Complete rotator cuff tear

What the rotator cuff does

The rotator cuff consists of four muscles with their tendons that guide the head of the humerus closely to the socket (glenoid) and finely control the shoulder in almost all positions. It stabilizes and enables lifting, turning and controlled movements overhead.

• Supraspinatus: raises the arm to the side and centers the head of the humerus
• Infraspinatus: external rotation and posterior stabilization
• Teres minor: external rotation and fine stabilization
• Subscapularis: Internal rotation and anterior stabilization

The long biceps tendon (LBS) passes through the acromion and can be irritated or involved in cuff tears. An intact cuff also works closely with the deltoid and scapular muscles (scapular control).

Causes and emergence

Complete ruptures occur either traumatically (e.g. fall on an outstretched arm, sudden tensile stress) or degeneratively due to chronic tendon damage. There is often a combination: a previously damaged tendon tears in a relatively minor event.

• Degenerative: age-related changes, reduced blood flow to the tendon, microtears, overhead strain
• Mechanical tightness (impingement), bony spurs or calcifications
• Acute trauma: falls, sudden lifting, shoulder dislocation
• Risk factors: smoking, diabetes, elevated blood lipids, systemic cortisone therapy, heavy physical work, repeated overhead sports

Which tendon is affected influences the symptoms and treatment planning. Most commonly, the supraspinatus is completely torn, often in combination with the infraspinatus or subscapularis.

Typical symptoms

The symptoms vary depending on the size of the tear, its duration and the affected tendon. Acute tears manifest themselves differently than ruptures that develop slowly.

• Severe shoulder pain, often stabbing, sometimes with an audible/palpable tear
• Night pain, lying on the affected side is hardly possible
• Loss of strength, especially during lateral raises (supraspinatus) or external/internal rotation
• Restricted movement up to pseudoparalysis (arm can hardly be raised actively, but passively)
• Feeling weak, snapping or rubbing feeling
• With chronic tears: often less pain, but noticeable functional deficits and fatigue

When is it urgent?

Some constellations require a prompt specialist examination in order to maintain the chances of good function.

• Acute severe weakness or pseudoparalysis after a fall
• Fresh tear in younger or very active patients
• Suspected subscapularis rupture (sudden loss of internal rotation/strength)
• Concomitant shoulder dislocation or biceps tendon dislocation
• Fever, redness, pronounced pain at rest after the procedure or injection (suspected infection: emergency)

Diagnostics in our practice

Diagnosis is based on history, clinical examination and imaging. The aim is to precisely record the size of the tear, the quality of the tendons/muscles and accompanying factors - the basis for the treatment decision.

We discuss the findings in an understandable manner and explain whether conservative treatment can achieve realistic goals or whether prompt surgery is likely to offer advantages.

Conservative treatment first – if appropriate

Not every complete rupture necessarily requires surgery. Particularly in the case of degenerative tears, low functional demands, older age or significant retraction, a non-surgical strategy can enable good pain control and everyday function.

• Pain relief: anti-inflammatory medication (if tolerated), cooling, short-term immobilization in an arm sling
• Targeted physiotherapy: centering the head of the humerus, strengthening the deltoid muscle and scapular stabilizers, posture and movement control
• Adaptation of everyday and work loads, ergonomic advice
• Subacromial injection of local anesthetic/cortisone to reduce pain with restraint (limited number, no series without clear indication)
• If necessary: ​​temporary abduction orthosis to reduce pain

Realistic goals of conservative therapy are, above all, less pain, better sleep and practical arm function. Anatomical fusion of a completely torn tendon is not expected. Follow-up checks clarify whether the chosen path is effective or whether a surgical option should be discussed again.

When to operate? Procedure at a glance

Surgery is particularly an option in the case of acute traumatic tears with significant functional impairment, in younger and sporty/professionally active people, or if conservative measures are unsuccessful. Pseudoparalysis, subscapularis tears and relevant accompanying lesions also suggest prompt surgical treatment.

• Arthroscopic reconstruction (suture): Refixation of the tendon to the bone, depending on the shape of the tear, using the single-row or double-row technique
• Debridement/smoothing: for irreparable tears to reduce pain and improve sliding
• Biceps tendon therapy: tenotomy or tenodesis with accompanying LBS pathology
• Partial reconstruction/bridging: functional restoration of selected force vectors when complete refixation is not possible
• Augmentation/Patch or Superior Capsular Reconstruction (SCR): in individual cases to improve stabilization
• Tendon transfer (e.g. latissimus dorsi, pectoralis major/minor): selected cases with specific deficits
• Inverted shoulder prosthesis: Option for irreparable cuffs with arthropathy and significant functional impairment in old age

Time frame: For acute traumatic rupture, earlier reconstruction (often within a few weeks) can provide advantages in terms of retraction and tissue quality. In the case of degenerative cracks, planning is less time-critical, but follows the individual objectives.

Risks and limitations are discussed transparently in advance: re-rupture, frozen shoulder, infection, nerve irritation, thrombosis and the possibility that not all expectations will be achieved despite correct surgery. Tissue quality, tear size, smoking and metabolic diseases influence healing.

Rehabilitation and aftercare

Follow-up treatment is crucial for the result – regardless of whether surgery was carried out or not. It is individually tailored and clearly structured.

• Office work: often possible after 2-4 weeks (individual).
• Physical work/overhead work: usually after 3-6 months, depending on the healing process.
• Driving: if it can be safely controlled, usually after 6-8 weeks (medical clearance).

Everyday life, expectations and forecast

The aim of every treatment is to achieve reliable, everyday shoulder function with as little pain as possible. Whether conservative or surgical – realistic expectations help to achieve satisfactory results.

• Conservative: often good pain relief and improvement in function in everyday life; Strength deficits may remain.
• Surgical: if the indication is suitable, there is a good chance of functional gain; Healing takes time and participation in physical therapy.
• Re-rupture risk: increases with tear size, age, poor muscle/tendon quality and nicotine consumption.

We support you with clear exercise plans and close progress monitoring - tailored to your personal goals, whether work, family or sport.

Prevention and shoulder health

Not every tear can be avoided, but some measures can reduce the risk and stabilize the shoulder in the long term.

• Regular training of the scapular stabilizers and deltoid muscles
• Technique training for overhead sports, measured increase in load
• Break management for repetitive work, ergonomic adjustments
• Quit smoking, optimized blood sugar and lipid values
• Early clarification if night pain or loss of strength persists

Special situations and decisions

The decision for or against an operation is individual. Some typical constellations:

• Younger, sporty/professionally active people with an acute tear: more likely to undergo surgical reconstruction if tissue quality allows this.
• Older people with a degenerative rupture, manageable demands and little pain: often conservative approach with a focus on function and pain reduction.
• Marked retraction/fat infiltration: complete refixation often not possible; Alternatives include partial reconstruction, debridement, tendon transfer or reverse prosthesis (for arthropathy).
• Accompanying lesions (biceps tendon, labrum): are also treated during surgical treatment.

Regenerative and complementary processes – what is proven?

Additional procedures can provide support in individual cases, but do not replace the basic therapeutic decision.

• PRP (Platelet-Rich Plasma): Evidence of pain reduction in tendinopathies; Benefit for complete ruptures and after reconstruction is inconsistent - careful indication.
• Hyaluron injections: Data on cuff rupture is limited.
• Shock wave therapy: not standard for complete tendon tears.
• Patch augmentation/SCR: specialized procedures for selected irreparable tears.

We provide transparent advice on opportunities and limitations and only use procedures where a plausible benefit can be expected.