Rotator Cuff Injuries

The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint. The supraspinatus sits on top and lifts the arm away from the body. The infraspinatus and teres minor sit behind the joint and rotate the arm outward. The subscapularis sits in front and rotates the arm inward. Together these tendons blend into a single sleeve that holds the ball of the shoulder centered in its shallow socket while the much larger deltoid muscle powers the arm.

This centering role is what makes the cuff so important. When a tendon tears, the ball no longer stays perfectly centered, and the shoulder loses both strength and the smooth mechanics that allow it to move overhead without pain.

A rotator cuff tear occurs when one or more of these tendons pulls partially or completely away from the bone. The pattern of the tear directly influences the treatment options Dr. Rynecki Baker recommends.

• Partial-thickness tears: Part of the tendon’s thickness is torn while the remainder stays attached. These often respond to nonoperative care, though they carry a meaningful risk of progressing.
• Full-thickness tears: The tendon is torn all the way through and has separated from its attachment on the bone. These range from small tears involving one tendon to large tears involving several.
• Subscapularis tears: Tears of the tendon at the front of the shoulder. These are frequently missed on both examination and imaging, and because the subscapularis is the shoulder’s primary internal rotator and a key front-side stabilizer, an unrecognized tear undermines the result of any repair performed behind it. Subscapularis tears are also commonly accompanied by instability or tearing of the biceps tendon, which runs in a groove alongside it.
• Massive and irreparable tears: Large, chronic tears in which the tendon has retracted and the muscle has been replaced by fat. In these cases, the tendon can no longer be brought back to the bone, and treatment shifts to reconstruction, tendon transfer, or shoulder replacement rather than repair.
• Rotator cuff tear arthropathy: The end stage of a long-standing massive tear, in which the ball rides upward against the underside of the shoulder blade and the joint develops arthritis. Patients often cannot lift the arm at all, a pattern called pseudoparalysis.

Rotator cuff tears develop through acute injury, gradual degeneration, or a combination of both. Common causes include:

• Acute injury: A sudden fall, shoulder dislocation, direct blow, or forceful overhead movement can tear an otherwise healthy tendon. A forced backward or outward twist of the arm is a classic mechanism for a subscapularis tear.
• Repetitive overhead activity: Athletes and workers who perform repeated overhead motions place chronic stress on the rotator cuff that can lead to tearing over time.
• Degenerative wear: Over time, tendons lose elasticity and blood supply, making them increasingly vulnerable to tearing. This is the most common cause in patients over the age of forty.
• Bone spurs: A spur on the underside of the shoulder blade can repeatedly impinge on the rotator cuff tendon with arm movement, gradually wearing it down until it tears.

Symptoms vary depending on which tendon is torn, the size of the tear, and how it occurred. Dr. Rynecki Baker encourages patients not to dismiss persistent shoulder pain, as early evaluation can prevent small tears from progressing. Common symptoms include:

• Pain at the side or front of the shoulder: A deep ache that worsens with overhead activity and is often present at night when lying on the affected side.
• Weakness: Difficulty lifting the arm or carrying objects is a hallmark symptom that distinguishes rotator cuff tears from other causes of shoulder pain.
• Limited range of motion: Difficulty reaching overhead or behind the back.
• Weakness turning the arm inward: Difficulty tucking in a shirt, reaching into a back pocket, or pushing off an armrest, which suggests involvement of the subscapularis.
• Inability to lift the arm at all: A shoulder that shrugs rather than elevates, which raises concern for a massive tear or cuff tear arthropathy.

This is one of the most important questions Dr. Rynecki Baker addresses with patients who are considering non-operative management. Research has demonstrated that partial-thickness rotator cuff tears carry a meaningful risk of progression to full-thickness tears over time. Approximately half of initially asymptomatic rotator cuff tears become symptomatic by two years, with more than half of these demonstrating tear enlargement on follow-up imaging.

Once a tear becomes larger, repair becomes more technically demanding, the quality of the remaining tendon tissue decreases, and the likelihood of achieving a durable repair diminishes. Muscle atrophy and fatty infiltration of the rotator cuff musculature, changes that develop progressively as the tendon remains disconnected from the bone, can become irreversible, limiting the functional outcome of any eventual surgery. This is why Dr. Rynecki Baker recommends careful monitoring of known rotator cuff tears, even when symptoms are initially manageable: early treatment, when it is needed, produces better outcomes than waiting until the tear has progressed.

Diagnosis begins with a thorough evaluation by Dr. Rynecki Baker, including a detailed history and a physical examination that tests strength and range of motion in each direction. She tests each tendon individually, including specific maneuvers for the subscapularis that are easy to overlook, and assesses whether the shoulder can be held in position against resistance.

Imaging confirms the diagnosis and guides treatment. X-rays assess for bone spurs, arthritis, and upward migration of the ball, which suggests a long-standing massive tear. MRI is the gold standard for evaluating the rotator cuff, allowing Dr. Rynecki Baker to assess the size and location of the tear, how far the tendon has retracted, the quality of the remaining tendon, and the degree of muscle atrophy and fatty infiltration, all of which determine whether a tear is repairable. CT is used in selected cases to evaluate bone anatomy when shoulder replacement is being considered.

Rotator cuff repair is a technically demanding procedure, and outcomes require close monitoring of rehabilitation afterward. Not every tear should be repaired the same way, and some should not be repaired at all: a massive, retracted tear treated with a repair that cannot hold leaves a patient worse off than a well-chosen reconstruction or replacement would have. Dr. Rynecki Baker’s training at NYU Langone Health and Hospital for Special Surgery, her dedicated focus on shoulder surgery and sports medicine, and her published research mean patients are evaluated by a specialist who understands the full complexity of rotator cuff pathology and who will be candid about which treatment fits the tear in front of her.

Dr. Rynecki Baker understands what a painful shoulder does to sleep, training, and daily life. She approaches every patient as an individual, taking the time to understand each person’s symptoms, activity level, and goals before recommending treatment.