Shoulder pain that lingers, a weakness you cannot quite explain, or an arm that simply will not reach where it used to — these are among the most common reasons people end up in an orthopaedic surgeon’s consulting room. Rotator cuff tears are one of the most frequent shoulder conditions I see, and one of the most frequently misunderstood.
The most common question patients ask is straightforward: do I actually need surgery? The honest answer is that it depends — and this article will help you understand what it depends on.
What Is the Rotator Cuff?
The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint, connecting the upper arm bone (humerus) to the shoulder blade (scapula). Together, they stabilise the ball of the shoulder within its socket and power the movements you use every day — reaching overhead, lifting, rotating your arm, and throwing.
The four muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis. The supraspinatus tendon, which runs along the top of the shoulder, is by far the most commonly torn — both in sports injuries and in the general population over time.
How Do Rotator Cuff Tears Happen?
Rotator cuff tears fall into two broad categories, and understanding which type you have matters for both treatment and prognosis.
Acute tears occur suddenly, most commonly following a fall onto an outstretched arm, a direct blow to the shoulder, or a sudden forceful pull — such as catching yourself on a railing or lifting something unexpectedly heavy. Acute tears are common in younger, active patients and in contact sports. In New Zealand, acute tears sustained through an accident are frequently eligible for ACC cover, which can significantly reduce the cost of assessment and treatment. Learn more about ACC and orthopaedic injuries.
Degenerative tears develop gradually over time as the tendons wear and fray, typically in patients over the age of 50. They may be present for months or years before causing significant symptoms — some people have substantial degenerative tears identified on imaging but experience very little pain or disability. A minor incident or increased activity may be what finally brings the symptoms to attention, but the tear itself has been developing quietly for much longer.
Symptoms of a Rotator Cuff Tear
The symptoms of a rotator cuff tear vary considerably depending on the size of the tear, whether it is acute or degenerative, and the individual. Common presentations include:
• Pain at the side or front of the shoulder, often radiating into the upper arm
• Pain that is worse at night and disrupts sleep — this is particularly characteristic of rotator cuff pathology
• Weakness when lifting the arm, reaching overhead, or rotating against resistance
• Difficulty with everyday tasks such as reaching behind the back, dressing, or lifting objects above shoulder height
• A catching or clicking sensation in the shoulder with certain movements
In acute tears following an injury, the onset is sudden and often dramatic. Degenerative tears tend to produce gradually worsening pain and weakness over months.
How Is a Rotator Cuff Tear Diagnosed?
Diagnosis begins with a clinical assessment — a careful history of how and when symptoms began, followed by a structured examination of the shoulder’s strength, range of motion, and provocation tests. Most experienced surgeons can form a strong clinical impression from examination alone.
Imaging confirms the diagnosis and provides essential information about the size and location of the tear:
• Ultrasound is the first-line imaging investigation for suspected rotator cuff pathology and is widely available in New Zealand. It is accurate, inexpensive, and can dynamically assess the tendons during movement. Your GP or physiotherapist can arrange this.
• MRI provides more detailed information about the tear size, retraction of the tendon, and the condition of the surrounding muscle — information that is particularly important in larger tears or when surgery is being planned.
For shoulder conditions, x-rays of the glenohumeral joint, scapular lateral, and axillary views are also valuable and should accompany any referral. View the full imaging guide for referring providers.
When Is Surgery the Right Choice?
This is the question I am most frequently asked, and the answer requires weighing several factors together rather than applying a single rule.
Surgery is generally recommended when:
• The tear is large or complete (full-thickness), particularly in a younger or active patient where the tendon is unlikely to recover meaningful function without repair
• Symptoms have not improved after a genuine trial of non-operative treatment — typically at least three to six months of supervised physiotherapy and, where appropriate, corticosteroid injection
• Weakness is significant and affecting daily function, work, or sport
• The tear is acute and occurred in a previously healthy tendon — acute full-thickness tears in younger patients generally benefit from early surgical repair before the tendon retracts and muscle atrophy develops
• There is an associated structural abnormality (such as a bone spur causing ongoing impingement) that physiotherapy alone cannot address
Surgery is less likely to be beneficial when:
• The tear is small or partial-thickness and symptoms are improving with physiotherapy
• The patient is older or less active and has acceptable function despite the tear
• The muscle behind the torn tendon has undergone significant atrophy and fatty infiltration — in this situation, repairing the tendon may not restore meaningful function
• Medical comorbidities increase the risks of surgery beyond the likely benefit
It is worth noting that not all rotator cuff tears cause pain, and not all painful shoulders have significant tears. Treatment decisions must be based on the whole clinical picture — your symptoms, your functional goals, and the imaging findings together — rather than the imaging report alone.
What Does Rotator Cuff Repair Involve?
Rotator cuff repair is performed through an open incision or arthroscopically — through small keyhole portals — under general anaesthetic, typically as a day or overnight procedure. The surgeon inspects the joint, prepares the torn tendon edges and the footprint on the bone where the tendon attaches, and uses small suture anchors to reattach the tendon securely to the humerus. Any other pathology identified during the procedure — such as a bone spur, labral damage, or biceps tendon pathology — can often be addressed at the same time.
The procedure typically takes 60–90 minutes depending on the size and complexity of the tear.
Recovery After Rotator Cuff Repair
Recovery from rotator cuff repair is gradual and requires patience. The repaired tendon must heal back to the bone — a biological process that takes time regardless of how well the surgery went.
A general timeline:
Weeks 1–6: The arm is kept in a sling to protect the repair. Gentle passive range-of-motion work can begin early under physiotherapy guidance.
Weeks 6–12: The sling is discontinued. Active range-of-motion exercises begin.
Months 3–6: Progressive strengthening of the rotator cuff, periscapular muscles, and rotator cuff. Most patients regain comfortable function for everyday activities during this phase. Return to heavier physical work generally occurs toward the end of this phase.
Months 6–12: Return to sport. Full recovery, including strength restoration, typically takes 9–12 months for larger repairs.
Adherence to the physiotherapy programme is one of the strongest predictors of a good outcome. View shoulder rehabilitation information.
Getting a Referral for Shoulder Pain in Auckland
If you are experiencing shoulder pain, weakness, or a suspected rotator cuff injury, the first step is to see your GP or physiotherapist. They can arrange initial investigations — including an ultrasound and x-rays — and provide a referral to an orthopaedic surgeon for further assessment.
Dr. Matthew Boyle is a fellowship-trained orthopaedic surgeon in Auckland specialising in shoulder surgery and sports injury management, with a particular interest in arthroscopic rotator cuff repair. His clinic is located at AUT Millennium, 17 Antares Place, Rosedale, Auckland. To request an appointment, ask your GP or physiotherapist for a referral or contact the clinic directly. GPs and physiotherapists can refer via HealthLink EDI: drmboyle.
This article is for general educational purposes only and does not constitute medical advice. Please consult your doctor or seek a specialist referral for personal medical advice.
