Rotator cuff tear — impingement and surgery options— full professional article

What is the rotator cuff?

The rotator cuff is a sleeve of tendons (supraspinatus, infraspinatus, teres minor, subscapularis) that converge on the humeral head, contribute to shoulder motion, stability, and normal glenohumeral mechanics.

What is a rotator cuff tear?

A tear is disruption of tendon fibers where they attach to the greater/lesser tuberosity. Tears may be partial-thickness or full-thickness. Partial tears leave some fibers intact at the footprint.

Full-thickness tears are described by size (small, medium, large, massive) based on tendon retraction from the footprint.

Tears often cause marked pain, including night pain that disrupts sleep, difficulty with overhead activity, and in severe cases inability to actively elevate the arm.

What causes rotator cuff tears?

Tears may be traumatic or degenerative (tendinopathy with progressive fiber failure).

Shoulder impingement syndrome—subacromial crowding and repetitive cuff compression—also contributes to cuff pathology.

What is shoulder impingement?

Impingement reflects mechanical narrowing between the humeral head and acromion, compressing cuff tendons in the subacromial space. Repetitive compression produces tendinopathy, inflammation, and over time may progress to tearing.

Contributors include cuff weakness, kinematic dysfunction, and sometimes acromial morphology (hooked acromion).

Typical symptoms include pain with forward flexion and rotation, often with night pain.

How is impingement treated?

Initial management is non-operative: physiotherapy to strengthen the cuff and scapular stabilizers, activity modification, and sometimes subacromial corticosteroid injection to reduce inflammation and enable effective rehab.

If conservative care fails, arthroscopic subacromial decompression (acromioplasty) may be considered to relieve mechanical impingement.

How are rotator cuff tears treated?

Non-operative options include structured physiotherapy and injections (corticosteroid or biologics such as PRP in selected cases).

Non-operative care suits mild symptoms, high surgical risk patients, or those who decline surgery.

Operative treatment is typically arthroscopic or mini-open repair to re-approximate tendon to bone when symptoms and tear pattern warrant intervention and risk is acceptable.

Postoperative rehabilitation follows phased goals: protected passive and active range of motion, then gradual strengthening of the cuff and scapular stabilizers. Sling use, lifting limits, and return-to-work timelines depend on tear size, tissue quality, repair tension, and whether additional procedures were performed.

Muscle fatty infiltration on imaging (for example, Goutallier-type changes) suggests a less favorable biological environment for healing and may influence repair feasibility versus alternative strategies.

What is the natural history risk of an untreated cuff tear?

Beyond pain and weakness, tears may propagate over time as muscle forces pull retracted tendon from the footprint. Chronic massive tears may become irreparable with fatty muscle degeneration.

Advanced dysfunction can mimic “pseudoparalysis”—inability to actively elevate the arm without assistance—though it is not true nerve palsy.

Large chronic tears may also accelerate glenohumeral osteoarthritis (cuff tear arthropathy).

How are massive tears and cuff tear arthropathy treated?

Massive irreparable tears and end-stage arthropathy may require open reverse total shoulder arthroplasty. In a reverse design, the ball-and-socket geometry is inverted relative to anatomic shoulder replacement, improving deltoid-dependent elevation when the cuff cannot function.

The reversed mechanics limit superior migration of the humeral component and improve the mechanical advantage of the deltoid for active elevation.