Pain guide · Shoulder pain
A tear in one or more rotator cuff tendons, most often the supraspinatus on top of the shoulder. Acute tears follow an injury, such as a fall on an outstretched arm or a jerking lift; degenerative tears develop slowly with age and are the majority. Typical symptoms are pain at rest and at night, pain lifting and lowering the arm, weakness lifting or turning it, and sometimes crackling. Some tears cause weakness without pain.
If your tear came on gradually, exercise is the first treatment and most people do well without surgery. If it followed an injury and you suddenly cannot lift your arm, or you are younger with a repairable tear, see a shoulder specialist soon: some tears do better repaired early, and unrepaired tears can get bigger.
Exercise is for pain that has been checked or is clearly mild and settling.
Tears are usually caused by an injury in young people and develop without one in older people. Acute tears follow a fall or a jerking lift; degenerative tears are the majority and come on gradually. The difference matters, because the advice is different.
On MRI of 96 people with no shoulder symptoms, 34% had a rotator cuff tear; over 60, 54% did (28% full-thickness). Pooled data from 30 studies (6,112 shoulders) showed cuff abnormalities rising from 9.7% at age 20 and under to 62% at 80 and over, with a similar rise whether or not people had symptoms; the authors call cuff degeneration a common part of normal ageing.
On ultrasound of 664 villagers, 22.1% had a full-thickness tear (none in their 20s to 40s, 36.6% in their 80s), and 65% of the tears caused no symptoms. Finding a tear on a scan does not prove the tear is what hurts.
UK care pathways say a rotator cuff tear caused by an injury needs urgent referral, ideally to the next specialist shoulder clinic. Weakness turning the arm outwards may mean a large acute tear. In people over 40 who dislocate a shoulder, about 40% also tear the cuff, so strength should be checked and early repair considered if there is a tear.
In the MOON cohort, 452 people with full-thickness tears that came on without an injury followed a physical therapy programme. Outcomes improved by 6 and 12 weeks; fewer than 25% chose surgery, mostly between 6 and 12 weeks and few after 3 months; the programme was effective in about 75% of people followed for 2 years. There was no comparison group.
An orthopaedic patient information page gives a higher figure, about 80 to 85%; that is patient information rather than a study.
In 180 shoulders with supraspinatus tears that came on without an injury, physiotherapy alone, physiotherapy plus acromioplasty, and cuff repair plus acromioplasty plus physiotherapy gave no significant difference in Constant score, pain or satisfaction at 2 years. Repaired tears were smaller on imaging (4.2 mm vs 11.0 mm). The authors call conservative treatment a reasonable first option in older patients.
Source 11
In a trial of 103 people with full-thickness tears up to 3 cm, repair did better than physiotherapy (with the option of later repair) at 10 years (by 9.6 Constant points and 1.8 points of pain on a 10 cm scale) and at 15 years (by 11.8 Constant points). In 26 tears treated with physiotherapy alone, the tear had grown from 16.2 to 31.6 mm. Fifteen of the 51 people in the physiotherapy group had crossed over to surgery.
A Cochrane review of 9 trials, mostly in people in their late 50s and 60s with full-thickness supraspinatus tears, found that at 1 year surgery probably gives little or no improvement in pain (0.87 points on a 10-point scale) and may give slightly better function (6 points on 100). The authors are uncertain whether repair gives clinically meaningful benefits.
Source 14
During shoulder strengthening, pain up to about 5 out of 10 is acceptable, and a little is expected. By your next session it should be back to where it was before. If it isn't, use a lighter band or weight or a smaller range next time, not nothing.
This is how the Holmgren trial set each person's load: pain was not allowed above 5 out of 10 during the exercises, and any increase had to settle back to the starting level before the next session; otherwise the load came down. If pain climbs week on week, or a warning sign appears, stop and get it checked.
Stop and get checked if you get a sharp pain with a sudden loss of strength: a small tear can get bigger.
Start at the first stage. Each move opens a full guide with a 3D demo.
Weeks 0 to 2. Doses are editorial; the structure follows the cuff and shoulder-blade focus of the exercise trials. Keep raises at or below shoulder height.
3D demoTable slide (seated forward reach)Beginner · A bench or box10 slow reps, twice a day
Easier: Pendulum exercise (Codman's pendulum) · Harder: Overhead lat stretch at a bench
3D demoStanding band external rotationBeginner · A band + An anchor point2 sets of 10 to 15, lightest band, elbow at your side
Harder: Side-lying external rotation
3D demoBand internal rotationBeginner · A band + An anchor point2 sets of 10 to 15
Harder: Side-lying external rotation
3D demoBand rowBeginner · A band + An anchor point2 sets of 12 to 15
3D demoDumbbell shoulder-blade punchBeginner · A dumbbell + A bench or box2 sets of 10, no weight at first · The shoulder-blade punch, lying
Harder: Scapular push-up (push-up plus)
Move on when: These stay within the pain rule and your strength is steady or improving.
Weeks 2 to 12. Work the deltoid and the rest of the cuff; keep raises at or below shoulder height until they are comfortable. The MOON cohort reviewed progress at 6 and 12 weeks.
3D demoSide-lying external rotationBeginner · A dumbbell3 sets of 12 to 15
Easier: Standing band external rotation · Harder: Cuban rotation
3D demoScaption raiseBeginner · A dumbbell3 sets of 10 to 15, very light, below shoulder height at first · Thumbs up
Easier: Band lateral raise · Harder: Smith machine upright row
3D demoFront raiseBeginner · A dumbbell2 to 3 sets of 10, thumbs up
Easier: Band lateral raise · Harder: Smith machine upright row
3D demoScapular push-up (push-up plus)Beginner · No equipment3 sets of 10 to 15 · After the wall push-up
Easier: Dumbbell shoulder-blade punch · Harder: Pike push-up
3D demoProne Y-T-W raisesBeginner · No equipment2 rounds of 8
Easier: Wall angel · Harder: Bent-over reverse fly
Move on when: You can raise the arm to shoulder height with control, and pain stays within the rule.
From about week 12, and for the long term. Doses are editorial.
3D demoLandmine Linear JammerIntermediate · A barbell3 sets of 8 to 12 · A landmine press, after the band press
Easier: Kettlebell Halo · Harder: Clean and jerk
3D demoCable external rotationBeginner · A cable machine3 sets of 10 to 12
Harder: Side-lying external rotation
3D demoFace pullIntermediate · A band3 sets of 12 to 15
Easier: Prone Y-T-W raises · Harder: Barbell rear-delt row
3D demoSeated cable rowBeginner · A cable machine3 sets of 8 to 12
Move on when: Add load gradually, one change at a time. If strength starts to slip, ask for a review.
No trial lists banned exercises for a torn cuff. These changes are sensible while strength rebuilds:
In the MOON cohort, people who chose surgery mostly did so between 6 and 12 weeks, and few did after 3 months. A sensible rule (editorial): if things are not clearly better by 12 weeks, or strength is getting worse, ask for a specialist opinion.
Source 10
The tear itself may not heal: in one trial, tears treated with physiotherapy alone had grown over the years. But many people with a worn tear manage well without surgery. In the MOON cohort, a physical therapy programme was effective in about 75% of people over 2 years. Tears after an injury, and some smaller tears in younger people, can do better with early repair.
Exercise within the pain rule is the first treatment for worn tears, and people in the MOON cohort improved with it. What to avoid is sudden heavy or jerking lifts and pushing through a sharp pain or sudden weakness. Unrepaired tears can slowly get bigger over years, which is one reason to keep the 12-week review point.
No trial lists banned exercises. Leave out sudden heavy or overhead lifts and anything that brings a sharp pain or sudden weakness, and keep raises at or below shoulder height until they are comfortable. After surgery, follow your surgeon's protocol.
There is no fixed timeline. In the MOON cohort, outcomes improved by 6 and 12 weeks, and most people who chose surgery decided between 6 and 12 weeks. If it is not clearly better by 12 weeks, or strength is getting worse, ask for a specialist opinion.
The trials here don't give an age cut-off. In older people whose tears came on without an injury, physiotherapy alone did as well as repair at 2 years in one trial, and a Cochrane review is uncertain whether repair adds meaningful benefit at 1 year. A tear after an injury needs urgent specialist review at any age.
Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.
