In this educational video, orthopedic shoulder surgeon Dr. Patrick Denard explains how to differentiate a rotator cuff tear from other shoulder problems and when imaging, especially MRI, is warranted. He begins with a brief overview of rotator cuff anatomy and the high prevalence of asymptomatic tears in older adults. He then outlines five clinical indicators that suggest a tear: night pain, shoulder weakness (especially in the scapular plane and external rotation lag), a sudden traumatic injury with a “pop,” lack of improvement after 6–12 weeks of physical therapy, and a painful arc of motion. For each sign he discusses its specificity, how to test it (e.g., drop‑arm test), and the supporting evidence linking it to full‑thickness tears. Dr. Denard emphasizes that traumatic tears require prompt MRI because early surgical repair (within weeks) yields better outcomes, whereas degenerative tears can be managed conservatively initially. He compares imaging modalities, noting that X‑rays only show bone, ultrasound can detect tears in some clinics, but MRI provides the most comprehensive view of tear size, muscle quality, and reparability. He also clarifies the surgeon’s role in interpreting MRI reports and counseling patients on repairability and expected outcomes. The video concludes with a decision algorithm: immediate MRI for acute injury or persistent pain/weakness after adequate therapy, followed by shared decision‑making about surgery versus continued non‑operative care.
Chapters
Most shoulder pain over the age of 40 involves a rotator cuff, but a sore irritated tendon and a torn tendon rotator cuff tear can feel almost exactly the same. And they're treated very differently. Now, I'm going to show you 5 things that you can use to think about or identify whether or not you have a rotator cuff tear and give you my guidelines on when an MRI may need or may be your best choice. I'm Dr. Patrick Denard. I'm an orthopedic surgeon who specializes in the shoulder. That's all 100% of my practice. I've done over 10,000 shoulder surgeries and published over 300 articles on the shoulder. And my goal here is to give you some guidelines to identify when you have a rotator cuff tear so that you can think about what is the appropriate guideline for treatment and need for MRI. So let's back up first. What is the rotator cuff? Well, the rotator cuff are 4 muscle tendons that surround the ball and socket joint. So we have the subscapularis in the front of the shoulder, the supraspinatus on the top of the shoulder, and then behind the infraspinatus and teres minor. Did The subscap being in the front helps internally rotate the shoulder. The supraspinatus helps raise the shoulder. And then the infraspinatus and teres minor wrapping around the back of the shoulder help rotate out to the side. So these 4 muscles come together to really supply stability. Another thing we call this is concavity compression because the shoulder is the most mobile joint in the body. The joint itself is not very deep or constrained. And you need the rotator cuff to maintain stability, especially as we are older. And again, helping with movement as well. When you get a tear, it's the tendon that tears off the bone. So a lot of people ask this question, is it muscle, is it tendon? It's actually most commonly like 95+% of the time or more, it's the tendon that tears off the bone. But here's something that most people don't know is that rotator cuff tears are really common. Some studies say 50% of people at age 65 roughly have a rotator cuff tear. There was another interesting study done in Japan and they looked at ultrasounds on people who were in village. 22% had a full thickness rotator cuff tear and this went up from about 11% in the '50s to 37% in the '80s. Again, U.S. data actually says it's a little bit higher, but what's interesting in that study is that 2 out of the 3 people who had tears had no symptoms at all. So just because you have a rotator cuff tear, tear doesn't mean it's actually causing a problem. So a tear on your MRI is not automatically the cause of your pain, and that's really why the exam and your story matters so much and what treatment you've undergone. So the first sign, which is really not very specific, is night pain. You can't sleep on your shoulder, it wakes you up at night. Now, this is a really common symptom with rotator cuff, and sleep or lack of sleep is the number one thing that drives people to see me in Because it starts affecting your psyche, your energy levels, and it becomes a downward spiral. But it's common with tendonitis and bursitis too, so it's not very specific. It just says that you have shoulder pain. In other words, night pain tells me there's something wrong with your shoulder, and often it's the rotator cuff, but it doesn't tell me if your rotator cuff is torn. Now, the second sign that's more valuable is weakness. So this is a big one, and sometimes it's a little bit difficult to distinguish weakness that's pain-related from true weakness. But if you cannot raise your arm in particular, that's a good indicator that there's— it's more likely that you have something going on with the rotator cuff. And when we think about this, we particularly think about this in the scapula plane. So right in line with the shoulder blade is really where I'm thinking about weakness. Another good one to look at is weakness out to the side. Now that's called external rotation. Now there's a sign called an external rotation lag sign where people have their arm taken out to the side and it just comes in. If it's so weak that the arm drops in, that's really a severe tear that's really been going on a long time because you have to have a complete tear of the infraspinatus in the back and that's also almost always associated with a complete tear of the supraspinatus. So how do you distinguish that pain-related weakness from true weakness? Well, if you're having trouble getting up, one thing is you can just raise with the opposite side and bring your arm up and you could put a weight there as you do that and see, can you Can you hold it up? Typically, the person with, it's more pain related, is going to have some difficulty getting there, but once they get there, they can hold their arm at that location. So that, that study out to the side is called the drop arm test. And when it's positive, it's usually right. It can miss tears, but in one study, it caught about a third of full thickness tears. So in other words, you can have a tear and still be able to do that, but if it's positive, You're much more likely to have a rotator cuff tear. This 3rd sign is a specific injury. So if you had a fall, you were reaching out to catch something and had a sudden pop followed by a sudden change in your symptoms, that's a sign of a traumatic rotator cuff tear. Now, these behave much differently than degenerative rotator cuff tears. Data has looked at this. A good study published in the Journal of Shoulder and Elbow Surgery from Rothman Clinic in Pennsylvania showed that those individuals who had acute, or that is immediate repair of an acute rotator cuff tear within 4 months, had better outcomes than those who waited. And even in that study, there was a trend toward those who had surgery within 3 weeks. That makes sense because the tissue is just better at that point in time. So if you have a traumatic injury with sudden change in your overall function, that's a time to get an MRI right out of the gate because that's a really good indicator of a rotator cuff tear and you want to know immediately. You don't want to mess around with therapy. So the message here is a fall and a pop is a problem. Traumatic tears have a different clock than degenerative rotator cuff tears. The 4th sign is really just that you're not getting better. Now, here's the good news about rotator cuff tears. There was a large study by the Moon Group in the United States looking at non-operative or conservative treatment outcomes of rotator cuff tears and they were treated with physical therapy. These were confirmed rotator cuff tears and the data showed that 75% of people got better with a 6-week course of physical therapy and actually, they did not go on to surgery over the next 10 years. So, the outcomes there are very good. But if it's not getting better over time, the data says that people do better long-term with a repair compared to physical therapy because you give the rotator cuff a chance to heal, whereas therapy, you rehab, but the tears can enlarge over time. So a sign that you have a rotator cuff tear and not just bursitis is one that does not get better with 6 to 12 weeks of physical therapy, and it's time to get an MRI. The 5th sign is the painful arc. Some people call this a near sign. So this is when you raise your arm straight up And in particular, people will have pain kind of in this mid-range. So that's a painful arc of range of motion. Now, a painful arc points to a rotator cuff problem, not necessarily a tear. And to be fair, you can actually have this sign with arthritis as well. But the power really is when you put it together. So when you put together a painful arc with weakness in external rotation at the side with the drop arm test that I talked about earlier, you have about a 91% chance of a full thickness rotator cuff tear. Conversely, if all 3 are negative based on the data, there's only about a 9%. So when do I get an MRI for rotator cuff? Really 2 reasons. I covered that earlier. First off, if you have a traumatic injury, especially with change in function, you need an MRI right away. Data shows better outcomes if you get that addressed immediately. The second reason to get an MRI is if somebody goes through physical therapy with or without an injection, They do 6 to 12 weeks. They're not where they want to be. They have persistent pain and weakness. It's time to get an MRI to get some more information. Don't do multiple injections. Find out first what is going on. So how do you evaluate for rotator cuff tear if you have these signs and tests? Well, it comes down to MRI because x-ray looks at bone. I get this question all the time in clinic. People want to see their x-rays and say, hey, do I have a tear? We can see bone on x-ray. Really to see the soft tissue, We need either an ultrasound, which some people will do in their clinic, or an MRI is the best way to do that because an MRI will not only tell you about the tear itself, show you the tear, but it will give you information about the muscle quality. And tear size and muscle quality in combination drive a lot of whether or not a rotator cuff tear is repairable and what your overall outcome is going to be. So often you'll get a report and the radiologist will say, hey, there's partial tearing here or full thickness tearing. So the radiologist really will tell you what's there, but a shoulder surgeon is going to be the one who's going to be able to look at it and tell you what are your odds of getting repair, what are your odds of getting a good outcome. So really I tell people the radiologist describes a tear, I tell you whether or not it can be fixed and tell you not whether or not you can get better with having surgery. So if you had an MRI and your report says tear of some kind, but nobody's really explained to you what that means, send me your images. I'll go over it video line by line, show you the exact cuts, whether or not you have a tear, where it is, and what the options are for you in your case. In other words, if your MRI says tear and nobody's explained that to you or showed that to you, that's the conversation I want to have because it's all about you being informed and then making the best decision for yourself. So here's the bottom line. Weakness and a clear injury, get it evaluated soon. Pain without weakness, slow onset, start with physical therapy, 6 to 12 weeks. Get an MRI if it's not better after that. And check out my video on what happens if you ignore a rotator cuff tear. There's a lot of information there that kind of gives you some guidelines on the timing and overall outcomes. And good luck.
