Rotator Cuff Tear

The rotator cuff consists of:

Supraspinatus
Infraspinatus
Teres minor
Subscapularis

The cuff centres the humeral head against the glenoid while allowing shoulder elevation and rotation.

Tears may be:

Traumatic
Degenerative
Partial thickness
Full thickness
Repairable
Irreparable

The supraspinatus is most commonly involved.

A practical full thickness tear size description is:

Small: below 1 cm
Medium: 1 to 3 cm
Large: 3 to 5 cm
Massive: greater than 5 cm or involving at least two tendons

Tear size alone does not define reparability.

Reparability also depends on:

Retraction
Muscle atrophy
Fatty infiltration
Tendon quality
Chronicity
Superior humeral migration

Pain is commonly:

Anterolateral
Worse with overhead activity
Worse at night
Worse when lying on the affected side

Patients may develop:

Weakness
Difficulty elevating the arm
Loss of external rotation
Pseudoparalysis with massive tears

A traumatic full thickness tear can present as sudden inability to elevate an arm that previously functioned normally.

Examination

Assess active and passive range separately.

Preserved passive motion with major loss of active elevation suggests rotator cuff dysfunction rather than adhesive capsulitis.

Useful tests include:

Supraspinatus

Jobe empty can
Full can

Infraspinatus

Resisted external rotation
External rotation lag

Subscapularis

Lift off
Belly press
Bear hug

A positive drop arm test suggests a substantial supraspinatus tear but is insensitive for smaller tears.

Plain radiographs: assess:

Acromial morphology
Glenohumeral arthritis
Superior humeral migration
Greater tuberosity changes
Acromiohumeral interval

Ultrasound: highly effective for experienced operators and useful for dynamic assessment.

MRI: investigation of choice when surgical planning is likely.

Define:

Tendons involved
Tear size
Retraction
Muscle atrophy
Fatty infiltration
Biceps pathology
Labral and cartilage disease

A chronic tear with severe muscle atrophy and advanced fatty infiltration may no longer be anatomically repairable even if the tendon edge can be identified.

Initial nonoperative treatment

Most degenerative tears can initially undergo:

Activity modification
Structured physiotherapy
Analgesia
Selected injection therapy

Physiotherapy should emphasise:

Rotator cuff strengthening
Scapular stabilisation
Posterior capsular mobility where restricted
Restoration of shoulder mechanics

Both physical therapy and surgery produce clinically meaningful improvement for many symptomatic small and medium full thickness tears. However, tears managed nonoperatively may enlarge and develop progressive muscle atrophy and fatty infiltration over subsequent years.

Analgesia

A practical regimen is:

Paracetamol 1 g orally every 6 to 8 hours as required, maximum 4 g daily in an adult without significant hepatic risk.

An NSAID may be added when renal, gastrointestinal and cardiovascular risk permits.

Corticosteroid injection

A single subacromial corticosteroid injection can provide short term improvement in pain and function.

Repeated injections should be avoided when surgical repair may ultimately be required because corticosteroid exposure can adversely affect tendon tissue and healing, particularly when performed close to surgery.

Partial thickness tear

A tear involving less than approximately 50% of tendon thickness is generally treated initially with rehabilitation.

Persistent symptoms can undergo:

Arthroscopic debridement
Treatment of associated pathology

A high grade partial tear involving more than approximately 50% of tendon thickness that remains symptomatic despite nonoperative treatment generally warrants repair rather than debridement alone.

Acute traumatic full thickness tear

A young or active patient with:

Acute traumatic tear
New objective weakness
Previously normal shoulder

should receive early surgical assessment.

Repair before major retraction and muscle degeneration develops is generally preferable when surgery is indicated.

Full thickness degenerative tear

Operate when there is:

Persistent pain despite appropriate rehabilitation
Function limiting weakness
Progressive tear
High functional demand
Repairable anatomy
Patient preference after informed discussion

Do not operate solely because MRI shows a tear in an asymptomatic shoulder.

Arthroscopic repair

The objective is secure tendon to bone healing at the greater tuberosity.

Steps include:

Mobilise tendon without excessive tension
Prepare the footprint
Repair tendon with suture anchors
Treat significant associated biceps pathology where required
Preserve viable tendon tissue

Single versus double row

For many small to medium tears, both single and double row fixation produce good clinical outcomes.

For tears above approximately 3 cm, double row constructs can reduce overall structural failure and may improve outcomes compared with simple single row repair.

The best repair is a low tension construct with adequate tendon mobilisation and good biological contact. A technically dense double row repair performed under excessive tension is not advantageous.

Biological augmentation

Routine platelet derived augmentation does not meaningfully improve patient reported outcomes.

Liquid PRP may reduce some structural retears, but the evidence does not justify routine use for every repair.

Massive repairable tear

Repair as much of the functional force couple as possible.

Restoring:

Subscapularis anteriorly
Infraspinatus and teres minor posteriorly

can restore meaningful shoulder function even when complete anatomical footprint coverage is difficult.

Options include:

Complete repair
Partial repair
Margin convergence
Augmentation in selected cases

Massive irreparable tear without arthritis

Treatment depends on:

Age
Pseudoparalysis
Which tendons are deficient
Subscapularis function
Glenohumeral cartilage

Options include:

Superior capsular reconstruction

Useful in selected younger patients with irreparable superior cuff deficiency and preserved joint surfaces.

Tendon transfer

For irreparable posterosuperior deficiency:

Latissimus dorsi transfer
Lower trapezius transfer

can restore external rotation in selected younger patients.

For irreparable subscapularis deficiency, pectoralis major or other transfer procedures may be considered.

Reverse shoulder arthroplasty

Particularly useful with:

Massive irreparable cuff tear
Cuff tear arthropathy
Persistent pseudoparalysis
Older lower demand patient
Failed previous cuff reconstruction

The reverse prosthesis allows the deltoid to elevate the arm despite absent rotator cuff function.

Avoid using reverse arthroplasty simply because an MRI calls a tear massive in a young patient with preserved function and no arthritis.

Postoperative rehabilitation

Healing is biological and takes months.

A typical programme progresses through:

Sling protection
Passive movement
Assisted movement
Active movement
Strengthening

Larger tears require greater initial protection.

Do not begin aggressive resisted cuff loading during the early tendon to bone healing phase.

Retear

Structural retear is more common with:

Large initial tear
Older age
Poor tendon quality
Advanced fatty infiltration
Smoking
Diabetes
Inadequate healing biology

A retear on MRI does not automatically require revision if function and pain remain acceptable.

Symptomatic repair failure requires reassessment of:

Tendon reparability
Muscle quality
Arthritis
Patient demand

before choosing revision repair, reconstruction, tendon transfer or reverse arthroplasty.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Assault-Related Injuries

Also known as: Interpersonal violence, Stab wound, Strangulation

Injuries resulting from interpersonal violence: blunt force trauma, penetrating trauma (stab or gunshot wounds), strangulation, or sexual assault. Management requires simultaneous attention to clinical injury, forensic documentation, and safeguarding or legal considerations.

Classified by mechanism: blunt (fists, weapons, kicks : contusions, fractures, organ injury without breach of skin), penetrating (direct tissue disruption along the trajectory), strangulation (manual or ligature: risk of delayed airway and vascular complications despite an initially reassuring presentation).

Follow the trauma primary survey (ABCDE) as for any traumatic injury ; mechanism dictates the injury pattern assessed.

Stab wounds: assess entry and exit wound location relative to underlying structures (thoracic; cardiac/great vessel/lung; abdominal ; solid or hollow organ; neck ; zones I-III guide investigation). Do NOT remove an in-situ weapon or foreign object in the field or ED ; it may be tamponading bleeding; remove only in a controlled theatre setting
Gunshot wounds: assess entry/exit wounds and trajectory; higher energy transfer causes more extensive tissue damage than the wound size suggests, with high suspicion for multiple organ involvement along the presumed path
Strangulation: petechiae (face, conjunctivae), voice change, dysphagia/odynophagia, neck bruising or ligature marks, subcutaneous emphysema (tracheal injury); significant risk of DELAYED airway compromise from progressive laryngeal edema, and of carotid or vertebral artery dissection, even with an unremarkable initial examination
Sexual assault: injuries may be absent or minimal even in confirmed assault; the presence or absence of injury neither confirms nor refutes an allegation
Signs of high-risk domestic violence: injury pattern inconsistent with the account, injuries at different healing stages, defensive wounds on the forearms, reluctance to disclose mechanism, a controlling partner present during consultation

Primary and secondary survey per trauma protocol
CT (chest/abdomen/neck as indicated by wound location and trajectory) for penetrating trauma in hemodynamically stable patients; immediate theatre for unstable patients
CT angiography neck: for strangulation with any neurological symptoms, or significant reported force or loss of consciousness: screens for arterial dissection
FAST scan: rapid assessment for hemoperitoneum or hemopericardium
Forensic documentation: body maps, photography with consent following local forensic protocol, preservation of clothing and evidence per chain-of-custody procedures: involve the forensic medical examiner per local pathway
STI and pregnancy screening, and forensic sample collection for sexual assault, ideally by a trained examiner within the recommended timeframe

Resuscitate per trauma principles ; clinical care takes priority over forensic considerations, though both can generally proceed in parallel.

Penetrating trauma: do not remove impaled objects; urgent surgical referral for exploration of wounds violating fascia, peritoneum or pleura; local wound exploration only for clearly superficial wounds
Strangulation: even asymptomatic patients require careful evaluation; consider CT angiography, extended observation (laryngeal edema can progress over 24-48 hours), low threshold for admission
Analgesia, tetanus prophylaxis, wound care as per soft tissue injury principles

Sexual assault:

Emergency contraception: levonorgestrel 1.5mg single dose within 72h, ulipristal acetate within 120h, or copper IUD within 5 days (most effective)
HIV post-exposure prophylaxis within 72h, ideally within hours ;combination ART for 28 days per local protocol
STI screening and empirical treatment, hepatitis B vaccination/immunoglobulin per status
Psychological support and counseling referral

Safeguarding: mandatory referral per local child or adult safeguarding protocols if a child is involved, a vulnerable adult, or the pattern suggests ongoing domestic violence. Document objectively; offer referral to domestic violence support services and police; patient autonomy is respected regarding police involvement unless a safeguarding duty overrides it.

Documentation: thorough and objective, as it may be required as evidence; factual language, avoiding conclusions about mechanism or perpetrator beyond the clinical findings.

Referral: trauma/general surgery for penetrating injury, ENT or vascular surgery for strangulation with airway or vascular concern, safeguarding team, sexual assault referral centre, psychiatry/psychology for acute severe distress.

Rotator Cuff Tear

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management