:

1. Internal/External rotation (also with a band)

2. Wall push-ups

3. Scapular retraction

A physical therapist's goal is to get you performing these exercises with no pain and get you stronger. If you feel pain, they may alter the exercise.

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Rotator cuff exercises: MedlinePlus Medical Encyclopedia

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The rotator cuff is a group of muscles and tendons that form a cuff over the shoulder joint. These muscles and tendons hold the arm in the shoulder joint and help it to move in a coordinated and pain-free

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A rotator cuff tear leads to pain and weakness within the joint of your shoulder, which causes decreased range of motion. One potential lifestyle change that can be helpful for a rotator cuff tear is finding a good exercise routine to reduce the risk of a tear. The goal with exercise is to rebuild your strength so that the muscles and tendons in your shoulder get stronger and regain some range of motion. Another potential lifestyle change is getting the right nutrition to support repair. For example, vitamin D is important to tissue health, bone growth, and can also be anti-inflammatory. Vitamin D deficiency is high among people with shoulder tears, so making sure you get enough can be beneficial.

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The role of vitamin D in shoulder health: a comprehensive review of its impact on rotator cuff tears and surgical results

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Vitamin D deficiency is highly prevalent in the general population and is associated with various chronic health conditions. In addition to its role in bone mineralization, Vitamin D has various physiological effects that may impact the pathogenesis…

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By incorporating exercises into a lifestyle change to help an injured rotator cuff, seeing a Physical Therapist would be the most beneficial. A Physical Therapist will be able to tailor a specific workout / stretching routine that will best serve the needs of each patient. Furthermore, A PT will be able to target the muscles listed below to hopefully reduce or completely alleviate any pain associated with an injured rotator cuff. A Physical Therapist will be able to isolate and target the following:

Deltoids (front, back and over the shoulder)

Trapezius muscles (upper back)

Rhomboid muscles (upper back)

Teres muscles (supporting the shoulder joint)

Supraspinatus (supporting the shoulder joint)

Infraspinatus (supporting the shoulder joint)

Subscapularis (front of shoulder)

Biceps (front of upper arm)

Triceps (back of upper arm)

It is advisable to seek a medical professional to assist the patient so they do not potentially injure themselves further.

Citation:

American Academy of Orthopaedic Surgeons. Rotator Cuff and Shoulder Conditioning Program. OrthoInfo. Last reviewed June 2022. Accessed November 14, 2025. https://orthoinfo.aaos.org/en/recovery/rotator-cuff-and-shoulder-conditioning-program/.

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After an injury or surgery, an exercise conditioning program will help you return to daily activities and enjoy a more active, healthy lifestyle. Following a well-structured conditioning program will also help you return to sports and other recreational activities.

This is a general conditioning program that provides a wide range of exercises. To ensure that the program is safe and effective for you, it should be performed under your doctor's supervision. Talk to your doctor or physical therapist about which exercises will best help you meet your rehabilitation goals.

Strength: Strengthening the muscles that support your shoulder will help keep your shoulder joint stable. Keeping these muscles strong can relieve shoulder pain and prevent further injury.

Flexibility: Stretching the muscles that you strengthen is important for restoring range of motion and preventing injury. Gently stretching after strengthening exercises can help reduce muscle soreness and keep your muscles long and flexible.

Target Muscles: The muscle groups targeted in this conditioning program include:

Deltoids (front, back and over the shoulder)

Trapezius muscles (upper back)

Rhomboid muscles (upper back)

Teres muscles (supporting the shoulder joint)

Supraspinatus (supporting the shoulder joint)

Infraspinatus (supporting the shoulder joint)

Subscapularis (front of shoulder)

Biceps (front of upper arm)

Triceps (back of upper arm)

Length of program: This shoulder conditioning program should be continued for 4 to 6 weeks, unless otherwise specified by your doctor or physical therapist. After your recovery, these exercises can be continued as a maintenance program for lifelong protection and health of your shoulders. Performing the exercises two to three days a week will maintain strength and range of motion in your shoulders.

Warmup:

Stretch: After the warm-up, do the stretching exercises shown on Page 1 before moving on to the strengthening exercises. When you have completeds the strengthening exercises, repeat the stretching exercises to end the program.

Do not ignore pain: You should not feel pain during an exercise. Talk to your doctor or physical therapist if you have any pain while exercising.

Ask questions: If you are not sure how to do an exercise, or how often to do it, contact your doctor or physical therapist.

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Rotator Cuff and Shoulder Conditioning Program - OrthoInfo - AAOS

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After an injury or surgery, an exercise conditioning program will help you return to daily activities and enjoy a more active, healthy lifestyle. Following a well-structured conditioning program will also help you return to sports and other recreational activities. This is a general conditioning program that provides a wide range of exercises.

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A key lifestyle change that can be very beneficial for a rotator cuff injury is to preform simple targeted stretches and exercises. Allowing yourself a few minutes in the morning to stretch and preform targeted exercises to the shoulders can help decrease the chance of irritating or further damaging the injury.

These exercises include retracting and externally rotating the shoulders and shoulder blades, flexing them so they are tight, allowing your chest to open up and stretch also. Preforming this series of exercises, your body to naturally form muscle, strengthen your shoulder and rotator cuff and therefore decrease your chance of injury.

Citation:

Duke Health. Preventing Rotator Cuff Injuries. Duke Health. Updated July 21, 2025. Accessed November 13, 2025. https://www.dukehealth.org/blog/preventing-rotator-cuff-injuries.

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Rotator cuff injuries are common, and everyone is susceptible. Simple exercises can prevent rotator cuff injuries.

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Occupational Therapy for Rotator Cuff Injury

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Occupational Therapy for Rotator Cuff Injury

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Why Occupational Therapy Helps

Occupational therapy is a key component of recovering arm function after a rotator cuff tear. OT treatment helps:

Reduce Pain: Hands-on techniques like massage alleviate muscle spasms and discomfort.

Regain Mobility: Stretches bring movement back to the stiff joint.

Build Strength: Targeted exercises stabilize and protect the shoulder.

Improve Function: Therapists work with you on impacted daily tasks like dressing, bathing, and driving.

Prevent Reinjury: OTs teach proper lifting mechanics and joint protection techniques.

Restore Confidence: Being able to use your arm again boosts mental health.

Occupational therapists take a holistic approach focused on healing while maintaining your independence and quality of life after injury.

What to Expect in Occupational Therapy

Your therapist will begin with a comprehensive evaluation assessing your range of motion, strength, pain levels, and ability to do daily activities. They will observe you performing movements to identify problem areas.

Based on the evaluation, your OT will customize a treatment plan that likely includes:

Range of Motion Exercises

Gentle stretches will be prescribed to improve flexibility and mobility in your shoulder joint. These should be done daily at home, along with OT sessions.

Strengthening Exercises

You’ll be given targeted exercises to rebuild strength in your rotator cuff muscles and surrounding structures like your trapezius, deltoids, and scapula. Resistance bands, light weights, and bodyweight exercises are often used.

Manual Techniques

Hands-on treatments like massage, trigger point release, and joint mobilization can help break up scar tissue and adhesions. This is especially useful after rotator cuff surgery.

Functional Retraining

OTs work with you on shoulder motions impacted by your injury, like brushing your hair, washing your back, and reaching overhead. They provide tips like modifying your grip and using your unaffected arm to assist.

Adaptive Equipment

Reaching aids, dressing sticks, jar openers, and long-handled tools can help protect your shoulder after injury. Your OT will recommend assistive devices to make activities easier.

Home Exercise Program

Consistently performing your prescribed exercises at home is vital for recovery. Your therapist will review the exercises weekly and advance them as your strength improves. They may recommend exercise apps or videos with demos as well.

How Occupational Therapy Can Help a Rotator Cuff Tear. Coastaltherapeutics.net. (2024, February 5). https://coastaltherapeutics.net/blog/occupational-therapy-rotator-cuff-tear/

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Physical therapy for rotator cuff injuries

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Physical therapy for rotator cuff injuries

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How Physical Therapy Can Help with Rotator Cuff Injuries

Imagine waking up one morning, eager to start your day, but as you attempt to brush your teeth, the pain in your shoulder sends a searing wave of discomfort through your entire arm. Suddenly, the simplest tasks become challenging.

This scenario is all too familiar for individuals dealing with rotator cuff injuries, which can severely limit daily life functions. However, there is hope in the form of physical therapy—a proven and effective way to regain strength, mobility, and overall shoulder function.

When you consult a physical therapist for a rotator cuff injury, the initial evaluation is a critical step in the recovery process. Here’s what you can expect:

Your physical therapist will start by discussing your medical history, including the onset and nature of your shoulder pain, any previous injuries, and your overall health.

A thorough physical examination follows, focusing on the affected shoulder. This includes assessing your range of motion, strength, and any signs of inflammation or instability. To understand how your injury impacts your daily life, your therapist will assess your ability to perform essential tasks like reaching, lifting, and dressing.

Based on the evaluation findings, your physical therapist will provide a diagnosis and work with you to establish clear goals for your rehabilitation.

Next, your therapist will design a program tailored to your unique needs, including:

Manual Therapy: Physical therapists often use manual therapy techniques, including joint mobilizations and soft tissue mobilizations, to alleviate pain and improve shoulder mobility. These techniques have been shown to reduce pain and enhance range of motion in individuals with rotator cuff injuries.

Therapeutic Exercises: A customized exercise program is a cornerstone of rotator cuff rehabilitation. Therapists prescribe exercises that target specific muscle groups, gradually improving strength and function.

Home Exercise Programs: Physical therapists provide patients with home exercise programs to promote continuity of care. Consistent adherence to these programs can improve rotator cuff rehabilitation outcomes.

Patient Education: Understanding the injury and learning how to prevent future problems is crucial. Our physical therapists educate patients about proper shoulder mechanics, posture, and ergonomics to reduce re-injury risk.

As you continue to progress in your recovery, functional training becomes vital. Tasks like lifting, reaching, and carrying are integrated into the rehabilitation program to ensure you regain your ability to perform daily activities without pain or limitation.

How physical therapy can help with rotator cuff injuries. College Park Physical Therapy. (2025, May 13). https://collegeparkpt.com/newsletter/how-physical-therapy-can-help-with-rotator-cuff-injuries/

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A physical therapist would be helpful for adhesive capsulitis. There are three phases to a frozen shoulder. The first is the freezing phase, during which the joint is in severe pain. Then the frozen phase, where the movement decreases. Lastly, the thawing phase, where there is a gradual return of motion. A physical therapist may prescribe different exercises for each phase:

1. Freezing: Pain-relieving techniques in 1-5 seconds duration.

Pendulum exercises

Pulley exercises

Heat/Ice can help as well

*It is important in this stage not to aggravate the shoulder, so you want to be careful with stretching too far.

2. Frozen: Similar to the freezing stage, with the addition of strengthening exercises to increase muscle strength.

Scapular retraction

Isometric shoulder external rotation

3. Thawing: More mobility and stretching with longer duration, with strength exercises progressing to the use of resistance bands and eventually weights.

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Physical therapy in the management of frozen shoulder

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Frozen shoulder, also known as adhesive capsulitis, is a common presentation in the primary care setting and can be significantly painful and disabling. The condition progresses in three stages: freezing (painful), frozen (adhesive) and thawing, and…

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One potential issue during rehabilitation for a rotator cuff tear is re-tearing, which can occur due to a lot of reasons, such as not adhering to the rehab plan correctly, as well as factors like age, type of tear, or quality of the tear. Each tear is specific, and each person is specific, so the treatment can vary. Larger tears are going to take longer to fully heal than smaller tears, so if the person goes back to high activity too quickly, they are at risk for a re-tear. One issue that can occur after surgery is adhesive capsulitis, also known as “frozen shoulder.” This is pain, stiffness, and a limited range of motion in the shoulder joint. The cause of this is said to be inflammation of the shoulder joint capsule. When the capsule is inflamed, it can lead to adhesions, which tighten the capsule and prevent movement.

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Continuing Education Activity

Rotator cuff pathology is a commonly encountered condition, and the natural history suggests tears increase with increasing age. This activity will discuss the diagnosis and management of the spectrum of disease from tendinopathy to tears. It will also discuss the relationship between the team members involved.
Objectives:

Identify the risks and physical exam findings associated with a complete rotator cuff tear.

Describe the appropriate referral for rotator cuff tear based on the clinical picture.

Review the indications for appropriate imaging (X-ray, MSK ultrasound, and MRI).

Explain the importance of collaboration and communication amongst the interprofessional team to ensure appropriate selection of candidates for rehabilitation, injections, and tendon repair surgery.

Earn continuing education credits (CME/CE) on this topic.
Introduction

The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate. The rotator cuff consists of four muscles originating on the scapula and inserting on the superior humeral head to improve stability. The subscapularis inserts on the lesser tubercle of the humerus, and it functions as an internal rotator. The supraspinatus muscles insert onto the greater tubercle of the humerus with its function as an abductor for the initial 30 degrees of abduction. The infraspinatus also inserts onto the greater tubercle, but a little inferior to the supraspinatus, and it functions as an external rotator. The teres minor inserts inferior to the infraspinatus on the greater tuberosity, and it functions as an external rotator as well. Additionally, they all work as stabilizers of the glenohumeral joint.

Rotator cuff injury runs the full spectrum from injury to tendinopathy to partial tears, and finally complete tears. Age plays a significant role. Injuries ranged from 9.7% in those 20 years and younger increasing to 62% in patients 80 years and older (whether or not symptoms were present).[1] Increasing age and those with unilateral pain are also at risk for a tear in the rotator cuff of the opposite shoulder. A study comparing patients with unilateral shoulder pain, the average age for a patient having no cuff tear was 48.7 years. After age 66, there is a 50% likelihood of bilateral tears. Additionally, age was linked to the presence and type of tear but did not correlate with tear size.[1]

Unfortunately, there is a lack of good evidence on the optimal treatment of tears in patients younger than 40.[2] The tears tend to be more traumatic and likely respond to surgery better, but the role of non-surgical management needs to be better defined.

Etiology

Age is the most common factor for rotator cuff disease. It is a degenerative process that is progressive.[3] Smoking is a known risk factor. A systematic review demonstrated increased rates and sizes of degenerative tears along with symptomatic tears seen in smokers; this has the potential to increase the number of surgeries.[4] Another risk factor is family history. In a study of rotator cuff disease in those under 40 years of age, there was a significant correlation between individuals with RC disease up to third cousins. [4] Interestingly, poor posture has also been shown to be a predictor of rotator cuff disease. Tears were present in 65.8% patients with kyphotic-lordotic postures, 54.3% with flat-back postures, and 48.9% with sway-back postures; tears were present in only 2.9% of patients with ideal alignment.[4] Other risk factors include trauma, hypercholesterolemia, and occupations or activities requiring significant overhead activity.[4][5]

Partial tears are at risk for further propagation. These risk factors include: tear size, symptoms, location, and age. Tear size: A small tear may remain dormant, while larger tears are more likely to undergo structural deterioration. The critical size for sending a small tear towards a larger or complete tear has yet to be defined.[6] Tear propagation correlates with symptom development. Actively enlarging tears have a five times higher likelihood of developing symptoms than those tears that remain the same size.[6] The location of the tear also influences progression. Anterior tears are more likely to progress to cuff degeneration.[6] Finally, age is a risk factor. Patients over age 60 are more likely to develop tears that progress. Younger patients with full-thickness tears appear more capable of adapting to stress and tear propagation than those 60 years of age and older.[6]

Epidemiology

In adults, rotator cuff injury is the most common tendon injury seen and treated. Statistically, approximately 30% of adults age over 60 have a tear, and 62% of adults over 80 have tears.[3] In Germany, a prospective study on 411 asymptomatic shoulders demonstrated a 23% overall prevalence of RC tears with 31% in those of age 70 and 51% in those 80 years of age. [7] Other studies from Europe gave slightly lower results. One study from Austria on 212 asymptomatic shoulders demonstrated only a 6% prevalence of full-thickness tears.[8] A Norwegian study on 420 asymptomatic volunteers ages 50 to 79 revealed FTT in 32 subjects (7.6%).[9]

Pathophysiology

Rotator cuff injury starts from trauma. Macro-trauma causes an acute tear, which is seen generally a younger patient resulting in a complete tear. Micro-trauma causes tendon degeneration and with insufficient healing, leads to degenerative tears. Typically, acute tears happen in younger patients, and degenerative tears occur in older patients. However, a smaller amount of force is needed to cause a complete tear if there is sufficient tendon degeneration.

History and Physical

The history of rotator cuff disease all starts with pain. The pain can be acute and arise from a traumatic event, or it can be gradual and mild, but steadily increasing. Generally, active individuals will present when they can no longer do their sport, activity, or job without causing pain. Often they will try to adapt or alter their biomechanics to remain active. Only when they can no longer adapt will they present. For instance, a baseball pitcher will begin to move their motion from an overhead movement to more of a sidearm throw to try and maintain velocity. Once the pain continues or the velocity drops sufficiently, will they seek care. Depending on when the patient presents, the tendon will be anywhere from tendinopathy to partial tear to complete tear.

Additionally, patients will report increasing pain and difficulty with overhead activity, activities of daily living. They may also report pain when lifting or carrying heavy objects. The pain can occasionally radiate down into the area of the deltoid muscle. Quite often, they will report pain when lying on their side to sleep. In younger patients, overuse tendinopathy is the cause, and older patients often have osteoarthritis as a contributing factor.

On physical exam, tenderness along at the insertion of the supraspinatus, infraspinatus, and teres minor muscles in the greater/lesser tuberosity can be present. With inspection, muscle atrophy may be visible in the supraspinatus or infraspinatus fossa of the scapula.[10] Additionally, checking the cervical range of motion and performing a Spurling test can help look for cervical disc disease as a source of the pain. The next step is to have the patient demonstrate the range of motion in both abduction and flexion. Rotator cuff pathology will cause pain in the range of motion; this is commonly called a painful arc. It is also helpful to observe the scapulothoracic motion. The longer the pain has been present, the more likely patients will develop scapular dyskinesis. Normally, the scapula does not begin to abduct until the arm abducts to 90 degrees. When dyskinesis is present, scapular motion initiates well before the arm reaches 90 degrees of abduction.

There is limited evidence for any of the tests commonly used in diagnosing rotator cuff disease as being very sensitive or specific.[11] The Jobe or empty can test used to evaluate for supraspinatus tendinopathy. The patient elevates the arm to about 90 degrees, and with the thumb down (having an empty can in the patient's hand), isometric force is applied downward. The full can test is a variation where the thumb is up (having a full can in the patient's hand). These tests have high sensitivity but are unfortunately not specific.[4] Next, resisted external rotation is used to evaluate for infraspinatus/teres minor muscle pathology. The patient adducts their arms to their side, and the patient isometrically resists an internal rotation force. For the subscapularis, the belly press is useful for evaluation. The patient places their hand on their abdomen and then resists the examiner's attempt to push the elbow forward off the abdominal wall. Pain or weakness with any of these motions is considered positive tests. If pain limits the exam, a diagnostic subacromial injection can be done to see if reducing the patient's pain improves the exam. Placing an anesthetic agent (lidocaine is the most common choice) in the subacromial space can improve the specificities of these tests.[4]

When considering a rotator cuff tear, there are variations in the tests noted above. If the patient cannot hold the empty can test position, it is called a drop arm test. Next is the external rotation lag sign. With the patient in external rotation, the arm is fully externally rotated. If the patient cannot maintain this position, there is a good chance they have a ruptured supraspinatus and/or infraspinatus muscle.[12] Finally, the inability to keep the hand on the abdominal wall with the belly press test suggests there is a chance the patient has ruptured their subscapularis muscle.

Evaluation

When it comes to shoulder imaging, there are three options: plain radiography, ultrasound, and MRI/MR arthrography. For rotator cuff disease, MR arthrography does not add any additional benefits over and MRI. It is more expensive and requires an intra-articular injection of gadolinium.

Imaging begins with X-rays, and the standard is four views AP, true AP (Grashey view), scapular Y (lateral), and axillary views. The Grashey view activates the deltoid muscle, thus allowing proximal humeral migration. In patients with a chronic, large tear, the proximal humerus will migrate superior. The scapular Y view evaluates for acromial spurs often associated with cuff tears. Finally, the axillary view will show joint space narrowing along with anterior or posterior humeral subluxation.[10]

Ultrasound has become an excellent tool for evaluating the rotator cuff. It is less expensive and has the capability of assessing dynamic movements of the shoulder. A 2013 review article compared MRI, MR arthrography, and ultrasound to diagnose rotator cuff tears. The gold standard was open or arthroscopic surgery gold standard. With partial-thickness tears, both MRI and ultrasound performed well. All three imaging modalities were able to rule in or rule out a full-thickness. For both partial- and full-thickness tears, no significant differenceswere shown of the imaging modalities' abilities to demonstrate a tear.[12] Ultrasound has limitations due to the skill required to obtain appropriate images, and it can be difficult to distinguish between chronic tears and tendinopathies.

MRI remains the gold standard in the US. The images are utilized in pre-procedure planning and can show tear size, location, retraction, muscle atrophy, chronic changes in the tendon and muscle associated with degenerative changes, and other associated pathology.[10][4] All these factors will go into planning a potential surgical procedure.

Treatment / Management

The treatment depends on the age of the patient, their functional demands, and the acuteness vs. chronicity of the tear. For complete tears in patients under 40, surgical treatment is the generally recommended treatment followed by appropriate rehabilitation. These are usually traumatic injuries and respond well to surgery. However, the data is limited and based mostly on studies in older patients.[2]

The American Academy of Orthopedic Surgeons developed some recommendations. They determined high-level evidence of surgical treatment for full-thickness tears was weak.[13] In the same article, the group determined there were appropriate use criteria based on available data and expert opinion. The authors reviewed five classes of treatment. First, non-surgical management is always appropriate, providing they are responding with improved function and decreased pain. Second, repairs can be appropriate even if the patient responds to non-surgical care. Third, for those healthy patients who remain symptomatic, then repair is the appropriate treatment. Fourth, for cases of chronic, massive tears, debridement/partial repair and/or reconstruction may be indicated. Finally, for those with painful pseudoparalysis with an irreparable tear, arthroplasty may be appropriate.[13]

For patients who do respond to non-surgical care, will do so in 6 to 12 weeks.[13]

Any patient with asymptomatic tears should have nonoperative management. Newly diagnosed, symptomatic rotator cuff tears may start with physical therapy addressing both core and scapular muscle strengthening. This approach is associated with similar clinical outcomes when compared to surgical repair for both small and medium-sized tears. Additionally, therapy was is an effective primary treatment modality in most patients, even with full-thickness rotator cuff tears followed over two years. Oddly enough, in this study group, low expectations regarding the efficacy of rehabilitation are the strongest predictor of patients who would eventually go to surgery.[3]Quite often subacromial injections with corticosteroids are frequently employed setting of rotator cuff tears. However, there is little reproducible evidence to support their effectiveness and improve long-term clinical outcomes when used alone.[3]

SLAP or other labral tears

Subacromial impingement from bursitis, os acromiale, bone spurs

Differential Diagnosis

Prognosis

A recent meta-analysis published in 2019 out of the United Kingdom evaluating the treatment outcomes (patient-reported outcomes) demonstrated both surgical and non-surgical treatment groups had the largest improvement at 12 months. Then improvements leveled out. There was no clear advantage of surgery over non-surgical treatments.[14]

An algorithm was developed to help guide with a patient selection where tears categorize into three groups. [10] Group 1: early operative repair. One indication would be patients with an acute event and imaging corroborating the history. Especially with a subscapularis tear with or without biceps tendon instability. In those patients with pain and weakness before the injury would likely be an acute on chronic tear scenario and early intervention can be considered when imaging shows minimal muscle atrophy or degenerative changes should undergo early surgical interventions. Patients younger than 62 to 65 with small and medium-sized tears with minimal to no atrophy on imaging would be another group to consider early operative management. Group 2: In patients with painful partial or full-thickness tears who do not have an acute onset of pain, even if tendons are potentially repairable, they should undergo non-surgical treatment initially. In these cases, rehabilitation has shown consistent benefit in improving function and outcomes. Group 3: should undergo maximal non-surgical treatment. This group would be those who are tendons are unlikely to heal. Included in this group are those over 70 years old, those with chronic full-thickness tears with significant tendon retraction, advanced degenerative changes in the muscles, any signs of proximal humeral migration.

Complications

The most likely complication would be retearing of the cuff repair - this is minimizable with proper patient selection. Postoperative complications, in addition to those generally seen, would be adhesive capsulitis, inability to regain motion, or cuff strength.

Deterrence and Patient Education

No studies examine prevention strategies. Theoretically, proper cuff function can help decrease the risk of degenerative tears. In an observational study, rotator cuff tears were seen more predominately in those with specific postures. Also, in another study looking at radiographically measured subacromial space found reduced acromio-humeral space correlated with hyperkyphotic posture.[4]

Enhancing Healthcare Team Outcomes

Rotator cuff disease is among the most common tendon injuries seen and generally affects the older popular. These patients tend to have more chronic conditions and take more medications. Most patients will do well with conservative measures, but open communication with their primary care physician, physical therapist, and a sports medicine physician will optimize outcomes.

When the decision is made to proceed to surgery, patients may need clearance to undergo anesthesia; this occasionally requires permission from their primary care doctor or other specialists like cardiology, pulmonary, nephrology if they have renal failure or are undergoing dialysis. The team will need to address any chronic metabolic conditions and should look to optimize blood glucose levels, A1C, as well as optimizing any blood coagulation.

After the surgical procedure, clear communication between the operative and post-operative teams of physicians and nurses (including nurses with specialty training in orthopedics) to ensure the continued safety of the patient as they recover is critical. Discussions about medications and medical conditions should be open and frank, so the entire team ensures an appropriate handoff. The nursing staff should perform post-operative monitoring, assist with patient and family education, and coordinate appropriate follow up.

As the patient proceeds with recovery and goes through the (typically long) rehabilitation process, open communication between the surgeon and physical therapist will optimize the patient's recovery. Physical therapists also often have involvement in conservatively managed cases or instances attempting conservative management in an attempt to preclude surgery. The therapist moist report back to the treating clinician with their findings regarding progress or lack thereof.

Managing rotator cuff tears requires an interprofessional team approach, including the clinicians, specialists, orthopedic and surgical nurses, and physical therapists.

Continuing Education / Review Questions

References

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The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate.

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When dealing with the rehabilitation of a rotator cuff injury, a limited range of motion is a typical issue patients might face. Working with a Physical Therapist can help improve the range of motion gradually, ensuring that no movements are overdone, to the ability of the patient. The rehabilitation begins with passive range of motion. The patient is in a sling in order to promote tendon healing, but no real range of motion exercises begin. Following that, assisted activity begins. A patient will undergo a basic range of motion exercises, while avoiding lifting, supporting the body, and sudden movements in order to avoid potentially worsening the injury. After this, a patient will go through the initial strengthening phase and then the advanced strengthening phase. In these phases, the patient will gradually add weight over time while participating in exercises that progress their range of motion as well. After about 6-7 months of rehabilitation while working with a physical therapist, individuals may begin to find themselves returning to regular sport/exercise. Maintaining proper stretching and exercise at home is important for strength retention and to hopefully avoid another injury.

Massachusetts General Brigham Sports Medicine. Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair - Large to Massive Tears PHASE I: IMMEDIATE POST-OP: Passive Range of Motion Phase (WEEKS 1-6 after SURGERY). https://www.massgeneral.org/assets/MGH/pdf/orthopaedics/sports-medicine/physical-therapy/rehabilitation-protocol-for-rotator-cuff-tear-large-to-massive-tear.pdf

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There are numerous worries that can encompass a rotator cuff injury during rehabilitation. One specific issue that may arise is muscle weakness. Weakness in the shoulder and the surrounding muscles is common after injury and surgery. This, coupled with the limited range of motion, means that individuals may feel stuck, as they cannot move their arm due to weakness and pain, or they cannot begin to strengthen their muscles due to lack of mobility. One other common issue people face is the fear of reinjury. Many can experience anxiety around using their shoulders for daily activities. They worry that they might run the risk of overexercising their muscles, even if they begin to work on strengthening them back up during rehabilitation. This may often hinder one’s progress, as their worry may prevent them from moving more and pushing beyond what their shoulders are truly capable of.

Common Challenges in Rotator Cuff Repair Rehab: Overcoming Obstacles - Chiron Physical Therapy. Chiron Physical Therapy. Published July 10, 2025. Accessed November 13, 2025. https://chironptva.com/common-challenges-in-rotator-cuff-repair-rehab-overcoming-obstacles/

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For adhesive capsulitis (frozen shoulder) the main health professional to help the patient would be a physical therapist. The treatment for a frozen shoulder is a delicate balance between increasing the range of motion through passive ROM exercises, and not causing further injury to the joint. The main treatments that a physical therapist can help the patient with include stretching the joint internally, externally, and above the head. These treatments typically will be with the patients body weight and not include any external weights.

Citation: Rotator Cuff and Shoulder Conditioning Program. OrthoInfo. American Academy of Orthopaedic Surgeons; 2021. Accessed November 11, 2025. https://orthoinfo.aaos.org/en/recovery/rotator-cuff-and-shoulder-conditioning-program/

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After an injury or surgery, an exercise conditioning program will help you return to daily activities and enjoy a more active, healthy lifestyle. Following a well-structured conditioning program will also help you return to sports and other recreational activities.

This is a general conditioning program that provides a wide range of exercises. To ensure that the program is safe and effective for you, it should be performed under your doctor's supervision. Talk to your doctor or physical therapist about which exercises will best help you meet your rehabilitation goals.

Strength: Strengthening the muscles that support your shoulder will help keep your shoulder joint stable. Keeping these muscles strong can relieve shoulder pain and prevent further injury.

Flexibility: Stretching the muscles that you strengthen is important for restoring range of motion and preventing injury. Gently stretching after strengthening exercises can help reduce muscle soreness and keep your muscles long and flexible.

Target Muscles: The muscle groups targeted in this conditioning program include:

Deltoids (front, back and over the shoulder)

Trapezius muscles (upper back)

Rhomboid muscles (upper back)

Teres muscles (supporting the shoulder joint)

Supraspinatus (supporting the shoulder joint)

Infraspinatus (supporting the shoulder joint)

Subscapularis (front of shoulder)

Biceps (front of upper arm)

Triceps (back of upper arm)

Length of program: This shoulder conditioning program should be continued for 4 to 6 weeks, unless otherwise specified by your doctor or physical therapist. After your recovery, these exercises can be continued as a maintenance program for lifelong protection and health of your shoulders. Performing the exercises two to three days a week will maintain strength and range of motion in your shoulders.

Warmup:

Stretch: After the warm-up, do the stretching exercises shown on Page 1 before moving on to the strengthening exercises. When you have completeds the strengthening exercises, repeat the stretching exercises to end the program.

Do not ignore pain: You should not feel pain during an exercise. Talk to your doctor or physical therapist if you have any pain while exercising.

Ask questions: If you are not sure how to do an exercise, or how often to do it, contact your doctor or physical therapist.

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Rotator Cuff and Shoulder Conditioning Program - OrthoInfo - AAOS

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After an injury or surgery, an exercise conditioning program will help you return to daily activities and enjoy a more active, healthy lifestyle. Following a well-structured conditioning program will also help you return to sports and other recreational activities. This is a general conditioning program that provides a wide range of exercises.

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A major concern for a torn rotator cuff is Adhesive Capsulitis. In layman's terms this means a frozen shoulder/joint. This happens when a patient injures their rotator cuff, develops extensive inflammation and pain that causes the patient to ‘guard’ the injury, and not allow the joint to move. By not allowing the humeral head and the glenohumeral joint to move and receive lubrication from the synovial fluid. This lack of movement and inflammation causes fibrotic changes to occur to the glenohumeral joint capsule and subsequently freezes the shoulder in place.

Citation:

Varacallo M, El Bitar Y, Mair SD. Rotator Cuff Tendonitis. In: StatPearls. StatPearls Publishing; 2024. Accessed November 11, 2025. https://www.ncbi.nlm.nih.gov/books/NBK532955/

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Adhesive capsulitis, commonly known as frozen shoulder, is characterized by painful and progressive shoulder motion loss due to fibrotic joint capsule changes.[1][2] This condition predominantly affects middle-aged adults, especially those with endocrine disorders such as diabetes or thyroid dysfunction, which can predispose individuals to more severe forms of the disease.[3] Despite its commonality, the pathophysiology remains only partially understood, and the condition is often under-recognized, leading to delays in treatment and prolonged disability. The persistent nature of adhesive capsulitis and its significant effect on a patient’s daily functioning emphasizes the critical need for expedient diagnosis, treatment, and a comprehensive care strategy involving multiple medical specialties.[4]

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There are a few ways to treat a rotator cuff injury, and they can depend on the age of the person injured and the severity of the injury. These treatments include:

Rest

Ice the area

Pain relievers

Physical therapy to strengthen the shoulder

A corticosteroid shot if other treatments don’t help with the pain

Heat the area

Electrical Stimulation

Surgery may be suggested if the injury does not improve within 6-12 months.

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The rotator cuff is made up of muscles and tendons in your shoulder area. Tendinitis, bursitis, and tears are common problems with the rotator cuff.

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One of the major symptoms of a rotator cuff injury is pain in the top part of your arm or shoulder. The pain may increase if you lift or lower your arm, lie down on your arm, or try to reach behind your back. Other symptoms include loss of strength in your arm or popping noises when moving your arm. To diagnose a rotator cuff injury, you have to examine the shoulder. You want to check its range of motion and where the pain is specifically. Health care providers will also test the strength of the shoulder as well as order tests such as an X-ray or an MRI.

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The rotator cuff is made up of muscles and tendons in your shoulder area. Tendinitis, bursitis, and tears are common problems with the rotator cuff.

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There are numerous ways a rotator cuff can be treated based on the severity of the injury. For mild injuries, a non-surgical remedy may be non-steroidal anti-inflammatory drugs such as ibuprofen. Corticosteroid injections and/or isometric exercises and physical therapy may also help with a mild injury. There are also regenerative medicines being used, such as PRP injections, but they are met with mixed results. For complete, and even some partial tears, surgery is recommended, especially for those who are active they engage in sports or overhead work.  Various surgical techniques, such as tendon repair or acromioplasty, may be used for more intense injuries.

Rotator Cuff Tear. Hospital for Special Surgery. Published January 3, 2025. https://www.hss.edu/health-library/conditions-and-treatments/list/rotator-cuff-tea

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Rotator cuff symptoms can include, and are not limited to: pain when lifting or lowering your elbow, weakness when using the shoulder, limited shoulder mobility, and difficulty when moving the shoulders in specific angles. A rotator cuff diagnosis can come in the form of a physical test, medical imaging, or a combination of the two. Healthcare providers can test your strength and range of motion through various tests to determine which part of the rotator cuff may be damaged. MRIs and Ultrasounds may be used for a suspected rotator cuff tear. X-rays may be used as well, but they may also show signs of other shoulder pains/injuries, like fractures and arthritis.

Torn rotator cuff symptoms, causes and how to know if you need surgery | Cultivating Health. cultivating-health. Published April 16, 2025. https://health.ucdavis.edu/blog/cultivating-health/torn-rotator-cuff-symptoms-causes-and-how-to-know-if-you-need-surgery/2025/04

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Treatment options for a rotator cuff tear depend on the severity of the injury. Minor injuries such as micro-tears could be as simple as rest, relaxation, and icing the joint; allowing the inflammation and injury to naturally heal itself. An intermediate option to treat a rotator cuff injury may include options like physical therapy or steroid injections to reduce inflammation. More complex tears may warrant surgical options that can also vary from a ‘simple’ scoping of the joint to having a complete shoulder replacement that requires removing the humeral head and glenohumeral joint and replacing them with a titanium prosthesis. In regards to the surgical options, the main objective is to alleviate the associated pain in the shoulder, not necessarily to restore complete range of motion.

Citation:

Craig, Richard S, et al. “Shoulder Replacement Surgery for Osteoarthritis and Rotator Cuff Tear Arthropathy.” Cochrane Database of Systematic Reviews, 21 Apr. 2020, https://doi.org/10.1002/14651858.cd012879.pub2. Accessed November 3, 2025.

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Shoulder replacement surgery for osteoarthritis and rotator cuff tear arthropathy

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Shoulder replacement surgery is an established treatment for patients with end‐stage glenohumeral osteoarthritis or rotator cuff tear arthropathy who have not improved with non‐operative treatment. Different types of shoulder replacement are…

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Your doctor may offer surgery as an option for a torn rotator cuff if your pain does not improve with nonsurgical methods. Continued pain is the main reason for having surgery. However, your doctor may also suggest surgery if you are very active and use your arms for overhead work or sports.

Other signs that surgery may be a good option for you include:

Your symptoms have lasted 6 to 12 months

You have a large tear (more than 3 cm) and the quality of the surrounding tendon tissue is good

You have significant weakness and loss of function in your shoulder

Your tear was caused by a recent, acute injury

Surgical Repair Options

There are a few options for repairing rotator cuff tears. Advances in surgical techniques for rotator cuff repair include less invasive procedures. While each of the methods available has its own advantages and disadvantages, all have the same goal: getting the tendon to heal back to bone.

The type of repair performed depends on several factors, including:

Your surgeon's experience and familiarity with a particular procedure

The size of your tear

Your anatomy

The quality of the tendon tissue and bone

Most surgical repairs can be done on an outpatient basis (same-day surgery) and do not require you to stay overnight in the hospital. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

You may have other shoulder problems in addition to a rotator cuff tear, such as:

Biceps tendon tears

Osteoarthritis

Bone spurs

Other soft tissue tears

During the operation, your surgeon may be able to take care of these problems, as well.

The techniques used for rotator cuff repair are:

Open repair

Arthroscopic repair (most common)

In the end, patients rate both repair methods the same for pain relief, strength improvement, and overall satisfaction.

Open Repair

In a traditional open repair, the surgeon makes an incision several centimeters long over the shoulder. They then detach or split part of one of the shoulder muscles (deltoid) to better see and gain access to the torn tendon.

During the procedure, the surgeon typically removes bone spurs from the underside of the acromion (this procedure is called an acromioplasty) in addition to repairing the tear. The surgeon views the shoulder structures directly, instead of viewing them on a video monitor.

An open repair may be a good option if:

The tear is large or complex

Additional reconstruction, such as a tendon transfer, is needed

Open repair was the first technique used for torn rotator cuffs. Over the years, new technology and improved surgeon experience has led to less invasive procedures.

Today, the procedure can often be performed through a smaller open incision than is used in traditional open repair. This is called a mini-open repair.

Arthroscopic Repair

Currently, most rotator cuff tears are repaired arthroscopically.

In an arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays a live video feed on a monitor, and your surgeon uses these images to guide miniature surgical instruments.

Many times orthopedist will try to stat you our with physical therapy to see if you can gain flexibility in the shoulder and gain strength around the shoulder.

References

https://orthoinfo.aaos.org/en/treatment/rotator-cuff-tears-surgical-treatment-options/

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Rotator Cuff Tears: Surgical Treatment Options - OrthoInfo - AAOS

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Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). A partial tear, however, may need only a trimming or smoothing procedure called a debridement. This article contains details about these and other surgical treatments commonly used for rotator cuff tears.

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Some symptoms of a torn rotator cuff can include reduced range of motion as well as pain when raising, lowering, and rotating your arm. Especially when attempting to lift an object overhead. Due to the varying degrees of tears and injuries to a rotator cuff, symptoms can range from a dull aching pain to sensations that feel like being stabbed. To properly diagnose a rotator cuff tear, a variety of diagnostic equipment can be used. An X-ray is able to diagnose bone spurs that may be causing inflammation, MRIs and sonograms can be used to see if the soft tissue has been compromised (such as muscles or tendons) and to what degree the injuries are.

Citation:

Mayo Clinic. Rotator cuff injury - Symptoms and causes. Mayo Clinic. Published May 11, 2023. Accessed November 3, 2025. https://www.mayoclinic.org/diseases-conditions/rotator-cuff-injury/symptoms-causes/syc-20350225

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What are the symptoms of a rotator cuff tear?

Rotator cuff tear symptoms include:

Difficulty, pain and weakness caused by raising, lowering or rotating your arm.

Popping, clicking or crackling sounds or sensations when moving your arm in certain positions.

Shoulder pain that worsens at night or when resting your arm.

Shoulder weakness and struggling to lift items.

What does a rotator cuff tear feel like?

It depends. You may feel a dull ache deep within your shoulder, or it may feel like you're being stabbed with a knife. Sudden tears from accidents or trauma cause immediate, intense shoulder pain and arm weakness. With degenerative tears, you may have mild pain that improves with over-the-counter (OTC) pain relievers. Over time, the pain gets worse, and pain relievers don't help. Not everyone has pain, but most people have some degree of arm and shoulder weakness.

What causes rotator cuff tears?

An accident, such as a fall, can cause a broken collarbone or dislocated shoulder that tears your rotator cuff.

More commonly, rotator cuff tears occur over time as your tendon wears down with age and use (degenerative tear). People over age 40 are most at risk.

Causes of degenerative tears include:

Bony growths can form on the top of your shoulder bone. These bone spurs rub against your tendon when you lift your arm. This shoulder impingement creates friction between your bone and tendon. Eventually, a partial or complete tear may occur.

Decreased blood flow: Blood flow to your rotator cuff decreases as you get older. Your muscles and tendons need a healthy blood supply to repair themselves. If blood doesn't nourish your tendons, they can tear.

Overuse: Repetitive shoulder movements during sports or on the job can stress your muscles and tendons, causing a tear.

What are risk factors for rotator cuff tears?

Anyone can experience a rotator cuff tear. These factors may increase your risk:

Biological family history of shoulder problems or rotator cuff injuries.

Poor posture.

Being age 40 or older.

Degenerative tears are more common among people who do the same repetitive shoulder movements, such as:

Carpenters.

Mechanics.

Painters.

Recreational and professional athletes who play baseball, softball and tennis or are part of a rowing crew.

What are the complications of a rotator cuff tear?

A rotator cuff tear can get worse without treatment. A complete tear can make it almost impossible to move your arm. Without treatment, you may have chronic shoulder pain and find it very difficult to use your injured arm.

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A rotator cuff tear causes shoulder pain and makes arm movements difficult. Your risk of a tear increases with age.

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Four common symptoms

Rotator cuff tears have a direct effect on shoulder movement, and they also cause a few distinctive symptoms, including the four common symptoms listed below. When you visit the doctor, describing your symptoms in detail will help guide diagnosis and treatment.

1. Pain and stiffness when raising your arm

Not surprisingly, rotator cuff tears can cause a significant amount of pain, especially when the tear is more severe. Often, pain presents as more of a dull or throbbing ache that just won’t go away. Since the muscles and tendons also help you move your arm, you may also have stiffness in your shoulder or problems lifting your arm.

2. Crackling or clicking noises when raising your arm

Popping, grinding, grating, clicking, or crackling sensations when you move your arm are another relatively common symptom of rotator cuff tears (and other shoulder injuries, as well).

The medical term for these sensations is crepitus, which happens when there’s excess friction inside or around a joint. Sometimes, crepitus occurs when tendons are inflamed and swollen, and moving causes them to rub against other parts of the joint, creating unpleasant sensations and sometimes, audible creaking or popping sounds.

3. Pain or aching that makes it hard to sleep

When you have a muscle strain, resting often makes the pain subside, at least for a little while. But when a tendon is damaged and torn, you can have pain all day — and all night.

In fact, with a rotator cuff tear, shoulder pain can sometimes feel worse at night, regardless of whether you’re lying on the “bad” side or on your back. Both positions can place extra strain on the muscles and tendons that support your shoulder, making it hard to get comfortable and really difficult to get a good night’s sleep.

4. Shoulder weakness and difficulty gripping or lifting items

Your rotator cuff muscles coordinate with other arm muscles to help you lift objects and even grasp or grab items. When you have a rotator cuff tear, even something as simple as lifting a coffee cup or combing your hair can be painful, and you may find that your arm feels especially weak or uncoordinated.

People need to pay close attention to these symptoms when they first arise. Treatment can be less invasive if it is taken care of quickly instead of waiting to see if it will heal on its own

Reference

https://www.txorthopaedic.com/blog/four-signs-that-youve-torn-your-rotator-cuff/

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There are a few risk factors for a rotator cuff injury, with one of the most notable ones being age. As age increases, the muscles around the shoulder joint weaken. Adults over the age of 60 are at the highest risk. Another risk factor is smoking, which has been said to cause degenerative tears. Lastly, anyone can be at a higher risk for injury depending on the activities of their day job as well as activity level in sports that require repeated motion with the shoulder joint.

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Continuing Education Activity

Rotator cuff pathology is a commonly encountered condition, and the natural history suggests tears increase with increasing age. This activity will discuss the diagnosis and management of the spectrum of disease from tendinopathy to tears. It will also discuss the relationship between the team members involved.
Objectives:

Identify the risks and physical exam findings associated with a complete rotator cuff tear.

Describe the appropriate referral for rotator cuff tear based on the clinical picture.

Review the indications for appropriate imaging (X-ray, MSK ultrasound, and MRI).

Explain the importance of collaboration and communication amongst the interprofessional team to ensure appropriate selection of candidates for rehabilitation, injections, and tendon repair surgery.

Earn continuing education credits (CME/CE) on this topic.
Introduction

The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate. The rotator cuff consists of four muscles originating on the scapula and inserting on the superior humeral head to improve stability. The subscapularis inserts on the lesser tubercle of the humerus, and it functions as an internal rotator. The supraspinatus muscles insert onto the greater tubercle of the humerus with its function as an abductor for the initial 30 degrees of abduction. The infraspinatus also inserts onto the greater tubercle, but a little inferior to the supraspinatus, and it functions as an external rotator. The teres minor inserts inferior to the infraspinatus on the greater tuberosity, and it functions as an external rotator as well. Additionally, they all work as stabilizers of the glenohumeral joint.

Rotator cuff injury runs the full spectrum from injury to tendinopathy to partial tears, and finally complete tears. Age plays a significant role. Injuries ranged from 9.7% in those 20 years and younger increasing to 62% in patients 80 years and older (whether or not symptoms were present).[1] Increasing age and those with unilateral pain are also at risk for a tear in the rotator cuff of the opposite shoulder. A study comparing patients with unilateral shoulder pain, the average age for a patient having no cuff tear was 48.7 years. After age 66, there is a 50% likelihood of bilateral tears. Additionally, age was linked to the presence and type of tear but did not correlate with tear size.[1]

Unfortunately, there is a lack of good evidence on the optimal treatment of tears in patients younger than 40.[2] The tears tend to be more traumatic and likely respond to surgery better, but the role of non-surgical management needs to be better defined.

Etiology

Age is the most common factor for rotator cuff disease. It is a degenerative process that is progressive.[3] Smoking is a known risk factor. A systematic review demonstrated increased rates and sizes of degenerative tears along with symptomatic tears seen in smokers; this has the potential to increase the number of surgeries.[4] Another risk factor is family history. In a study of rotator cuff disease in those under 40 years of age, there was a significant correlation between individuals with RC disease up to third cousins. [4] Interestingly, poor posture has also been shown to be a predictor of rotator cuff disease. Tears were present in 65.8% patients with kyphotic-lordotic postures, 54.3% with flat-back postures, and 48.9% with sway-back postures; tears were present in only 2.9% of patients with ideal alignment.[4] Other risk factors include trauma, hypercholesterolemia, and occupations or activities requiring significant overhead activity.[4][5]

Partial tears are at risk for further propagation. These risk factors include: tear size, symptoms, location, and age. Tear size: A small tear may remain dormant, while larger tears are more likely to undergo structural deterioration. The critical size for sending a small tear towards a larger or complete tear has yet to be defined.[6] Tear propagation correlates with symptom development. Actively enlarging tears have a five times higher likelihood of developing symptoms than those tears that remain the same size.[6] The location of the tear also influences progression. Anterior tears are more likely to progress to cuff degeneration.[6] Finally, age is a risk factor. Patients over age 60 are more likely to develop tears that progress. Younger patients with full-thickness tears appear more capable of adapting to stress and tear propagation than those 60 years of age and older.[6]

Epidemiology

In adults, rotator cuff injury is the most common tendon injury seen and treated. Statistically, approximately 30% of adults age over 60 have a tear, and 62% of adults over 80 have tears.[3] In Germany, a prospective study on 411 asymptomatic shoulders demonstrated a 23% overall prevalence of RC tears with 31% in those of age 70 and 51% in those 80 years of age. [7] Other studies from Europe gave slightly lower results. One study from Austria on 212 asymptomatic shoulders demonstrated only a 6% prevalence of full-thickness tears.[8] A Norwegian study on 420 asymptomatic volunteers ages 50 to 79 revealed FTT in 32 subjects (7.6%).[9]

Pathophysiology

Rotator cuff injury starts from trauma. Macro-trauma causes an acute tear, which is seen generally a younger patient resulting in a complete tear. Micro-trauma causes tendon degeneration and with insufficient healing, leads to degenerative tears. Typically, acute tears happen in younger patients, and degenerative tears occur in older patients. However, a smaller amount of force is needed to cause a complete tear if there is sufficient tendon degeneration.

History and Physical

The history of rotator cuff disease all starts with pain. The pain can be acute and arise from a traumatic event, or it can be gradual and mild, but steadily increasing. Generally, active individuals will present when they can no longer do their sport, activity, or job without causing pain. Often they will try to adapt or alter their biomechanics to remain active. Only when they can no longer adapt will they present. For instance, a baseball pitcher will begin to move their motion from an overhead movement to more of a sidearm throw to try and maintain velocity. Once the pain continues or the velocity drops sufficiently, will they seek care. Depending on when the patient presents, the tendon will be anywhere from tendinopathy to partial tear to complete tear.

Additionally, patients will report increasing pain and difficulty with overhead activity, activities of daily living. They may also report pain when lifting or carrying heavy objects. The pain can occasionally radiate down into the area of the deltoid muscle. Quite often, they will report pain when lying on their side to sleep. In younger patients, overuse tendinopathy is the cause, and older patients often have osteoarthritis as a contributing factor.

On physical exam, tenderness along at the insertion of the supraspinatus, infraspinatus, and teres minor muscles in the greater/lesser tuberosity can be present. With inspection, muscle atrophy may be visible in the supraspinatus or infraspinatus fossa of the scapula.[10] Additionally, checking the cervical range of motion and performing a Spurling test can help look for cervical disc disease as a source of the pain. The next step is to have the patient demonstrate the range of motion in both abduction and flexion. Rotator cuff pathology will cause pain in the range of motion; this is commonly called a painful arc. It is also helpful to observe the scapulothoracic motion. The longer the pain has been present, the more likely patients will develop scapular dyskinesis. Normally, the scapula does not begin to abduct until the arm abducts to 90 degrees. When dyskinesis is present, scapular motion initiates well before the arm reaches 90 degrees of abduction.

There is limited evidence for any of the tests commonly used in diagnosing rotator cuff disease as being very sensitive or specific.[11] The Jobe or empty can test used to evaluate for supraspinatus tendinopathy. The patient elevates the arm to about 90 degrees, and with the thumb down (having an empty can in the patient's hand), isometric force is applied downward. The full can test is a variation where the thumb is up (having a full can in the patient's hand). These tests have high sensitivity but are unfortunately not specific.[4] Next, resisted external rotation is used to evaluate for infraspinatus/teres minor muscle pathology. The patient adducts their arms to their side, and the patient isometrically resists an internal rotation force. For the subscapularis, the belly press is useful for evaluation. The patient places their hand on their abdomen and then resists the examiner's attempt to push the elbow forward off the abdominal wall. Pain or weakness with any of these motions is considered positive tests. If pain limits the exam, a diagnostic subacromial injection can be done to see if reducing the patient's pain improves the exam. Placing an anesthetic agent (lidocaine is the most common choice) in the subacromial space can improve the specificities of these tests.[4]

When considering a rotator cuff tear, there are variations in the tests noted above. If the patient cannot hold the empty can test position, it is called a drop arm test. Next is the external rotation lag sign. With the patient in external rotation, the arm is fully externally rotated. If the patient cannot maintain this position, there is a good chance they have a ruptured supraspinatus and/or infraspinatus muscle.[12] Finally, the inability to keep the hand on the abdominal wall with the belly press test suggests there is a chance the patient has ruptured their subscapularis muscle.

Evaluation

When it comes to shoulder imaging, there are three options: plain radiography, ultrasound, and MRI/MR arthrography. For rotator cuff disease, MR arthrography does not add any additional benefits over and MRI. It is more expensive and requires an intra-articular injection of gadolinium.

Imaging begins with X-rays, and the standard is four views AP, true AP (Grashey view), scapular Y (lateral), and axillary views. The Grashey view activates the deltoid muscle, thus allowing proximal humeral migration. In patients with a chronic, large tear, the proximal humerus will migrate superior. The scapular Y view evaluates for acromial spurs often associated with cuff tears. Finally, the axillary view will show joint space narrowing along with anterior or posterior humeral subluxation.[10]

Ultrasound has become an excellent tool for evaluating the rotator cuff. It is less expensive and has the capability of assessing dynamic movements of the shoulder. A 2013 review article compared MRI, MR arthrography, and ultrasound to diagnose rotator cuff tears. The gold standard was open or arthroscopic surgery gold standard. With partial-thickness tears, both MRI and ultrasound performed well. All three imaging modalities were able to rule in or rule out a full-thickness. For both partial- and full-thickness tears, no significant differenceswere shown of the imaging modalities' abilities to demonstrate a tear.[12] Ultrasound has limitations due to the skill required to obtain appropriate images, and it can be difficult to distinguish between chronic tears and tendinopathies.

MRI remains the gold standard in the US. The images are utilized in pre-procedure planning and can show tear size, location, retraction, muscle atrophy, chronic changes in the tendon and muscle associated with degenerative changes, and other associated pathology.[10][4] All these factors will go into planning a potential surgical procedure.

Treatment / Management

The treatment depends on the age of the patient, their functional demands, and the acuteness vs. chronicity of the tear. For complete tears in patients under 40, surgical treatment is the generally recommended treatment followed by appropriate rehabilitation. These are usually traumatic injuries and respond well to surgery. However, the data is limited and based mostly on studies in older patients.[2]

The American Academy of Orthopedic Surgeons developed some recommendations. They determined high-level evidence of surgical treatment for full-thickness tears was weak.[13] In the same article, the group determined there were appropriate use criteria based on available data and expert opinion. The authors reviewed five classes of treatment. First, non-surgical management is always appropriate, providing they are responding with improved function and decreased pain. Second, repairs can be appropriate even if the patient responds to non-surgical care. Third, for those healthy patients who remain symptomatic, then repair is the appropriate treatment. Fourth, for cases of chronic, massive tears, debridement/partial repair and/or reconstruction may be indicated. Finally, for those with painful pseudoparalysis with an irreparable tear, arthroplasty may be appropriate.[13]

For patients who do respond to non-surgical care, will do so in 6 to 12 weeks.[13]

Any patient with asymptomatic tears should have nonoperative management. Newly diagnosed, symptomatic rotator cuff tears may start with physical therapy addressing both core and scapular muscle strengthening. This approach is associated with similar clinical outcomes when compared to surgical repair for both small and medium-sized tears. Additionally, therapy was is an effective primary treatment modality in most patients, even with full-thickness rotator cuff tears followed over two years. Oddly enough, in this study group, low expectations regarding the efficacy of rehabilitation are the strongest predictor of patients who would eventually go to surgery.[3]Quite often subacromial injections with corticosteroids are frequently employed setting of rotator cuff tears. However, there is little reproducible evidence to support their effectiveness and improve long-term clinical outcomes when used alone.[3]

SLAP or other labral tears

Subacromial impingement from bursitis, os acromiale, bone spurs

Differential Diagnosis

Prognosis

A recent meta-analysis published in 2019 out of the United Kingdom evaluating the treatment outcomes (patient-reported outcomes) demonstrated both surgical and non-surgical treatment groups had the largest improvement at 12 months. Then improvements leveled out. There was no clear advantage of surgery over non-surgical treatments.[14]

An algorithm was developed to help guide with a patient selection where tears categorize into three groups. [10] Group 1: early operative repair. One indication would be patients with an acute event and imaging corroborating the history. Especially with a subscapularis tear with or without biceps tendon instability. In those patients with pain and weakness before the injury would likely be an acute on chronic tear scenario and early intervention can be considered when imaging shows minimal muscle atrophy or degenerative changes should undergo early surgical interventions. Patients younger than 62 to 65 with small and medium-sized tears with minimal to no atrophy on imaging would be another group to consider early operative management. Group 2: In patients with painful partial or full-thickness tears who do not have an acute onset of pain, even if tendons are potentially repairable, they should undergo non-surgical treatment initially. In these cases, rehabilitation has shown consistent benefit in improving function and outcomes. Group 3: should undergo maximal non-surgical treatment. This group would be those who are tendons are unlikely to heal. Included in this group are those over 70 years old, those with chronic full-thickness tears with significant tendon retraction, advanced degenerative changes in the muscles, any signs of proximal humeral migration.

Complications

The most likely complication would be retearing of the cuff repair - this is minimizable with proper patient selection. Postoperative complications, in addition to those generally seen, would be adhesive capsulitis, inability to regain motion, or cuff strength.

Deterrence and Patient Education

No studies examine prevention strategies. Theoretically, proper cuff function can help decrease the risk of degenerative tears. In an observational study, rotator cuff tears were seen more predominately in those with specific postures. Also, in another study looking at radiographically measured subacromial space found reduced acromio-humeral space correlated with hyperkyphotic posture.[4]

Enhancing Healthcare Team Outcomes

Rotator cuff disease is among the most common tendon injuries seen and generally affects the older popular. These patients tend to have more chronic conditions and take more medications. Most patients will do well with conservative measures, but open communication with their primary care physician, physical therapist, and a sports medicine physician will optimize outcomes.

When the decision is made to proceed to surgery, patients may need clearance to undergo anesthesia; this occasionally requires permission from their primary care doctor or other specialists like cardiology, pulmonary, nephrology if they have renal failure or are undergoing dialysis. The team will need to address any chronic metabolic conditions and should look to optimize blood glucose levels, A1C, as well as optimizing any blood coagulation.

After the surgical procedure, clear communication between the operative and post-operative teams of physicians and nurses (including nurses with specialty training in orthopedics) to ensure the continued safety of the patient as they recover is critical. Discussions about medications and medical conditions should be open and frank, so the entire team ensures an appropriate handoff. The nursing staff should perform post-operative monitoring, assist with patient and family education, and coordinate appropriate follow up.

As the patient proceeds with recovery and goes through the (typically long) rehabilitation process, open communication between the surgeon and physical therapist will optimize the patient's recovery. Physical therapists also often have involvement in conservatively managed cases or instances attempting conservative management in an attempt to preclude surgery. The therapist moist report back to the treating clinician with their findings regarding progress or lack thereof.

Managing rotator cuff tears requires an interprofessional team approach, including the clinicians, specialists, orthopedic and surgical nurses, and physical therapists.

Continuing Education / Review Questions

References

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The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate.

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The primary anatomical structures that are involved in a rotator cuff tear are the muscles in the shoulder joint:

1. The subscapularis, which does medial rotation of the shoulder and prevents anterior dislocation of the humerus.

2. The supraspinatus, which does the abduction of the arm.

3. Infraspinatus, which does the lateral rotation of the arm.

4. Teres Minor, which also does lateral rotation of the arm.

5. The humeral head (the ball) allows the humerus head to move freely.

6. The Glenohumeral joint (the socket), which keeps the humeral head secure in place. It also provides a great range of motion for the shoulder.

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Introduction

The rotator cuff is a group of muscles in the shoulder that allow a wide range of movement while maintaining the stability of the glenohumeral joint (see Image. Rotator Cuff Muscles). The rotator cuff includes the following muscles[1][2][3]:

A helpful mnemonic to remember these muscles is "SITS".

The glenohumeral joint is a ball and socket joint and comprises a large spherical humeral head and a small glenoid cavity. This anatomy makes the joint highly mobile, however, really unstable. Stabilization in the shoulder is provided collectively by the non-contractile tissue of the glenohumeral joint (static stabilizers) such as the capsule, the labrum, the negative intraarticular pressure, and the glenohumeral ligaments; and the contractile tissues (dynamic stabilizers) such as the rotator cuff muscles and the long head of the biceps brachii. See Image. Muscles and Fascia of the Shoulder.

Structure and Function

The primary biomechanical role of the rotator cuff is to stabilize the glenohumeral joint by compressing the humeral head against the glenoid. These four muscles arise from the scapula and insert into the humerus. The tendons of the rotator cuff muscles blend with the joint capsule and form a musculotendinous collar that surrounds the posterior, superior, and anterior aspects of the joint, leaving the inferior aspect unprotected. This arrangement is an important factor since most shoulder luxations occur because the humerus slides inferiorly through the unprotected part of the joint. During arm movements, the rotator muscles contract and prevent the sliding of the head of the humerus, allowing full range of motion and providing stability.

Additionally, rotator cuff muscles help in the mobility of the shoulder joint by facilitating abduction, medial rotation, and lateral rotation.

Subscapularis: Medial (internal) rotation of the shoulder

Supraspinatus: Abduction of the arm

Necessary for the initial 0 to 15 degrees of shoulder abduction motion

The deltoid muscle abducts the arm beyond 15 degrees

Infraspinatus: Lateral (external) rotation of the shoulder

Teres Minor: Lateral (external) rotation of the shoulder

During physical examination, each muscle can be evaluated independently based on its specific movements.

Embryology

Mesoderm gives rise to the muscles and ligaments in the body.

Blood Supply and Lymphatics

The vascular supply to the rotator cuff muscles is mainly via the suprascapular artery, the subscapular artery, and the posterior circumflex humeral artery.

The suprascapular artery is a branch of the thyrocervical trunk (a major branch of the subclavian artery) and originates at the base of the neck. It enters the posterior scapular region superior to the suprascapular foramen (the nerve passes through the foramen) and supplies the supraspinatus and infraspinatus muscles.

The subscapular artery is the largest branch of the axillary artery. It originates from the third part of the axillary artery, follows the inferior margin of the subscapularis muscle, and then divides into the circumflex scapular artery and the thoracodorsal artery. It gives vascular supply to the subscapularis muscle.

The posterior circumflex humeral artery originates from the third part of the axillary artery in the axilla. It enters the posterior scapular region through the quadrangular space (accompanied by the axillary nerve) and supplies the teres minor muscle.

All lymphatics from the upper limb drain into lymph nodes in the axilla.

Nerves

The subscapular nerve (upper and lower branches) innervates the subscapularis muscle.

Originate from the posterior cord of the brachial plexus

The suprascapular nerve innervates the infraspinatus and supraspinatus

Originates from the superior trunk of the brachial plexus

Passes through the suprascapular foramen

The axillary nerve innervates teres minor

Originates from the posterior cord of the brachial plexus

Passes through the quadrangular space into the posterior scapula region

Muscles

The subscapularis is the largest component of the posterior wall of the axilla. It prevents the anterior dislocation of the humerus during abduction and medially rotates the humerus. A large bursa separates the muscle from the neck of the scapula [4].

The supraspinatus muscle is the only muscle of the rotator cuff that is not a rotator of the humerus.

Origin: supraspinous fossa of the scapula

Passes above the glenohumeral joint

Insertion: greater tuberosity of the humerus

The infraspinatus is a powerful lateral rotator of the humerus. The tendon of this muscle is sometimes separated from the capsule of the glenohumeral joint by a bursa.

Origin: infraspinous fossa of the scapula

Insertion: greater tuberosity of the humerus, immediately below the supraspinatus.

The teres minor is a narrow and long muscle entirely covered by the deltoid, hardly differentiated from the infraspinatus.

Origin: lateral border of the scapula (below the infraglenoid tubercle)

Insertion: greater tuberosity of the humerus, below the infraspinatus tendon.

Clinical Significance

Physical Examination[5]

Rotator cuff muscles can undergo independent evaluation when the patient presents with rotator cuff syndrome.

Supraspinatus muscle: The evaluation of this muscle is with the Jobe's test, commonly known as the "empty can" test. It is done with a 90 degrees abduction and internal rotation (thumb pointing to the floor) of the arm while pressing down on the arm. The test is positive if this is painful or weak.

Infraspinatus muscle: Evaluation of this muscle is via lateral rotation against resistance with the elbow flexed and the arm in a neutral abduction/adduction position.

Teres minor muscle: This muscle's evaluation is with the hornblower's test, done with the arm at 90 degrees abduction, the elbow flexed (90 degrees), and doing a lateral rotation against resistance. The test is positive if this is painful or weak.

Subscapularis muscle: Evaluating this muscle uses the "lift-off" and the "bear hug" test. In the lift-off test, the patient brings the hands around the back to the lumbar region with the palms facing outward. The test is positive if the patient is unable to lift the hands away from the back. On the Bear hug test, the patient places the ipsilateral palm on the opposite deltoid and tries to resist the examiner pulling it away anteriorly.

Rotator cuff syndrome (RCS) describes a spectrum of clinical pathology ranging from minor injuries such as acute rotator cuff tendinitis to advanced/chronic rotator cuff tendinopathy and degenerative conditions.

Rotator cuff injuries represent a common cause of shoulder pain. The rotator cuff tendons, particularly the supraspinatus tendon, are uniquely susceptible to the compressive forces of subacromial impingement. Improper athletic technique, poor posture, poor conditioning, and failure of the subacromial bursa to protect the supporting tendons results in a progressive injury from acute inflammation, to calcification, to degenerative thinning, and finally to a tendon tear (see Image. Rotator Cuff Tear).

Rotator cuff (RC) Tendonitis/Tendinosis

Internal impingement[9]: Common in overhead-throwing athletes such as baseball pitchers and javelin throwers. Impingement occurs at the posterior/lateral articular side of the cuff as it abuts the posterior/superior glenoid rim and labrum when the shoulder is in maximum abduction and external rotation (i.e., the "late cocking" phase of throwing)

The term "thrower's shoulder" refers to a common set of anatomic adaptive changes that occur over time in this subset of athletes.

These adaptive changes include but are not limited to increased humeral retroversion and posterior capsular tightness.

Glenohumeral internal rotation deficit (GIRD) is a condition resulting from these anatomic adaptations, and GIRD is known to predispose the thrower's shoulder to internal impingement.

External impingement: a term used synonymously with SIS. External impingement (EI) encompasses etiologies of external compressive sources (i.e., the acromion), leading to subacromial bursitis and bursal-sided injuries to the RC [10].

Acute or chronic tendinopathic conditions that result from a vulnerable environment for the RC secondary to repetitive eccentric forces and predisposing anatomical/mechanical risk factors.

Shoulder Impingement

A clinical term often used nonspecifically to describe patients experiencing pain/symptoms with overhead activities. It is best to subdivide shoulder impingement into internal and external conditions:

History and Physical for RCS

The primary complaint is shoulder pain localized on the lateral aspect. It worsens with overhead activities, and patients often describe a painful arc during flexion and abduction at 60 degrees to 120 degrees and report pain at night due to lying on the same side. The presentation can be acute or chronic in onset. Young patients usually have an acute presentation because of a recent traumatic event or significant overexertion (e.g., lifting a heavy box). The function is often significantly impaired. Older patients or patients with repetitive overhead activities present chronically, and the loss of strength and function occurs gradually. The range of motion is normal, with positive provocative tests like Hawkins (pain on passive forced internal rotation of the shoulder). The drop arm test is confirmatory. If weakness is present on shoulder abduction, a rotator cuff tear should be suspected (MRI is the best test for diagnosis of rotator cuff tear).

The American Academy of Orthopedic Surgeons (AAOS) suggests patients with rotator cuff problems without tears can be treated conservatively with exercise and NSAIDs. The patient must understand to limit overhead activities and to use ice packs or heating pads. Proper physical therapy effectively treats most patients without subacromial decompression. No difference in outcome has been reported for surgery over physical therapy in several trials. Subacromial injection with steroids showed a short-term benefit in some trials and may improve a patient's compliance with physical therapy. Surgical consultation merits consideration if symptoms do not improve three months after conservative management. Arthroscopic acromioplasty may be a topic to discuss with the patient.

Partial- versus Full-Thickness Rotator Cuff Tears

Etiologies and underlying causes are known to be multifactorial. Degeneration, impingement, and tension overload due to trauma may all lead to rotator cuff tears. Most often, the tears initially begin as partial tears of the supraspinatus tendon. Eventually, they can progress to full-thickness tears including all four of the rotator cuff muscles.

It primarily presents in middle-aged to older patients. Repetitive overhead activities are commonly the reason for younger athletes.

History and Physical

Pain and weakness are the presenting symptoms. Pain is prominent over the lateral deltoid, worsens with overhead activities, and by lying on the side at night. The absence of pain, however, does not exclude the diagnosis because a chunk of patients may also be asymptomatic. In fact, partial thickness tears cause more pain and disability than full-thickness tears. Painful arc test, drop arm test, and weakness in the external rotation is the most common observations on physical examination.

X-rays are usually normal and can help in diagnosing large rotator cuff tears if imaging shows humeral migration over the glenoid, and the patient has a symptomatic shoulder.

MRI can provide key information as to the degree of muscle tear, tendon retraction, and muscle atrophy, which is critical in planning for rotator cuff repair.

Treatment

Conservative treatment with NSAIDs, and most importantly, physical therapy, should be the first attempt at therapy. Surgical treatment with arthroscopy is done in cases of both acute or chronic full-thickness tears since delay can result in significant muscle atrophy, tendon retraction, and poorer surgical results.

References

1.

Varacallo M, El Bitar Y, Sina RE, Mair SD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Mar 5, 2024. Rotator Cuff Syndrome. [ PubMed: 30285401 ]

2.

Varacallo MA, El Bitar Y, Mair SD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 4, 2023. Rotator Cuff Tendonitis. [ PubMed: 30335303 ]

3.

Cowan PT, Mudreac A, Varacallo MA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 8, 2023. Anatomy, Back, Scapula. [ PubMed: 30285370 ]

4.

5.

6.

7.

Inderhaug E, Kalsvik M, Kollevold KH, Hegna J, Solheim E. Long-term results after surgical treatment of subacromial pain syndrome with or without rotator cuff tear. J Orthop. 2018 Sep;15(3):757-760. [ PMC free article: PMC6014565 ] [ PubMed: 29946199 ]

8.

9.

10.

11.

Disclosure: Smita Maruvada declares no relevant financial relationships with ineligible companies.

Disclosure: Antonio Madrazo-Ibarra declares no relevant financial relationships with ineligible companies.

Disclosure: Matthew Varacallo declares no relevant financial relationships with ineligible companies.

# data[].attributes.attachment_link.description
The rotator cuff is a group of muscles in the shoulder that allow a wide range of movement while maintaining the stability of the glenohumeral joint (see Image. Rotator Cuff Muscles). The rotator cuff includes the following muscles[1][2][3]:

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The rotator cuff is a group of muscles and tendons that surround the shoulder joint. These muscles keep the ball of the upper arm bone firmly within the shallow socket of the shoulder. A rotator cuff injury can cause a dull ache in the shoulder that worsens at night.

Rotator cuff injuries are common and increase with age. These injuries may occur earlier in people who have jobs that require repeatedly performing overhead motions, such as painters and carpenters.

Physical therapy exercises can improve flexibility and strength of the muscles surrounding the shoulder joint. For many people with rotator cuff problems, these exercises are all that's needed to manage their symptoms.

Sometimes, rotator cuff tears may occur from a single injury. In those circumstances, people should seek medical advice quickly because they might need surgery.

Symptoms

The pain associated with a rotator cuff injury may:

Be described as a dull ache deep in the shoulder.

Disturb sleep.

Make it difficult to comb your hair or reach behind your back.

Be accompanied by arm weakness.

Some rotator cuff injuries don't cause pain.

When to see a doctor

Your family healthcare professional can evaluate short-term shoulder pain. See your care team right away if you have immediate weakness in your arm after an injury.

Citation

Mayo Foundation for Medical Education and Research. (2025, May 22). Rotator cuff injury. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/rotator-cuff-injury/symptoms-causes/syc-20350225

All too often I have clients that hurt their shoulder and refuse to seek medical attention. They do not want to miss work, or go under the knife. This ends up hurting them in the long run, because they keep barring weight on the joints and ligaments and end up with a complete tear or something worse

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What are common rotator cuff injuries?

Rotator cuff injuries are common because you use them so often for so many activities throughout your day. Injuries can happen suddenly or build up over time. Rotator cuff damage is a common sports injury.

The most common rotator cuff injuries include:

Overuse syndrome.

Shoulder impingement syndrome (rotator cuff tendinitis).

Rotator cuff tears.

Shoulder sprains.

Swimmer’s shoulder.

How do I know if I tore my rotator cuff?

Rotator cuff tears cause shoulder pain. You may feel a dull ache deep within your shoulder, or the pain may feel sharp and stabbing. Sudden tears from traumas cause immediate, intense shoulder pain and arm weakness.

Visit a healthcare provider if you’re experiencing shoulder pain that doesn’t get better in a few days. Go to the emergency room if you can’t move your shoulder or experience trauma.

Which tests do providers use to diagnose injuries?

A healthcare provider will diagnose a rotator cuff injury with a physical exam and some imaging tests. They’ll examine your shoulder and ask about your symptoms. Tell them when you first noticed pain, and if any activities make your symptoms feel better or worse.

You might need a few tests, including:

Shoulder X-ray.

Magnetic resonance imaging (MRI).

Ultrasound.

What are common treatments for rotator cuff injuries?

Which treatments you’ll need depends on which injury you have and its severity. Your provider will suggest treatments to relieve pain and help your rotator cuff heal, including:

Rest and avoiding the physical activity that caused the injury.

Icing your shoulder. Your provider will tell you how often (and for how long) you should ice your shoulder. Wrap ice packs in a thin towel to avoid putting them directly on your skin.

Over-the-counter NSAIDs (nonsteroidal anti-inflammatory drugs) or acetaminophen relieve pain and reduce inflammation. Don’t take pain relievers for more than 10 days in a row without talking to your provider.

Physical therapy can strengthen your shoulder muscles and help you regain your mobility, especially after an injury. A physical therapist will give you rotator cuff exercises to increase your strength and flexibility.

Your provider may give you cortisone shots (steroid injections) — doses of corticosteroids (prescription anti-inflammatory medications) injected into your rotator cuff.

You may need surgery to repair serious injuries or if other, nonsurgical treatments don’t relieve your symptoms after a few months. Your provider or surgeon will tell you which type of surgery you’ll need and what to expect.

Care

How can I prevent rotator cuff injuries?

The best way to prevent rotator cuff injuries is to avoid overusing your shoulders:

Stop exercise or physical activities as soon as you feel pain. Never “play through the pain” if your shoulder hurts during or after physical activity.

Warm up and cool down before and after training or working out.

Wear the right equipment for all sports and physical work.

Follow a diet and physical activity plan that’s healthy for you.

Visit a healthcare provider as soon as you notice pain or other symptoms.

Can a rotator cuff heal on its own?

Rest and avoiding physical activities can help your rotator cuff heal, but you should always get injuries examined and diagnosed by a healthcare provider. Don’t ignore symptoms like pain, weakness or a reduced range of motion (how far you can move your shoulder).

Continuing to use your shoulder or putting more stress on your rotator cuff can make minor injuries worse.

professional, C. C. medical. (2025, May 24). What is the anatomy of the rotator cuff?. Cleveland Clinic. https://my.clevelandclinic.org/health/body/rotator-cuff

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Rotator cuff injury can be common due to the tight space in which they move and are confined in. The friction that can be cause by moving the shoulder to the limit by its natural range of motion can cause inflammation, and if this inflammation build up, it can cause tears. Injuries can include rotator cuff tendonitits, shoulder bursitis, or even complete rotato cuff tears. Athletic movements such as throwing a baseball, push-ups, or even swimming make the arm reach overhead, thus pushing the shoulder and the rotaro cuff muscles in a stretched state. Non-atletic moements like painting, or starting a lawn mower can be abrupt, causing strain to the shoulder. While tears can happen, simple inflammation can cause pain when the arm is rotaed, or lifted upward. Without treatment, pain from strains or tears can last months to years, impeding day to day life, and presenting pain with the simplest of shoulder movements.

Harvard Health Publishing. Rotator Cuff Injury - Harvard Health. Harvard Health. Published December 19, 2018. https://www.health.harvard.edu/a_to_z/rotator-cuff-injury-a-to-z

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The rotator cuff is a group of 4 muscles: supraspinatus, infraspinatus, subscapularis, teres minor.

Supraspinatus: Deals with adduction of the shoulder, helping you move your arm to your side, away from the midline of the body.

Infraspinatus: Facilitates external rotation which is the rotation of your arm outward of the shoulder. It also helps keep the shoulder joint in its socket, especially during more strenuous activities.

Subscapularis: The largest muscle of the rotator cuff which helps with internal rotation. It helps stabalize the ball of the shoulder to the socket, during movements such as pushing or lifting.

Teres Minor: It is adjacent, and below the Infradpinatus, and it also helps facilitate rotation, despite being a much smaller muscle. It is more active when the arm is in certain positions and angles.

All these muscles are held together by tendons connected to the humeral head, or the ball part of the shoulder joint.

Rotator Cuff Tear. Hospital for Special Surgery. Published January 3, 2025. https://www.hss.edu/health-library/conditions-and-treatments/list/rotator-cuff-tear#injury

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Rotator cuff tears are most commonly caused by micro or macro traumas. These traumas are easily defined as small tears. An example of a macro-trauma would be a quarterback taking several hits during a football game, then in the fourth quarter, attempting to throw a 60 yard pass to which his subscapularis would tear due to the intensity of the throw coupled with the trauma he has received over the prior 50 minutes.

An example of micro-trauma could be doing a labor intensive job for 20 years. Preforming continuous manual labor creates small tears in the muscle which never fully heal. Over time all of the small micro-tears ultimately succumb to the repetitive traumas and cause a complete tear of the muscle.

Citation:

Aguirre K, Mudreac A, Kiel J. Anatomy, Shoulder and Upper Limb, Subscapularis Muscle. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.

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Anatomy, Shoulder and Upper Limb, Subscapularis Muscle

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The subscapularis muscle is a large and powerful triangle-shaped muscle originating at the subscapular fossa and inserting at the lesser tubercle of the humerus. The muscle derives its name from its orientation under the scapula: sub (under) scapula (wing bone). The subscapularis is one of the four muscles which compose the rotator cuff apparatus. The other three are the supraspinatus, infraspinatus, and teres minor muscles. The subscapularis muscle’s primary function is internal rotation but can also aid in adducting the humerus. The subscapularis nerve innervates the muscle. The subscapular artery provides blood supply, and lymph drainage flows into the axillary nodes. This muscle and tendon are less likely to tear than other rotator cuff muscles.[1][2]

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The primary anatomical structures involved in rotator cuff tears are:

- The supraspinatus muscle, which starts at the posteriosuperior part of the scapula, wraps around and stabilize the head of the humerus.

- The infraspinatus muscle, which starts at the posterior part of the scapula, wraps around the humeral head, and allows the humerous to externally rotate.

- The teres minor, which is on the posterolateral section of the scapula, and is a supporting and stabilizing muscle for the humeral head.

- The subscapularis, located on the anterior surface of the scapula, this muscle allows the humerus to rotate internally.

- The humeral head, commonly referred to as the 'ball joint' is located on the superior part of the humerus, and allows the humerus to move freely.

- Finally, the glenohumeral joint, commonly referred to as the socket joint. This joint makes the final piece of the puzzle and keeps the humeral head securely in place with the help of the stabilizer muscles while allowing excellent range of motion.

Citation:

May T, Garmel GM. Rotator Cuff Injury. NCBI Bookshelf. Published June 26, 2023. Accessed October 24, 2025. https://www.ncbi.nlm.nih.gov/books/NBK547664/

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Continuing Education Activity

Rotator cuff pathology is a commonly encountered condition, and the natural history suggests tears increase with increasing age. This activity will discuss the diagnosis and management of the spectrum of disease from tendinopathy to tears. It will also discuss the relationship between the team members involved.
Objectives:

Identify the risks and physical exam findings associated with a complete rotator cuff tear.

Describe the appropriate referral for rotator cuff tear based on the clinical picture.

Review the indications for appropriate imaging (X-ray, MSK ultrasound, and MRI).

Explain the importance of collaboration and communication amongst the interprofessional team to ensure appropriate selection of candidates for rehabilitation, injections, and tendon repair surgery.

Earn continuing education credits (CME/CE) on this topic.
Introduction

The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate. The rotator cuff consists of four muscles originating on the scapula and inserting on the superior humeral head to improve stability. The subscapularis inserts on the lesser tubercle of the humerus, and it functions as an internal rotator. The supraspinatus muscles insert onto the greater tubercle of the humerus with its function as an abductor for the initial 30 degrees of abduction. The infraspinatus also inserts onto the greater tubercle, but a little inferior to the supraspinatus, and it functions as an external rotator. The teres minor inserts inferior to the infraspinatus on the greater tuberosity, and it functions as an external rotator as well. Additionally, they all work as stabilizers of the glenohumeral joint.

Rotator cuff injury runs the full spectrum from injury to tendinopathy to partial tears, and finally complete tears. Age plays a significant role. Injuries ranged from 9.7% in those 20 years and younger increasing to 62% in patients 80 years and older (whether or not symptoms were present).[1] Increasing age and those with unilateral pain are also at risk for a tear in the rotator cuff of the opposite shoulder. A study comparing patients with unilateral shoulder pain, the average age for a patient having no cuff tear was 48.7 years. After age 66, there is a 50% likelihood of bilateral tears. Additionally, age was linked to the presence and type of tear but did not correlate with tear size.[1]

Unfortunately, there is a lack of good evidence on the optimal treatment of tears in patients younger than 40.[2] The tears tend to be more traumatic and likely respond to surgery better, but the role of non-surgical management needs to be better defined.

Etiology

Age is the most common factor for rotator cuff disease. It is a degenerative process that is progressive.[3] Smoking is a known risk factor. A systematic review demonstrated increased rates and sizes of degenerative tears along with symptomatic tears seen in smokers; this has the potential to increase the number of surgeries.[4] Another risk factor is family history. In a study of rotator cuff disease in those under 40 years of age, there was a significant correlation between individuals with RC disease up to third cousins. [4] Interestingly, poor posture has also been shown to be a predictor of rotator cuff disease. Tears were present in 65.8% patients with kyphotic-lordotic postures, 54.3% with flat-back postures, and 48.9% with sway-back postures; tears were present in only 2.9% of patients with ideal alignment.[4] Other risk factors include trauma, hypercholesterolemia, and occupations or activities requiring significant overhead activity.[4][5]

Partial tears are at risk for further propagation. These risk factors include: tear size, symptoms, location, and age. Tear size: A small tear may remain dormant, while larger tears are more likely to undergo structural deterioration. The critical size for sending a small tear towards a larger or complete tear has yet to be defined.[6] Tear propagation correlates with symptom development. Actively enlarging tears have a five times higher likelihood of developing symptoms than those tears that remain the same size.[6] The location of the tear also influences progression. Anterior tears are more likely to progress to cuff degeneration.[6] Finally, age is a risk factor. Patients over age 60 are more likely to develop tears that progress. Younger patients with full-thickness tears appear more capable of adapting to stress and tear propagation than those 60 years of age and older.[6]

Epidemiology

In adults, rotator cuff injury is the most common tendon injury seen and treated. Statistically, approximately 30% of adults age over 60 have a tear, and 62% of adults over 80 have tears.[3] In Germany, a prospective study on 411 asymptomatic shoulders demonstrated a 23% overall prevalence of RC tears with 31% in those of age 70 and 51% in those 80 years of age. [7] Other studies from Europe gave slightly lower results. One study from Austria on 212 asymptomatic shoulders demonstrated only a 6% prevalence of full-thickness tears.[8] A Norwegian study on 420 asymptomatic volunteers ages 50 to 79 revealed FTT in 32 subjects (7.6%).[9]

Pathophysiology

Rotator cuff injury starts from trauma. Macro-trauma causes an acute tear, which is seen generally a younger patient resulting in a complete tear. Micro-trauma causes tendon degeneration and with insufficient healing, leads to degenerative tears. Typically, acute tears happen in younger patients, and degenerative tears occur in older patients. However, a smaller amount of force is needed to cause a complete tear if there is sufficient tendon degeneration.

History and Physical

The history of rotator cuff disease all starts with pain. The pain can be acute and arise from a traumatic event, or it can be gradual and mild, but steadily increasing. Generally, active individuals will present when they can no longer do their sport, activity, or job without causing pain. Often they will try to adapt or alter their biomechanics to remain active. Only when they can no longer adapt will they present. For instance, a baseball pitcher will begin to move their motion from an overhead movement to more of a sidearm throw to try and maintain velocity. Once the pain continues or the velocity drops sufficiently, will they seek care. Depending on when the patient presents, the tendon will be anywhere from tendinopathy to partial tear to complete tear.

Additionally, patients will report increasing pain and difficulty with overhead activity, activities of daily living. They may also report pain when lifting or carrying heavy objects. The pain can occasionally radiate down into the area of the deltoid muscle. Quite often, they will report pain when lying on their side to sleep. In younger patients, overuse tendinopathy is the cause, and older patients often have osteoarthritis as a contributing factor.

On physical exam, tenderness along at the insertion of the supraspinatus, infraspinatus, and teres minor muscles in the greater/lesser tuberosity can be present. With inspection, muscle atrophy may be visible in the supraspinatus or infraspinatus fossa of the scapula.[10] Additionally, checking the cervical range of motion and performing a Spurling test can help look for cervical disc disease as a source of the pain. The next step is to have the patient demonstrate the range of motion in both abduction and flexion. Rotator cuff pathology will cause pain in the range of motion; this is commonly called a painful arc. It is also helpful to observe the scapulothoracic motion. The longer the pain has been present, the more likely patients will develop scapular dyskinesis. Normally, the scapula does not begin to abduct until the arm abducts to 90 degrees. When dyskinesis is present, scapular motion initiates well before the arm reaches 90 degrees of abduction.

There is limited evidence for any of the tests commonly used in diagnosing rotator cuff disease as being very sensitive or specific.[11] The Jobe or empty can test used to evaluate for supraspinatus tendinopathy. The patient elevates the arm to about 90 degrees, and with the thumb down (having an empty can in the patient's hand), isometric force is applied downward. The full can test is a variation where the thumb is up (having a full can in the patient's hand). These tests have high sensitivity but are unfortunately not specific.[4] Next, resisted external rotation is used to evaluate for infraspinatus/teres minor muscle pathology. The patient adducts their arms to their side, and the patient isometrically resists an internal rotation force. For the subscapularis, the belly press is useful for evaluation. The patient places their hand on their abdomen and then resists the examiner's attempt to push the elbow forward off the abdominal wall. Pain or weakness with any of these motions is considered positive tests. If pain limits the exam, a diagnostic subacromial injection can be done to see if reducing the patient's pain improves the exam. Placing an anesthetic agent (lidocaine is the most common choice) in the subacromial space can improve the specificities of these tests.[4]

When considering a rotator cuff tear, there are variations in the tests noted above. If the patient cannot hold the empty can test position, it is called a drop arm test. Next is the external rotation lag sign. With the patient in external rotation, the arm is fully externally rotated. If the patient cannot maintain this position, there is a good chance they have a ruptured supraspinatus and/or infraspinatus muscle.[12] Finally, the inability to keep the hand on the abdominal wall with the belly press test suggests there is a chance the patient has ruptured their subscapularis muscle.

Evaluation

When it comes to shoulder imaging, there are three options: plain radiography, ultrasound, and MRI/MR arthrography. For rotator cuff disease, MR arthrography does not add any additional benefits over and MRI. It is more expensive and requires an intra-articular injection of gadolinium.

Imaging begins with X-rays, and the standard is four views AP, true AP (Grashey view), scapular Y (lateral), and axillary views. The Grashey view activates the deltoid muscle, thus allowing proximal humeral migration. In patients with a chronic, large tear, the proximal humerus will migrate superior. The scapular Y view evaluates for acromial spurs often associated with cuff tears. Finally, the axillary view will show joint space narrowing along with anterior or posterior humeral subluxation.[10]

Ultrasound has become an excellent tool for evaluating the rotator cuff. It is less expensive and has the capability of assessing dynamic movements of the shoulder. A 2013 review article compared MRI, MR arthrography, and ultrasound to diagnose rotator cuff tears. The gold standard was open or arthroscopic surgery gold standard. With partial-thickness tears, both MRI and ultrasound performed well. All three imaging modalities were able to rule in or rule out a full-thickness. For both partial- and full-thickness tears, no significant differenceswere shown of the imaging modalities' abilities to demonstrate a tear.[12] Ultrasound has limitations due to the skill required to obtain appropriate images, and it can be difficult to distinguish between chronic tears and tendinopathies.

MRI remains the gold standard in the US. The images are utilized in pre-procedure planning and can show tear size, location, retraction, muscle atrophy, chronic changes in the tendon and muscle associated with degenerative changes, and other associated pathology.[10][4] All these factors will go into planning a potential surgical procedure.

Treatment / Management

The treatment depends on the age of the patient, their functional demands, and the acuteness vs. chronicity of the tear. For complete tears in patients under 40, surgical treatment is the generally recommended treatment followed by appropriate rehabilitation. These are usually traumatic injuries and respond well to surgery. However, the data is limited and based mostly on studies in older patients.[2]

The American Academy of Orthopedic Surgeons developed some recommendations. They determined high-level evidence of surgical treatment for full-thickness tears was weak.[13] In the same article, the group determined there were appropriate use criteria based on available data and expert opinion. The authors reviewed five classes of treatment. First, non-surgical management is always appropriate, providing they are responding with improved function and decreased pain. Second, repairs can be appropriate even if the patient responds to non-surgical care. Third, for those healthy patients who remain symptomatic, then repair is the appropriate treatment. Fourth, for cases of chronic, massive tears, debridement/partial repair and/or reconstruction may be indicated. Finally, for those with painful pseudoparalysis with an irreparable tear, arthroplasty may be appropriate.[13]

For patients who do respond to non-surgical care, will do so in 6 to 12 weeks.[13]

Any patient with asymptomatic tears should have nonoperative management. Newly diagnosed, symptomatic rotator cuff tears may start with physical therapy addressing both core and scapular muscle strengthening. This approach is associated with similar clinical outcomes when compared to surgical repair for both small and medium-sized tears. Additionally, therapy was is an effective primary treatment modality in most patients, even with full-thickness rotator cuff tears followed over two years. Oddly enough, in this study group, low expectations regarding the efficacy of rehabilitation are the strongest predictor of patients who would eventually go to surgery.[3]Quite often subacromial injections with corticosteroids are frequently employed setting of rotator cuff tears. However, there is little reproducible evidence to support their effectiveness and improve long-term clinical outcomes when used alone.[3]

SLAP or other labral tears

Subacromial impingement from bursitis, os acromiale, bone spurs

Differential Diagnosis

Prognosis

A recent meta-analysis published in 2019 out of the United Kingdom evaluating the treatment outcomes (patient-reported outcomes) demonstrated both surgical and non-surgical treatment groups had the largest improvement at 12 months. Then improvements leveled out. There was no clear advantage of surgery over non-surgical treatments.[14]

An algorithm was developed to help guide with a patient selection where tears categorize into three groups. [10] Group 1: early operative repair. One indication would be patients with an acute event and imaging corroborating the history. Especially with a subscapularis tear with or without biceps tendon instability. In those patients with pain and weakness before the injury would likely be an acute on chronic tear scenario and early intervention can be considered when imaging shows minimal muscle atrophy or degenerative changes should undergo early surgical interventions. Patients younger than 62 to 65 with small and medium-sized tears with minimal to no atrophy on imaging would be another group to consider early operative management. Group 2: In patients with painful partial or full-thickness tears who do not have an acute onset of pain, even if tendons are potentially repairable, they should undergo non-surgical treatment initially. In these cases, rehabilitation has shown consistent benefit in improving function and outcomes. Group 3: should undergo maximal non-surgical treatment. This group would be those who are tendons are unlikely to heal. Included in this group are those over 70 years old, those with chronic full-thickness tears with significant tendon retraction, advanced degenerative changes in the muscles, any signs of proximal humeral migration.

Complications

The most likely complication would be retearing of the cuff repair - this is minimizable with proper patient selection. Postoperative complications, in addition to those generally seen, would be adhesive capsulitis, inability to regain motion, or cuff strength.

Deterrence and Patient Education

No studies examine prevention strategies. Theoretically, proper cuff function can help decrease the risk of degenerative tears. In an observational study, rotator cuff tears were seen more predominately in those with specific postures. Also, in another study looking at radiographically measured subacromial space found reduced acromio-humeral space correlated with hyperkyphotic posture.[4]

Enhancing Healthcare Team Outcomes

Rotator cuff disease is among the most common tendon injuries seen and generally affects the older popular. These patients tend to have more chronic conditions and take more medications. Most patients will do well with conservative measures, but open communication with their primary care physician, physical therapist, and a sports medicine physician will optimize outcomes.

When the decision is made to proceed to surgery, patients may need clearance to undergo anesthesia; this occasionally requires permission from their primary care doctor or other specialists like cardiology, pulmonary, nephrology if they have renal failure or are undergoing dialysis. The team will need to address any chronic metabolic conditions and should look to optimize blood glucose levels, A1C, as well as optimizing any blood coagulation.

After the surgical procedure, clear communication between the operative and post-operative teams of physicians and nurses (including nurses with specialty training in orthopedics) to ensure the continued safety of the patient as they recover is critical. Discussions about medications and medical conditions should be open and frank, so the entire team ensures an appropriate handoff. The nursing staff should perform post-operative monitoring, assist with patient and family education, and coordinate appropriate follow up.

As the patient proceeds with recovery and goes through the (typically long) rehabilitation process, open communication between the surgeon and physical therapist will optimize the patient's recovery. Physical therapists also often have involvement in conservatively managed cases or instances attempting conservative management in an attempt to preclude surgery. The therapist moist report back to the treating clinician with their findings regarding progress or lack thereof.

Managing rotator cuff tears requires an interprofessional team approach, including the clinicians, specialists, orthopedic and surgical nurses, and physical therapists.

Continuing Education / Review Questions

References

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The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate.

# data[].attributes.body
Something I found particularly interesting regarding the cause of rotator cuff injuries was that it may not be just from overuse. People over the age of 40 are at the highest risk, and a big reason for that can be due to decreased blood flow. As we age, blood flow to the rotator cuff decreases, which can impede the muscle’s and tendon’s ability to repair themselves. Without blood nourishing them, muscles and tendons have a higher susceptibility to tears. Another interesting cause can be due to bone spurs. Bone spurs, at the top of your shoulder, can rub up on the tendon as you bring your arm up. This shoulder impingement can create the needed friction to cause a tear in the rotator cuff.

Cleveland Clinic. Rotator Cuff Tear. Cleveland Clinic. Published August 21, 2023. https://my.clevelandclinic.org/health/diseases/8291-rotator-cuff-tear

# data[].attributes.body
Rotator cuff injuries are quite common. According to some estimates, rotator cuff tears in the general population over the age of 20 are 20%. That number increases to 25% in those over the age of 50. Tears can appear in either partial or full tears, but they can also be classified as acute or degenerative. Despite rotator cuff injuries being associated with exercise or heavy lifting, thus being classified as acute, degenerative tears are much more common, as the tendon typically wears down over time with age. Repetitive use, accompanied by poor shoulder and head posture, can negatively impact the health of the tendon. Tears in your dominant arm are more common due to overuse, and once one rotator cuff tears due to degeneration, the other one is more susceptible to a tear as well.

Rotator Cuff Tears. Physicaltherapyspecialists.org. Published 2018. Accessed October 21, 2025. https://www.physicaltherapyspecialists.org/Newsletters/Full-Articles/Rotator-Cuff-Tears/a~14460/article.html

# data[].attributes.body
I find it very informative and interesting that 30% of adults over 60 have rotator cuff injuries, and that statistic spikes significantly to 62% of adults over the age of 80. I believe this highlights the unfortunate truth that as we get older, our bodies deteriorate at an exponential rate.

Citation: May T, Garmel GM. Rotator Cuff Injury. StatPearls Publishing; 2025. Accessed October 16, 2025. https://www.ncbi.nlm.nih.gov/books/NBK547664/

# data[].attributes.attachment_link.readable_text
Continuing Education Activity

Rotator cuff pathology is a commonly encountered condition, and the natural history suggests tears increase with increasing age. This activity will discuss the diagnosis and management of the spectrum of disease from tendinopathy to tears. It will also discuss the relationship between the team members involved.
Objectives:

Identify the risks and physical exam findings associated with a complete rotator cuff tear.

Describe the appropriate referral for rotator cuff tear based on the clinical picture.

Review the indications for appropriate imaging (X-ray, MSK ultrasound, and MRI).

Explain the importance of collaboration and communication amongst the interprofessional team to ensure appropriate selection of candidates for rehabilitation, injections, and tendon repair surgery.

Earn continuing education credits (CME/CE) on this topic.
Introduction

The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate. The rotator cuff consists of four muscles originating on the scapula and inserting on the superior humeral head to improve stability. The subscapularis inserts on the lesser tubercle of the humerus, and it functions as an internal rotator. The supraspinatus muscles insert onto the greater tubercle of the humerus with its function as an abductor for the initial 30 degrees of abduction. The infraspinatus also inserts onto the greater tubercle, but a little inferior to the supraspinatus, and it functions as an external rotator. The teres minor inserts inferior to the infraspinatus on the greater tuberosity, and it functions as an external rotator as well. Additionally, they all work as stabilizers of the glenohumeral joint.

Rotator cuff injury runs the full spectrum from injury to tendinopathy to partial tears, and finally complete tears. Age plays a significant role. Injuries ranged from 9.7% in those 20 years and younger increasing to 62% in patients 80 years and older (whether or not symptoms were present).[1] Increasing age and those with unilateral pain are also at risk for a tear in the rotator cuff of the opposite shoulder. A study comparing patients with unilateral shoulder pain, the average age for a patient having no cuff tear was 48.7 years. After age 66, there is a 50% likelihood of bilateral tears. Additionally, age was linked to the presence and type of tear but did not correlate with tear size.[1]

Unfortunately, there is a lack of good evidence on the optimal treatment of tears in patients younger than 40.[2] The tears tend to be more traumatic and likely respond to surgery better, but the role of non-surgical management needs to be better defined.

Etiology

Age is the most common factor for rotator cuff disease. It is a degenerative process that is progressive.[3] Smoking is a known risk factor. A systematic review demonstrated increased rates and sizes of degenerative tears along with symptomatic tears seen in smokers; this has the potential to increase the number of surgeries.[4] Another risk factor is family history. In a study of rotator cuff disease in those under 40 years of age, there was a significant correlation between individuals with RC disease up to third cousins. [4] Interestingly, poor posture has also been shown to be a predictor of rotator cuff disease. Tears were present in 65.8% patients with kyphotic-lordotic postures, 54.3% with flat-back postures, and 48.9% with sway-back postures; tears were present in only 2.9% of patients with ideal alignment.[4] Other risk factors include trauma, hypercholesterolemia, and occupations or activities requiring significant overhead activity.[4][5]

Partial tears are at risk for further propagation. These risk factors include: tear size, symptoms, location, and age. Tear size: A small tear may remain dormant, while larger tears are more likely to undergo structural deterioration. The critical size for sending a small tear towards a larger or complete tear has yet to be defined.[6] Tear propagation correlates with symptom development. Actively enlarging tears have a five times higher likelihood of developing symptoms than those tears that remain the same size.[6] The location of the tear also influences progression. Anterior tears are more likely to progress to cuff degeneration.[6] Finally, age is a risk factor. Patients over age 60 are more likely to develop tears that progress. Younger patients with full-thickness tears appear more capable of adapting to stress and tear propagation than those 60 years of age and older.[6]

Epidemiology

In adults, rotator cuff injury is the most common tendon injury seen and treated. Statistically, approximately 30% of adults age over 60 have a tear, and 62% of adults over 80 have tears.[3] In Germany, a prospective study on 411 asymptomatic shoulders demonstrated a 23% overall prevalence of RC tears with 31% in those of age 70 and 51% in those 80 years of age. [7] Other studies from Europe gave slightly lower results. One study from Austria on 212 asymptomatic shoulders demonstrated only a 6% prevalence of full-thickness tears.[8] A Norwegian study on 420 asymptomatic volunteers ages 50 to 79 revealed FTT in 32 subjects (7.6%).[9]

Pathophysiology

Rotator cuff injury starts from trauma. Macro-trauma causes an acute tear, which is seen generally a younger patient resulting in a complete tear. Micro-trauma causes tendon degeneration and with insufficient healing, leads to degenerative tears. Typically, acute tears happen in younger patients, and degenerative tears occur in older patients. However, a smaller amount of force is needed to cause a complete tear if there is sufficient tendon degeneration.

History and Physical

The history of rotator cuff disease all starts with pain. The pain can be acute and arise from a traumatic event, or it can be gradual and mild, but steadily increasing. Generally, active individuals will present when they can no longer do their sport, activity, or job without causing pain. Often they will try to adapt or alter their biomechanics to remain active. Only when they can no longer adapt will they present. For instance, a baseball pitcher will begin to move their motion from an overhead movement to more of a sidearm throw to try and maintain velocity. Once the pain continues or the velocity drops sufficiently, will they seek care. Depending on when the patient presents, the tendon will be anywhere from tendinopathy to partial tear to complete tear.

Additionally, patients will report increasing pain and difficulty with overhead activity, activities of daily living. They may also report pain when lifting or carrying heavy objects. The pain can occasionally radiate down into the area of the deltoid muscle. Quite often, they will report pain when lying on their side to sleep. In younger patients, overuse tendinopathy is the cause, and older patients often have osteoarthritis as a contributing factor.

On physical exam, tenderness along at the insertion of the supraspinatus, infraspinatus, and teres minor muscles in the greater/lesser tuberosity can be present. With inspection, muscle atrophy may be visible in the supraspinatus or infraspinatus fossa of the scapula.[10] Additionally, checking the cervical range of motion and performing a Spurling test can help look for cervical disc disease as a source of the pain. The next step is to have the patient demonstrate the range of motion in both abduction and flexion. Rotator cuff pathology will cause pain in the range of motion; this is commonly called a painful arc. It is also helpful to observe the scapulothoracic motion. The longer the pain has been present, the more likely patients will develop scapular dyskinesis. Normally, the scapula does not begin to abduct until the arm abducts to 90 degrees. When dyskinesis is present, scapular motion initiates well before the arm reaches 90 degrees of abduction.

There is limited evidence for any of the tests commonly used in diagnosing rotator cuff disease as being very sensitive or specific.[11] The Jobe or empty can test used to evaluate for supraspinatus tendinopathy. The patient elevates the arm to about 90 degrees, and with the thumb down (having an empty can in the patient's hand), isometric force is applied downward. The full can test is a variation where the thumb is up (having a full can in the patient's hand). These tests have high sensitivity but are unfortunately not specific.[4] Next, resisted external rotation is used to evaluate for infraspinatus/teres minor muscle pathology. The patient adducts their arms to their side, and the patient isometrically resists an internal rotation force. For the subscapularis, the belly press is useful for evaluation. The patient places their hand on their abdomen and then resists the examiner's attempt to push the elbow forward off the abdominal wall. Pain or weakness with any of these motions is considered positive tests. If pain limits the exam, a diagnostic subacromial injection can be done to see if reducing the patient's pain improves the exam. Placing an anesthetic agent (lidocaine is the most common choice) in the subacromial space can improve the specificities of these tests.[4]

When considering a rotator cuff tear, there are variations in the tests noted above. If the patient cannot hold the empty can test position, it is called a drop arm test. Next is the external rotation lag sign. With the patient in external rotation, the arm is fully externally rotated. If the patient cannot maintain this position, there is a good chance they have a ruptured supraspinatus and/or infraspinatus muscle.[12] Finally, the inability to keep the hand on the abdominal wall with the belly press test suggests there is a chance the patient has ruptured their subscapularis muscle.

Evaluation

When it comes to shoulder imaging, there are three options: plain radiography, ultrasound, and MRI/MR arthrography. For rotator cuff disease, MR arthrography does not add any additional benefits over and MRI. It is more expensive and requires an intra-articular injection of gadolinium.

Imaging begins with X-rays, and the standard is four views AP, true AP (Grashey view), scapular Y (lateral), and axillary views. The Grashey view activates the deltoid muscle, thus allowing proximal humeral migration. In patients with a chronic, large tear, the proximal humerus will migrate superior. The scapular Y view evaluates for acromial spurs often associated with cuff tears. Finally, the axillary view will show joint space narrowing along with anterior or posterior humeral subluxation.[10]

Ultrasound has become an excellent tool for evaluating the rotator cuff. It is less expensive and has the capability of assessing dynamic movements of the shoulder. A 2013 review article compared MRI, MR arthrography, and ultrasound to diagnose rotator cuff tears. The gold standard was open or arthroscopic surgery gold standard. With partial-thickness tears, both MRI and ultrasound performed well. All three imaging modalities were able to rule in or rule out a full-thickness. For both partial- and full-thickness tears, no significant differenceswere shown of the imaging modalities' abilities to demonstrate a tear.[12] Ultrasound has limitations due to the skill required to obtain appropriate images, and it can be difficult to distinguish between chronic tears and tendinopathies.

MRI remains the gold standard in the US. The images are utilized in pre-procedure planning and can show tear size, location, retraction, muscle atrophy, chronic changes in the tendon and muscle associated with degenerative changes, and other associated pathology.[10][4] All these factors will go into planning a potential surgical procedure.

Treatment / Management

The treatment depends on the age of the patient, their functional demands, and the acuteness vs. chronicity of the tear. For complete tears in patients under 40, surgical treatment is the generally recommended treatment followed by appropriate rehabilitation. These are usually traumatic injuries and respond well to surgery. However, the data is limited and based mostly on studies in older patients.[2]

The American Academy of Orthopedic Surgeons developed some recommendations. They determined high-level evidence of surgical treatment for full-thickness tears was weak.[13] In the same article, the group determined there were appropriate use criteria based on available data and expert opinion. The authors reviewed five classes of treatment. First, non-surgical management is always appropriate, providing they are responding with improved function and decreased pain. Second, repairs can be appropriate even if the patient responds to non-surgical care. Third, for those healthy patients who remain symptomatic, then repair is the appropriate treatment. Fourth, for cases of chronic, massive tears, debridement/partial repair and/or reconstruction may be indicated. Finally, for those with painful pseudoparalysis with an irreparable tear, arthroplasty may be appropriate.[13]

For patients who do respond to non-surgical care, will do so in 6 to 12 weeks.[13]

Any patient with asymptomatic tears should have nonoperative management. Newly diagnosed, symptomatic rotator cuff tears may start with physical therapy addressing both core and scapular muscle strengthening. This approach is associated with similar clinical outcomes when compared to surgical repair for both small and medium-sized tears. Additionally, therapy was is an effective primary treatment modality in most patients, even with full-thickness rotator cuff tears followed over two years. Oddly enough, in this study group, low expectations regarding the efficacy of rehabilitation are the strongest predictor of patients who would eventually go to surgery.[3]Quite often subacromial injections with corticosteroids are frequently employed setting of rotator cuff tears. However, there is little reproducible evidence to support their effectiveness and improve long-term clinical outcomes when used alone.[3]

SLAP or other labral tears

Subacromial impingement from bursitis, os acromiale, bone spurs

Differential Diagnosis

Prognosis

A recent meta-analysis published in 2019 out of the United Kingdom evaluating the treatment outcomes (patient-reported outcomes) demonstrated both surgical and non-surgical treatment groups had the largest improvement at 12 months. Then improvements leveled out. There was no clear advantage of surgery over non-surgical treatments.[14]

An algorithm was developed to help guide with a patient selection where tears categorize into three groups. [10] Group 1: early operative repair. One indication would be patients with an acute event and imaging corroborating the history. Especially with a subscapularis tear with or without biceps tendon instability. In those patients with pain and weakness before the injury would likely be an acute on chronic tear scenario and early intervention can be considered when imaging shows minimal muscle atrophy or degenerative changes should undergo early surgical interventions. Patients younger than 62 to 65 with small and medium-sized tears with minimal to no atrophy on imaging would be another group to consider early operative management. Group 2: In patients with painful partial or full-thickness tears who do not have an acute onset of pain, even if tendons are potentially repairable, they should undergo non-surgical treatment initially. In these cases, rehabilitation has shown consistent benefit in improving function and outcomes. Group 3: should undergo maximal non-surgical treatment. This group would be those who are tendons are unlikely to heal. Included in this group are those over 70 years old, those with chronic full-thickness tears with significant tendon retraction, advanced degenerative changes in the muscles, any signs of proximal humeral migration.

Complications

The most likely complication would be retearing of the cuff repair - this is minimizable with proper patient selection. Postoperative complications, in addition to those generally seen, would be adhesive capsulitis, inability to regain motion, or cuff strength.

Deterrence and Patient Education

No studies examine prevention strategies. Theoretically, proper cuff function can help decrease the risk of degenerative tears. In an observational study, rotator cuff tears were seen more predominately in those with specific postures. Also, in another study looking at radiographically measured subacromial space found reduced acromio-humeral space correlated with hyperkyphotic posture.[4]

Enhancing Healthcare Team Outcomes

Rotator cuff disease is among the most common tendon injuries seen and generally affects the older popular. These patients tend to have more chronic conditions and take more medications. Most patients will do well with conservative measures, but open communication with their primary care physician, physical therapist, and a sports medicine physician will optimize outcomes.

When the decision is made to proceed to surgery, patients may need clearance to undergo anesthesia; this occasionally requires permission from their primary care doctor or other specialists like cardiology, pulmonary, nephrology if they have renal failure or are undergoing dialysis. The team will need to address any chronic metabolic conditions and should look to optimize blood glucose levels, A1C, as well as optimizing any blood coagulation.

After the surgical procedure, clear communication between the operative and post-operative teams of physicians and nurses (including nurses with specialty training in orthopedics) to ensure the continued safety of the patient as they recover is critical. Discussions about medications and medical conditions should be open and frank, so the entire team ensures an appropriate handoff. The nursing staff should perform post-operative monitoring, assist with patient and family education, and coordinate appropriate follow up.

As the patient proceeds with recovery and goes through the (typically long) rehabilitation process, open communication between the surgeon and physical therapist will optimize the patient's recovery. Physical therapists also often have involvement in conservatively managed cases or instances attempting conservative management in an attempt to preclude surgery. The therapist moist report back to the treating clinician with their findings regarding progress or lack thereof.

Managing rotator cuff tears requires an interprofessional team approach, including the clinicians, specialists, orthopedic and surgical nurses, and physical therapists.

Continuing Education / Review Questions

References

# data[].attributes.attachment_link.description
The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate.

# data[].attributes.body
There are numerous interesting facts within this article regarding the epidemiology of rotator cuff tears. I find it intreguing that men have a significantlly higher chance of tearing their rotaor cuff from birth through their 60's. However once people reach their 70's and 80's, women equalize their chance of tears in their 70's and surpass males in their 80's regarding tearing their rotator cuffs.

Citation: Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. J Orthop. 2013;10(1):8-12. Published 2013 Feb 26. Accessed October 16,2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC3768248/

# data[].attributes.attachment_link.title
Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village

# data[].attributes.attachment_link.description
Rotator cuff tear is the most common shoulder disease in patients with shoulder problems, but its prevalence is not well known. We performed a health care check-up of locomotive organs in 664 residents (21.3% of the population) in one village.…

# data[].attributes.body
I found it interesting that ‌poor posture has also been shown to be a predictor of rotator cuff injuries. In this study, tears were present in 65.8% of patients with kyphotic-lordotic postures, 54.3% with flat-back postures, and 48.9% with sway-back postures; tears were present in only 2.9% of patients with ideal alignment. This is because when you change your posture, it changes the balance of the shoulder and keeps the rotator cuff from working correctly. To improve your posture and lower your risk, you can work on strengthening the shoulder and back muscles.

# data[].attributes.attachment_link.readable_text
Continuing Education Activity

Rotator cuff pathology is a commonly encountered condition, and the natural history suggests tears increase with increasing age. This activity will discuss the diagnosis and management of the spectrum of disease from tendinopathy to tears. It will also discuss the relationship between the team members involved.
Objectives:

Identify the risks and physical exam findings associated with a complete rotator cuff tear.

Describe the appropriate referral for rotator cuff tear based on the clinical picture.

Review the indications for appropriate imaging (X-ray, MSK ultrasound, and MRI).

Explain the importance of collaboration and communication amongst the interprofessional team to ensure appropriate selection of candidates for rehabilitation, injections, and tendon repair surgery.

Earn continuing education credits (CME/CE) on this topic.
Introduction

The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate. The rotator cuff consists of four muscles originating on the scapula and inserting on the superior humeral head to improve stability. The subscapularis inserts on the lesser tubercle of the humerus, and it functions as an internal rotator. The supraspinatus muscles insert onto the greater tubercle of the humerus with its function as an abductor for the initial 30 degrees of abduction. The infraspinatus also inserts onto the greater tubercle, but a little inferior to the supraspinatus, and it functions as an external rotator. The teres minor inserts inferior to the infraspinatus on the greater tuberosity, and it functions as an external rotator as well. Additionally, they all work as stabilizers of the glenohumeral joint.

Rotator cuff injury runs the full spectrum from injury to tendinopathy to partial tears, and finally complete tears. Age plays a significant role. Injuries ranged from 9.7% in those 20 years and younger increasing to 62% in patients 80 years and older (whether or not symptoms were present).[1] Increasing age and those with unilateral pain are also at risk for a tear in the rotator cuff of the opposite shoulder. A study comparing patients with unilateral shoulder pain, the average age for a patient having no cuff tear was 48.7 years. After age 66, there is a 50% likelihood of bilateral tears. Additionally, age was linked to the presence and type of tear but did not correlate with tear size.[1]

Unfortunately, there is a lack of good evidence on the optimal treatment of tears in patients younger than 40.[2] The tears tend to be more traumatic and likely respond to surgery better, but the role of non-surgical management needs to be better defined.

Etiology

Age is the most common factor for rotator cuff disease. It is a degenerative process that is progressive.[3] Smoking is a known risk factor. A systematic review demonstrated increased rates and sizes of degenerative tears along with symptomatic tears seen in smokers; this has the potential to increase the number of surgeries.[4] Another risk factor is family history. In a study of rotator cuff disease in those under 40 years of age, there was a significant correlation between individuals with RC disease up to third cousins. [4] Interestingly, poor posture has also been shown to be a predictor of rotator cuff disease. Tears were present in 65.8% patients with kyphotic-lordotic postures, 54.3% with flat-back postures, and 48.9% with sway-back postures; tears were present in only 2.9% of patients with ideal alignment.[4] Other risk factors include trauma, hypercholesterolemia, and occupations or activities requiring significant overhead activity.[4][5]

Partial tears are at risk for further propagation. These risk factors include: tear size, symptoms, location, and age. Tear size: A small tear may remain dormant, while larger tears are more likely to undergo structural deterioration. The critical size for sending a small tear towards a larger or complete tear has yet to be defined.[6] Tear propagation correlates with symptom development. Actively enlarging tears have a five times higher likelihood of developing symptoms than those tears that remain the same size.[6] The location of the tear also influences progression. Anterior tears are more likely to progress to cuff degeneration.[6] Finally, age is a risk factor. Patients over age 60 are more likely to develop tears that progress. Younger patients with full-thickness tears appear more capable of adapting to stress and tear propagation than those 60 years of age and older.[6]

Epidemiology

In adults, rotator cuff injury is the most common tendon injury seen and treated. Statistically, approximately 30% of adults age over 60 have a tear, and 62% of adults over 80 have tears.[3] In Germany, a prospective study on 411 asymptomatic shoulders demonstrated a 23% overall prevalence of RC tears with 31% in those of age 70 and 51% in those 80 years of age. [7] Other studies from Europe gave slightly lower results. One study from Austria on 212 asymptomatic shoulders demonstrated only a 6% prevalence of full-thickness tears.[8] A Norwegian study on 420 asymptomatic volunteers ages 50 to 79 revealed FTT in 32 subjects (7.6%).[9]

Pathophysiology

Rotator cuff injury starts from trauma. Macro-trauma causes an acute tear, which is seen generally a younger patient resulting in a complete tear. Micro-trauma causes tendon degeneration and with insufficient healing, leads to degenerative tears. Typically, acute tears happen in younger patients, and degenerative tears occur in older patients. However, a smaller amount of force is needed to cause a complete tear if there is sufficient tendon degeneration.

History and Physical

The history of rotator cuff disease all starts with pain. The pain can be acute and arise from a traumatic event, or it can be gradual and mild, but steadily increasing. Generally, active individuals will present when they can no longer do their sport, activity, or job without causing pain. Often they will try to adapt or alter their biomechanics to remain active. Only when they can no longer adapt will they present. For instance, a baseball pitcher will begin to move their motion from an overhead movement to more of a sidearm throw to try and maintain velocity. Once the pain continues or the velocity drops sufficiently, will they seek care. Depending on when the patient presents, the tendon will be anywhere from tendinopathy to partial tear to complete tear.

Additionally, patients will report increasing pain and difficulty with overhead activity, activities of daily living. They may also report pain when lifting or carrying heavy objects. The pain can occasionally radiate down into the area of the deltoid muscle. Quite often, they will report pain when lying on their side to sleep. In younger patients, overuse tendinopathy is the cause, and older patients often have osteoarthritis as a contributing factor.

On physical exam, tenderness along at the insertion of the supraspinatus, infraspinatus, and teres minor muscles in the greater/lesser tuberosity can be present. With inspection, muscle atrophy may be visible in the supraspinatus or infraspinatus fossa of the scapula.[10] Additionally, checking the cervical range of motion and performing a Spurling test can help look for cervical disc disease as a source of the pain. The next step is to have the patient demonstrate the range of motion in both abduction and flexion. Rotator cuff pathology will cause pain in the range of motion; this is commonly called a painful arc. It is also helpful to observe the scapulothoracic motion. The longer the pain has been present, the more likely patients will develop scapular dyskinesis. Normally, the scapula does not begin to abduct until the arm abducts to 90 degrees. When dyskinesis is present, scapular motion initiates well before the arm reaches 90 degrees of abduction.

There is limited evidence for any of the tests commonly used in diagnosing rotator cuff disease as being very sensitive or specific.[11] The Jobe or empty can test used to evaluate for supraspinatus tendinopathy. The patient elevates the arm to about 90 degrees, and with the thumb down (having an empty can in the patient's hand), isometric force is applied downward. The full can test is a variation where the thumb is up (having a full can in the patient's hand). These tests have high sensitivity but are unfortunately not specific.[4] Next, resisted external rotation is used to evaluate for infraspinatus/teres minor muscle pathology. The patient adducts their arms to their side, and the patient isometrically resists an internal rotation force. For the subscapularis, the belly press is useful for evaluation. The patient places their hand on their abdomen and then resists the examiner's attempt to push the elbow forward off the abdominal wall. Pain or weakness with any of these motions is considered positive tests. If pain limits the exam, a diagnostic subacromial injection can be done to see if reducing the patient's pain improves the exam. Placing an anesthetic agent (lidocaine is the most common choice) in the subacromial space can improve the specificities of these tests.[4]

When considering a rotator cuff tear, there are variations in the tests noted above. If the patient cannot hold the empty can test position, it is called a drop arm test. Next is the external rotation lag sign. With the patient in external rotation, the arm is fully externally rotated. If the patient cannot maintain this position, there is a good chance they have a ruptured supraspinatus and/or infraspinatus muscle.[12] Finally, the inability to keep the hand on the abdominal wall with the belly press test suggests there is a chance the patient has ruptured their subscapularis muscle.

Evaluation

When it comes to shoulder imaging, there are three options: plain radiography, ultrasound, and MRI/MR arthrography. For rotator cuff disease, MR arthrography does not add any additional benefits over and MRI. It is more expensive and requires an intra-articular injection of gadolinium.

Imaging begins with X-rays, and the standard is four views AP, true AP (Grashey view), scapular Y (lateral), and axillary views. The Grashey view activates the deltoid muscle, thus allowing proximal humeral migration. In patients with a chronic, large tear, the proximal humerus will migrate superior. The scapular Y view evaluates for acromial spurs often associated with cuff tears. Finally, the axillary view will show joint space narrowing along with anterior or posterior humeral subluxation.[10]

Ultrasound has become an excellent tool for evaluating the rotator cuff. It is less expensive and has the capability of assessing dynamic movements of the shoulder. A 2013 review article compared MRI, MR arthrography, and ultrasound to diagnose rotator cuff tears. The gold standard was open or arthroscopic surgery gold standard. With partial-thickness tears, both MRI and ultrasound performed well. All three imaging modalities were able to rule in or rule out a full-thickness. For both partial- and full-thickness tears, no significant differenceswere shown of the imaging modalities' abilities to demonstrate a tear.[12] Ultrasound has limitations due to the skill required to obtain appropriate images, and it can be difficult to distinguish between chronic tears and tendinopathies.

MRI remains the gold standard in the US. The images are utilized in pre-procedure planning and can show tear size, location, retraction, muscle atrophy, chronic changes in the tendon and muscle associated with degenerative changes, and other associated pathology.[10][4] All these factors will go into planning a potential surgical procedure.

Treatment / Management

The treatment depends on the age of the patient, their functional demands, and the acuteness vs. chronicity of the tear. For complete tears in patients under 40, surgical treatment is the generally recommended treatment followed by appropriate rehabilitation. These are usually traumatic injuries and respond well to surgery. However, the data is limited and based mostly on studies in older patients.[2]

The American Academy of Orthopedic Surgeons developed some recommendations. They determined high-level evidence of surgical treatment for full-thickness tears was weak.[13] In the same article, the group determined there were appropriate use criteria based on available data and expert opinion. The authors reviewed five classes of treatment. First, non-surgical management is always appropriate, providing they are responding with improved function and decreased pain. Second, repairs can be appropriate even if the patient responds to non-surgical care. Third, for those healthy patients who remain symptomatic, then repair is the appropriate treatment. Fourth, for cases of chronic, massive tears, debridement/partial repair and/or reconstruction may be indicated. Finally, for those with painful pseudoparalysis with an irreparable tear, arthroplasty may be appropriate.[13]

For patients who do respond to non-surgical care, will do so in 6 to 12 weeks.[13]

Any patient with asymptomatic tears should have nonoperative management. Newly diagnosed, symptomatic rotator cuff tears may start with physical therapy addressing both core and scapular muscle strengthening. This approach is associated with similar clinical outcomes when compared to surgical repair for both small and medium-sized tears. Additionally, therapy was is an effective primary treatment modality in most patients, even with full-thickness rotator cuff tears followed over two years. Oddly enough, in this study group, low expectations regarding the efficacy of rehabilitation are the strongest predictor of patients who would eventually go to surgery.[3]Quite often subacromial injections with corticosteroids are frequently employed setting of rotator cuff tears. However, there is little reproducible evidence to support their effectiveness and improve long-term clinical outcomes when used alone.[3]

SLAP or other labral tears

Subacromial impingement from bursitis, os acromiale, bone spurs

Differential Diagnosis

Prognosis

A recent meta-analysis published in 2019 out of the United Kingdom evaluating the treatment outcomes (patient-reported outcomes) demonstrated both surgical and non-surgical treatment groups had the largest improvement at 12 months. Then improvements leveled out. There was no clear advantage of surgery over non-surgical treatments.[14]

An algorithm was developed to help guide with a patient selection where tears categorize into three groups. [10] Group 1: early operative repair. One indication would be patients with an acute event and imaging corroborating the history. Especially with a subscapularis tear with or without biceps tendon instability. In those patients with pain and weakness before the injury would likely be an acute on chronic tear scenario and early intervention can be considered when imaging shows minimal muscle atrophy or degenerative changes should undergo early surgical interventions. Patients younger than 62 to 65 with small and medium-sized tears with minimal to no atrophy on imaging would be another group to consider early operative management. Group 2: In patients with painful partial or full-thickness tears who do not have an acute onset of pain, even if tendons are potentially repairable, they should undergo non-surgical treatment initially. In these cases, rehabilitation has shown consistent benefit in improving function and outcomes. Group 3: should undergo maximal non-surgical treatment. This group would be those who are tendons are unlikely to heal. Included in this group are those over 70 years old, those with chronic full-thickness tears with significant tendon retraction, advanced degenerative changes in the muscles, any signs of proximal humeral migration.

Complications

The most likely complication would be retearing of the cuff repair - this is minimizable with proper patient selection. Postoperative complications, in addition to those generally seen, would be adhesive capsulitis, inability to regain motion, or cuff strength.

Deterrence and Patient Education

No studies examine prevention strategies. Theoretically, proper cuff function can help decrease the risk of degenerative tears. In an observational study, rotator cuff tears were seen more predominately in those with specific postures. Also, in another study looking at radiographically measured subacromial space found reduced acromio-humeral space correlated with hyperkyphotic posture.[4]

Enhancing Healthcare Team Outcomes

Rotator cuff disease is among the most common tendon injuries seen and generally affects the older popular. These patients tend to have more chronic conditions and take more medications. Most patients will do well with conservative measures, but open communication with their primary care physician, physical therapist, and a sports medicine physician will optimize outcomes.

When the decision is made to proceed to surgery, patients may need clearance to undergo anesthesia; this occasionally requires permission from their primary care doctor or other specialists like cardiology, pulmonary, nephrology if they have renal failure or are undergoing dialysis. The team will need to address any chronic metabolic conditions and should look to optimize blood glucose levels, A1C, as well as optimizing any blood coagulation.

After the surgical procedure, clear communication between the operative and post-operative teams of physicians and nurses (including nurses with specialty training in orthopedics) to ensure the continued safety of the patient as they recover is critical. Discussions about medications and medical conditions should be open and frank, so the entire team ensures an appropriate handoff. The nursing staff should perform post-operative monitoring, assist with patient and family education, and coordinate appropriate follow up.

As the patient proceeds with recovery and goes through the (typically long) rehabilitation process, open communication between the surgeon and physical therapist will optimize the patient's recovery. Physical therapists also often have involvement in conservatively managed cases or instances attempting conservative management in an attempt to preclude surgery. The therapist moist report back to the treating clinician with their findings regarding progress or lack thereof.

Managing rotator cuff tears requires an interprofessional team approach, including the clinicians, specialists, orthopedic and surgical nurses, and physical therapists.

Continuing Education / Review Questions

References

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The shoulder joint classifies as a ball and socket joint; however, the joint sacrifices stability for mobility. The glenoid is a shallow rim, and one description is as looking like a golf ball on a tee or a basketball on a dinner plate.

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I found it interesting that athletes are also more at risk for a rotator cuff injury, in addition to people over the age of 40 and people in jobs that require a lot of heavy lifting. One of the biggest sports at risk is baseball, especially pitchers. This is because when you pitch, you are putting repetitive, high-velocity movement on the shoulder that can cause small tears in the rotator cuff muscle over time. This is why it is so important for athletes to have correct form and recovery to prevent overuse.

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The rotator cuff is made up of muscles and tendons in your shoulder area. Tendinitis, bursitis, and tears are common problems with the rotator cuff.

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Epidemiology

United States statistics

It is difficult to determine the exact prevalence of rotator cuff tears, as many patients are asymptomatic and do not have any pain or weakness that would lead them to seek medical care. Certain population screening studies have identified the prevalence of rotator cuff tear using shoulder ultrasonography techniques, including a cross-sectional study of women in the UK that showed 22.2% of a study population of 1000 in the UK had a full-thickness rotator cuff tear. Observational studies in Asian populations demonstrated higher prevalence in individuals aged ≥57 years and in men compared with women. [6]

https://emedicine.medscape.com/article/92814-overview#a6

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Rotator cuff injuries are a common cause of shoulder pain in people of all age groups. They represent a spectrum of disease, ranging from acute reversible tendinitis to massive tears involving the supraspinatus, infraspinatus, and subscapularis.

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I have seen numerous shoulder injuries in the gym. Many clients during a group setting will try to push themselves or try to rush through an exercise and it is so important for trainers to be observant and pay attention to every little detail when it comes to from and technique. 

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Rotator cuff injuries are common in weightlifting due to factors like improper technique, overuse, and excessive weight. Studies show that young males (20-29 years old) are frequently injured, with strains and sprains being common diagnoses in emergency departments. Weightlifters with longer training durations report higher injury rates, and there is evidence of a dose-response relationship between occupational exposure and rotator cuff pathology.