Looking for a shoulder and elbow specialist in Singapore? For symptoms involving the shoulder, elbow, or wider upper limb, the best next step is often a specialist assessment that looks beyond the painful area alone. Dr Lester Tan is a Senior Consultant Orthopaedic Surgeon whose practice covers shoulder and elbow conditions such as tendon injuries, stiffness, instability, fractures, arthritis, and nerve compression around the elbow.
A rotator cuff injury often starts as a dull ache in the shoulder, one that can feel milder during the day but tends to worsen at night. It can also make everyday movements harder, like combing your hair, reaching behind your back, or lifting your arm out to the side. In most cases, the damage behind these symptoms builds gradually through wear and overuse. This is partly why these injuries become more likely with age, and why they’re seen more often in people whose work or activity involves repetitive shoulder movement or heavy lifting. A fall or similar accident might tear the cuff as well, though this usually brings on sudden, intense pain and weakness instead.
In both cases, the damage involves the tendons of the rotator cuff. They sit where the arm meets the shoulder, connecting four muscles on the shoulder blade to the top of the upper arm bone and wrapping around its ball like a cuff. This position lets the muscles keep the ball centred in its shallow socket while they help lift and rotate the arm. Once a tendon frays or pulls away from the bone, pain can follow, and the cuff might not do either job as well. Not every injury involves a tear, though. The damage can range from changes within the tendon to partial and complete tears, so it helps to start with the main types and how each one affects movement.
Rotator cuff injuries can be described by where the damage is located and how far it extends into the tendon. Location matters because the cuff’s role in lifting and rotating the arm is split between its four muscles: the supraspinatus at the top helps lift the arm out to the side, the infraspinatus and teres minor at the back rotate it outwards, and the subscapularis at the front turns it inwards. Most tears occur in the supraspinatus tendon, though the tendons of the other three can tear as well. The depth of the damage, on the other hand, is what tells the main types apart.
The mildest type involves a tendon that’s worn but still intact. With age and repeated use, it can gradually weaken as its tissue breaks down faster than the body can repair it. This can make the shoulder ache, especially during activity, though many people with these changes have no symptoms. Sometimes, calcium deposits would form inside the tendon instead, most often in the supraspinatus. Known as calcific tendinopathy, the condition can be more painful, but its symptoms tend to settle once the body has cleared the deposits. Eventually, a worn tendon can begin to fray, and this is often where a partial tear starts.
When the fraying goes deeper into the tendon but not all the way through, the damage becomes a partial-thickness tear. The tear can sit on the tendon’s upper surface, within it, or most commonly on its underside facing the joint. Wherever it sits, the tendon is thinner but still attached to the bone, so the untorn part can keep working. Even so, a partial tear can cause pain and weakness when lifting or rotating the arm. If the shoulder keeps being used through increasing pain, the tear can also worsen over time, and some eventually become full-thickness tears.
Once a tear goes all the way through, part of the tendon is no longer attached to the bone, and if the whole tendon detaches, it leaves a hole. These tears range from small, under one centimetre at their widest, to massive, which usually means over five centimetres or at least two tendons completely torn. In long-standing massive tears, the tendons involved influence what the shoulder loses. A tear through the supraspinatus and the whole subscapularis tends to affect lifting and inward turning, while one through the supraspinatus, infraspinatus, and teres minor can weaken lifting and outward turning.
Since rotator cuff injuries range from a worn tendon to a tear, the symptoms can vary from one shoulder to the next. With a worn tendon, pain is usually what people notice most. Once a tear develops, weakness can set in as well, though some tears weaken the arm with little or no pain at all. As a result, the symptoms below don’t always appear together. Common symptoms include:
A rotator cuff injury can’t always be traced to a single moment, even when a fall or heavy lift seems to mark the start. The more useful question is what has been straining or weakening the tendon, whether through how the shoulder is used, an injury to the joint, or factors such as age and family history. Common causes include:
Diagnosis usually begins with a specialist assessment to check whether the symptoms come from the rotator cuff, or whether frozen shoulder or arthritis is causing them. Since the level of pain doesn’t always match how much damage there is, the specialist also considers how long the problem has been there, how well the shoulder moves, how strong it remains, and, where needed, the size of any tear and changes in the muscle and tendon. In Singapore, the following methods are commonly used to diagnose rotator cuff injuries:
Treatment for a rotator cuff injury depends on several factors, including how the damage came about and how much of the tendon is affected. When the tendon has weakened over time, as with tendinopathy or a partial tear, non-surgical care is usually the first step, helping to ease the pain and restore strength. When a tear is sudden, such as after a fall, and leaves the arm noticeably weak, repair is often recommended early, since a delay can make a torn tendon harder to reattach.
How much harder depends largely on four things: how long the tear has been there, how large it is, whether the muscle shows fatty atrophy, and how far the tendon has pulled back. The specialist uses these details, along with age, activity level, and general health, to plan treatment. If the symptoms don’t settle with physiotherapy and pain relief, surgery to repair the tendon will be considered. For massive tears that can’t be repaired, other options, including shoulder replacement, might be discussed.
Non-surgical treatment usually works in stages, settling the pain first before moving on to exercise. Although it can’t heal a torn tendon, strengthening the muscles around the shoulder can help the arm work better with less pain.
Rotator cuff repair surgery reattaches the torn tendon to the arm bone, so the muscle can pull on it again. The approach depends largely on how large the tear is, where it sits, and how healthy the remaining tendon is.
When a tear is too large or has been there too long to reattach, lifting the arm can become difficult, or in some cases impossible. In these cases, a reverse shoulder replacement might be considered, particularly if arthritis has also developed in the joint.
Pain from tendinopathy, where the tendon is irritated but not torn, often eases with rest and care at home, so a sore shoulder doesn’t always need to be seen straight away. Weakness is a different matter, as it can be a sign of a tear instead.
Since symptoms alone don’t show the difference, a specialist can clarify whether the problem is tendinopathy, a partial tear, or a complete tear. It’s important to have it checked when:
At this stage, an assessment can help determine whether the shoulder can continue with non-surgical care, whether more targeted pain relief might help movement, or whether surgery should be discussed if the tear is large or the arm stays weak.
When shoulder pain is still mild, working around it can seem easier than having it checked. This might mean reaching with the other arm, carrying bags on the stronger side, or sleeping on the other shoulder. Changes like these take the strain off the sore shoulder, but they also mean it’s used less, so any weakness can go unnoticed for a while. It might only show when that arm is needed, such as for hanging out the laundry or serving at tennis, and lifting takes more effort than it should. Since this is sometimes a sign of a tear, it’s a good point to stop adapting and have a specialist explain what’s causing it.
This is where assessment at Oxford Orthopaedics helps provide clarity. As part of this, your medical history, shoulder strength, range of movement, and any imaging are reviewed together to tell tendinopathy apart from a tear, rule out conditions such as frozen shoulder, and gauge how large and long-standing any tear might be. With this information, Dr Lester Tan can advise on the treatment options best suited to the type and extent of your condition. To arrange for a consultation, please contact the clinic to book an appointment.
A torn rotator cuff tendon generally doesn’t heal on its own. Even so, treatment for a partial tear usually begins without surgery, using anti-inflammatory medication to ease the pain and physiotherapy to strengthen the muscles around the shoulder so the arm can work better. Tendinopathy is different, since the tendon is still intact, and the pain often settles with rest and changes to daily activities.
A rotator cuff tear can get larger, and a partial one might eventually become a complete tear. As time passes, the tear becomes harder to repair, and in some cases, the tendon can no longer be reattached. If so, the shoulder might be left with lasting weakness or loss of movement, and long-standing massive tears can also lead to a form of arthritis known as cuff tear arthropathy.
Surgery is usually discussed when a complete tear causes ongoing pain and weakness, or when symptoms of a partial tear persist despite physiotherapy and pain relief. An operation might also be suggested if you’re very active or use your arms for overhead work or sports. With a sudden tear, such as one from a fall, repair is often advised sooner, especially if the arm is noticeably weak, so it helps to have it checked quickly.
Arthroscopic, or keyhole repair is usually done under general anaesthesia (GA), through a few minimally invasive incisions. First, an arthroscope, a thin tube with a camera, is placed in one incision to show the inside of the shoulder on a screen. Guided by the camera, the surgeon then makes the other incisions and works through them to stitch the torn tendon back onto the bone. Most people can go home on the same day or the day after, with the arm in a sling.
Recovery takes place in stages, starting with four to six weeks in a sling. During this time, a physiotherapist gently moves the arm for you to stop the shoulder from stiffening. Exercises using your own muscles follow, and strengthening usually starts at around eight to 12 weeks. Most people regain useful movement and strength by four to six months, though full recovery can take 12 to 18 months.
For the first few weeks, the sling stays on day and night, only coming off for your rehabilitation exercises. Since you’ll be largely one-handed, it helps to have family or friends assist with dressing, bathing, and the preparation of meals. At night, try not to lie on the operated side for about six weeks. It’s also advisable not to lift anything at all for eight to 12 weeks, while the tendon heals onto the bone.
You can return to normal activities gradually, starting with the ones that put the least strain on your shoulder. Driving and desk-bound work usually come first, at around six to eight weeks after surgery. Jobs involving heavy lifting or manual work take more time, typically at least three months off. Sports takes longer still, around six months for non-contact ones and nine months to a year for contact ones.
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