How Common Are Rotator Cuff Tears, and Do They Get Worse Without Surgery?

Quick answer: Rotator cuff tears are very common. About 1 in 5 adults has a full-thickness tear, and the chance rises with every decade after 50 ^{[1, 2]}. Most of these tears cause no pain ^[2]. Tears do not heal back to the bone on their own, though, and over several years about half of them get larger ^{[10, 13]}. Full-thickness tears, larger tears, older age and changes in the muscle make growth more likely ^{[12, 14, 16]}. A tear that grows is more likely to start hurting ^[9–11]. That is why a tear treated without surgery should be monitored, and why younger, active patients with a full-thickness tear are often offered repair.

How Common Are Rotator Cuff Tears?

The rotator cuff is the group of four tendons that keep the ball of the shoulder centered and help lift and rotate the arm ^[21]. Large population studies, in which everyone in a community was scanned whether or not they had symptoms, show how common tears are:

• About 1 in 5 adults. Ultrasound of 1,366 shoulders from a Japanese village found full-thickness tears in 20.7%. A history of injury, use of the dominant arm and older age were the main risk factors ^[1]. A second village study of 664 residents found tears in 22.1% ^[2].
• Rare before 50, common after 60. In that second study, no one in their 20s to 40s had a full-thickness tear. Tears were found in 10.7% of people in their 50s, 15.2% in their 60s, 26.5% in their 70s and 36.6% in their 80s ^[2].
• Most cause no symptoms. About two-thirds of the tears in the general population were painless ^[2].
• The pattern is consistent across studies. A pooled analysis of 30 studies and more than 6,000 shoulders found rotator cuff abnormalities in about 10% of people aged 20 and younger and in 62% of people 80 and older ^[3].

Tears in people with no shoulder pain

Study	Who was scanned	What was found
Sher et al. 1995 (MRI) [4]	96 adults without shoulder pain	Tears in 34% overall. Among people over 60, 54% had a tear and 28% had a full-thickness tear.
Milgrom et al. 1995 (ultrasound) [5]	90 adults without shoulder pain	Partial or full tears in more than half of dominant shoulders in people in their 60s and in 80% of people over 80
Tempelhof et al. 1999 (ultrasound) [6]	411 volunteers without shoulder pain	Tears in 13% of people in their 50s, 20% in their 60s, 31% in their 70s and 51% over 80

Because of these numbers, the researchers in each study drew the same conclusion: a tear on an MRI is not, by itself, a reason for surgery ^[3–5]. Treatment depends on symptoms, strength and how the tear behaves over time.

If one shoulder has a tear, the other often does too

In 588 patients with pain in one shoulder, the average age was 48.7 years for those with no tear, 58.7 for those with a tear in one shoulder and 67.8 for those with tears in both. After age 66 there was a 50% chance of tears in both shoulders. Of patients with a painful full-thickness tear, 35.5% had a full-thickness tear in the other, painless shoulder ^[7].

Do Rotator Cuff Tears Get Worse Without Surgery?

A torn tendon does not reattach to the bone on its own. What happens next has been studied by following patients with repeat ultrasound or MRI over years.

Tears that don't hurt

• A classic study, included in the American Shoulder and Elbow Surgeons (ASES) curriculum, followed patients whose tear in one shoulder caused no pain. Over an average of 2.8 years, 51% developed symptoms. Of those rescanned, 9 of 23 tears had grown and none had gotten smaller ^[8].
• The largest prospective study followed 224 people for a median of 5.1 years. Tears grew in 61% of full-thickness tears and 44% of partial-thickness tears, typically within about 3 years. New pain developed in about half of those with a full-thickness tear, and tear growth was linked to the start of pain ^[10].
• When a painless tear starts to hurt, it has often grown. Of tears that became painful, 18% of full-thickness tears had grown by more than 5 mm and 40% of partial-thickness tears had become full-thickness ^[9].
• In a three-year MRI study, tears that became painful grew by an average of 10.6 mm, compared with 3.3 mm in tears that stayed painless. They were also more likely to show fatty change in the muscle ^[11].

Tears that do hurt, treated without surgery

• In patients 60 or younger with a full-thickness tear, 49% of tears grew over about 2½ years. A larger tear went along with more pain, and a quarter of the "normal" opposite shoulders developed a new tear ^[13].
• In an MRI study, 52% of full-thickness tears grew compared with 8% of partial-thickness tears. Tears were more likely to grow with follow-up longer than 18 months, in patients over 60 and when the muscle already showed fatty change ^[12].
• In another MRI study followed for an average of about 2 years, 82% of full-thickness tears and 26% of partial-thickness tears got larger. Being full-thickness was the strongest predictor of growth ^[14].

Not every tear progresses

Small tears can stay stable. In 24 patients with a small, isolated full-thickness supraspinatus tear who chose not to have surgery, the tear stayed about the same on average over 3½ years. It grew in 6 patients and was smaller or no longer visible in 11, and shoulder function stayed good ^[15]. In a large multicenter study of painful full-thickness tears without an injury, about 75% of patients treated with physical therapy had not needed surgery at two years ^[20].

Why Tear Growth Matters

When a tear grows, the tendon pulls back and its muscle can shrink and fill with fat. Tears that enlarged were more likely to develop fatty muscle change, and muscle change made further growth more likely ^[16]. That muscle damage generally does not reverse even after a successful repair, and it is linked to weaker results ^[18].

Over time, a reparable tear can become one that can no longer be fixed. In a study of large tears treated without surgery, function was reasonable at four years, but the tears grew, arthritis progressed, and half of the tears that were reparable at diagnosis became irreparable ^[17].

Long-term trial results point the same way. In a Norwegian randomized trial of small and medium tears, patients repaired up front had better strength, motion and pain scores than those treated with physiotherapy, and the difference was still present at 15 years. In patients treated with therapy alone, the average tear width roughly doubled, from 16 mm to 32 mm ^[19].

What This Means for You

• A tear found on an MRI is common and is not, by itself, a reason for surgery, especially after 60 and when it isn't painful ^[2–6].
• Physical therapy is a reasonable first step for many painful degenerative tears, and most patients do well ^[20].
• If a tear is treated without surgery, it should be monitored. Researchers recommend repeat imaging over time, especially for full-thickness tears, because size is linked to symptoms ^{[7, 12, 13]}.
• Repair is more often recommended for younger, active patients with a full-thickness tear, for tears that are growing or causing weakness, and for tears caused by an injury. Repairing these tears before the muscle deteriorates keeps more options open ^{[13, 17–19]}.

If your tear came from a fall or injury, see Acute Traumatic vs. Chronic Rotator Cuff Tears. To compare treatments, see Rotator Cuff Tear: Surgery vs. Physical Therapy. Learn more about rotator cuff tears and rotator cuff repair.

Dr. Tej Joshi sees patients with rotator cuff tears in Manhattan, Bay Ridge, Brooklyn and Lake Success, Long Island. Request an appointment.

FAQs

How common are rotator cuff tears? About 1 in 5 adults has a full-thickness tear on ultrasound, and the rate climbs with age, to more than a third of people in their 80s. Most of these tears cause no pain ^{[1, 2]}.

Will my rotator cuff tear get worse if I don't have surgery? Not always, but often. Studies that rescanned patients over 2 to 5 years found that about half of full-thickness tears grew ^{[10, 12, 13]}. Small tears can stay stable ^[15]. Growth is more likely with full-thickness tears, larger tears, age over 60 and fatty change in the muscle ^{[12, 14, 16]}.

Can a rotator cuff tear heal on its own? A full-thickness tear does not reattach to the bone on its own. In one study, none of the rescanned tears got smaller ^[8], and in others only a few did ^{[12, 13]}. Pain can still improve with therapy even when the tear remains.

I have a tear on MRI but no pain. What should I do? Usually nothing surgical. Painless tears are common ^[4–6]. About half become painful within a few years, often when the tear grows ^{[8, 10]}, so see a specialist if you develop new pain or weakness.

How often should a tear be checked? Researchers have recommended repeat imaging at about yearly intervals for known tears treated without surgery ^[7]. Your surgeon will tailor this to your age, tear type and symptoms.

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References

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