Part of Shoulder impingement
Shoulder impingement vs a rotator cuff tear: telling them apart
Warning signs, and when to get help
Shoulder impingement vs rotator cuff tear: what is actually different?
The difference is not the one most people are looking for. Impingement and a cuff tear are not two conditions in two places; they are points on one spectrum in one small space, and what separates them clinically is weakness and how the pain began, not the name itself. A tear that arrived with a fall or a sudden pull, leaving the arm weak, is the one difference that changes what happens next and how fast.
Two readers arrive here from opposite ends. One has had a sore shoulder for months, has been given a word by a clinician or a search engine, and wants to know whether something is torn. The other fell last week, cannot lift the arm, and is reading instead of being examined. The second reader gets answered first, in the next section, because the answer there is urgent and short.
For the reader with the long-standing shoulder, the news is better than expected. The names sit on top of one another rather than beside one another. Your letter or your physio may say impingement, subacromial pain, subacromial pain syndrome, rotator cuff tendinopathy or rotator cuff related shoulder pain, and current guidance treats those as much the same shoulder: the Dutch guideline replaced impingement with subacromial pain syndrome (Diercks and colleagues, 2014), Lewis (2016) describes rotator cuff related shoulder pain as an over-arching term covering a spectrum of shoulder conditions, and UK shoulder surgeons say the diagnosis behind the different words is essentially the same (Kulkarni and colleagues, 2015). Why the old word fell out of favor is a longer story, and it sits on the shoulder impingement program and on what causes shoulder impingement.
A tear is not outside that group either. Lewis (2016) puts symptomatic partial and full thickness cuff tears under the same umbrella term, and the 2026 Dutch update deliberately brought degenerative isolated full-thickness supraspinatus tears inside subacromial pain syndrome, while keeping multi-tendon and irreparable tears out of its scope (Lambers Heerspink and colleagues, 2026). That is the honest answer, and it is messier than the one most comparison pages give you.
So what does separate them? Two things, and neither is the amount of pain: how the shoulder started hurting, and whether the arm has become weak.
Did it start with a fall or a sudden pull?
If so, this page is not where today goes. Read the rest of this section, all of it, and then make a phone call.
The pain started after a fall, a pull or another injury, especially if the arm has been weak since, for example you cannot lift it out to the side or hold it up. This can be a broken bone or a torn tendon. Get medical advice the same day, and say how it happened and that the arm has been weak since, because UK shoulder surgeons advise urgent referral for a rotator cuff tear caused by an injury.
Sudden, very bad shoulder pain, or you suddenly cannot lift or move your arm at all. Get medical help the same day.
Those two lines are not caution for its own sake. The BESS and BOA care pathway states that an acute cuff tear resulting from a traumatic event needs urgent referral, ideally to the next available clinic (Kulkarni and colleagues, 2015). The NHS routes sudden or very bad shoulder pain, an arm you cannot move, and pain that began after an injury or accident such as a fall to an urgent GP appointment or NHS 111. And the reason the gradual-onset advice does not stretch to cover you is written into the definition: the Dutch guideline defines its syndrome as non-traumatic shoulder complaints, so a shoulder injured in an accident was never inside it (Diercks and colleagues, 2014; Lambers Heerspink and colleagues, 2026).
OrthoInfo describes the two usual mechanisms for an acute tear as falling on an outstretched arm and lifting something too heavy with a jerking motion, and notes that such a tear can happen alongside a broken collarbone or a dislocated shoulder. A tear that happens suddenly usually causes intense pain, and that source describes a snapping sensation and immediate weakness in the upper arm with it, so a snap followed by an arm that will not lift belongs here even if the pain has since quieted down. Being young does not take you out of this section either. OrthoInfo notes that most tears in young adults are caused by a traumatic injury such as a fall, and a young shoulder with good tissue is the one where a repair has the most to gain and the least time to wait.
If the shoulder came out of joint, start at shoulder dislocation. If a bone may be broken, proximal humerus fracture covers that shoulder. Either way, being seen comes before any program.
What to ask for is worth saying plainly, because the history is what makes this urgent rather than routine. Give the date, say how it happened, and say the arm has been weak since. The BESS and BOA pathway puts an acute traumatic cuff tear among the shoulder red flags that need urgent referral into specialist care, so if you are sent away with rest and painkillers and no appointment has been arranged, go back and say so (Kulkarni and colleagues, 2015).
Where bursitis fits, and why it is usually not a separate problem
Bursitis gets treated online as a third diagnosis to be sorted out from the other two. The sources do not read it that way.
OrthoInfo describes a lubricating sac, the bursa, sitting between the rotator cuff and the bone on top of the shoulder blade, where it lets the tendons glide as the arm moves. It calls bursitis inflammation of that sac and tendinitis inflammation of the cuff tendons, and explains that the acromion can rub against the tendon and the bursa below it, which is where the old word impingement came from. The bursa and the tendon are millimeters apart and take load together, which is why one label rarely arrives cleanly on its own.
The guidelines follow suit. Bursitis is listed as part of subacromial pain syndrome in the Dutch guideline (Diercks and colleagues, 2014), and the UK pathway notes that bursitis, tendinitis and supraspinatus tendinopathy are terms used differently across professions for essentially the same diagnosis (Kulkarni and colleagues, 2015). Subacromial bursitis, then, is mostly a statement of location. There is no separate bursitis program here, and there should not be one.
One bursitis warning is worth stating in full, because an irritated bursa and an infected joint share a word in everyday speech and nothing else.
The shoulder is hot, red and swollen, or you have a fever or feel unwell. This can be a joint infection, which needs treatment quickly. Go to an emergency department the same day, and call emergency services if you feel very unwell.
What a tear adds that impingement does not
Weakness is the feature that pushes a shoulder toward the tear end of the group, although it does not belong to a tear alone: the NHS lists weakness in the arm among the symptoms of impingement as well, and OrthoInfo describes loss of strength as a cuff problem progresses. OrthoInfo lists the symptoms of a cuff tear as pain at rest and at night, worse when lying on that shoulder, weakness when lifting or rotating the arm, and crepitus, a crackling feeling in certain positions. Painful-but-strong and painful-and-weak are different stories, and the difference between being unable to lift because it hurts and being unable to lift because the arm will not answer is worked through on shoulder pain when lifting your arm.
How a tear arrives is the other difference. OrthoInfo says most tears are the result of the tendon wearing down slowly over time, with repeated load and a blood supply to the cuff tendons that decreases as we age, which is why a tear can turn up in a shoulder nobody ever injured. The Dutch guideline makes the same point from the other direction: once the pinching explanation lost ground, more weight went to tendon degeneration, which it says can lead to tears (Diercks and colleagues, 2014).
Then there is what a tear does not reliably bring with it. It does not always bring pain, since OrthoInfo states that some cuff tears are not painful, and that source adds the half that matters: those tears may still produce arm weakness and other symptoms. So painless is not the same as harmless, and weakness is the thing to notice.
The words used for the size of a tear are worth knowing too, because both of them get misread. A partial tear does not completely detach the tendon from the bone, in OrthoInfo's words: the tear goes only part of the way through the thickness of the tendon, which is left attached but thinner than normal. A full-thickness tear goes all the way through, and the same source splits it in two. A full-thickness incomplete tear is one where only a small part of the tendon is detached from the bone. A full-thickness complete tear is one where the tendon is detached, leaving what OrthoInfo calls essentially a hole in it. Full thickness, then, does not have to mean the whole tendon is off the bone, which is how most people hear it. The word tear covers everything from a frayed surface to that hole. None of that makes a tear unimportant. It makes the loudness of the pain useless as a measure of it.
Is there a way to tell at home?
No, and a page that offers you one is selling certainty it does not have.
There are clinical tests. The Dutch guideline tells clinicians to use the drop-arm test and the supraspinatus and infraspinatus strength tests when a cuff tear is suspected (Diercks and colleagues, 2014). Those belong in an examination, performed by someone who can compare the two sides, hold the arm properly and interpret what happens, and they are not a self-check. Performed on yourself in a bathroom mirror they mostly measure how much it hurts to try.
Imaging does not hand over a clean label either. The Dutch guideline notes that ultrasound is not reliable enough to tell an intact cuff from a partial lesion, and the UK pathway warns that ultrasound is operator-dependent and that partial tears seen on a scan can be symptomless or falsely reported (Diercks and colleagues, 2014; Kulkarni and colleagues, 2015). Whether a scan belongs in your case is a separate question, and it has its own page: do you need a scan for shoulder impingement.
What you can do is describe your shoulder accurately, which is worth more at an appointment than a name. Note the date and the mechanism if there was one, whether the arm is weak or only sore, what it can no longer do, whether the pain wakes you, and how many weeks or months this has been going on.
Can you have more than one of them at once?
Yes, and in this part of the shoulder that is the normal state rather than a complication. The Dutch guideline's single diagnosis holds bursal irritation, calcific change, tendinopathy and partial tearing together, which is a statement that these things coexist (Diercks and colleagues, 2014). OrthoInfo mentions that tears in the cuff tendons are sometimes seen on the MRI of a shoulder being managed as impingement.
A couple of neighbors get mistaken for a tear, and each is worth a sentence. An acute flare of calcific tendinitis can be severe enough that people assume something has snapped, and the calcium deposit and shockwave treatment belong on that page. Pain at the front of the shoulder may be coming from the biceps tendon instead, which biceps tendinopathy covers.
A shoulder that is stiff in every direction, including turning the arm outward with the elbow tucked in, is a different question again and points toward frozen shoulder. That comparison has its own page: shoulder impingement or frozen shoulder.
Does the name change the treatment?
For gradual-onset shoulder pain, less than the hunt for the right name suggests. The 2026 Dutch update states that non-surgical treatment should comprise exercise therapy, and it says so about a syndrome that now includes degenerative full-thickness supraspinatus tears (Lambers Heerspink and colleagues, 2026). The UK pathway puts rest, exercise, physiotherapy and painkillers in first-line care for subacromial shoulder pain from cuff problems, a group it describes as including tendonitis, calcific tendonitis and cuff tears (Kulkarni and colleagues, 2015). And the 2025 physical therapy clinical practice guideline on rotator cuff tendinopathy covers tendinopathy, with or without calcification, together with partial-thickness cuff tears in one document (Desmeules and colleagues, 2025). One document for both labels tells you how they are handled day to day.
There is one part of this that people are too often sent away without. If a scan has found a tear and the plan is exercise rather than an operation, the 2026 Dutch update asks that you be told the tear can grow larger on non-surgical treatment, and that your shoulder be followed up (Lambers Heerspink and colleagues, 2026, part 2). So if no review appointment was arranged, ask for one. The same guideline puts the point for reconsidering a repair at 3 to 6 months without improvement, and reports worse results when surgery is put off for more than a year, which makes a program with no review date attached to it the thing to query.
That is also why the programs on this site are not divided by label. The staged work for the tendon lives on the rotator cuff tendinopathy program, the version that leans more on shoulder blade control lives on the shoulder impingement program, and both start gently, with exercises such as isometric shoulder abduction and side lying external rotation where lifting the arm still hurts. Your physio will adjust which program you start on, and the load, to your shoulder.
Be clear about what this section is not saying. It is not saying a tear does not matter, and it is not saying a tear needs an operation. Both are decisions for a clinician with an examination in front of them, and the traumatic story with a weak arm is the one that changes the route and the speed.
Nor does it mean exercise instead of an opinion. Two shoulders should be assessed rather than worked around: the one injured in a fall or a sudden pull, and the one that has genuinely lost strength, where you cannot lift the arm or hold it up rather than simply finding it painful to try. An arm that suddenly will not lift, and weakness that is getting worse, both have a same-day line in the warning signs below. Weakness that has been there a while and is not changing does not, but it still belongs at an appointment rather than in a program on its own, because the months spent exercising are months a tendon can be changing. The 2026 Dutch update lists tear size, muscle wasting, fatty change in the muscle and a retracted tendon among the things that make a repair less likely to succeed (Lambers Heerspink and colleagues, 2026, part 2), which is the plain reason a weak arm gets looked at early rather than later.
What an assessment adds, and what to bring to it
An examination reaches what a description cannot: how much movement you have, how much the other hand can add to it, where the tenderness sits, and what the cuff can hold against resistance. A physiotherapist or physical therapist will also look at your neck, because pain can refer into the shoulder from there. The UK pathway is useful on how decisions get made after that, saying referral should rest on symptoms and function rather than on an ultrasound report (Kulkarni and colleagues, 2015).
Bring the things nobody can reconstruct later. How it started and when. Whether there was a fall, a pull or a heavy lift, and what the arm could do in the hours afterwards.
Then the everyday detail. Which movements are now impossible, which are merely painful, and whether it wakes you. Any previous shoulder trouble, injections or operations on that side. What you need the arm back for, whether that is a ceiling to paint, a baby to lift or a serve. If the nights are the worst part of it, sleeping with shoulder impingement covers what to do about them, and say so at the appointment.
If you are still working out which part of the shoulder this is, the shoulder pages list the conditions and symptoms covered here.
When shoulder pain or weakness needs to be seen sooner
Which label fits can wait for an appointment. Some of what follows cannot.
An injury followed by a weak arm, a shoulder you suddenly cannot lift at all, or sudden very bad pain all need medical advice the same day. A shoulder that is hot, red and swollen, or comes with a fever, needs an emergency department the same day. Chest pain or tightness that spreads to the arm, neck or jaw, or shoulder pain with breathlessness, sweating or feeling sick, needs emergency services now, because that pattern can be a heart attack rather than a shoulder at all. So does an arm or hand that turns cold, pale, blue or gray compared with the other side.
Below the emergencies sit the signs that change the timetable without being emergencies: numbness or pins and needles in the arm that will not go, weakness that is getting worse, night pain that nothing eases and that keeps building, and aching stiffness in both shoulders in the morning in an older reader. The full list is in the warning signs section further down this page, each line with how soon it needs attention.
Related exercise programs
Warning signs
Get emergency help now
- Chest pain or tightness, which may spread to your arm, neck or jaw, or shoulder or arm pain that comes with shortness of breath, sweating or feeling sick. This can be a heart attack. Call emergency services straight away.
- The shoulder is hot, red and swollen, or you have a fever or feel unwell. This can be a joint infection, which needs treatment quickly. Go to an emergency department the same day, and call emergency services if you feel very unwell.
- The shoulder feels as if it has slipped out of place, looks a different shape or suddenly locks so you cannot move the arm, or the pain is severe after a fall or an injury. Go to an emergency department straight away, without driving yourself, and do not try to put the shoulder back in yourself.
- Your arm, hand or fingers turn cold, pale, blue or gray compared with the other side. Call emergency services or go to an emergency department straight away, and do not drive yourself. The blood supply to the arm may be blocked.
Get help today
- Sudden, very bad shoulder pain, or you suddenly cannot lift or move your arm at all. Get medical help the same day.
- The pain started after a fall, a pull or another injury, especially if the arm has been weak since, for example you cannot lift it out to the side or hold it up. This can be a broken bone or a torn tendon. Get medical advice the same day, and say how it happened and that the arm has been weak since, because UK shoulder surgeons advise urgent referral for a rotator cuff tear caused by an injury.
- Pins and needles or numbness in the arm that does not go away, no feeling in part of the arm, or weakness that is getting worse. Get medical advice the same day. For pain spreading down the arm from your neck, ask for an urgent appointment with your doctor. If one side of your face or body suddenly goes numb or weak, or your speech becomes slurred or muddled, call emergency services, even if it goes away.
- Severe pain in both shoulders that has come on recently. Get medical advice the same day.
- You are over 50 and have aching and stiffness in both shoulders, often in the neck or hips too, that is worst in the morning and lasts more than 45 minutes after you get up. This can be an inflammatory condition (polymyalgia rheumatica) rather than impingement. If you also get a new headache, pain or tenderness at your temples or on your scalp, or jaw pain when you eat or talk, get medical advice the same day, and if your vision changes, call emergency services. Even without those extra signs, see your doctor within a few days about the aching and stiffness.
- Pain at night or at rest that is constant, that no rest or change of position eases at all, and that keeps getting worse. If you are being treated for cancer now, contact your cancer team the same day.
Book an appointment
- New shoulder pain and you have had cancer, now or in the past, or you are losing weight without trying. See your doctor within a day or two and mention it.
- Pain at night or at rest that is constant, that no rest or change of position eases at all, and that keeps getting worse. If you have had cancer, now or in the past, or are losing weight without trying, see your doctor sooner, within a day or two, and mention it. This applies even if the pain is not getting worse.
- Night pain is common with this condition, but get checked within a few days if the pain is constant, no rest or change of position eases it at all, and it keeps getting worse.
Common questions
Is subacromial bursitis different from shoulder impingement?
Subacromial only says where it is: under the acromion, the bony tip at the top of the shoulder. OrthoInfo describes the bursa there as a lubricating sac between the rotator cuff and the bone on top of the shoulder blade, which lets the tendons glide as the arm moves, and calls bursitis inflammation of that sac. The Dutch guideline lists bursitis as part of subacromial pain syndrome rather than as a separate condition (Diercks and colleagues, 2014), and UK shoulder surgeons note that bursitis and tendinitis are among the words used differently across professions for what is essentially the same diagnosis (Kulkarni and colleagues, 2015). There is no separate bursitis program on this site because the sources do not treat it as a separate problem.
Is tendonitis a third thing?
It is another word for the same group. OrthoInfo uses rotator cuff tendinitis for inflammation of the cuff tendons and discusses it on the same page as impingement. Physiotherapists more often say tendinopathy now, a word that points at change in the tendon rather than at inflammation alone, and the Dutch guideline gives weight to tendon degeneration, which it says can go on to produce tears (Diercks and colleagues, 2014). The staged loading program for the tendon itself sits on our rotator cuff tendinopathy page.
Which is more painful, impingement or a tear?
Pain is a poor guide to the tissue, which is the single most useful thing to know before you grade your own shoulder. OrthoInfo states plainly that some rotator cuff tears are not painful, though it adds that those tears may still produce arm weakness and other symptoms, and that a slowly developing tear may bring no symptoms at all. The same source says a tear that happens suddenly, such as in a fall, usually causes intense pain, often with a snapping sensation and immediate weakness. So a quiet ache can sit on top of a tear and a furious shoulder can have an intact cuff. What changes the route is not how loud the pain is but whether the arm is weak, and whether it started with an injury.
Does a rotator cuff tear mean surgery?
Not by itself, and that decision belongs to a surgeon who has examined you. For a tear that came on gradually, the usual first step is exercise rather than an operation, with a review date set rather than an open-ended wait. The 2026 Dutch update says non-surgical treatment should include exercise therapy for subacromial pain syndrome, which in that guideline includes a degenerative full-thickness supraspinatus tear (Lambers Heerspink and colleagues, 2026). Part 2 of the same update puts it in order for that exact group, recommending that a tear which is isolated, symptomatic and not caused by an injury starts with non-surgical therapy such as exercise, with or without a corticosteroid injection, and that surgery is considered if that has not worked after 3 to 6 months (Lambers Heerspink and colleagues, 2026, part 2). Two things are worth asking for at that appointment, because the guideline asks for both: to be told whether your tear can grow larger over time, and a follow-up rather than being left to get on with it. The same guideline reports that putting surgery off for more than a year after non-surgical treatment gives worse results than a delay of 3 to 6 months, and that tear size, muscle wasting, fatty change inside the muscle and a tendon that has pulled back all count against a repair, which is why 3 to 6 months is a point to review the decision and not a wait with no end to it. Two groups should not read that recommendation as theirs: multi-tendon and irreparable tears sit outside the guideline altogether, and the clinical question behind it was asked about adults under 70, so an older shoulder is a decision for the surgeon who examines it rather than one this guideline settles. The UK pathway makes the broader point in surgical language: a cuff tear on a scan does not always match the symptoms and does not imply a definite need for surgery in every case (Kulkarni and colleagues, 2015). OrthoInfo lists a tear caused by a recent, acute injury, and significant weakness and loss of function in the shoulder, among the signs that surgery may be the better option. If you have already had a repair, follow your surgeon's protocol and see rehab after rotator cuff repair rather than any program on this page.
References
- Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthopaedica. 2014;85(3):314-322. https://doi.org/10.3109/17453674.2014.920991
- Lambers Heerspink FO, Veen EJD, Dorrestijn O, et al. Update of guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopedic Association. Part 1: preventive measures, diagnostics, and non-surgical treatment of subacromial pain syndrome. Acta Orthopaedica. 2026;97:91-98. https://doi.org/10.2340/17453674.2026.45365
- Lambers Heerspink FO, Veen EJD, Dorrestijn O, et al. Update of guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopedic Association. Part 2: operative considerations and treatment of various conditions related to subacromial pain syndrome. Acta Orthopaedica. 2026;97:99-104. https://doi.org/10.2340/17453674.2026.45410
- Kulkarni R, Gibson J, Brownson P, Thomas M, Rangan A, Carr AJ, Rees JL. Subacromial shoulder pain. BESS/BOA Patient Care Pathways. Shoulder and Elbow. 2015;7(2):135-143. https://doi.org/10.1177/1758573215576456
- Lewis J. Rotator cuff related shoulder pain: assessment, management and uncertainties. Manual Therapy. 2016;23:57-68. https://doi.org/10.1016/j.math.2016.03.009
- Desmeules F, Roy JS, Lafrance S, et al. Rotator cuff tendinopathy diagnosis, nonsurgical medical care, and rehabilitation: a clinical practice guideline. Journal of Orthopaedic and Sports Physical Therapy. 2025;55(4):235-274. https://doi.org/10.2519/jospt.2025.13182
- American Academy of Orthopaedic Surgeons. Shoulder impingement/rotator cuff tendinitis. OrthoInfo. https://www.orthoinfo.org/en/diseases--conditions/shoulder-impingementrotator-cuff-tendinitis/
- American Academy of Orthopaedic Surgeons. Rotator cuff tears. OrthoInfo. https://www.orthoinfo.org/en/diseases--conditions/rotator-cuff-tears/
- NHS. Shoulder pain. Page last reviewed 22 May 2023. https://www.nhs.uk/symptoms/shoulder-pain/
- NHS. Shoulder impingement. Page last reviewed 26 November 2024. https://www.nhs.uk/conditions/shoulder-impingement-syndrome/
- NHS. Heart attack. Page last reviewed 31 March 2026. https://www.nhs.uk/conditions/heart-attack/
- NHS. Polymyalgia rheumatica. Page last reviewed 23 April 2023. https://www.nhs.uk/conditions/polymyalgia-rheumatica/
- NHS. Temporal arteritis. Page last reviewed 14 August 2023. https://www.nhs.uk/conditions/temporal-arteritis/
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-18.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.