rotator cuff suspension bridge concept

Can You Have a Rotator Cuff Tear and No Symptoms?

Over the years, our knowledge and ability to treat rotator cuff tears have really advanced significantly.  rotator cuff tearThis includes advances in surgical technique, rehabilitation processes, and even training modifications.  photo from Wikipedia

I see a lot of clients that report shoulder pain that appears to be coming from rotator cuff pathology.  Notice that I just simple say “rotator cuff pathology.”  To me, it doesn’t really matter if it’s torn, partially torn, impinged, inflamed, or anything else.  Shoulder impingement is sort of a junk term.  The only thing that matters to me is how well you function.  Can you lift your arm?  Can you work or play sports without difficulty?  Are you happy with your shoulder?

Still, when people come to see me, all they care about is if their rotator cuff is torn.

Over the years, we have learned that diagnostic tests, like x-rays and MRIs, often don’t correlate with the level of pathology.  This has been shown for injuries such as arthritis and disc pathology.  I have seen films of people with really nasty looking backs and knees and minimal complaints.  Conversely, I have seen films of people with minimal findings but debilitating symptoms.

I was recently asked by a client, “is it possible to have a rotator cuff tear and no symptoms.”  I thought this was a great question and worth sharing my answer.

We know in elite level overhead athletes that Conner et al showed that 40% of asymptomatic shoulders had rotator cuff tears.  I always say that throwing a baseball isn’t good for your body!  But what about everyone else?

One of the nicer articles on the subject was publish back in 1999 by Tempelhof et al.  They studied 411 asymptomatic shoulders using ultrasound and noted that 23% of subjects had a rotator cuff tear.   That’s 1 in 4!  Pretty big number in my mind, but take a look at the breakdown by age:

  • 13% of people aged 50 to 59
  • 20% of people aged 60 to 69
  • 31% of people aged 70-79
  • 51% of people aged 80 or above

As you can see, there is a linear increase in the presence of rotator cuff tears as we age.  So the answer to my clients question was a pretty clear “absolutely!”

How Can You Have a Rotator Cuff Tear and No Symptoms?

rotator cuff tear symptomsI really put symptoms and function together.  If you have symptoms you probably aren’t functioning well (lifting your arm etc.), and if you aren’t functioning well, that is essentially a symptom itself.  So the question is, how can you have a rotator cuff tear and no symptoms?  photo by verygreen

The answer has to do with a suspension bridge!

Burkhart et al described what is called the suspension bridge concept of rotator cuff anatomy.  If you look at the shoulder from overhead, you can imagine a suspension bridge surrounding the humeral head.  In this model, imagine that there is a tear of the supraspinatus muscle on the top of the bridge.  If the anterior and posterior rotator cuff (the two suspension towers) are intact and functioning well, shoulder function may be maintained.  photo from Burhart et al

rotator cuff tear symptoms

This explains the massive irreparable rotator cuff tears that we see and can eventually rehabilitate them back to lifting their shoulder again.  This also explains why so many rotator cuff repairs fail after surgery, but patients are still satisfied with their outcome.  Essentially if we enhance the anterior and posterior cuff’s ability to dynamically stabilize, you can still maintain function with a supraspinatus tear.

So, you can have a rotator cuff tear and no symptoms, you just need a strong and stable cuff around the tear to help dynamically stabilize.

20 replies
  1. MIKE
    MIKE says:

    I agree that if you have a tear of the suprspinatus you can still be asymptomatic . So if the subscap or infraspinatus are torn, what are your chances or regaining pain free function? I have had several patients over the years that are weak with internal or external rotation and rehab has been difficult trying to regain functional use of the shoulder. So the big take away for me is yes we can have a RTC tear and be functional if the pillars of the suspension bridge are intact.

  2. Richard Haynes
    Richard Haynes says:

    Good article. I ruptured the proximal bicep tendon, long head about 10 years ago, non-traumatic injury. I am going to an orthopedic surgeon to check it out. Will need some film . I want to be sure the RC is intact. Though I do not have sx. of a RC tear, I am sure there has been some degenerative damage done over the years. I workout with weights consistently and notice I have about 60-70 strength in my affected shoulder. Thanks for the info. you provide!

  3. Evanthis Raftopoulos
    Evanthis Raftopoulos says:

    I want to note that I do find good value in the suspension bridge concept of rotator cuff anatomy as explaining this concept to those diagnosed with tears may help reduce fear avoidance.

  4. Evanthis Raftopoulos
    Evanthis Raftopoulos says:

    Hi Mike, thank you for your response. We are in agreement that we cannot say with certainty that there is one and only reason why tear but no symptoms. Joe brings valid points here as well. To leave no room for misinterpretations, I would suggest emphasizing that from a purely mechanical perspective the shoulder as a functional unit [in case of a tear] continues to have the capacity to move in certain planes controlled by the muscle/tendon with the tear, and this is most likely due to the remaining intact attachments (remaining of “suspension bridge”). We have to leave pain and perceived symptoms out of this argument though, otherwise we have to dig into neurophysiology. So in my opinion the suspension bridge proposition is a fair explanation of why asymptomatic people with rotator cuff tears (without traumatic injury and not knowing about it) function well. However and as we see patients for post-injury rehab, there is no valid/reliable way for establishing % contributions of anatomy vs physiology to the limited function that we observe at any given moment. We just don’t know. The literature suggests that physiological changes are always necessary for perceived symptoms while anatomical changes not always.
    Thank you for this discussion.

    Evan Raftopoulos,PT

    • Marjolein Groenevelt
      Marjolein Groenevelt says:

      Good Morning Mike,

      Thank you as always for the information. But my lack of engineering leaves me puzzled. If the top of the suspension bridge is torn, is the bridge not unstable? So sure, all the other principles of function, motor control in humans etc still hold, but how is a model of a broken bridge a good model? Does that suspension bridge still have good function?

  5. Joe Brence
    Joe Brence says:

    Mike when you state, “But going back to your comment, I dont think it matters if it is “weakness” or “diminished motor planning.” Both represent a dysfunctional suspension bridge.” I have to respectfully disagree. There is a large difference between an inability to plan a movement vs. being able to plan a movement but have physical weakness. And I suspect this is something we need to be assessing (through programs as Recognise). There is alot of neuroscience in this, especially when we talk about pain and so-called weakness (I actually wasn’t getting into pain w/ my last post; just stating that the neuromatrix results in more than pain). What do you think happens to an asymptomatic individual when you tell or show them that they “have a TEAR”? This is something that needs to be investigated. That stated, do you suspect we be responsible for the weakness through our words creating more of a threat resulting in a defensive response? Why can some people function and have no symptoms with the same injury that is debilitating for others? More than biomechanics…

    • Mike Reinold
      Mike Reinold says:

      I agree Joe, being unable to “plan” a movement and being unable to “perform” a movement are two different things. But both do represent a dysfunctional bridge, regardless of “why” the bridge is dysfunctional, the bridge isn’t working. If the bridge isn’t working, you aren’t going to be able to lift your arm.

      I think you are looking at this too deeply for some reason.

      Remember we are talking about a rotator cuff that is torn. You can decrease their perceived threat all day, if the rotator cuff is not intact, you aren’t going to able to biomechanically function very well. The suspension bridge concept was discussed as a possible explanation as to why someone with a small tear can still elevate their arm, basically because enough of the anterior/posterior cuff suspension bridge is still intact.

      I agree with you on the flip side, if enough of the cuff is intact that the suspension bridge is functioning well, and the patient now can NOT lift their arm, than that is completely different than what I am discussing. To use your example – someone can elevate their arm, has no symptoms, but then after being told has a cuff tear now can NOT lift their arm, that is another story that we definitely both agree on. I am talking about someone that CAN lift their arm after being told they have a rotator cuff tear. Perhaps that is biomechanics allowing it to happen and neuroscience not getting in the way of that!

  6. Joe Brence
    Joe Brence says:

    Hey Mike,
    I am w/ Evanthis here and was curious how one can differentiate weakness of the cuff from diminished motor planning of supporting musculature? We understand that “pain” is only one output from the neuromatrix, and that “altered action programs” may also arise as a defensive response. So is the answer a “suspension bridge” or is it cortical representation and planning (or lack there of) to lift the arm? Potentially why so many asymptomatic individuals function fine with a torn cuff.

    • Mike Reinold
      Mike Reinold says:

      Joe, I think you need to read my response to Evan. Pain is only one symptom. If someone can’t raise their arm without a shrug, that is a symptomatic to me, even if pain free.

      But going back to your comment, I dont think it matters if it is “weakness” or “diminished motor planning.” Both represent a dysfunctional suspension bridge. If the tear is so massive it extends from supraspinatus all the way to the posterior cuff, they lost their suspension bridge and it’s going to be very hard to elevate their arm from a biomechanical and structural explanation. I don’t think cortical planning is going to allow them to lift their arm very well.

      I respect the neuroscience aspect of this, but there is a good old fashion biomechanical and structural explanation as well. Like everything else, these are just potential explanations and the truth is probably a combo of these and many more!

  7. Evanthis Raftopoulos
    Evanthis Raftopoulos says:

    Hi Mike, I can relate to this “Still, when people come to see me, all they care about is if their rotator cuff is torn.”

    I agree that it’s good to consider symptoms and function together as they are usually inversely correlated, however, I do not think that the ’93 cadaveric study(Burkhart et al)confidently answers the question “how can you have a rotator cuff tear and no symptoms?”, unless the only symptom you are referring to is functional capacity limitations. The “suspension bridge”proposition can explain why somebody with a tear continues to have the capacity to move the shoulder, however, the literature suggests that symptom manifestation as perceived by the patient is not linear with anatomical changes (I think you agree). A few references:

    Moreover, symptoms(eg pain) arise within the nervous system and what determines this phenomenon is multidimensional (Melzack, 2001). Assigning the “suspension bridge” as the one and only determinant of symptom manifestation (if I’m reading you correctly) may not be accurate (again, unless the only symptom is functional limitations). I’m interested to hear your thoughts.

    Evan Raftopoulos, PT

    • Mike Reinold
      Mike Reinold says:

      Hi Evan,
      Thanks for the comment, great points!

      I tried to tie together symptoms and function. Symptoms to me does not just mean pain, it means functional limitations. So an athlete can’t compete and a general orthopedic patient can function as normal.

      That all being said, you are right, we can’t say there is one (and only one) reason why someone can have a rotator cuff tear but no symptoms. The explanation above is more along the lines of function. If someone has a nasty shrug sign and can’t raise their arm, I consider this a symptom, even if they are pain free.

      So the above model is designed to help explain one potential rationale as to why someone can function with a rotator cuff tear. I would say if athletes can compete and everyone else can lift their arm pain free, they will be happy, even with a rotator cuff tear. Does that involve neuroscience? Sure, but there is also a biomechanical explanation.

      I think we are in agreement. Thanks for sharing,

  8. Kenny
    Kenny says:

    I think it’s important to mention what we know about current pain science and how the neuromatrix shapes an individual’s pain experience.

    A strong “suspension bridge” may help decrease the brain’s perceived threat related to the RC impairment, but is certainly not the SOLE factor in a RC tear being asymptomatic.

  9. Brandon G. MscPT
    Brandon G. MscPT says:

    Interesting read Mike. Considering as well that the deltoid can take over some of the functionality of the supraspinatus in the force couple, it’s no wonder that a supraspinatus tear can be asymptomatic with intact I.T.S musculature.

  10. Stephen Thomas, PhD, ATC
    Stephen Thomas, PhD, ATC says:

    Mike nice post. We have done some rat model research looking at this same exact idea. Here is the link:

    Basically we measured ground reaction forces during walking in the rats following a combined supra and infra tear. Then at 4 weeks we performed repairs of both the supra and infra or just a repair of the infra (reestablishing the anterior-posterior force balance or the suspension bridge concept). We found that repairing just the infra restored the ground reaction forces as well as repairing both the supra and infra. This is a great surgical option since most supra tears are too retracted to have a successful repair.

  11. Marcello
    Marcello says:

    Great post Mike!! I love the suspension bridge explanation, very useful for the general population.

    Thanks as always for your great posts!!

    – Marcello

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