The rotator cuff is a set of muscles and tendons surrounding the shoulder area. This delicate area connects the bone of the upper arm (humerus) to the shoulder blade (scapula), while stabilizing and promoting rotation of the shoulder joint.
Injuries to the rotator cuff are incredibly common, accounting for approximately 4.1 million doctor visits each year. Rotator cuff injuries can result from trauma (such as a fall or car accident), aging, or repetitive overhead motions (such as tennis, swimming, and household chores). These injuries most commonly occur in athletes, and as a result of work injuries by manual laborers (such as construction workers, painters, and carpenters), and individuals between 40 and 70 years of age.
Anatomy of the Rotator Cuff
The rotator cuff is comprised of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles (commonly called the “SITS” muscles). These muscles originate in the scapula (shoulder blade), then converge and attach via tendons to the humerus (upper arm bone).
Symptoms of Rotator Cuff Injury
There are various forms of rotator cuff injury. It’s important to note that medical treatment should be sought for any shoulder-related pain or discomfort, as rotator cuff injuries can get progressively worse when left untreated. The following categories describe the most common rotator cuff injuries and their associated symptoms:
Rotator Cuff Tear:
A tear to the muscles or tendons of the rotator cuff, most often caused by degenerative aging or a traumatic injury.
Pain that occurs primarily at night
Loss of motion
Difficulty raising the arm overhead
Cracking sensation when moving the shoulder
Less Common Symptom:
Snapping sensation followed by weakness (occurs as a result of traumatic injury)
Inflammation of the tendons, commonly caused by a build-up of calcium on the tendons (calcific deposits) or shoulder impingement (the rubbing of tendons against the bony protrusion of the shoulder blade). Tendinitis is often the result of aging, and occurs frequently in individuals over the age of 40.
Additionally, individuals who perform repeated overhead motions (swimmers, tennis players, housepainters, etc.) are at a higher risk for developing rotator cuff tendinitis.
Adhesive capsulitis, also known as “frozen shoulder” (this condition causes a loss of motion in the shoulder joint)
Pain in the front of the shoulder that radiates downward, stopping above the elbow joint
Weakness when lifting the arm overhead
Difficulty performing activities of daily living (i.e. brushing hair, reaching overhead)
Pain when attempting to sleep on the affected side
Less Common Symptoms:
Inflammation of the bursa, a fluid-filled sac that cushions the joint, commonly caused by overuse or a traumatic injury.
Pain (may be sharp upon exertion)
Adhesive capsulitis, also known as “frozen shoulder” (this condition causes a loss of motion in the shoulder joint)
Less Common Symptoms:
The tendons of the rotator cuff thread through a narrow space in the top of the shoulder blade, just underneath the acromion (bony protrusion of the shoulder blade). When impingement occurs (due to overuse, bone spurs, bursitis, calcium deposits, or anatomical abnormalities) the tendons and bursa rub against acromion, resulting in pain.
Difficulty reaching behind the back
Pain when reaching overhead
Frequently Asked Questions
Can rotator cuff injury cause neck pain?
Rotator cuff injury can cause neck pain, as the neck and shoulders share nerve pathways. Furthermore, injury to the rotator cuff may cause neck muscles to compensate for weak shoulder muscles, leading to discomfort and stiffness in the neck.
Can rotator cuff injury cause numbness in the hand?
Numbness in the hand may occur if a rotator cuff injury results in pinched or damaged blood vessels or nerves.
Can rotator cuff injury cause chest pain?
Chest pain is not a typical symptom of rotator cuff injury. If chest pain occurs, medical attention should be sought immediately.
Can rotator cuff injury cause back pain?
Rotator cuff injury may cause back pain, as back muscles may compensate for weak shoulder muscles. Pain in the upper back, particularly the trapezius muscles, is common.
Which rotator cuff muscle is most commonly injured?
The location of rotator cuff injuries varies, but the most commonly injured area is the supraspinatus muscle and its corresponding tendon. The supraspinatus muscle lies at the top of the four muscle-group that forms the rotator cuff.
What is rotator cuff tendinopathy?
Rotator cuff tendinopathy refers to pain in the shoulder caused by overuse. This overuse ultimately changes the formation of the tendons, resulting in pain. Unlike rotator cuff tendinitis, inflammation is minimal or non-existent in those with tendinopathy, making traditional anti-inflammatory treatments ineffective. Research is being performed regarding the best treatments to address this condition.
What is rotator cuff tear arthropathy?
Rotator cuff tear arthropathy occurs when a tear in the rotator cuff is not properly treated. Lack of treatment leads to degenerative arthritis in the shoulder, which can cause pain and a reduction in both range of motion and shoulder strength.19 Therefore, it’s critical to seek medical attention for any shoulder injury or discomfort.
What is rotator cuff syndrome?
Rotator cuff syndrome is another term used to describe an injury to the rotator cuff.
How do I know if I have a rotator cuff injury or bursitis?
Common symptoms of rotator cuff injury include pain, stiffness, or weakness in the shoulder area. Bursitis may also cause swelling or adhesive capsulitis, also known as “frozen shoulder”. However, the only way to accurately diagnose a rotator cuff injury or bursitis is to seek medical treatment for proper evaluation.
Can a rotator cuff injury heal by itself?
Many rotator cuff injuries do not require surgery. However, treatments such as anti-inflammatory medication, rehabilitative exercise, and the application of heat and ice are often required to encourage healing. Therefore, it is imperative to seek medical attention for any shoulder injury.
Can a rotator cuff injury heal without surgery?
Depending on the location and extent of the injury, surgery may or may not be required. Medical attention should be sought to determine a proper diagnosis.
How long does it take for a rotator cuff tear to heal?
Recovery time for a rotator cuff tear varies greatly and may take many months, depending on the extent of the injury. If surgical intervention is required, recovery will take longer. A patient’s willingness to follow the recommend course of treatment, including diligent exercise and stretching, will also affect healing time.
There are various tests that can be used to diagnose injury to the rotator cuff. Doctors typically begin by examining a patient’s medical history and current symptoms. They will then proceed to manipulate the shoulder area, pressing on various parts of the shoulder to determine which areas elicit pain.
They will also have the patient move their arm in a variety of positions, testing shoulder strength and range-of-motion. The doctor may also check for pinched nerves in the neck or evidence of arthritis to rule-out these conditions.
Upon completion of the exam, the doctor will likely order imaging tests. Common imaging tests for rotator cuff injuries include:
X-ray technology utilises electromagnetic waves to capture two-dimensional images of the body. X-rays do not adequately capture images of soft tissues. Therefore, this technology is best used to check for the presence skeletal abnormalities, such bone spurs, that may be causing shoulder discomfort.
Ultrasound utilises high-frequency sound waves to capture internal images. This test is better equipped to capture images of soft tissues, such as tendons and muscles. The doctor may utilise ultrasound to examine the rotator cuff for tears or inflammation.
MRI (Magnetic Resonance Imaging)
MRI utilises radio waves, a magnetic field, and computer technology to capture images of the body. MRIs are excellent for obtaining images of soft tissues, allowing the doctor to check for tears or inflammation in the rotator cuff.
It is important to seek treatment for rotator cuff injury, as an untreated injury may lead to permanent stiffness, weakness, or arthritis (arthropathy) in the shoulder joint. Furthermore, avoiding shoulder movement for long periods of time may result in adhesive capsulitis, commonly known as “frozen shoulder”, which results in stiffness, discomfort, and reduced range-of-motion in the shoulder joint.
Depending on a patient’s diagnosis, a doctor may recommend a variety of treatments, including at-home interventions, physiotherapy, or even surgery.
Ice (for the first few days following an injury, ice should be applied for 15-20 minutes, every 3-4 hours to reduce inflammation)
Heat (after the initial few days, ice can be discontinued and a heating pad applied when necessary to reduce soreness and muscle tension)
Over-the-Counter Pain Relievers (pain relievers, such as ibuprofen, acetaminophen, or naproxen sodium, can be used as directed)
Corticosteroid injections, such as betamethasone, methylprednisolone, and triamcinolone may be used to relieve inflammation and soreness in the shoulder area. Injections are often used to relieve pain, allowing doctors to determine if limited motion in the shoulder joint is caused by pain or muscle weakness.
The doctor may recommend physiotherapy for the treatment of rotator cuff injury. Physiotherapists use a variety of treatments to encourage healing and strengthening of the rotator cuff following injury or surgery. Treatments include:
Exercise (rotator cuff exercises are often performed with elastic tubing)
Joint Mobilisation (physiotherapist applies force to the body, mimicking the movement of bones)
Dry Needling (the insertion of tiny needles into trigger points (taut bands of muscle inside large muscle groups) to relieve pain)
Acupuncture (the stimulation of nerves, muscles, and connective tissues through the insertion of thin needles into strategic points on the body.)
Transcutaneous Electrical Nerve Stimulation (TENS) (the application of low-voltage electricity to induce pain relief)
Kinesiology Taping (the application of special tape to stabilize the shoulder joint)
A doctor may also refer patients to an exercise physiologist, as exercise and stretching is the most effective treatment for strengthening and restoring movement to the rotator cuff. Exercise physiologists are health experts trained to prescribe exercise and stretching routines that encourage rotator cuff healing and rehabilitation.
Chiropractors specialise in the realignment and manipulation of the skeletal system, particularly the spine. Chiropractors believe that misalignment of the skeletal system negatively affects nerves, tissues, and organs, leading to disease and pain. Common chiropractic treatments for rotator cuff injuries include:
Manual Adjustment of the Shoulder Joint and Other Affected Areas
Functional Movement Screening (a series of tests used to identify and correct muscular imbalances)
Active Release Technique (ART) (the application of force to dissolve fibrous scar tissue)
Graston Technique (the use of instruments to identify and dissolve scar tissue)
Kinesiology Taping (the application of special tape to stabilise the shoulder joint)
Natural & Alternative Treatments
Yoga (gentle forms of yoga that do not place stress on the shoulder area, such as yin or kripalu yoga, can help strengthen and restore movement to the shoulder joint)
Acupuncture (the stimulation of nerves, muscles, and connective tissues through the insertion of thin needles into strategic points on the body)
Submersion in a jetted whirpool or bathtub
Sleeping with a Rotator Cuff Injury
Getting a good night’s sleep with a rotator cuff injury may prove difficult. Here are some tips to promote quality sleep while injured:
Change sleeping positions. Avoid the affected side and sleep on the back, if possible.
Place a pillow under the arm for support if sleeping on the side.
Add another pillow underneath the head to reduce stress on the shoulder.
Take pain-relieving medications as directed by a doctor.
Perform stretching exercises before bed.
Rotator Cuff Surgery
A doctor may recommend surgery if:
A tear is larger than 3 centimeters
The shoulder is severely weakened
A severe loss of function occurs
Pain does not respond to non-surgical interventions
Pain has been present longer than 6 months
A tear is caused by a severe injury, such as a fall or automobile accident
Three surgical methods are used to operate on the rotator cuff:
Open Repair (the use of an incision, several centimeters long, to gain access to the rotator cuff)
All-Arthroscopic Repair (the insertion of a tiny camera into a small incision in the shoulder joint, which guides the surgeon as he uses instruments to repair the rotator cuff)
Mini-Open Repair (the use of a 3-5 centimeter incision to access the rotator cuff)
There are many different types of rotator cuff surgery. Here are some of the most common:
Arthroscopic Tendon Repair (reattachment of a torn tendon to the upper arm bone (humerus) using arthroscopic tools and a tiny incision)
Open tendon repair (reattachment of a torn tendon to the humerus using a large incision and tools)
Bone Spur Removal (a reduction in the size of the acromion, the bony portion of the shoulder blade, which can impinge on the rotator cuff)
Tendon Transfer (the replacement of a damaged tendon with a tendon from another part of the body (most commonly the tendon of the latissimus dorsi))
Shoulder Replacement (Reverse Arthroplasty) (the replacement of a damaged shoulder joint with an artificial ball and socket joint)
General vs. Local Anesthesia
Depending on the type of surgery performed, general or local anesthesia may be used. General anesthesia renders a patient unconscious and is commonly used for more extensive procedures, such as shoulder replacement or tendon transfer.
Conversely, patients receiving local anesthesia may be conscious during the procedure. Local anesthesia eliminates sensation in certain parts of the body, and is often used during small tendon repairs, especially if performed arthroscopically. Patients undergoing local anesthesia are usually given intravenous sedatives to keep them relaxed during the operation.
Outpatient vs. Inpatient
Arthroscopic procedures and the repair of small tears are typically outpatient procedures. However, more extensive procedures, such as an open tendon repair or shoulder replacement, may require a hospital stay (though procedures vary depending on the specific medical system).
Recovery Time/Pain After Surgery
Recovering from a rotator cuff surgery may take many months, and pain levels vary depending on the type of procedure. Fortunately, doctors often prescribe medication to aid in pain management.
Rotator Cuff Exercise
Whether or not a patient undergoes surgery, rotator cuff exercise and stretching is almost always prescribed by a doctor. Diligent exercise can strengthen and restore motion in the shoulder joint, reducing pain and allowing patients to perform daily activities with ease. Depending on the type of injury, exercise and stretching recommendations will vary.
A doctor, physiotherapist, or exercise physiologist should always be consulted to determine which exercises are safe and effective. Here are a few common exercises that may be recommended:
Common Strength Exercises for the Rotator Cuff
External Rotation with Elastic Tubing
This simple exercise utilises elastic tubing, also known as a theraband, to provides gentle resistance throughout the entire range of motion. This exercise targets the infraspinatus and teres minor of the rotator cuff.
Stand up straight, feet hip-width apart.
Place upper arms next to the torso.
Grip elastic tubing with both hands (palms upward), lifting the forearms until they’re straight in front of the body, forming two, 90-degree angles between the forearms and upper arms.
Externally rotate the forearms. (Reduce range of motion if pinching or discomfort occurs).
Bring arms back to the starting position.
Perform 3 sets of 10 repetitions.
Side-Lying Internal Rotation with Dumbbell
This exercise strengthens the subscapularis and fosters flexibility and range of movement in the rotator cuff.
Lie on the side with the knees stacked, cradling the head.
Pick up a very light weight (no heavier than 2 kilograms).
Place the upper portion of the arm closest to the floor directly in front of the chest, with the forearm bent to create a 90-degree angle, palm facing upwards.
Lift forearm towards the chest and lower until the forearm almost touches the floor.
Perform 3 sets of 10 repetitions per arm.
Prone Horizontal Abduction with Dumbbell
This movement promotes rotator cuff strength by working the infraspinatus and teres minor muscles. It’s also excellent for encouraging good posture.
Lie face-down on a firm surface (i.e. a workout bench)
Let one arm hang off the bench, holding a light dumbbell (no heavier than 2 kilograms)
Keeping a slight bend in the elbow, retract the shoulders and lift the arm directly to the side of the body until almost parallel to the floor.
Lower and repeat.
Perform 3 sets of 10 repetitions per arm.
Common Flexibility Exercises for the Rotator Cuff
The pendulum is a simple, relaxing movement that encourages rotational flexibility in the rotator cuff.
Lean forward, placing one hand on the thigh for support.
Let the other arm hang down, relaxing the shoulder blade.
Gently circle the arm in one direction for 10 rotations, then perform 10 rotations in the opposite direction. Perform 3 sets of this stretch on each arm.
Cross-Body Shoulder Stretch
This stretch provides a release for the back of the shoulder.
Take one arm across the body, placing the hand behind the elbow to hold it in place.
Gently apply pressure until a release is felt.
Hold for 30 seconds per arm.
This stretch not only provides a release for the chest muscles, but also targets the subscapularis of the rotator cuff.
Place one hand on the wall (about shoulder level)
Gently rotate the body until a gentle stretch is felt (stop if pain or a pinching sensation occurs)
Hold for stretch for 30 seconds on each arm.
Exercises to Avoid
When healing from a rotator cuff injury, avoid activities that involve moving heavy weights or lifting overhead (such as a military press). Additionally, any activities that require quick, jarring movements to the shoulder joint be avoided. Most importantly, a medical professional should be consulted to determine the best course of treatment.
Avoid Further Injury
The rotator cuff is a delicate, injury-prone area of the body. Here are some tips for preventing and avoiding further injury to this area:
Warm-up for at least 5 minutes before participating in vigorous exercise. Dynamic stretching and light cardiovascular exercise can be used to prepare the rotator cuff for activity.
Incorporate rotator cuff exercises using light weight and high repetitions to strengthen the area and prevent injury.
Stretch the shoulders regularly, especially after a workout or when lifting heavy weights.
Avoid consistently sleeping on one side of the body.
Practice caution when performing movements that require moving the arm overhead. If discomfort is felt, take a break and stretch.
Practice yoga to encourage flexibility.
Get regular massages to relax the rotator cuff and promote blood flow.
Injuries to the rotator cuff (which consists of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles and their corresponding tendons), are all-too-common, accounting for 4.1 million doctor visits annually.
The most common causes of injury include overuse, aging, and traumatic injury. Rotator cuff injuries vary in type and severity, and almost always require rest, the application of heat and ice, over-the-counter medications, and a regimen of flexibility and strength training to promote recovery. More extensive injuries (or those that won’t heal properly) may require surgical intervention.
Regardless of the type and extent of a rotator cuff injury, it is always important to seek medical guidance to determine the best course of treatment. Doctors work in conjunction with physiotherapists, exercise physiologists, chiropractors, and surgeons to help patients repair their rotator cuffs and live pain-free lives.
Rotator cuff problems. Medline Plus website. https://medlineplus.gov. Updated July 23, 2015. Accessed June 21, 2016.
ACE-certified Personal Trainer, Group Fitness Instructor, Nutrition Coach, Blogger. Qualified with Bachelor of Science in Nutrition Science & Master of Science in Applied Nutrition (Concentration in Fitness and Nutrition).