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Supraspinatus Tear

Original Editor - Brecht Haex

Top Contributors - Muhammad Arslan, Leana Louw, Kim Jackson, Mats Vandervelde, Brecht Haex, Fasuba Ayobami, Alexandra Stead, Vidya Acharya, Naomi O'Reilly, Wendy Walker, Saimat Lachinova, Habibu Salisu Badamasi, Simisola Ajeyalemi, Wout Van Hees, Joao Costa, Shreya Pavaskar, Anthony Mertens, Wanda van Niekerk and Rachael Lowe

Introduction

Supraspinatus muscle (highlighted in green) - posterior view
Supraspinatus muscle (highlighted in green) - posterior view[1]

A supraspinatus tear refers to a partial- or full-thickness disruption of the supraspinatus tendon, which forms part of the rotator cuff of the shoulder.[2] It may occur following acute trauma or develop gradually due to repetitive loading and degenerative changes.[3] Quite often, the tear occurs in the tendon or as an avulsion from the greater tuberosity.[4] Although the supraspinatus tendon is commonly affected in isolation, tears may also involve one or more of the other rotator cuff tendons.[5][1]

Clinical Relevant Anatomy

The shoulder joint is made up of three bones: the humerus, scapula and clavicle. The head of the humerus and the glenoid of the scapula form a ball-and-socket joint.[6] The supraspinatus muscle is located on the back of the shoulder, forming part of the rotator cuff.[7] The rotator cuff consists of supraspinatus, infraspinatus, subscapularis and teres minor.[8] The rotator cuff covers the head of the humerus and keeps it in place and these muscles help to lift and rotate the arm.[9]

The supraspinatus tendon passes beneath the acromion and attaches to the greater tubercle of the humerus.[10][11] It contributes to shoulder abduction and helps maintain glenohumeral stability during arm movement.[12] Injury to this tendon may cause pain during arm elevation, weakness during resisted abduction and difficulty performing overhead activities.[13] Larger tears may result in substantial weakness and impaired active shoulder elevation.[14]

Chronic or larger supraspinatus tears may also be associated with tendon retraction, muscle atrophy and fatty infiltration.[15] These changes can influence the potential for tendon repair and the choice of treatment.[16] Clinical assessment should therefore consider not only the presence of a tear but also its size, functional effects and associated muscle changes.[17]

Please see the shoulder page for more detailed information.

Muscles of the scapular region anterior aspect[18]

Supraspinatus

Below is the detailed anatomy of supraspinatus:[6][19][20]

Origin: Supraspinous fossa of the scapula.[21]

Insertion: Superior facet of the greater tuberosity of the humerus.[11]

Innervation: Suprascapular nerve (C5–C6).[22]

Function:

  • Assists in abduction of the arm at the glenohumeral joint.[23]
  • Contributes to dynamic stabilisation of the glenohumeral joint by helping to maintain the humeral head within the glenoid cavity.[24]
  • Works synergistically with the other rotator cuff muscles to control humeral head movement during shoulder motion.[25]

Epidemiology

The aetiology of supraspinatus tears is multifactorial, consisting of age-related degeneration, microtrauma, and macrotrauma.[26] It mostly affects the dominant arm with about 50% of people in their 80s experiencing this condition.[27][28] Injury and degeneration are the two main causes of rotator cuff tears.[29] Rotator cuff tears are associated with older patients, those with a history of trauma and mostly affect the dominant arm.[30]

Supraspinatus tears are among the most frequently reported tendon injuries of the rotator cuff, with their occurrence increasing with age.[31] A prospective study conducted in Brazil by Yazigi Junior et al. (2018), involving 80 patients with shoulder pain, identified partial-thickness supraspinatus tears in 38.75% and full-thickness tears in 16.2% of participants.[32] This study also reported that supraspinatus tears were more frequently identified in patients over 40 years of age (68.4%) compared with those aged 40 years or younger (21.7%). These findings demonstrate the association between increasing age and supraspinatus tendon pathology, although the results represent a symptomatic clinical population rather than the general population.

A 2021 meta-analysis by Zhao et al. included nine observational studies from eight countries: Japan, the United States, Argentina, Italy, Switzerland, Brazil, India and South Korea.[33] Among the 3,240 participants included, 687 (21.2%) were classified as having supraspinatus tears.[33] Furthermore, a 2025 study conducted in India found that the supraspinatus tendon accounted for 85.9% of all identified rotator cuff tears, including partial- and full-thickness tears.[34] These findings highlight the frequent involvement of the supraspinatus tendon in rotator cuff pathology, although the reported percentages reflect different study populations and should not be interpreted as general population prevalence estimates.

A meta-analysis was conducted by Zhao et al., which included studies from eight countries and identified male sex as a risk factor for supraspinatus tears.[33] The difference between these findings may reflect variations in study populations, participant characteristics and sampling methods. Therefore, further population-based research is required to establish the prevalence of supraspinatus tears across different age groups and between males and females.

Aetiology

The aetiology of supraspinatus tears is multifactorial, involving several intrinsic and extrinsic factors that contribute to tendon degeneration and injury.[26] The following are the main causes associated with the development of supraspinatus tears:

  • Age-related degeneration: Progressive changes in tendon structure, collagen organisation and tissue elasticity reduce the tendon's ability to tolerate mechanical stress, increasing susceptibility to tears, particularly in older adults.[35][36]
  • Repetitive mechanical loading: Repeated shoulder movements, particularly overhead activities, can expose the supraspinatus tendon to excessive mechanical stress, contributing to microtrauma and progressive tendon deterioration.[37]
  • Reduced tendon vascularity: Relatively limited blood supply in certain regions of the supraspinatus tendon may contribute to impaired tissue repair and increased susceptibility to degenerative changes.[38]
  • Extrinsic mechanical compression: Anatomical variations and changes in the subacromial structures may contribute to mechanical compression of the supraspinatus tendon during shoulder movement.[39]
  • Acute trauma: Sudden excessive loading or traumatic injury may cause partial- or full-thickness tears, particularly when the tendon is subjected to forces beyond its capacity.[40][37]

Mechanism of Injury

Supraspinatus tears can develop through acute traumatic injury or repetitive mechanical loading, which may lead to progressive tendon damage. The mechanisms of injury include:

Acute traumatic tears

Acute traumatic tears occur when a sudden excessive tensile force is applied to the supraspinatus tendon, exceeding its mechanical capacity and resulting in partial- or full-thickness disruption.[37] Common mechanisms include:[41]

  • Falling onto an outstretched arm or directly onto the shoulder.
  • Sudden forceful lifting or pulling.
  • Shoulder dislocation, particularly following traumatic injury.
  • Direct impact or high-energy trauma involving the shoulder.

Repetitive loading and progressive tendon failure

Repeated loading of the supraspinatus tendon, particularly during activities involving shoulder elevation and overhead movements, can produce cumulative microdamage.[42] When the rate of damage exceeds the tendon's capacity for repair, progressive structural deterioration may occur, eventually resulting in a partial- or full-thickness tear.[37] This mechanism is commonly associated with:[43]

  • Repetitive overhead activities during occupational or sporting tasks.
  • Repeated shoulder elevation and abduction under load.
  • Prolonged or excessive mechanical loading without adequate recovery.
  • Progressive deterioration of tendon integrity, which may increase susceptibility to rupture during relatively low-force activities.

A pre-existing degenerative tendon may also sustain an acute tear following a relatively minor traumatic event, resulting in an acute-on-chronic injury.[44]

Risk Factors

Following are risk factors of supraspinatus tear:[33]

  • Individuals over 40 years of age have an increased likelihood of developing supraspinatus tendon tears, with prevalence increasing further with advancing age.[30][45]
  • Supraspinatus tears have been reported more frequently in males than females, with male sex identified as a potential risk factor.[30][46]
  • Smoking
  • Genetics
  • Hypercholesterolemia
  • Body mass index
  • Height
  • Repetitive stress/lifting
  • History of trauma
  • Lack of blood supply
  • Bony spurs
  • Overhead activities and other people who do overhead work: Tennis players, Baseball pitchers, Painters, Carpenters, and Plumbers.
  • Traumatic injury e.g. fall (more common cause in younger individuals)[6]

Clinical presentation

Supraspinatus tears are classified as partial-thickness or full-thickness tears.[47] They may be symptomatic or asymptomatic, depending on factors such as tear size, location and associated tendon and muscle changes.[48]

Partial thickness:

  • Involve incomplete disruption of the supraspinatus tendon fibres, with some fibres remaining intact.[3]
  • May involve the articular surface, bursal surface or the internal substance of the tendon.[49]
  • Can increase in size and potentially progress to full-thickness tears.[50][51]

Full thickness:

  • Involve disruption across the entire thickness of the supraspinatus tendon and muscle fibres, from the articular to the bursal surface.[52]
  • May involve partial or complete detachment of the tendon from its insertion on the greater tuberosity.[53]
  • Larger tears may be associated with tendon retraction, supraspinatus muscle atrophy and fatty infiltration.[54]

Signs and Symptoms

Patients with a supraspinatus tear may present with the following signs and symptoms:[6][28][55][46]

Pain:

  • Pain over the anterolateral and superior aspect of the shoulder, which may radiate towards the deltoid insertion.
  • Pain during shoulder movements, particularly lifting or lowering the arm.
  • Pain during overhead activities and forward elevation.
  • Night pain, particularly when lying on the affected shoulder.
  • Pain at rest, particularly in more symptomatic or advanced cases.

Presentation according to the type of tear:

  • Traumatic tears: Sudden onset of severe shoulder pain, sometimes accompanied by a snapping sensation and immediate weakness following an injury.
  • Degenerative tears: Gradual onset of shoulder pain, initially associated with activity, which may become more persistent over time.

Movement limitations:

  • Reduced active shoulder abduction and forward elevation.
  • Difficulty performing overhead activities.
  • Difficulty reaching behind the back, dressing and combing the hair.
  • Passive range of motion may remain relatively preserved, particularly in isolated supraspinatus tears.

Muscle weakness:

  • Weakness during resisted shoulder abduction.
  • Reduced strength when lifting the arm against resistance.
  • Difficulty maintaining the arm in an elevated position, particularly with larger or full-thickness tears.

Other associated symptoms:

  • Shoulder stiffness, particularly when associated with prolonged pain or reduced movement.
  • Clicking or crepitus during shoulder movement, although these symptoms are not specific to supraspinatus tears.

Clinical Examination

Clinical examination of a suspected supraspinatus tear involves assessing shoulder range of motion, muscle strength, pain, functional limitations and specific rotator cuff tests.[56] A systematic examination helps identify possible tendon pathology, evaluate shoulder function and distinguish supraspinatus tears from other shoulder conditions.[57] Clinical findings should be interpreted alongside the patient's history and imaging when indicated.[58]

Following assessment should be considered when suspecting a patient diagnosed with supraspinatus tear:

Subjective assessment:[26][59][60][61]

  • Onset: Determine whether symptoms developed spontaneously (atraumatic) or following an injury or trauma.
  • Duration: Establish how long the patient has experienced shoulder pain.
  • Pain characteristics: Assess pain location, severity, nature and aggravating or relieving factors.
  • Night pain: Determine whether pain interferes with sleep or increases when lying on the affected shoulder.
  • Previous history: Ask about previous shoulder injuries, pain or similar episodes.
  • Functional limitations: Identify difficulties with activities of daily living, particularly reaching overhead, lifting objects, dressing and grooming.
  • Medical history: Review relevant comorbidities, previous treatments, medications and shoulder surgery.
  • Occupational and recreational activities: Identify repetitive overhead activities, sporting participation and occupational demands.

Observation:[62]

  • Assess shoulder posture, symmetry and any visible deformity.
  • Look for muscle atrophy, particularly in the supraspinatus and infraspinatus fossae.
  • Observe scapular positioning and movement for abnormalities such as scapular dyskinesis.[63][64][65]
  • Compare both shoulders.

Range of motion (ROM):[66]

  • Assess both active and passive shoulder ROM.
  • Active ROM may be reduced, particularly in flexion and abduction, due to pain or weakness.
  • Passive ROM is often relatively preserved in isolated rotator cuff tears.
  • A greater passive than active ROM may suggest rotator cuff dysfunction, particularly when accompanied by weakness.
  • Assess external and internal rotation to identify additional restrictions.

Muscle strength:[67][68]

  • Assess supraspinatus strength using resisted shoulder abduction.
  • Perform the Jobe test (Empty Can test): position the shoulder at approximately 90° abduction in the scapular plane, with the thumb pointing downwards and apply downward resistance while the patient attempts to maintain the position.[69][70]
  • Pain or weakness may indicate supraspinatus pathology.
  • Assess infraspinatus and teres minor through resisted external rotation.
  • Assess subscapularis through resisted internal rotation.
  • Assess scapular muscle function and control.

Palpation:[60][71]

  • Palpate the greater tuberosity of the humerus, where the supraspinatus tendon inserts.
  • Assess for local tenderness around the rotator cuff insertion.
  • Palpate the subacromial region, acromioclavicular joint and long head of the biceps tendon to identify associated pathology.
  • Assess supraspinatus and infraspinatus muscle bulk for atrophy, comparing both sides.

Special tests:

Drop-arm test[72][73][74]

Purpose:

To assess rotator cuff integrity, particularly the supraspinatus tendon, and identify possible significant rotator cuff tears.

Patient position:

The patient is positioned in a sitting or standing position, with the affected arm initially relaxed alongside the body and the elbow extended.

Physiotherapist position:

The physiotherapist stands beside the affected shoulder, facing the patient, to support the arm during positioning and observe the patient's ability to control shoulder movement.

Procedure:

  1. The physiotherapist passively abducts the patient's affected shoulder to approximately 90° in the scapular plane, keeping the elbow extended.
  2. The patient is instructed to slowly lower the arm towards the side of the body in a controlled manner.
  3. The physiotherapist observes the movement, assessing the patient's ability to maintain control throughout the lowering phase.
  4. The test is performed on both shoulders when appropriate for comparison.

Positive test:

  • The patient is unable to lower the arm slowly and smoothly.
  • The arm suddenly drops towards the side due to an inability to maintain controlled abduction.
  • Significant pain or weakness may occur during the lowering movement.

[75]

Drop Arm Test video provided by Clinically Relevant

[76]

Jobe's test (Supraspinatus / Empty Can Test):[72][77][78]

Purpose: To assess the supraspinatus muscle and tendon, particularly for detecting supraspinatus tendinopathy or rotator cuff tears.
Patient position: The patient is positioned standing or sitting, with both arms elevated to 90° in the scapular plane (approximately 30–45° anterior to the frontal plane), elbows extended and thumbs pointing downwards (internal rotation). Physiotherapist position: The physiotherapist stands in front of the patient, facing them, with their hands positioned over the distal forearms or wrists to apply resistance.
Procedure:
  1. The patient abducts both shoulders to approximately 90° in the scapular plane.
  2. The shoulders are internally rotated so that the thumbs point towards the floor, as if emptying a can.
  3. The physiotherapist applies downward resistance to the patient's arms while instructing them to maintain the elevated position.
  4. The patient is asked to resist the downward force and maintain shoulder elevation.
  5. The physiotherapist assesses pain, muscle strength and the ability to maintain the position. Both shoulders can be tested for comparison. Positive test:
  • Reproduction of pain over the anterolateral shoulder during resisted abduction.
  • Weakness or inability to maintain the arm in the elevated position against resistance. A positive test suggests supraspinatus tendon pathology, including tendinopathy or a possible tear. However, pain alone does not confirm a tear, and weakness should be interpreted alongside other clinical findings.

[79]

Empty Can Test video provided by Clinically Relevant

[80]

Full can test:[81][82][78]

Purpose: To assess the function and integrity of the supraspinatus muscle and tendon, particularly for identifying supraspinatus tendinopathy or rotator cuff tears. Patient position: The patient is positioned in sitting or standing, with the arms elevated to approximately 90° in the scapular plane (30–45° anterior to the frontal plane). The elbows remain extended, and the thumbs point upwards (external rotation), as if holding two full cans. Physiotherapist position: The physiotherapist stands in front of the patient, facing them, with their hands positioned over the distal forearms or wrists to apply downward resistance. Procedure:
  1. The patient is instructed to elevate both arms to approximately 90° in the scapular plane.
  2. The shoulders are externally rotated so that the thumbs point upwards.
  3. The physiotherapist places their hands over the patient's distal forearms or wrists.
  4. Downward resistance is gradually applied while the patient is instructed to maintain the elevated arm position.
  5. The patient attempts to resist the downward force without allowing the arms to drop.
  6. The physiotherapist assesses pain, muscle strength and the ability to maintain the position against resistance.
  7. Both shoulders can be assessed for comparison. Positive test:
  • Reproduction of pain over the anterolateral aspect of the shoulder during resisted abduction.
  • Weakness or inability to maintain the arm position against downward resistance. A positive test suggests supraspinatus tendon pathology, including tendinopathy or a possible tear. However, pain or weakness alone does not confirm a supraspinatus tear and should be interpreted alongside other clinical examination findings.

[83]

Full Can Test video provided by Clinically Relevant

[84]

Subacromial grind test:[85]

Purpose: To assess palpable crepitus or grinding sensations around the subacromial region during passive shoulder rotation, which may indicate underlying subacromial or rotator cuff pathology. Patient position: The patient is positioned in standing, with the affected arm relaxed initially and the elbow flexed to approximately 90°. Physiotherapist position: The physiotherapist stands in front of the patient, facing the affected shoulder, with one hand supporting the patient's elbow and the other hand positioned over the anterior aspect of the shoulder near the acromion and greater tuberosity. Procedure:
  1. The physiotherapist supports the patient's flexed elbow and passively abducts the shoulder to approximately 90° in the scapular plane.
  2. The physiotherapist places the other hand over the anterior acromial region and greater tuberosity to palpate the subacromial area.
  3. While maintaining the shoulder in the abducted position, the physiotherapist gently performs passive internal and external rotation of the shoulder.
  4. The physiotherapist palpates for any crepitus, grinding sensation or abnormal mechanical movement during rotation.
  5. The procedure can be repeated on the unaffected shoulder for comparison. Positive test:
  • Palpable crepitus or a grinding sensation around the subacromial region during passive internal and external rotation.
  • Reproduction of discomfort or pain may accompany the crepitus. A positive test may suggest subacromial or rotator cuff-related pathology. However, palpable crepitus alone is not diagnostic of a supraspinatus tear and should be interpreted alongside other clinical examination findings and imaging when indicated.

[86] [87][11]

Differential Diagnosis

The following conditions may present with symptoms similar to those of a supraspinatus tear and should be considered during clinical assessment:[88][89]

Shoulder joint and surrounding structures

Conditions affecting the shoulder joint and adjacent structures, including joint degeneration, tendon disorders, bursitis, labral injuries, instability, dislocations and fractures, should be considered as potential differential diagnoses of supraspinatus tears.

Cervical and neurological conditions

Disorders affecting the cervical spine, nerve roots or peripheral nerves may produce referred shoulder pain, sensory disturbances or muscle weakness, which can mimic the clinical presentation of a supraspinatus tear.[90] These conditions should be considered during differential diagnosis, particularly when symptoms extend beyond the shoulder or are accompanied by neurological signs.[91] Following conditions should be considered:

Referred pain

Cardiac conditions may cause referred shoulder pain due to the convergence of visceral and somatic sensory pathways within the central nervous system.[92] This pain may be perceived in the shoulder or upper limb rather than being localised to the chest, and should be considered when assessing unexplained shoulder pain, particularly when accompanied by other cardiac symptoms.[93] Following conditions should be considered:

  • Angina pectoris
  • Myocardial infarction

Diagnostic Investigations

X-rays

  • Plain radiographs cannot directly visualise the supraspinatus tendon or confirm a tendon tear.[94]
  • They can demonstrate indirect features associated with rotator cuff disease, including superior migration of the humeral head, reduced acromiohumeral distance, greater tuberosity sclerosis, cystic changes and acromial osteophytes.[95]
  • They can help assess the acromion morphology and identify associated bony abnormalities.[96]
Supraspinatus tear as seen in radiographics

MRI

  • MRI can directly visualise the supraspinatus tendon and identify partial-thickness and full-thickness tears.[97]
  • It can demonstrate tendon retraction, muscle atrophy and fatty infiltration.[98]
  • It can identify associated abnormalities, including subacromial-subdeltoid bursitis, tendinopathy and muscle oedema.[99]
  • It can also assess associated capsular and other soft-tissue abnormalities.[100]

CT Scan

  • Conventional CT is primarily useful for evaluating bony structures, including the acromion, greater tuberosity and glenoid.[101]
  • CT arthrography involves injecting contrast into the shoulder joint to help visualise intra-articular structures and identify certain rotator cuff tears.[102]
  • CT arthrography may be considered when MRI is contraindicated or unavailable.[103][104]

Ultrasound

  • Musculoskeletal ultrasound can directly visualise the supraspinatus tendon and identify partial-thickness and full-thickness tears.[105]
  • It can assess tendon thickness, continuity, retraction and associated subacromial-subdeltoid bursal abnormalities.[106]
  • Dynamic ultrasound allows assessment of the tendon during shoulder movement.[107]
  • It is non-invasive, relatively inexpensive and allows comparison with the unaffected shoulder.[108]
  • Its accuracy depends on the operator's experience and the quality of the examination.[109]

Outcome Measures

Management

Conservative Management

Indications:[27][28]

  • Older (>70 years) patients with a chronic tear
  • Patients with irreparable tears with irreversible changes
  • Patients of any age with small (<1 cm) full-thickness tears
    • As a result of the slow rate of progression of these tears
  • Patients without a full-thickness tear

Management includes:[115]

NSAID's:

  • Ibuprofen

Corticosteroid injections:

  • Eliminate pain for a period of time, making physiotherapy management easier
  • Tendon tissue can be weakened by these injections (which would have an adverse effect on the outcome of a possible surgery)
  • Limited to 2 injections
  • Physiotherapy (see Physiotherapy management below)

Physiotherapy Management of Partial-Thickness Supraspinatus Tears

Physiotherapy management depends on the extent of the tear and plays an important role in both conservative management as well as post-surgical rehabilitation.[116] More details can also be obtained from the rotator cuff page.

Physiotherapy goals:[117]

  • Improve pain together with NSAID’s (2-6 weeks)
  • Cryotherapy (only in first 48 hours)
  • Massage
  • Improve circulation (to control inflammation and speed up the healing process)
  • Improve range of motion:
    • Stretching (careful with timing, as stretching of acute injury may aggravate the tear):[118] 
      • Crossover arm stretch: 12 seconds, 5 times a day; 5-6days/week 

Kristian Berg. Prescriptive stretching; Human Kinetics [119]

  • Door stretch: 5 x 30 seconds (5 second rest in between)
  • Passive/Active range of motion:[120]
    • Pendulum exercises: Forward and back, side-to-side, circular motion. 2 sets of 10 a day, 5-6days/week
    • Symptom limited active-assisted range of motion exercises

Kristian Berg. Prescriptive stretching; Human Kinetics [119]

  • Increase strength:[121][122]
    • Rotator cuff (especially supraspinatus) strengthening to improve muscle control and strength
    • Prone Horizontal Abduction progress by using resistance bands
    • Prone Row with External Rotation
  • Regain function of affected upper limb (up to 3 months)
  • Home exercise programme

Surgical Management

Indications:[27][28][123]

  • Failed conservative management
  • Larger symptomatic full-thickness tears (1-1,5cm) as a result of the high rate of progression. Should be considered for earlier surgical repair in younger patients if the tear is repairable and the muscle degeneration is limited
  • Acute large tears (> 1 cm-1.5 cm) or
  • Young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes
  • Complete tear with significant pain and dysfunction after 6 months of treatment
  • Repeated dislocations

Rotator cuff repair

Most repairs are done arthroscopically.[123] Severity (partial vs full-thickness) will determine the approach.

  • Partial repair: The tendon and surrounding bone will be smoothed to avoid further damage and therefore allowing the tendon to heal mostly on its own.[124]
  • Complete tear: Tear in middle of tendon: Suture the two parts of the tendon back together. Tear close or on its point of attachment on the head of the humerus: Attach the tendon back to its original place by an anchor (sometimes two). This anchor actually consists of a small screw that is bored into the head of the humerus with on the back surgical wires which hold the tendon in place.[125]

Post-operative Rehabilitation Protocol After Rotator Cuff Repair

Post-operative rehabilitation following supraspinatus tendon repair is essential for restoring shoulder mobility, strength and functional capacity while protecting the repaired tendon during the healing process.[126][127] Rehabilitation generally progresses through four phases over approximately six months.[128] However, the programme should be individualised according to tear size, tendon quality, repair integrity, surgical technique and patient-related factors.[129]

Patients with large or massive tears, poor tendon quality, revision surgery or additional risk factors for impaired healing may require a more conservative rehabilitation programme.[130] Close communication between the surgeon and physiotherapist is important to ensure appropriate progression throughout recovery.[131]

Following are the phases of post-operative rehabilitation following rotator cuff repair:[128]

Phase 1: Protection and restoration of passive range of motion (weeks 1–6)

Goals:

  • Protect the surgical repair and facilitate tendon-to-bone healing.
  • Maintain shoulder mobility and minimise post-operative stiffness.
  • Reduce pain and inflammation.
  • Maintain mobility of the elbow, wrist and hand.

Physiotherapy management:

  • Immobilisation: The shoulder is generally supported in a sling, potentially with an abduction pillow, for approximately six weeks. The duration depends on tear size, repair integrity and the surgeon's recommendations.
  • Passive range of motion (PROM): Gentle passive shoulder flexion, scaption and internal and external rotation may be introduced according to the prescribed rehabilitation protocol. External rotation in the scapular plane should generally not exceed 45° during this phase.
  • Pendulum exercises: Gentle pendular movements may be performed to maintain shoulder mobility without excessive muscular activation.
  • Active-assisted range of motion (AAROM): Gradually introduce assisted shoulder flexion and external rotation when permitted, particularly for smaller tears.
  • Scapular exercises: Gentle scapular setting and controlled scapular movements may be incorporated to maintain scapulothoracic mobility.
  • Distal joint exercises: Encourage active elbow, wrist and hand movements to maintain joint mobility. Hand-gripping exercises using therapy putty may also be introduced.
  • Isometric exercises: Pain-free, gentle shoulder isometric exercises may be introduced when authorised by the surgeon, without placing excessive tension on the repaired tendon.
  • Pain management: Cryotherapy may be applied following exercise sessions to help manage post-operative pain and inflammation.

Precautions:

  • Avoid active shoulder flexion and abduction during the initial post-operative period.
  • Avoid lifting, pushing, pulling or weight-bearing through the operated arm.
  • Avoid excessive shoulder external rotation and forceful stretching.
  • Following biceps tenodesis, active elbow movements should generally be avoided during the first three weeks, according to the surgical protocol.

Phase 2: Restoration of active movement and shoulder stability (weeks 6–12)

Goals:

  • Progressively restore active and passive shoulder range of motion.
  • Re-establish appropriate scapulohumeral rhythm.
  • Initiate controlled muscle activation.
  • Improve scapular stability and shoulder proprioception.

Physiotherapy management:

  • Range of motion exercises: Progress passive and active-assisted shoulder movements towards full range of motion, including flexion, scaption and internal and external rotation.
  • Active range of motion (AROM): Gradually introduce active shoulder movements, initially in supine and subsequently progressing to sitting and standing positions.
  • Stretching: Introduce gentle posterior capsule and internal rotation stretches where restricted movement is identified.
  • Joint mobilisation: Therapist-directed glenohumeral joint mobilisation, particularly posterior and inferior glides, may be used when indicated to improve shoulder mobility.
  • Scapular strengthening: Introduce controlled scapular exercises, including resisted rows, shoulder shrugs and serratus anterior punches.
  • Rotator cuff activation: Progress to gentle internal and external rotation exercises using light resistance bands when appropriate.
  • Proprioceptive training: Introduce rhythmic stabilisation exercises, progressing from supported positions towards more functional positions.
  • Functional exercises: Controlled two-handed medicine ball activities may be introduced towards the latter part of this phase, depending on shoulder control and tolerance.

Precautions:

  • Avoid excessive resistance or sudden loading of the repaired tendon.
  • Progress active movement gradually, ensuring appropriate scapular control.
  • Avoid forceful stretching or exercises that provoke significant pain.

Phase 3: Progressive strengthening and functional movement (weeks 12–14)

Goals:

  • Restore full active shoulder range of motion.
  • Improve rotator cuff strength and muscular endurance.
  • Develop scapular stability and neuromuscular control.
  • Introduce functional strengthening exercises.

Physiotherapy management:

  • Progressive resistance exercises: Gradually introduce resistance exercises targeting the rotator cuff and surrounding shoulder musculature.
  • Supraspinatus strengthening: Introduce controlled scaption and shoulder elevation exercises, initially using low resistance and progressing according to movement quality and tolerance.
  • External rotation strengthening: Progress resistance-band exercises to improve rotator cuff strength and dynamic shoulder stability.
  • Scapular stabilisation: Progress strengthening exercises targeting the serratus anterior, middle trapezius and lower trapezius.
  • Prone strengthening exercises: Introduce prone scaption, horizontal abduction, shoulder extension and external rotation exercises as tolerated.
  • Closed-chain exercises: Progress to modified push-up exercises, beginning against a wall and advancing to a table or other supported surfaces.
  • Functional strengthening: Gradually incorporate controlled reaching and upper-limb coordination exercises.

Precautions:

  • Strengthening should generally not commence before 12 weeks following tendon repair unless specifically authorised.
  • Avoid excessive resistance and sudden eccentric loading.
  • Monitor compensatory shoulder movements during strengthening exercises.

Phase 4: Advanced strengthening and return to functional activities (weeks 14–24)

Goals:

  • Restore functional shoulder strength and endurance.
  • Improve dynamic shoulder stability and neuromuscular coordination.
  • Facilitate return to occupational, recreational and sporting activities.
  • Establish an independent strengthening programme.

Physiotherapy management:

  • Progressive strengthening: Increase resistance and exercise intensity to develop rotator cuff strength and muscular endurance.
  • Advanced rotator cuff exercises: Introduce progressive eccentric strengthening and controlled deceleration exercises.
  • Plyometric training: Progress from two-handed to single-handed medicine ball exercises to improve upper-limb power and coordination.
  • Scapular and shoulder strengthening: Incorporate more demanding exercises targeting the rotator cuff and scapular stabilisers.
  • Functional training: Introduce progressive lifting, carrying, pushing and pulling activities relevant to daily living and occupational requirements.
  • Overhead activities: Gradually reintroduce overhead reaching and lifting once adequate strength, mobility and shoulder control have been achieved.
  • Sport-specific rehabilitation: Athletes may progress to sport-specific drills, including throwing and racket-related movements, according to their functional requirements.
  • Independent exercise programme: Develop a progressive gym-based programme to maintain strength, endurance and shoulder function.

Return to demanding occupational or sporting activities should be determined by functional recovery, clinical assessment and surgical clearance rather than time alone.

Summary

A supraspinatus tear is a common rotator cuff injury that may develop following an acute traumatic event or through progressive degenerative changes associated with repetitive microtrauma and ageing.[3] Tears may involve partial or complete disruption of the tendon fibres and commonly occur within the tendon or at its insertion on the greater tuberosity of the humerus.[132][133] Clinical presentation varies depending on the size, depth and severity of the tear, with shoulder pain, muscle weakness and restricted range of motion being among the most frequently reported symptoms.[2] Individuals may experience pain during shoulder abduction, difficulty performing overhead activities and reduced functional capacity.[134] In chronic or extensive tears, muscle atrophy, tendon retraction and fatty infiltration may also develop, potentially affecting tendon reparability and functional recovery.[135]

Diagnosis involves a comprehensive clinical assessment, including patient history, physical examination and appropriate imaging investigations, such as ultrasonography or MRI, to identify the presence and extent of the tear.[100] Management depends on factors such as tear severity, patient age, functional requirements, symptom duration and response to previous treatment.[136] Conservative management may include activity modification, appropriate analgesia or non-steroidal anti-inflammatory drugs (NSAIDs), and an individualised physiotherapy programme focusing on pain reduction, restoration of shoulder mobility, progressive strengthening of the rotator cuff and scapular muscles, and improvement of functional capacity.[137] Surgical intervention, including rotator cuff repair, may be considered for selected patients, particularly those with significant traumatic tears, persistent symptoms or substantial functional impairment despite appropriate conservative management.[138][137] Rehabilitation is essential following both conservative and surgical treatment to optimise shoulder function and facilitate return to daily activities, work and sport.[139]

References

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  124. ↑ American Academy of Orthopedic Surgeons. Rotator Cuff Tears: Surgical Treatment Options. https://orthoinfo.aaos.org/en/treatment/rotator-cuff-tears-surgical-treatment-options/ (accessed 30/08/2018).
  125. ↑ Akpınar S, Uysal M, Pourbagher MA, Ozalay M, Cesur N, Hersekli MA. Prospective evaluation of the functional and anatomical results of arthroscopic repair in small and medium-sized full-thickness tears of the supraspinatus tendon. Acta orthopaedica et traumatologica turcica 2011;45(4):248-53.
  126. ↑ Hao B, Li H, Liang A. Effects of early exercise and immobilization after arthroscopic rotator cuff repair surgery: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2025;26:254.
  127. ↑ Ciardi G, Novara D, Quattrini F, Ricci E. Rehabilitation outcome domains following rotator cuff surgical repair: a systematic review. J Orthop Rep. 2025;4(2):100409.
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  130. ↑ Sußiek J, Buchmann S, Beitzel K, Lappen S, Rehabilitation Committee of the German, Austrian and Swiss Shoulder and Elbow Society. Patient-specific risk factors for repair failure and poor functional outcome after rotator cuff repair: an umbrella review. BMC Musculoskelet Disord. 2026;27(1):167.
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  132. ↑ Reilly P, Amis AA, Wallace AL, Emery RJ. Supraspinatus tears: propagation and strain alteration. Journal of shoulder and elbow surgery. 2003 Mar 1;12(2):134-8.
  133. ↑ Ahmad ZY, Diaz LE, Roemer FW, Goud A, Guermazi A. Imaging review of subscapularis tendon and rotator interval pathology. Radiology Research and Practice. 2022;2022(1):4009829.
  134. ↑ Yeung A, Fernando A, Patel M, Gatto L, Ackland DC. Muscle and joint function in the rotator cuff deficient shoulder. Journal of Orthopaedic Research®. 2024 Oct;42(10):2131-9.
  135. ↑ Bowen E, Waque A, Su F, Davies M, Ode G, Lansdown D, Feeley B, Bedi A. Muscle health & fatty infiltration with advanced rotator cuff pathology. Current Reviews in Musculoskeletal Medicine. 2025 Apr;18(4):160-72.
  136. ↑ Saccomanno MF, Lisai A, Romano AM, Vitullo A, Pannone A, Spoliti M, Di Giunta AC, Castricini R, Giordano MC. High degree of consensus on diagnosis and management of rotator cuff tears: a Delphi approach. Knee Surgery, Sports Traumatology, Arthroscopy. 2023 Oct;31(10):4594-600.
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  138. ↑ Randelli PS, Radici M, Liccardi A, Cavaciocchi M, Padolino A, Fici P, et al. Position paper of the Italian Society of Orthopaedics and Traumatology (SIOT) on the treatment of rotator cuff tears. Orthop J Sports Med. 2025;13(7):23259671251351901.
  139. ↑ Adamus JP, Dywan K, Paszt Z, Dąbrowska J, Tracz MJ, Łęgosz P, Struzik S. From Clinical Signs to Functional Recovery: A Practice-Oriented Review of Rotator Cuff Tear Management in Primary Care. Journal of Clinical Medicine. 2026 Aug 29;15(17):6697.
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