Pain at night, and inability to lie on that side. Often the symptom that finally brings people in.
Pain reaching overhead, out to the side, or behind you.
Weakness lifting the arm, or the arm dropping when you try to hold it out.
Difficulty with everyday actions: fastening a seatbelt, washing your hair, taking something from a shelf.
A creaking or catching sensation as the arm lifts.
Pain radiating down the outer side of the upper arm — but not usually past the elbow.
In a large tear, being unable to lift the arm at all under its own power.
Why it happens
Gradual wear of the tendon with age — the commonest cause, and often with no injury at all.
A fall onto the arm or shoulder.
Lifting something heavy, or a sudden pull on the arm.
Years of overhead work: painting, plastering, ceiling work, loading.
Overhead sport — bowling, swimming, volleyball, tennis.
A bony spur above the tendon rubbing against it over years.
A shoulder dislocation, particularly in someone over forty, where the cuff tears at the same time.
See someone sooner if…
You cannot lift your arm at all after a fall or injury, which may indicate a large acute tear that does better repaired early.
There is weakness rather than only pain — weakness is more significant than discomfort.
Night pain has stopped you sleeping for more than a few weeks.
The shoulder is hot, red and swollen and you feel unwell, which needs assessment today.
You have numbness or pins and needles down the arm into the hand, which suggests the neck may be involved.
What the rotator cuff is
Four muscles wrap around your shoulder blade and merge into a single continuous sheet of tendon that grips the ball of the shoulder joint like a hand around a doorknob. That sheet is the rotator cuff. Its job is not power — the big muscles do that. Its job is to hold the ball centred in its very shallow socket while the arm moves.
When part of the cuff tears, the ball loses its centring. Lifting the arm becomes painful because the tendon is inflamed and pinched, and weak because the mechanism holding the joint together has a hole in it.
The most important thing to understand
Rotator cuff tears become steadily more common with age, and many cause no symptoms whatsoever. Studies scanning the shoulders of people with no complaints find tears in a substantial minority by their sixties and a large proportion by their eighties. Most of those people have full function and no pain.
This has a direct consequence: a tear on your MRI report is not automatically the reason your shoulder hurts, and it is not automatically a reason to operate. What matters is whether you are weak, how the tear started, how big it is, how healthy the tendon looks, and how much your shoulder is limiting your life.
Aspect
Often settles with treatment
Usually needs repair
Depth
Partial thickness
Full thickness
Onset
Gradual, over months or years
A specific injury — a fall or heavy pull
Main problem
Pain, with strength preserved
Genuine weakness lifting the arm
Age and demand
Older, lower demand
Younger, or physically demanding work
Tendon on MRI
Retracted, muscle wasted, fatty change
Healthy tendon, little retraction
Response so far
Improving with exercises and an injection
No improvement after three months of proper physiotherapy
Which tears usually do well without surgery, and which usually do not.
But waiting is not free either
The counterweight to all of the above: a full-thickness tear in a younger, active shoulder tends to enlarge over months and years. As it enlarges, the tendon retracts, the muscle wastes and turns to fat, and at some point it becomes irreparable. A tear repaired at that stage does not hold.
So the honest position is neither 'operate on everything' nor 'never operate'. It is that the decision has a time value, and if you are in the group where the tear is likely to progress, you deserve to be told so plainly rather than sent away for another six months of painkillers.
How it is diagnosed
Examination is the core of it: specific strength tests isolate each of the four cuff muscles, and there are reliable signs for a large tear.
X-ray, which shows a bony spur, arthritis, or the ball riding upwards — the last being a sign of a long-standing large tear.
Ultrasound, which is quick, dynamic and good at showing whether a tear is full or partial thickness.
MRI, which shows tear size, retraction, and — crucially — whether the muscle has wasted or turned to fat. That is what predicts whether a repair will hold.
It is also worth checking the neck. Pain from the cervical spine refers to the shoulder convincingly, and pins and needles reaching the hand points away from the cuff.
First, without surgery
What to try before an operation
This list comes first on purpose. For most people reading this page, it is the whole treatment — and where it is not, having genuinely worked through it makes the decision to operate a much clearer one.
A three-month structured programme focused on the shoulder blade muscles and the remaining cuff, supervised by a physiotherapist experienced with shoulders.
Modifying overhead activity temporarily, rather than resting the arm completely — a shoulder that stops moving stiffens quickly.
Sleeping semi-upright, or with a pillow supporting the arm, which many patients find is the single most useful change early on.
Anti-inflammatory medication for flares.
A corticosteroid injection into the space above the tendon, best used to reduce pain enough to make the exercises possible.
Reviewing how you lift and work — changing the height at which you work overhead often changes the symptoms.
Reassessment at three months, with imaging if there has been no progress, so the plan changes rather than repeats.
If surgery is needed
And when it genuinely is
Each option below says when it applies, not just what it is. If your situation does not match, that is a good reason to ask more questions.
Two years of broken sleep ended in the first fortnight
“I had not slept a full night in nearly two years. I could not lie on that side and I could not reach the top shelf in my own shop. The six weeks in the sling were hard and I was warned they would be. But the night pain went within two weeks of the operation, and that alone was worth it.”
Ashok M., 58 · Textile business owner
Adajan · 9 months after treatment
Outcome. Arthroscopic repair of a full-thickness rotator cuff tear. Out of the sling at five weeks, overhead reach restored by four months, back to full work.
A consultation means your imaging on the screen, a plain explanation of what is actually wrong, and an honest opinion on whether you need surgery — including when the answer is no.