Rotator cuff tear symptoms: how to recognize a tear and what to do next

This guide is for people with shoulder pain who suspect a rotator cuff tear, and for anyone who has just been told they have one. It explains what the symptoms mean, how a partial tear differs from a full-thickness tear, how the diagnosis is made, and when a surgeon starts talking about repair. The facts come from the American Academy of Orthopaedic Surgeons, Alberta Health Services, HealthLink BC and published studies.

What does a rotator cuff tear feel like?

The rotator cuff is four tendons that wrap the ball of the shoulder, hold it in the socket and help you lift and rotate the arm. The American Academy of Orthopaedic Surgeons lists four common symptoms when one of those tendons tears:

• Pain at rest and at night, especially when lying on the affected shoulder.
• Pain when lifting and lowering the arm or with specific movements, such as reaching overhead or behind you.
• Weakness when lifting or rotating the arm.
• Crepitus, a crackling sensation, when you move the shoulder in certain positions.

How the pain starts says a lot about the tear. A tear from a fall or a heavy, jerking lift usually causes intense pain right away, sometimes with a snapping sensation and immediate weakness in the upper arm. A degenerative tear, the kind that builds up over years, often starts as mild pain when you lift the arm overhead and can progress to pain at rest. HealthLink BC adds that the pain usually sits on the side and front of the upper arm and shoulder, and can spread down the outer arm toward the elbow.

Some tears cause no pain at all. In a Japanese village screening study of 1,366 shoulders, 20.7% had a full-thickness tear on ultrasound, and 16.9% of people with no symptoms had one. The main risk factors were age, a history of trauma and the dominant arm. The AAOS adds overhead occupations such as painting and carpentry, and sports such as tennis, baseball pitching, rowing and weightlifting. HealthLink BC also lists smoking, prior shoulder injuries and a tear in the other shoulder.

Partial vs full-thickness tears: what is the difference?

Surgeons describe tears by how far they go through the tendon and whether the tendon is still attached to the bone. Most tears involve the supraspinatus tendon and begin as fraying before they progress.

The size and type of tear shape the plan. A partial tear is a common reason to start with physiotherapy. A full-thickness tear with weakness, especially after an injury, is the pattern that moves a surgeon toward repair. HealthLink BC notes that you can have a complete tear without symptoms, especially as an older adult who is less active, which is why imaging findings are always read alongside your exam and your goals.

How is a rotator cuff tear diagnosed?

The exam

A surgeon or sports medicine physician checks for tenderness, measures how far the arm moves on its own and with help, tests strength in each rotator cuff muscle and examines the neck to rule out a pinched nerve. Alberta Health Services’ shoulder assessment clinical pathway lists the features that point to a rotator cuff tear: age over 40, pain with overhead activity, night pain when lying on the affected side, a painful arc when the arm is raised, full passive motion, and weakness on specific tests such as the empty-can test and the external rotation lag sign.

X-ray first

X-rays do not show tendons, so they are usually normal with a cuff tear. They still come first, because they rule out arthritis and other causes of pain and can reveal signs of an old, long-standing tear. The Alberta pathway orders a standard shoulder X-ray series for every patient with shoulder pain.

Ultrasound or MRI

Both show the tendons, the location of the tear and its size. A Cochrane review of 20 studies found MRI and ultrasound performed about equally for full-thickness tears: sensitivity and specificity of 94% and 93% for MRI, and 92% and 93% for ultrasound. Both were weaker for partial-thickness tears, and the review cautioned that ultrasound may miss more partial tears than MRI. A 2021 meta-analysis of 2,054 shoulders again found no significant difference between ultrasound and MRI for full- or partial-thickness supraspinatus tears, with one caveat: ultrasound was far more sensitive for partial tears in the hands of radiologists than surgeons (0.86 versus 0.57).

In practice, the AAOS notes that ultrasound may be quicker to schedule, while MRI also shows the quality of the muscle, which tells the surgeon how old the tear is and how well it is likely to heal after repair. If surgery is on the table, expect an MRI. Pathway’s rotator cuff repair page notes that a recent MRI helps but is optional before a consultation; your Pathway surgeon can order imaging after reviewing your case.

When is physiotherapy enough?

Most of the time. The AAOS reports that nonsurgical treatment relieves pain and improves function in about 80 to 85% of patients. That treatment means rest from painful overhead activity, anti-inflammatory medication, and a physiotherapy program that strengthens the cuff and the muscles around the shoulder blade. A cortisone injection relieves pain in about two-thirds of patients for at least 3 months, although repeated injections carry risks and HealthLink BC notes surgeons may avoid them close to a planned repair.

The Alberta pathway sets the standard most Canadian clinicians follow: at least 12 weeks of appropriate, active, strength-based physiotherapy. If pain and motion have not improved after 6 weeks, it adds pain control such as NSAIDs or an injection and continues physiotherapy for another 6 weeks. HealthLink BC adds a practical warning: avoid keeping the shoulder completely still, because immobilization can lead to stiffness or frozen shoulder.

Physiotherapy treats the pain and the weakness around the tear. The AAOS is clear about the trade-off: without repair, the tear may grow over time, and some activities may need to be limited.

When is surgery considered?

The AAOS lists the situations in which a surgeon is likely to recommend repair:

• Pain that persists despite nonsurgical treatment, or symptoms lasting 6 to 12 months.
• A large tear (more than 3 cm) with good surrounding tissue quality.
• Significant weakness or loss of function.
• A tear caused by a recent, acute injury.
• Very active people, and people who need the arm for overhead work or sport.

The strongest evidence for repair comes from a Norwegian randomized trial. Its 15-year results, published in 2024, followed 103 patients with full-thickness tears of 3 cm or less who were assigned to tendon repair or physiotherapy. Repair stayed ahead at every follow-up: a mean 11.8-point advantage on the Constant score, 1.8 cm less pain on a 10 cm scale, and more pain-free motion. Fifteen of the 51 physiotherapy patients crossed over to surgery, and in the tears treated with physiotherapy alone, the mean tear width grew from 16.2 mm to 31.6 mm. The authors concluded that repair should be the primary treatment for small-to-medium full-thickness tears.

Repair at Pathway is arthroscopic: the surgeon reattaches the tendon to the bone with suture anchors through small incisions, as an outpatient procedure. If a tear is massive and irreparable, a reverse shoulder replacement may be the better option, because that design relies on the deltoid rather than the cuff to lift the arm.

Why timing matters for larger and traumatic tears

Two things happen to a torn tendon that is left alone. The torn end retracts away from the bone, and the muscle attached to it shrinks and fills with fat, a change surgeons call fatty infiltration. Both make a repair harder to do and less likely to heal.

A study of 1,688 patients with rotator cuff tears measured how fast this happens. Moderate fatty infiltration of the supraspinatus muscle appeared an average of 3 years after symptoms began, severe infiltration at about 5 years, and muscle atrophy at about 4.5 years. The authors advised repairing tears before moderate fatty infiltration and atrophy appear, especially when more than one tendon is torn.

Tears also grow. In a prospective study of 224 people with a painless degenerative tear, 49% of tears enlarged over a median of 5.1 years of follow-up, with a median time to enlargement of 2.8 years. Full-thickness tears enlarged most often (61%), enlargement was linked to new pain, and muscle degeneration progressed in 30% of shoulders where the tear grew compared with 4% where it stayed stable.

For tears caused by an injury, the window is shorter. A 2021 study of 206 patients with traumatic full-thickness tears found that repair within 4 months of injury gave an estimated 10.3-point better ASES function score than later repair, and patients repaired within 3 weeks had the largest gains of all. An earlier comparison of 35 patients found better function and motion when traumatic tears were repaired within 3 weeks. A 2026 evidence review from the Brazilian Society of Shoulder and Elbow Surgery rated the certainty of this evidence as very low, but still recommended repairing traumatic tears as early as possible, because early repair lowered the chance that a larger tear would need a tendon graft.

Canadian pathways reflect this. The Alberta pathway treats a large or massive acute, traumatic tear in a person who cannot lift the arm to 90 degrees as a red flag that needs an urgent surgical referral, and sets an ideal timeline of 6 weeks to a surgical consultation and 12 weeks to surgery for other tears that fail physiotherapy. Pathway’s surgeons see patients within 1–4 business days, and surgery typically follows 2–4 weeks after consultation and quote approval. No referral is required.

When to see a doctor about shoulder pain

The NHS advises seeing a doctor if shoulder pain is getting worse or has not improved after 2 weeks, or if you have significant difficulty moving the arm. Seek urgent care for:

• Sudden or very bad shoulder pain, or an arm you cannot move.
• Pain that started after an injury or a fall.
• A change in the shape of the shoulder or marked swelling.
• Numbness or pins and needles that persist.
• Feeling feverish or unwell with the shoulder pain.

If you had a fall and now cannot lift the arm to shoulder height, treat that as urgent. It is the pattern of a large traumatic tear, and it is the one where weeks matter.

Quick answers

What are the first signs of a rotator cuff tear?

The four most common signs are pain at rest and at night, especially when lying on the affected shoulder; pain when lifting or lowering the arm; weakness when lifting or rotating the arm; and a crackling sensation with certain movements. A tear from a fall usually causes sudden intense pain, sometimes a snapping sensation, and immediate weakness.

Can a rotator cuff tear get better without surgery?

Often, yes. The American Academy of Orthopaedic Surgeons reports that nonsurgical treatment relieves pain and improves function in about 80 to 85% of patients. The tear itself can still grow: in a 15-year randomized trial, unrepaired small and medium tears roughly doubled in width. Your surgeon weighs your tear size, strength and goals.

Do I need an MRI to diagnose a rotator cuff tear?

Usually an X-ray comes first to rule out arthritis, then ultrasound or MRI to see the tendon. A Cochrane review found MRI and ultrasound perform about equally for full-thickness tears. MRI adds a view of the muscle quality, which matters when surgery is on the table. Ultrasound is often quicker to book and works well in experienced hands.

How do I know if my tear is partial or full-thickness?

Symptoms alone cannot tell you. A partial tear thins the tendon but leaves it attached; a full-thickness tear goes all the way through, and in a complete tear the tendon has detached from the bone. Imaging makes the call, and marked weakness after an injury points toward a full-thickness tear.

How long can I wait before rotator cuff surgery?

For a tear after an injury, sooner is better: in a study of 206 traumatic tears, repair within 4 months gave better function, and within 3 weeks gave the largest gains. For gradual tears, a trial of physiotherapy for about 12 weeks is standard. Over years, untreated tears can retract and the muscle can turn to fat, which makes repair harder.

Questions to ask your surgeon

• Is my tear partial or full-thickness, and how large is it?
• Which tendons are involved, and has the tendon retracted?
• Does my MRI show fatty infiltration or muscle atrophy, and what does that mean for healing?
• Is physiotherapy a reasonable first step for my tear, and for how long?
• If I wait, what is the risk that the tear grows or becomes harder to repair?
• If you repair it, what does recovery look like for my job and my sport?
• Is a reverse shoulder replacement a better option for my tear?

If repair is likely, Pathway’s guide to rotator cuff surgery recovery time walks through the sling, sleep, driving and strengthening phases week by week, and the guide to shoulder surgery wait times in Canada covers what to expect from public referral. You can also read about Pathway shoulder surgeons Dr. Jason Smith and Dr. Bashar Alolabi.

References

1. American Academy of Orthopaedic Surgeons (OrthoInfo). Rotator Cuff Tears. Accessed October 21, 2026.
2. HealthLink BC. Rotator Cuff Disorders. Current as of November 9, 2022. Accessed October 21, 2026.
3. Alberta Health Services (Bone and Joint Health). Shoulder Assessment Clinical Pathways, version 4 (May 2022, revised July 2023). Accessed October 21, 2026.
4. NHS. Shoulder pain. Last reviewed May 22, 2023. Accessed October 21, 2026.
5. Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19(1):116–120.
6. Lenza M, Buchbinder R, Takwoingi Y, et al. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database Syst Rev. 2013;(9):CD009020.
7. Farooqi AS, Lee A, Novikov D, et al. Diagnostic accuracy of ultrasonography for rotator cuff tears: a systematic review and meta-analysis. Orthop J Sports Med. 2021;9(10):23259671211035106.
8. Moosmayer S, Lund G, Seljom US, et al. Fifteen-year results of a comparative analysis of tendon repair versus physiotherapy for small-to-medium-sized rotator cuff tears: a concise follow-up of previous reports. J Bone Joint Surg Am. 2024;106(19):1785–1796.
9. Melis B, DeFranco MJ, Chuinard C, Walch G. Natural history of fatty infiltration and atrophy of the supraspinatus muscle in rotator cuff tears. Clin Orthop Relat Res. 2010;468(6):1498–1505.
10. Keener JD, Galatz LM, Teefey SA, et al. A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears. J Bone Joint Surg Am. 2015;97(2):89–98.
11. Gutman MJ, Joyce CD, Patel MS, et al. Early repair of traumatic rotator cuff tears improves functional outcomes. J Shoulder Elbow Surg. 2021;30(11):2475–2483.
12. Hantes ME, Karidakis GK, Vlychou M, et al. A comparison of early versus delayed repair of traumatic rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. 2011;19(10):1766–1770.
13. Lara PHS, Belangero PS, Schiefer M, et al. Evidence-based reviews and recommendations from the Brazilian Society of Shoulder and Elbow Surgery: early versus late repair for traumatic rotator cuff tears. Acta Ortop Bras. 2026;34(spe1):e308952.

Health information notice: This article provides general information about rotator cuff tear symptoms and diagnosis and cannot replace individual medical advice. Your surgeon and care team set your treatment plan based on your exam, your imaging, and your goals.