Overview and Evidence Summary

Rotator cuff tears are one of the most common causes of shoulder pain and functional limitation, particularly in adults over 40. The rotator cuff comprises four muscles and their tendons—supraspinatus, infraspinatus, teres minor, and subscapularis—that work together to stabilize the shoulder and guide its enormous range of motion. Because of the mechanical load placed on these tendons and their relatively modest blood supply (especially as we age), they are vulnerable to both injury and degeneration.

A tear may occur suddenly, such as when someone falls on an outstretched arm or lifts something unexpectedly heavy. These are referred to as acute traumatic tears, and they tend to present with immediate pain and weakness, often in younger or physically active people. Far more common, however, are degenerative tears, which develop gradually over time. In many cases, these tears are completely painless and discovered only when imaging is done for unrelated reasons. This disconnect between structural damage and symptoms is one of the most important concepts in modern rotator cuff research.

When a tear does become symptomatic, people usually describe pain in the lateral upper arm, difficulty lifting or reaching overhead, and disturbed sleep, especially when lying on the affected shoulder. Weakness, particularly in elevation and external rotation, varies depending on tear size and chronicity. For both clinicians and patients, it is essential to understand that the mere presence of a tear on MRI does not automatically mean surgery is required. Research increasingly shows that many individuals do extremely well with non-operative care, especially when rehabilitation is well structured.

Summary of Current Evidence for Rotator Cuff Tears

Condition Overview

Rotator cuff tears can be understood along a continuum. At one end, small partial-thickness tears often arise in the setting of rotator cuff tendinopathy and may produce pain during overhead activity without major strength deficits. At the other end, massive full-thickness tears involving multiple tendons can lead to marked weakness, altered biomechanics, and compensatory movement patterns.

Degenerative tears progress at varying rates. Some remain unchanged for years, while others gradually enlarge. The presence of fatty infiltration in the rotator cuff muscles is a key predictor of poorer surgical outcomes, but it does not automatically imply poor outcomes with conservative management. In fact, many people with long-standing full-thickness tears function surprisingly well when rehabilitation focuses on optimizing the neuromuscular system that supports the shoulder.

A key insight from recent research is that symptoms are not driven simply by the size of the tear. Pain may relate more to tendon inflammation, altered load distribution, neuromuscular inhibition, or compensatory movement patterns. This helps explain why strengthening-based rehabilitation can be so effective even in the presence of structural defects.

Evidence-Based Management Discussion

Non-Operative Care as the Foundation

For most degenerative tears, non-operative care is the recommended starting point. This includes clear patient education about the natural history of tears, reassurance that many tears do not worsen functionally, and guidance on modifying aggravating activities while beginning a structured rehabilitation program.

Exercise Therapy

Exercise is the cornerstone of conservative management. Studies consistently show improvements in pain, range, and everyday function with well-designed programs. What appears most important is not the specific exercises chosen but the thoughtful progression from lower-load, controlled movements to more demanding tasks that reflect the patient’s real-world activities and goals. Programs emphasising scapular mechanics and motor control may have slightly better outcomes, though the overall effect sizes in the literature are modest.

Exercises do not need to be completely pain-free. Allowing mild, tolerable discomfort does not worsen long-term outcomes and may improve adherence. Patients should be monitored for delayed flares or unmanageable pain, which suggest the need to adjust load or technique.

Manual Therapy

Manual therapy—joint mobilisations, soft tissue treatment, passive stretching—has a role in managing pain and improving mobility, especially early in treatment when the shoulder feels irritable or stiff. However, long-term improvements are driven by active rehabilitation rather than passive modalities.

Medications and Injections

NSAIDs may provide short-term relief and allow patients to engage more effectively in rehabilitation. For individuals whose pain is particularly high, a single subacromial corticosteroid injection can create a temporary window of opportunity for progress. Repeated injections should be avoided due to concerns about tendon health.

The evidence for platelet-rich plasma (PRP) remains inconclusive. Some studies show benefit for partial tears or tendinopathy, but results vary widely across trials.

Surgical Considerations

Surgery is not the default treatment for degenerative rotator cuff tears. It becomes appropriate when:

• The tear resulted from clear trauma in a younger adult

• There is significant or progressive weakness

• Conservative management has been thorough and unsuccessful

• The patient requires high-demand shoulder function for work or sport

Surgical repair can restore strength and function, but outcomes depend heavily on tendon quality and chronicity. Even after successful repair, re-tear rates are not insignificant, especially in larger or long-standing tears.

References

American Academy of Orthopaedic Surgeons. Management of Rotator Cuff Injuries: Clinical Practice Guideline. 2025.

Desmeules, F., et al. “Rotator Cuff Tendinopathy: Diagnosis, Non-Surgical Management, and Post-Operative Rehabilitation.” American Physical Therapy Association, 2025.

Lafrance, S., et al. “Motor Control Exercises Versus Non-Specific Exercises for Rotator Cuff–Related Shoulder Pain: Systematic Review and Meta-Analysis.” Musculoskeletal Science and Practice, 2024.

Wu, Y., et al. “Effectiveness of Specific Exercise Interventions for Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis.” Journal of Orthopaedic & Sports Physical Therapy, 2025.

Cavaggion, P., et al. “Exercising into Pain Versus Pain-Free Exercise for Chronic Rotator Cuff–Related Shoulder Pain: Randomized Controlled Trial.” Journal of Bodywork and Movement Therapies, 2024.

Moosmayer, S., et al. “Tear Progression of Symptomatic and Asymptomatic Rotator Cuff Tears: A Prospective Cohort Study.” Journal of Bone and Joint Surgery, 2014.

Yamamoto, A., et al. “Prevalence and Risk Factors of a Rotator Cuff Tear in the General Population.” Journal of Shoulder and Elbow Surgery, 2010.

Kuhn, J. E. “Exercise in the Treatment of Rotator Cuff Tears: A Review of the Evidence.” Journal of Shoulder and Elbow Surgery, 2009 (with subsequent updates).

Disclaimer:
The information provided in this article is intended for educational purposes only and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for formal medical training or clinical judgment, nor does it constitute medical advice, diagnosis, or treatment. Although every effort has been made to ensure accuracy and reflect current evidence at the time of publication, research and clinical guidelines may change over time.

Readers should always work within the legal scope of their professional practice and follow regional regulatory requirements. Any hands-on techniques described should only be performed by appropriately trained and licensed professionals. Individuals experiencing pain or symptoms should be referred to a suitably qualified healthcare provider for assessment. Niel Asher Education does not accept responsibility for any injury, loss, or damage resulting from the use or misuse of information contained in these materials.