Rotator Cuff Injuries
Four small muscles and their tendons hold the ball of your shoulder in its socket and help lift and turn the arm. When they’re overloaded or worn, the shoulder aches. Most people get better with exercise, even with many tears.
Quick answer: Rotator cuff injuries range from irritated tendons to tears. Most, including many tears, get better with exercise over 6–12 weeks; surgery is mainly for sudden tears after an injury or tears that stay weak and painful after rehab. See your GP within a few days if you suddenly can’t lift your arm after a fall.
Symptoms. An ache in the outer upper arm, worse lifting the arm out to the side or overhead, reaching behind your back, or lying on it at night. Weakness lifting the arm suggests a bigger tear.
Types. Tendon pain (tendinopathy, often called impingement) is the most common. Wear-and-tear tears are very common with age and often painless: in one study, about 1 in 10 people in their 50s and 1 in 3 in their 80s had one. Sudden tears after a fall or heavy lift cause pain and immediate weakness, and need prompt assessment.
How it’s diagnosed. Mostly from your story and how the shoulder moves and resists when your GP or physio examines it. An ultrasound helps after an injury with sudden weakness, or if you’re not improving after about 3 months of exercise. An X-ray can check for arthritis.
The rotator cuff ladder
Exercise is the main treatment for most rotator cuff problems; the other steps help you do it or are kept for the few who need them.
- Step 1 · Self-careRotator cuff exercisesHolds first if moving hurts, then rotation, rows and wall slides, most days for at least 12 weeks.
- Works
- The main treatment. In the UK GRASP trial (708 people), one physio advice session did as well over a year as up to six sessions of progressive exercise
- Cost
- Free at home with our handout
- How long
- 12 weeks or more
- Watch for
- Mild pain up to 3–4/10 is fine if it settles by the next morning.
Tendons want load, gradually. Not cotton wool.
- Step 2 · PharmacyPain relief (paracetamol, ibuprofen or anti-inflammatory gel)To make sleep and exercise possible.
- Works
- Short-term pain relief; doesn’t heal the tendon
- Cost
- About $5–15 a pack
- How long
- Days to a couple of weeks at a time
- Watch for
- Anti-inflammatory tablets: stomach, kidney and blood pressure risks. Check with a pharmacist if you have other conditions.
A painkiller is a ticket to move, not the destination.
- Step 3 · ProcedureSteroid injectionInto the space above the rotator cuff, often guided by ultrasound.
- Works
- Can ease pain for a few weeks, which may help you exercise. In GRASP it gave no benefit over 12 months
- Cost
- Medicare rebates; out-of-pocket fees vary, especially with imaging
- How long
- One injection, occasionally repeated
- Watch for
- Short-lived flare, skin thinning at the site, raised blood sugar for a few days with diabetes.
A window to get moving, not a fix.
- Step 4 · SpecialistRotator cuff repair surgeryKeyhole stitching of the tendon back to bone.
- Works
- Considered for sudden tears after injury, especially in younger, active people, and for tears still painful and weak after rehab. For small wear-and-tear tears in people over 55, physio did as well as surgery at 6 years
- Cost
- Public waiting lists; private fees vary
- How long
- Sling for about 4–6 weeks; full recovery about 6–9 months
- Watch for
- Stiffness, infection, and the repair not holding in some people.
Worth it for the right tear. Not every scan finding is the right tear.
Save your money
Popular, heavily marketed or often asked about, but the evidence is weak or says no.
- Decompression surgery for impingementIn the UK CSAW trial, shaving bone from above the tendon did no better than a placebo keyhole operation.
- Relying on injections aloneThey can take the edge off for a few weeks, but gave no benefit over a year in the GRASP trial. Exercise does the long-term work.
- Resting it in a slingUnless it’s after surgery, long rest makes the shoulder weaker and stiffer.
What you can do
- Follow our rotator cuff exercise handout: seven moves in two stages, with pain rules.
- For impingement-type pain, our shoulder impingement exercises follow a trial program.
- Keep using the arm for everyday tasks below shoulder height; ease off heavy or repeated overhead lifting for now.
- Sleep on your back or good side with a pillow hugging the sore arm.
See your GP if
- Shoulder pain isn’t easing after a few weeks of sensible exercise
- Pain is waking you most nights
- Your shoulder is getting stiff in every direction (this may be frozen shoulder)
- Numbness, pins and needles or pain running down the arm, which may be coming from your neck
See your GP within a few days if you suddenly can’t lift your arm, especially after a fall or injury. See a doctor the same day for a hot, swollen shoulder with fever, or a shoulder that looks out of place. Get urgent help for shoulder or arm pain with chest pain, breathlessness, sweating or nausea: call 000 (Australia) or your local emergency number. Night pain with weight loss or a past cancer also needs checking.
Common questions
What does a rotator cuff injury feel like?
An ache in the outer upper arm, worse lifting the arm out to the side or overhead, reaching behind your back, or lying on that side at night. Real weakness lifting the arm suggests a bigger tear.
Is rotator cuff pain the same as shoulder impingement?
Largely, yes. ‘Impingement’ is an older name for painful, irritated rotator cuff tendons, now usually called rotator cuff-related shoulder pain. A tear is an actual split in a tendon. Both usually start with exercise.
Do I need surgery for a rotator cuff tear?
Most people don’t. Repair is considered for sudden tears after an injury, especially in younger, active people, and for tears that stay painful and weak after a good trial of exercise. For small wear-and-tear tears in people over 55, physio did as well as surgery at 6 years in a Finnish trial.
How long does a rotator cuff tear take to heal?
With exercise, most people improve within 6–12 weeks, some over 3–6 months. A full-thickness tear doesn’t knit back, but the shoulder often works well anyway. After repair surgery, full recovery takes about 6–9 months.
Is a rotator cuff tear common?
Very, especially with age. In a Japanese village study, about 1 in 5 adults had a full-thickness tear on ultrasound, rising to about 1 in 3 in their 80s, and two-thirds of tears caused no symptoms.
Helpful resources
- Rotator cuff exercise handoutPrintable, one page, with diagrams, two stages and pain rules. Free, from us.
- Shoulder impingement exercise handoutThe 12-week program from a Swedish trial. Free, from us.
Evidence and more information
- BESS, BOA and RCS England 2014: Commissioning guide for subacromial shoulder pain (care pathway and red flags)
- Hopewell et al, Lancet 2021: GRASP trial of exercise, advice and steroid injection for rotator cuff disorders
- Kukkonen et al, J Shoulder Elbow Surg 2021: surgery versus physio for small supraspinatus tears, 6-year follow-up
- Beard et al, Lancet 2018: CSAW trial of decompression surgery versus placebo surgery
- Minagawa et al, J Orthop 2013: how common rotator cuff tears are, with and without symptoms
- The Dudley Group NHS: Rotator cuff tears (treatment and recovery after surgery)
- NHS Dorset MSK: Rotator cuff related shoulder pain (exercises and pain rules)
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