Intended for healthcare professionals

Practice Easily Missed?

Acute rotator cuff tears

BMJ 2017; 359 doi: (Published 11 December 2017) Cite this as: BMJ 2017;359:j5366
  1. Richard Craig, research fellow1,
  2. Tim Holt, senior clinical research fellow and general practitioner2,
  3. Jonathan Lloyd Rees, professor of orthopaedic surgery and musculoskeletal science1
  1. 1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford OX3 7LD, UK
  2. 2Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 2ET, UK
  1. Correspondence to: J L Rees jonathan.rees{at}

What you need to know

  • Shoulder pain with an inability to abduct above 90° after trauma is a red flag for referral for a same day, plain x ray assessment

  • Refer the following patients urgently to a specialist clinic for consideration of ultrasound or magnetic resonance imaging:

    • Patients unable to abduct the arm above 90° more than two weeks after a shoulder injury

    • Any patient aged >40 years after dislocation of the glenohumeral joint

  • Offer patients with a confirmed acute rotator cuff tear urgent referral to a specialist surgeon to discuss potential surgical repair

A 45 year old woman falls on ice and injures her shoulder. Assessment at her local hospital reveals bruising only and no bony injury on plain radiographs. Despite ongoing reassurance and participation in a physiotherapy programme for three months, she continues to complain of pain, weakness, and inability to raise her arm. Eventually she is referred to a specialist shoulder clinic, where an ultrasound scan confirms she has suffered an acute full thickness tear of her supraspinatus tendon.

Failing to identify an acute full thickness rotator cuff tear is a common problem, and this article is aimed at raising awareness of the condition and its correct management. The article is directed to all clinicians, but especially emergency department clinicians, trauma clinic clinicians, and general practitioners, who tend to see such cases.

What is an acute rotator cuff tear?

The rotator cuff comprises four important muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) which attach close to the humeral head via tendons and are critically involved in stability and function of the shoulder. A rotator cuff tear is when one or more of these tendons tears or detaches from the humerus (fig 1). These tears can vary in size and be acute or chronic. Chronic full and partial thickness tears are due to tendon degeneration and attrition, and these patients …

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