RheumatologyTier 1Disease (DEADMAN)

Musculoskeletal conditions - rotator cuff tear

Description

Tear of one or more of the four rotator cuff tendons (supraspinatus most commonly, infraspinatus, teres minor, subscapularis)
Partial-thickness (low/intermediate grade - some fibres intact) vs full-thickness (complete tear through the tendon) - a key distinction for prognosis and treatment choice
Degenerative/chronic (commonest, atraumatic, older adults) vs acute traumatic (younger patients, often a specific injury/fall/dislocation) - different natural history and urgency

Prevalence rises steeply with age - full-thickness tears present in a substantial proportion of asymptomatic adults over 60 on imaging, rising further with age
Risk factors: age, repetitive overhead activity/occupation, smoking, diabetes, prior shoulder injury/dislocation

Degenerative tears - chronic tendon degeneration from reduced vascularity in the "critical zone" near the tendon insertion, combined with subacromial impingement/mechanical wear over decades
Acute traumatic tears - fall onto an outstretched arm, shoulder dislocation, or a sudden eccentric load, often in a younger patient or on a background of pre-existing degeneration
Progressive untreated tears - muscle atrophy and fatty infiltration develop over time, which is largely irreversible and predicts poorer surgical repair outcomes if intervention is delayed too long

Clinical

Shoulder pain (often worse at night, lying on the affected side) and weakness, particularly with overhead activity
Positive impingement signs (Neer, Hawkins-Kennedy), weakness on resisted abduction/external rotation, drop-arm sign suggests a large/full-thickness tear
Distinguish from adhesive capsulitis (frozen shoulder) - global restriction of both active and passive range of motion, whereas cuff tears typically preserve passive range

Imaging

Ultrasound - accessible, dynamic, good sensitivity/specificity for full-thickness tears, operator-dependent
MRI - better for partial-thickness tears, tear size/retraction, and assessing muscle atrophy/fatty infiltration - relevant to surgical planning
Plain X-ray - excludes other pathology (calcific tendinitis, glenohumeral OA), shows superior humeral head migration in chronic massive tears

A. First-line for most - physiotherapy-directed conservative management

Physiotherapy (rotator cuff strengthening and scapular stabilisation exercises) produces significant improvement in patient-reported outcomes for small-medium full-thickness tears and low/intermediate-grade partial tears, and is appropriate first-line for the majority
NSAIDs and corticosteroid injection - symptomatic adjuncts for pain control, do not heal the tear itself

B. When to consider surgery

Acute traumatic tear in a younger, active patient - earlier surgical repair generally favoured given better healing potential and to limit progressive atrophy/retraction
Persistent pain and functional impairment after an adequate trial of conservative therapy - surgical repair can improve outcomes at this point
Large/massive tears with significant weakness/functional loss - lower threshold for surgical referral

C. The trade-off to discuss with the patient

Conservative management avoids surgical risk but tear size, muscle atrophy, and fatty infiltration may progress over 5-10 years with nonoperative management, potentially reducing future repairability
Healed surgical repairs show better patient-reported and functional outcomes than physiotherapy alone or a failed/unhealed repair - but not all repairs heal, particularly in older patients/larger tears/poorer tissue quality
Shared decision-making incorporating age, activity demands, tear characteristics, and patient priorities - there is no single correct pathway for every patient

D. Massive irreparable tears (older, low-demand patients)

Reverse total shoulder arthroplasty - option for cuff tear arthropathy with significant functional limitation

Age, smoking, diabetes - impair tendon healing capacity
Prior shoulder dislocation/trauma
Subacromial impingement syndrome, calcific tendinitis - overlapping shoulder pathology
Adhesive capsulitis - important differential, occasionally coexists

Many degenerative tears remain asymptomatic for years and are found incidentally on imaging for another reason
Untreated symptomatic tears - progressive tear enlargement, muscle atrophy, and fatty infiltration over years, which can render later surgical repair less successful or not feasible
Cuff tear arthropathy - a late complication of chronic massive tears, with superior humeral head migration and secondary glenohumeral arthritis
With appropriate conservative or surgical management matched to tear characteristics and patient factors, the majority achieve meaningful functional improvement

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