What Exactly Is a Rotator Cuff Tear?
A rotator cuff tear happens when one or more of the tendons connecting the shoulder muscles to the bone rip or wear down. These four muscles - supraspinatus, infraspinatus, teres minor, and subscapularis - work together to keep your shoulder stable and let you lift and rotate your arm. Think of them like the four straps holding a heavy backpack securely to your shoulders. When one of those straps breaks, the load shifts, and pain and weakness follow.
These tears don’t always come from a single injury. Many develop slowly over time, especially after age 40. In fact, studies show that over half of people over 60 have a rotator cuff tear without ever feeling pain. That’s right - you can have a torn tendon and still move your arm fine. But when the tear starts causing discomfort, stiffness, or weakness - especially when reaching overhead or behind your back - it’s time to pay attention.
How Do Doctors Know It’s a Rotator Cuff Tear?
Before any scan, your doctor will do a physical exam. They’ll move your arm in specific ways to test strength and find where it hurts. Tests like the Empty Can test, Neer impingement test, and Hawkins-Kennedy test are standard. If your shoulder drops when you try to lift your arm straight out, or if it hurts when they push your arm upward, that’s a red flag.
But physical exams alone aren’t enough. You need imaging to see what’s really going on inside. That’s where X-rays, ultrasound, and MRI come in.
Imaging: X-Ray, Ultrasound, or MRI - Which One Do You Need?
X-rays are almost always the first step. They don’t show tendons, but they reveal bone problems like arthritis, bone spurs, or changes in joint position that might be causing the pain. If your X-ray looks normal but you still have symptoms, the next step is soft tissue imaging.
Here’s where things get practical. For most people, ultrasound is the best next move. It’s cheaper - around $200 to $400 - compared to MRI’s $500 to $1,200. It’s faster, no machines to climb into, and you can see the tendon move in real time. If you lift your arm while the probe is on your shoulder, the doctor watches the tendon stretch and snap back. If it doesn’t move right, that’s a tear. Studies show ultrasound catches 87-91% of full-thickness tears. It’s also safe if you have metal implants or pacemakers - something MRI can’t say.
But ultrasound has a catch: it depends on who’s holding the probe. Only about 45% of general radiologists have the special training needed to read these scans well. If your clinic doesn’t have a musculoskeletal ultrasound expert, the results might miss subtle tears.
That’s where MRI comes in. It gives a detailed, high-res picture of the tendons, muscles, and fluid around the joint. It’s 92% accurate for full-thickness tears and better than ultrasound at spotting partial tears. MRI is the go-to if you’re planning surgery. It shows the size of the tear, how retracted the tendon is, and whether the muscle has started to waste away - all critical for deciding if repair is even possible.
Most doctors skip contrast dye unless they’re checking for a re-tear after surgery. And no, you don’t need an MRI right away. The American Academy of Orthopaedic Surgeons now recommends trying physical therapy for 6-8 weeks first. Why? Because many tears don’t need surgery. And if you skip the rehab and go straight to scans, you might pay for imaging that doesn’t change your treatment.
Rehabilitation: Can You Heal Without Surgery?
Yes - and for many people, you should try.
Studies show that 85% of people with partial-thickness tears recover function with a structured rehab program. Even some full-thickness tears can be managed without surgery, especially in older adults or those who don’t do heavy lifting or sports.
Rehab follows three clear phases:
- Weeks 1-6: Protect and Move - No lifting, no pushing, no reaching overhead. You do passive stretches - someone else moves your arm for you - to keep the shoulder from freezing up. Ice and anti-inflammatories help control pain.
- Weeks 6-12: Rebuild Control - You start moving your arm on your own. Light resistance bands, scapular stabilization exercises, and gentle rotator cuff activation begin. This phase is about retraining your brain to use the shoulder properly.
- After Week 12: Strengthen and Return - Resistance training gets heavier. Dumbbells, cable machines, and functional movements like pushing, pulling, and throwing are reintroduced slowly. Athletes often take 4-6 months to get back to full activity.
Consistency matters more than intensity. Skipping days slows progress. And if you push too hard too soon, you risk making the tear worse. A good physical therapist will adjust your plan based on your pain, strength gains, and how your shoulder feels day to day.
Surgery: When and How Is It Done?
Surgery isn’t a last resort - it’s the right choice for the right person. If you’re under 65, active, and have a full-thickness tear that’s causing ongoing weakness or pain after 3 months of rehab, surgery is often recommended.
Today, 90% of repairs are done arthroscopically. That means the surgeon makes three or four tiny keyhole incisions, inserts a camera and small tools, and repairs the tendon using sutures and anchors drilled into the bone. It’s not open surgery. No large cuts. No long hospital stays.
Arthroscopic repair has three big advantages over old-school open surgery:
- 30% lower complication rate (7.2% vs. 10.3%)
- Faster return to daily tasks - 25% quicker
- Less scarring and less pain post-op
Recovery now starts immediately. Gone are the days of 6 weeks in a sling. Most patients begin passive motion the day after surgery. By week 2, you’re doing gentle active motion. By week 6, you’re doing resistance exercises. Full strength returns around 4-6 months.
For massive tears - those over 3 cm - things get trickier. The tendon may be too retracted or the muscle too wasted. Surgeons might use patch grafts or biological scaffolds to help the tendon heal. Platelet-rich plasma (PRP) injections during surgery are sometimes used, but the evidence is mixed. The Cochrane Review in 2021 found only moderate support for PRP - it’s not standard care yet.
What Happens After Surgery?
Success isn’t just about the operation. It’s about sticking to rehab.
At 5 years, 82% of patients report being happy with their results. But retear rates vary. Small tears (<1 cm) have a 12% chance of re-tearing. Large tears (>3 cm) jump to 27%. That’s why rehab doesn’t end at 6 months. You need to keep doing shoulder-strengthening exercises for life.
Some people return to heavy lifting, construction, or sports. Others adapt to lighter work. The goal isn’t always to get back to exactly how you were - it’s to get back to what matters to you.
What’s New in Rotator Cuff Care?
The field is changing fast. Machine learning is being tested to read MRIs automatically. A 2023 study in Radiology: Artificial Intelligence showed AI could distinguish partial from full-thickness tears with 89% accuracy - faster and sometimes more consistent than human readers.
Also, surgeons are moving toward earlier intervention. If you’re young and active and have a full-thickness tear, waiting 6 months to see if rehab works might mean the tendon shrinks too much to repair well. Now, many experts recommend surgery within 3 months if there’s no improvement.
And while ultrasound is becoming more common as a first-line tool, access is still uneven. In rural areas or smaller clinics, MRI might be the only option. But where it’s available, ultrasound is changing the game - faster, cheaper, and just as accurate for most cases.
What Should You Do If You Think You Have a Rotator Cuff Tear?
Don’t rush to an MRI. Don’t assume you need surgery. Start with a good physical exam and a trial of rehab. See a physical therapist who specializes in shoulders. Give it 6-8 weeks. If you’re not getting better, then get imaging - ultrasound first, unless your case is complex.
If surgery is needed, choose a surgeon who does a lot of arthroscopic repairs. Ask how many they do a year. Look for someone who emphasizes early motion in rehab - that’s the modern standard.
And remember: a torn tendon doesn’t mean the end of your active life. With the right approach, most people get back to their normal activities - just smarter, stronger, and more aware of how to protect their shoulders.
Jessica Chambers
November 15, 2025 AT 09:43Andrew Eppich
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