Supraspinatus tear: do you need surgery or physio?

Many shoulder tendon tears do well without surgery. How a supraspinatus tear is diagnosed, which tears need a surgeon, and how physio helps the rest.

Your shoulder has been aching for weeks. Lifting your arm to reach a cupboard or put on a jacket hurts, and lying on that side at night is out of the question. An ultrasound comes back: "Partial-thickness tear of the supraspinatus tendon." Or perhaps a full-thickness tear.

The word "tear" sounds alarming, and many people assume it means surgery. Often it does not. The supraspinatus is the rotator cuff tendon torn most often, tears become very common as we get older — frequently without any pain at all — and several good trials show that many people do just as well with a structured physiotherapy programme. This guide explains what a supraspinatus tear is, how it is diagnosed, which tears need an early surgical opinion, and what rehab involves.

What is the supraspinatus?

The rotator cuff is four muscles that start on the shoulder blade and wrap around the ball of the shoulder joint. Together they keep the ball centred in its shallow socket while the bigger muscles move the arm. The supraspinatus sits along the top of the shoulder blade, and its tendon runs under the bony roof of the shoulder (the acromion) to attach to the top of the arm bone. It helps lift the arm out to the side, especially in the first part of the movement.

Its position under that bony arch, and the fact that it works with nearly every arm movement, help explain why it is the tendon that most often wears and tears.

Types of tear

• Partial-thickness tear: the tendon is frayed or torn part of the way through.
• Full-thickness tear: a hole goes all the way through the tendon. It may be small, or large enough to involve more than one tendon.
• Degenerative (gradual) tear: develops over years with age-related tendon changes, often with no single injury.
• Traumatic (acute) tear: caused by a specific event — a fall onto the arm, a dislocation, or a sudden heavy lift or pull.

Tears are common — and often painless

This is the most important thing to understand about rotator cuff tears. In a classic MRI study of people with no shoulder pain, published in the Journal of Bone and Joint Surgery, about a third had a rotator cuff tear, and among those over 60, more than half did. A later pooled analysis confirmed that rotator cuff changes become steadily more common with each decade of life.

So a tear on a scan does not automatically explain your pain, and it does not automatically need repairing. Many people live normal, active lives with a tear they never knew they had. The question is not just "is there a tear?" but "how is the shoulder working, and what is causing the pain?"

“A scan tells us what the tendon looks like. How the shoulder moves, how strong it is, and how the tear happened tell us what to do about it.”

— UpPlus Physiotherapy team

Symptoms

• Pain on the outside of the shoulder or upper arm, often aching down towards the elbow
• Pain lifting the arm out to the side or overhead, often worst through the middle of the movement
• Night pain, and difficulty lying on the affected side
• Weakness lifting or rotating the arm
• With a large or sudden tear: being unable to lift the arm properly at all

Neck problems can refer pain into the shoulder and arm, so a good assessment checks the neck too. If your pain runs down past the elbow with pins and needles, see our guide to neck pain that runs down your arm.

How it is diagnosed

A physiotherapist or doctor will ask how it started, then assess your range of movement, strength in different directions, and a set of shoulder tests. Ultrasound is commonly used in Australia to look at the rotator cuff tendons, and MRI may be used before surgery or when the picture is unclear. An X-ray can show arthritis, calcium deposits or changes in the bony arch.

Understanding your scan report

Ultrasound and MRI reports are written for doctors, and the wording can sound far more dramatic than it is. Here is what some common phrases usually mean.

If your report mentions a tear, it is worth asking: how big is it, does it go all the way through, has the tendon pulled back, and did it happen with an injury or gradually? Those answers, together with how your shoulder moves and how strong it is, guide the decision about surgery much more than the word "tear" alone.

Does a partial tear turn into a full tear?

Some do, and some tears get bigger over time, which is one reason to keep strengthening and to review the shoulder if symptoms or strength change. But many partial tears stay stable, and symptoms often improve even when the tear itself does not change. Pain and function, not the scan, are the main guide.

Surgery or physiotherapy? What the research says

For gradual, non-traumatic tears

• A Finnish randomised trial of people over 55 with non-traumatic supraspinatus tears compared physiotherapy alone with surgery plus physiotherapy. At one year, there was no clinically meaningful difference between the groups.
• A large multicentre study from the United States (the MOON group) followed people with non-traumatic full-thickness tears through a physiotherapy programme. About three-quarters avoided surgery at two years, and those who did choose surgery mostly decided within the first 12 weeks.
• A Cochrane review concluded that, for people with degenerative tears, surgery may provide little or no clinically important benefit over non-surgical treatment, although the certainty of the evidence was low.
• A Norwegian trial with 10-year follow-up of small and medium-sized tears found results modestly favoured surgical repair over time, and that tears managed without surgery often grew. This is a reason to review progress, particularly in younger and more active people, rather than a reason for everyone to have surgery.

Put together: for most people with a gradual, age-related supraspinatus tear, a good physiotherapy programme is a sensible first step. If it does not work well enough after about three months, surgery remains an option.

For traumatic tears

A tear caused by a fall or significant injury, especially with sudden weakness, in a younger or active person, is different. These tears often do better when repaired relatively early, before the tendon retracts and the muscle weakens. If this sounds like you, ask for an early referral to a shoulder surgeon — physiotherapy can still help while you wait and afterwards.

Physiotherapy for a supraspinatus tear

Exercise is the core of non-surgical treatment, and a systematic review of exercise for rotator cuff tendinopathy found it helped pain and function. The aim is to strengthen the remaining rotator cuff and the muscles around the shoulder blade so the shoulder works well despite the tear.

Stage 1: settle the pain

• Modify the activities that flare it — especially repeated or sustained overhead work and heavy lifting with the arm away from the body.
• Gentle movement within comfort to stop the shoulder stiffening.
• Pain relief advice, and sleeping positions that reduce night pain (a pillow under the arm often helps).

Stage 2: build strength and control

• Isometric exercises: pressing the arm gently against a wall or doorframe without moving it.
• Resistance band rotations: elbow at your side, rotating outwards and inwards.
• Shoulder blade exercises: rows and controlled shrugs.
• Lifting the arm in a slightly forward ("scaption") position, first unweighted and then with light weights.

Stage 3: return to full function

• Gradually heavier strength work and work overhead
• Work-, sport- and hobby-specific training: lifting, throwing, swimming, gardening
• A long-term maintenance programme, two or three sessions a week

Expect to give a structured programme around 12 weeks before judging how well it is working. Many people notice less pain and better movement well before then.

What about injections?

A corticosteroid injection can reduce pain enough to allow exercise in some people, but the benefit is often short-lived and repeated injections may weaken tendon tissue. They are best used as a short-term aid, not a replacement for rehab.

Everyday tips with a sore shoulder

• Keep frequently used items between waist and shoulder height.
• Carry shopping close to your body, split between both hands.
• Avoid sleeping on the sore side; hug a pillow when lying on the other side.
• Break up overhead jobs — painting, hanging washing, reaching into high cupboards — with rests.

When to see a physio or doctor

• Shoulder pain lasting more than two or three weeks, or getting worse
• Night pain stopping you from sleeping
• Weakness lifting the arm, or difficulty with work and daily tasks
• You have a scan report mentioning a tear and want to know what it means for you

See a doctor promptly if you suddenly cannot lift your arm after a fall or injury, if the shoulder dislocated, or if you have fever, redness or unexplained pain with feeling unwell.

How UpPlus Physiotherapy helps

• A full shoulder and neck assessment, and help understanding your scan
• A staged, progressive strengthening programme, in the clinic and at home
• Clear guidance on when a surgical opinion is worth getting, and referral if needed
• Rehab after surgery if you do have a repair — see our rotator cuff repair recovery guide

Read more about rotator cuff tendinopathy, shoulder impingement and frozen shoulder.

Finding a physio near me for a rotator cuff tear

When searching for the best physio for a rotator cuff or supraspinatus tear, look for a thorough shoulder and neck assessment, an exercise programme that progresses over 12 weeks or more, and honest advice about when surgery makes sense.

Our clinic is at 177 Trimmer Parade, Seaton, a short drive from Woodville, Findon, West Lakes, Grange and Albert Park. No referral is needed, and you can claim on the spot with private health cover.

If shoulder pain or a scan result is worrying you, our physiotherapists can assess your shoulder and explain your options. Book online or call 0403 907 587.

This article is general information, not a diagnosis or a substitute for an individual assessment. If you are unsure about your symptoms, see a health professional.