Clinical Decision-Making in Rotator Cuff Tears

As physios, we spend a lot of time reassuring patients that what shows up on a scan isn’t always the source of their pain. That’s especially true for the rotator cuff, where imaging findings are common even in people with completely pain-free shoulders. But what happens when the story is a little different?

A patient presents with shoulder pain following a fall eight months ago. They’ve already completed a course of physiotherapy. And now they’re sitting in front of you holding an MRI report that shows a high-grade rotator cuff tear.

What do you do next?

This was the scenario Dr Kathryn Fahy explored in her Case Study. The patient was a 77-year-old male who had fallen onto an outstretched arm eight months earlier. Despite completing ten physiotherapy sessions elsewhere, he continued to experience symptoms and was looking for answers. This blog covers some of the key clinical lessons from Kathryn’s case.

If you want to know exactly how an expert physio manages a rotator cuff tear in an older adult, check out Kathryn’s full Case Study here.

Start by understanding the impact of the symptoms

While the patient came in with their MRI, Kathryn informed them she wanted to get a good picture of what was going on clinically so she could then match what she was seeing with the MRI, rather than the other way around.

Some of the most important information comes from the subjective and understanding how the shoulder is affecting their function.

In this case, pain had improved from 5/10 initially to 2/10, but increased again when the patient attempted to return to golf. He described a dull ache with occasional sharp pain and reported catching and clicking with some movements. He also described weakness.

Sleep is another area that should not be overlooked. Night pain was one of the patient’s most aggravating symptoms and significantly disrupted his sleep, so taking time to explain why this occurs and discussing practical strategies such as positioning and appropriate analgesia was an important first step in Kathryn’s management of the patient.

Don’t overcomplicate the objective

Shoulder assessment can quickly become overwhelmed by ‘special tests’, many of which add little to clinical decision-making. Instead, Kathryn demonstrated a simple and pragmatic approach focused on identifying whether a rotator cuff tear is likely to be contributing to the patient’s presentation.

The patient had full flexion and extension, pain through hand-behind-back movements and a reduction in external rotation. Importantly, cervical pathology had already been excluded.

Rather than relying on numerous special tests, Kathryn highlighted a small cluster of straightforward examination findings that can provide useful information when a rotator cuff tear is suspected. Watch her explain in this clip from her Case Study:

These simple findings can help guide your clinical reasoning far more effectively than working through a lengthy list of provocative tests.

Imaging should support, not replace, clinical reasoning

The patient had already undergone MRI, which revealed a high-grade full-thickness or near full-thickness rotator cuff tear involving the supraspinatus tendon and the junction between supraspinatus and infraspinatus. For many patients, seeing this type of report immediately raises concerns about surgery.

However, Kathryn emphasised that the findings still need to be interpreted alongside the patient’s symptoms, function and goals. Watch Kathryn reason through this patient’s presentation in this snippet from her Case Study:

After discussing the options, Kathryn and the patient decided conservative management was appropriate, with surgery remaining an option if required later. The rehabilitation approach was built around education and exercise. Early structured loading was introduced and progressed gradually from single-plane movements towards more functional, multiplanar tasks. A minimum rehabilitation timeframe of 12 weeks was discussed, alongside the importance of regular supervision and a structured home exercise program.

But rehab is rarely linear!

Several months later, the patient attempted to return to golf and experienced an increase in symptoms. At that stage, he requested an orthopaedic opinion for which Kathryn referred him, noting the importance of gathering different management perspectives.

Interestingly, the surgeon did not favour surgery as the next step. Instead, a corticosteroid injection was recommended, highlighting that the decision is not always between rehabilitation and surgery. There are often multiple management options available, and the most appropriate choice may change over time.

Following the injection, rehabilitation remained the focus. The reduction in pain simply provided a window to increase loading and continue progressing strength and function. This blip provided a good opportunity to further reinforce the idea of load modification and self-monitoring for the patient, who was now mostly completing gym-based exercise, viewing this as an ongoing and life-long management strategy.

Wrapping up

Rotator cuff tears are common, particularly in older adults, but the biggest challenge is determining how much that tear matters for the individual sitting in front of you.

As Kathryn’s case demonstrates, effective management comes back to the fundamentals: understanding the patient’s goals, identifying meaningful weakness and functional limitations and interpreting imaging within the broader clinical picture.

If you want to see exactly how Kathryn managed this case from start to finish, watch her full Case Study here.