Rotator cuff injury: tendinopathy, tears and rehab

What the rotator cuff is and how it gets injured

The rotator cuff is made up of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis) whose tendons wrap around the top of the arm bone. Together they keep the ball of the shoulder centred in its shallow socket while the bigger muscles, such as the deltoid, lats and pecs, produce most of the force. Without a well-functioning cuff, pressing, pulling and throwing all feel less secure.

Rotator cuff injuries fall into three broad groups. Tendinopathy is an overloaded, sensitive tendon, and is the most common. Degenerative tears develop gradually with age and are very often painless; they are commonly found on scans of people over 60 with no symptoms at all. Traumatic tears happen suddenly, usually from a fall onto an outstretched arm, a shoulder dislocation or a very heavy lift.

Who gets it

Rotator cuff problems become more common from about 40 onwards. People who do a lot of overhead work, such as plasterers, electricians and decorators, are at higher risk, as are swimmers, tennis players and lifters who push pressing volume quickly. Smoking, diabetes and poor sleep are also linked with slower tendon healing.

In the gym, a typical story is someone who returns to training after a year off and goes straight back to their old bench or overhead press numbers, or a HYROX athlete who suddenly adds hundreds of wall balls a week. Our page on shoulder impingement covers the closely related pattern of pain with overhead movement.

Typical symptoms

• An ache at the top, front or side of the shoulder, often spreading down the outside of the upper arm
• Pain when lifting the arm out to the side or overhead, or reaching behind you
• Weakness, particularly lifting or rotating the arm outwards
• Night pain, especially lying on the affected side
• Clicking or catching, sometimes with a feeling that the shoulder is less stable

The key thing to notice is whether your strength has suddenly changed. Pain that has built over weeks is usually tendinopathy. If you felt a tear or pop and immediately could not lift your arm properly, that points towards a traumatic tear.

What a physio assessment looks at

Your physio will take a detailed history, screen the neck and rule out problems that can refer pain to the shoulder. They will compare active and passive movement, test the strength of each part of the cuff, and look at how the shoulder blade moves. Tests that reproduce your symptoms help build a picture, but no single test is definitive.

If a significant traumatic tear is suspected, particularly in someone who was previously strong and pain-free, the physio will usually recommend an urgent scan and a specialist opinion. Some acute tears do better with surgical repair carried out within weeks rather than months, so this is a case where waiting to see is not the best plan.

What usually helps

For tendinopathy and most degenerative tears, a progressive strengthening programme is the main treatment and research consistently shows it helps many people as much as surgery. The programme usually starts with isometric holds and light external rotation, then builds towards heavier rows, presses and overhead work over weeks to months. Load management, meaning reducing the aggravating lifts rather than stopping, runs alongside it.

Manual therapy can ease pain and stiffness and help you tolerate exercise. A GP may discuss a steroid injection when pain is severe, mainly as a way to make rehab possible. After surgical repair, rehab follows a staged protocol from your surgeon and full return to heavy lifting commonly takes 6 to 12 months.

What you can start with at home

1. Isometric external rotation against a door frame, 30 to 45 seconds at moderate effort, 4 to 5 times daily.
2. Band external and internal rotation with the elbow at your side, 3 sets of 12 to 15.
3. Side-lying external rotation with a light dumbbell, adding weight gradually.
4. Rows and the face pull for the upper back, 3 sets of 10 to 15.
5. Light lateral raises in a pain-free range, 2 to 3 sets of 12, raising to shoulder height only at first.

Once these feel easy for 3 sets, progress in small steps: slightly heavier weights, then pressing below shoulder height, then overhead work, and finally the fast or heavy movements your sport or training needs. Moving up a stage every one to two weeks is a sensible pace for many people, as long as the shoulder is not worse the next day.

Keep pain to a mild level during exercise and check that it settles by the next morning. A good general warm-up for lifting with a few band rotation sets can help the shoulder feel ready once you are back on the bar.

Recovery time and when to get urgent help

Tendons adapt slowly. Many people with tendinopathy see clear improvement in 6 to 12 weeks, and continue to gain strength for several months. The on-site physio at Lycan Strength can guide that process, with 20% off for members, and you can book a physio appointment online or by phone.

• Call 999 if shoulder or arm pain comes with chest pain, breathlessness, sweating or nausea.
• Go to A&E if the shoulder looks deformed or dislocated, or you cannot move the arm after an injury.
• See a GP or physio within a few days if you suddenly lost strength lifting the arm after a fall or heavy lift.
• Call NHS 111 or see a GP urgently if the shoulder is hot, red and swollen, or you have a fever.
• See your GP if you have unexplained weight loss or constant pain at night.

Questions