Medically reviewed by Thomas Freeman, MD | Reviewed July 2026
When I was a team doctor for Michigan and Eastern Michigan football, I saw many shoulder injuries in athletes, including rotator cuff tears. But the patients I see in my practice today often have a different story. Most rotator cuff tears are not caused by one dramatic event; instead, they develop gradually as the tendon becomes worn and more vulnerable over time. Many patients cannot identify a specific injury that started their symptoms; they simply notice increasing shoulder pain, weakness, or difficulty with everyday movements.
Key Takeaways
- A rotator cuff tear is damage to one or more of the tendons that stabilize and move the shoulder joint.
- Tears fall into two broad categories: acute tears from a specific injury and degenerative tears that develop gradually from years of wear.
- Most rotator cuff tears are treated conservatively first, with physical therapy as a component of that approach. When conservative treatment fails or for severe tears, surgery may be considered.
What the Rotator Cuff Actually Does
The rotator cuff is made up of four tendons (the supraspinatus, infraspinatus, teres minor, and subscapularis) that surround the head of the humerus and help keep the shoulder joint centered as it moves. In my practice, I often explain to patients that the shoulder is unique because it prioritizes motion over stability. The rotator cuff plays a key role in balancing those two demands by keeping the ball of the shoulder moving smoothly within the socket.
The deltoid muscle provides much of the strength needed to raise the arm, but the rotator cuff helps control that movement. When a rotator cuff tendon is torn, patients may first notice pain, a catching sensation, or difficulty with certain activities rather than an obvious loss of strength. Over time, depending on the size and severity of the tear, weakness and loss of function can become more noticeable.
Acute Tears vs. Degenerative Tears
An acute tear happens in a single event: a fall on an outstretched arm, a hard check into the boards, a ski pole catching wrong on an icy run. These tears tend to cause immediate, sharp pain and a noticeable loss of strength, and I usually see these patients within days because something clearly happened.
Degenerative tears are different. The tendon frays gradually as blood supply to that area of the shoulder naturally decreases with age, and years of overhead motion, whether that’s swinging a hammer, painting, or reaching into orchard trees, accelerates the process. Most people with a degenerative tear can tell me exactly when the pain got bad enough to make an appointment, but the tear may have actually started years before that.
Recognizing the Symptoms
Two symptoms come up more than any others in my exam room. The first is night pain, specifically pain that’s worse lying on the affected shoulder, which is one of the more reliable indicators that a cuff tendon is involved rather than a general shoulder strain. The second is a specific weakness pattern: difficulty lifting the arm away from the body or rotating it outward, especially against resistance, even when the patient can technically still move the shoulder through a full range.
A lot of patients also describe a catching or clicking sensation with overhead reaching, which tends to come from the torn tissue getting caught between the humeral head and the acromion during certain arm positions. None of these symptoms alone confirms a tear. Together, with a physical exam and usually an MRI, they build a clearer picture.
How a Tear Gets Diagnosed and Managed
Diagnosis starts with a physical exam that tests specific strength and pain patterns for each of the four cuff tendons, followed by imaging. X-rays rule out arthritis and check bone alignment. An MRI shows the soft tissue directly and tells me the size of the tear, how much the tendon has retracted, and how much fat has infiltrated the muscle, which matters a great deal for surgical planning.
Initial treatment for most rotator cuff tears is non-surgical: activity modification, physical therapy focused on strengthening the surrounding shoulder muscles, and anti-inflammatory medication or a corticosteroid injection for pain control. This works well for a meaningful portion of tears, particularly smaller or partial ones. In some cases, platelet-rich plasma (PRP) therapy, a regenerative treatment, may be considered.
Surgery gets discussed when conservative treatment fails to control pain or restore function, when the tear is large, or when someone has a physically demanding job or sport that depends on that shoulder holding up under load. Usually I perform rotator cuff repairs arthroscopically, which is a minimally invasive technique performed through small incisions. For massive tears, particularly in older patients where the tendon quality makes a standard repair unlikely to hold, or where arthritis has developed alongside the tear, reverse shoulder replacement sometimes becomes the more reliable option instead.
What I See in My Patients
Traverse City runs on physical work and physical recreation, sometimes in the same person on the same weekend. I see cherry orchard crews with degenerative tears from decades of overhead picking, marina workers whose shoulders take a beating hauling lines and gear all summer, and skiers from Crystal Mountain and Boyne who come in with acute tears from a fall on an icy run. I also see a fair number of former athletes in their forties and fifties who assume the pain they’re feeling now is just “getting older” catching up with an old football or hockey shoulder.
My honest opinion is that assumption costs people function unnecessarily. A shoulder that’s been quietly degenerating for years responds very differently to treatment than one that gets addressed early, and I’d rather see someone in clinic for a shoulder that turns out to be fine than have them wait two more years assuming there’s nothing to be done about it.
My Approach to Treatment
I don’t push surgery as a first move for most rotator cuff tears, and I tell patients that directly in the first visit. I plan for a structured physical therapy trial before we talk about the operating room, because a lot of tears, especially partial ones, respond well to strengthening the muscles around the tear rather than repairing it.
When surgery is the right call, MRI findings drive the plan, not a standard protocol applied to every tear. A small, repairable tear in an otherwise healthy shoulder gets treated very differently than a massive tear with significant retraction and fatty infiltration in a seventy-year-old with early arthritis. For that second group, I’ll often be direct that a repair is unlikely to hold long term, and that a reverse shoulder replacement, while it sounds like a bigger step, tends to give a more predictable result.
Summary
If you’re waking up because you rolled onto that shoulder, or you’ve noticed you can’t lift your arm out to the side the way you used to, don’t wait for it to become undeniable. An MRI answers most of the important questions early, while there are still more treatment options on the table. Schedule an evaluation and bring a specific list of what movements or activities the shoulder is stopping you from doing. That detail matters more to how I plan treatment than a general description of pain.
Frequently Asked Questions
Can a rotator cuff tear heal on its own?
A torn tendon generally does not heal itself once it’s fully torn, but pain and function often improve significantly with physical therapy that strengthens the surrounding muscles, even without surgical repair.
How do I know if my rotator cuff tear needs surgery?
That decision depends on tear size, how long symptoms have persisted despite conservative treatment, tissue quality on MRI, and how much the tear is limiting your specific activities and job demands.
What’s the difference between a rotator cuff repair and a reverse shoulder replacement?
A repair reattaches torn tendon to bone and works best on smaller or moderate tears with good tissue quality. A reverse shoulder replacement is used when the tear is too large or the tissue too damaged for a repair to reasonably hold, particularly when arthritis is also present.
How long is recovery after rotator cuff surgery?
Recovery varies with tear size and the type of procedure, but most patients are in a sling for a period of weeks followed by a structured therapy program lasting several months before full strength returns.
Is it normal for a rotator cuff tear to hurt more at night?
Yes. Night pain, especially lying on the affected side, is one of the more common and recognizable symptoms of a rotator cuff tear.
