Rotator cuff injuries are one of the most common causes of shoulder pain in active adults. Whether you’re a weekend warrior, a desk jockey with nagging aches, or an athlete pushing overhead loads, chances are you or someone you know has dealt with a rotator cuff issue.
If you’ve been told you have a tear or tendinopathy, you may be wondering: Do I need surgery, or can physical therapy actually fix this?
At Rise Rehab and Sport Performance in Denver, we help people make that decision every day. The short answer? Many rotator cuff injuries respond extremely well to physical therapy—and in a lot of cases, surgery can be avoided entirely.
In this blog, we’ll break down the anatomy of the rotator cuff, how injuries occur, when surgery might be necessary, and why physical therapy is often the most effective first step.
What Is the Rotator Cuff?
The rotator cuff is a group of four muscles and their tendons that stabilize and move your shoulder joint. These muscles originate from your scapula (shoulder blade) and attach to the head of your humerus (upper arm bone), forming a cuff-like structure around the joint.
The Four Muscles:
- Supraspinatus – Initiates arm elevation (abduction) and is the most commonly injured
- Infraspinatus – External rotation and stabilization
- Teres Minor – External rotation and assists in horizontal abduction
- Subscapularis – Internal rotation and anterior stability
Together, these muscles control motion and keep the humeral head centered in the socket (glenoid fossa) during movement.
How Do Rotator Cuff Injuries Happen?
Rotator cuff injuries occur when one or more of the tendons become irritated, inflamed, or torn. This can happen from trauma (like a fall) or more commonly, from repetitive microtrauma and overuse over time.
Common Causes:
- Repetitive overhead motions (throwing, swimming, lifting)
- Poor shoulder mechanics or scapular control
- Age-related tendon degeneration (more common over age 40)
- Weakness or imbalance in the rotator cuff and surrounding muscles
- Sudden load increases (e.g., lifting a heavy box overhead or returning to the gym too fast)
Types of Rotator Cuff Injuries
Not all rotator cuff injuries are the same. Here’s how we break them down:
1. Tendinopathy (aka Tendinitis or Tendinosis)
- Chronic overload leads to tendon thickening, degeneration, and pain
- No tear is present, but the tendon is irritated and less elastic
- Very responsive to physical therapy
2. Partial-Thickness Tear
- A portion of the tendon is frayed or torn, but not all the way through
- Can be on the surface (bursal side), underside (articular side), or within the tendon
- Often still functional with proper strengthening and rehab
3. Full-Thickness Tear
- Complete rupture of one or more tendons
- May or may not be associated with significant weakness or dysfunction
- Severity and size vary widely
4. Massive or Retraction Tears
- Multiple tendons involved, often with tendon retraction
- More common in older adults or after significant trauma
- Surgery is more likely necessary, but prehab improves outcomes
Symptoms of a Rotator Cuff Injury
Rotator cuff injuries often sneak up on you. Symptoms may start mild and worsen with time. Here’s what to look for:
- Pain on the outside or top of the shoulder
- Pain with lifting the arm, especially overhead
- Night pain or difficulty sleeping on the affected side
- Weakness or loss of motion
- Clicking, catching, or popping during movement
These symptoms can overlap with other shoulder conditions like impingement, labral tears, or bursitis—so getting an accurate diagnosis is key.
Do You Need Surgery for a Rotator Cuff Tear?
Not necessarily. Many people—even those with partial or full-thickness tears—improve significantly with conservative treatment.
When Surgery May Be Avoidable:
- You can still lift the arm overhead
- Strength loss is minimal
- Pain improves with targeted exercises
- Imaging shows a small or partial tear
- You’re willing to commit to a focused rehab program
When Surgery May Be Necessary:
- Large full-thickness tear with significant retraction
- Arm weakness or inability to lift overhead
- Tear from acute trauma (e.g., fall, lifting injury)
- No improvement after 12+ weeks of consistent physical therapy
That said, even when surgery is indicated, pre-surgical PT (“prehab”) is shown to improve outcomes post-op by reducing pain, improving range of motion, and strengthening the surrounding musculature.
Why Physical Therapy Works
The shoulder is a complex joint that relies on a dynamic balance of mobility, stability, and control. Even when a tear is present, pain often results from:
- Poor scapular mechanics
- Muscle imbalance
- Joint capsule stiffness
- Loss of neuromuscular coordination
PT Can Address These by:
- Restoring shoulder and thoracic mobility
- Improving rotator cuff and scapular strength
- Reducing compensatory movement patterns
- Modifying activities to reduce flare-ups
- Progressively loading the tendon to stimulate healing
Specific PT Strategies for Rotator Cuff Rehab
1. Scapular Stabilization
The shoulder blade sets the foundation for arm movement. PT will often start here.
Examples:
- Prone Ys and Ts
- Scapular retraction with resistance bands
- Serratus wall slides
2. Rotator Cuff Activation and Strengthening
Progressive resistance training helps strengthen the tendon and surrounding muscles.
Examples:
- Sidelying external rotation (for infraspinatus and teres minor)
- Internal rotation with band (for subscapularis)
- Full can raises (for supraspinatus)
3. Thoracic and Glenohumeral Mobility
Stiffness in the spine or shoulder joint often contributes to overload.
Examples:
- Thoracic extension over foam roller
- Open books and windmills
- Posterior capsule mobilizations
4. Neuromuscular Control and Load Progression
Your PT will guide you through movement patterns that gradually restore function:
- Closed-chain exercises (e.g., quadruped weight shifts)
- Open-chain overhead lifts (e.g., kettlebell carries, landmine presses)
- Sport or task-specific loading (e.g., return-to-press, throwing mechanics, swimming drills)
Realistic Timelines for Recovery
Every shoulder is different, but here are general expectations:
Tendinopathy or Mild Partial Tear:
- 6–12 weeks of progressive PT
- Significant reduction in pain and return to function
Moderate Tear (Non-Surgical):
- 8–16 weeks depending on severity and activity demands
Post-Surgical Repair:
- 4–6 months for return to full activity
- Up to 12 months for return to sport, heavy overhead lifting, or contact activities
What If PT Doesn’t Work?
If symptoms persist despite consistent rehab, additional imaging or an orthopedic referral may be appropriate. But that’s not the norm—most people improve significantly without surgery.
If surgery is needed, your physical therapist can help guide you through:
- Pre-op strengthening and range of motion prep
- Post-op recovery and milestone tracking
- Return-to-sport planning and progression
The Bottom Line
Rotator cuff injuries can be painful, limiting, and frustrating—but surgery isn’t always the best or only option.
In many cases, targeted physical therapy is all you need to reduce pain, restore strength, and get back to the activities you love without going under the knife.
At Rise Rehab and Sport Performance in Denver, we specialize in performance-focused shoulder rehab. Whether you’re lifting weights, training for a triathlon, or just trying to get back to sleeping comfortably, we’re here to help you understand your injury and create a plan that works.
Not sure what your shoulder needs? Book a FREE Discovery Call with one of our experts and start your recovery today.