The rotator cuff is a series of four small muscles that control your shoulder. Tears in the rotator cuff are very very common. It turns out that using the term “tear” really isn’t very accurate. Most rotator cuff tears are degenerative. That means your tissue simply wore out – it didn’t tear. It’s a sad fact of life: many people have rotator cuff tears and do not even know it. Many of you have shoulder pain and your MRI revealed a degenerative rotator cuff tear. Why do some “tears” hurt while other do not? We do not know the answer to that question.
Just because something is torn does not mean that it always needs to be fixed. In many cases your shoulder pain will respond to non-surgical measures such as injections, supplements, support sleeves or braces, a shoulder pillow to sleep with, medications and physical therapy. For those of you with traumatic tears following a significant injury or fall (not picking up a box, etc) then surgery is the recommended treatment. However, the vast majority of rotator cuff tears are degenerative or atraumatic.
The American Academy of Orthopedic Surgery put forth a series of guidelines on how to manage patients with rotator cuff tears. It shows that there is very little evidence in the scientific literature to support surgery as the initial treatment option of degenerative, atraumatic rotator cuff tears. They published a guideline for surgeons and it reveals that we do not really know how to manage these degenerative tears. The issue is that some tears will grow larger, yet many will not. Many will respond to physical therapy, yet some may not. More importantly, most research shows that the integrity of your rotator cuff… does NOT correlate with whether or not you have shoulder pain. That means that you may have had rotator cuff surgery, feel great, but if we image your shoulder we find that the rotator cuff tear did not heal. Confusing isn’t it? That’s why you can get four opinions on how to manage your rotator cuff tear and receive many different opinions.
A recent study out of Finland showed no benefit to choosing surgery over physical therapy in the management of patients with small rotator cuff tears.
Your take home message:
IF you have a degenerative tear of your rotator cuff, and did not suffer a significant injury, then it is likely safe and prudent to consider physical therapy as your primary treatment.
Disclaimer: this information is for your education and should not be considered medical advice regarding diagnosis or treatment recommendations. Some links on this page may be affiliate links. Read the full disclaimer.
Dr. Luks…thanks for what and how you write. It is patient-centric, to be sure, and i read your very useful mailings regularly (I’m an internist, mainly gastroenterology).
As for rotator cuff injury, that was a year ago, starting abruptly in my dominant arm abruptly after a bit of overly ambitious work with weights in the local gym (I’m age 77). An Orthopedic Surgeon recommended surgery, which I declined once learning that my arm would be in a sling for a number of weeks/months, and any accident while driving may not be covered by my insurance. These consequential but seemingly trivial post-operative problems are worth mentioning as one ponders the wisdom of elective surgical therapy, and I recommend them for your writings.
Very slowly I’ve had 80+ recovery in function, and a bit of discomfort and weakness when putting on a coat.
Thanks again for your valuable service in demystifying any number of orthopedic matters.
Andrew Plaut
Hi Andrew … Thank you very much for stopping by … and I really appreciate your comments !
Good luck with your recovery
Howard
Hi…I am a 76 year old female in relatively excellent condition however I do seem to have a number of aches and pains including two sore shoulders. My left one has been slightly sore for a while my right one started hurting after I slipped and fell back and caught myself with my arm. It basically hurts when I raise it so I do it very carefully. I have not seen a doctor and I know I’m not in enough pain to need surgery. What do you suggest. I live in Napkes Fl.
If a fall worsened your discomfort then it is worth seeing a shoulder doc.
Good Luck
Howard Luks
Hi I am 61 yrs and am very active. I have a full tear of the supraspinatus and a torn bicep tendon in my left shoulder. First I developed Frozen Shoulder in both shoulders and did not realize I should take it easy, so I kept golfing which tore it. My doctor said I should have surgery because I would lose the ability to raise my arm and I should do it soon because the tendon would start to recede. My question is, is it OK to have surgery while I still have Frozen Shoulder?
Second question, do have any thoughts on helping thaw Frozen Shoulder?
Hi Dan …
As you likely read in the post surgery is not the only answer for this type of tear… unfortunately there is no scientific literature to support what your surgeon is telling you. Second and perhaps MOST important… a rotator cuff repair is a stiffening procedure. That means that repairing someone’s rotator cuff has the chance of causing stiffness. It is a very bad idea to consider fixing a rotator cuff when the patient already has a frozen shoulder. The stiffness after that surgery could be significant… and very hard to overcome with therapy.
Good Luck with your decision making… time for another sit down with your doc or a second opinion.
Howard Luks
Thank you for your quick response! One quick question, do I have time to wait for the frozen shoulder to subside. He said the tendon can recede beyond repair. I am going to gat a second opinion Again thanks
Some tendons will retract… some may not. Some may atrophy, some may not. That’s why the American Academy of Ortho Surgeons fails to recommend surgery as initial treatment for small degenerative rotator cuff tear. There’s simply no research to support that recommendation. Follow the links to the articles I posted to help you with your research. You must restore motion before considering a repair… otherwise your stiffness could be profound.
Good Luck
I really value your input on this it has put me in a new direction. I got a second opinion and this Dr said that it would be risky – and might lead to more stiffness – to do the surgery while the shoulder is frozen. He said because time is not in my favor on the complete tendon tear he advises to do arthroscopic release of the frozen shoulder, then let that heal and get my range of motion back in therapy, then do the rotator cuff surgery. Again thanks for the candid information.
Good Luck Dan … this will be a long road. Happy Holidays
Dr. Luks,
I appreciate you having this site and I have been doing extensive research regarding this issue. iam a 52 year old RN that was a pedestrian hit by a car, landing on my dominant arm and shoulder. Just this week, they determined via MRI that I have a complete tear of the supraspinaus tendon. I was interested in your comment that a traumatic injury usually requires surgery. I am hesitant to have surgery, but would like to hear your rationale to support the surgery. My ortho did not stress surgery over the PT route. Thank you for your time.
HI Norma .. .
Most all shoulder surgeons recommend a repair for acute tears. That is because the muscle/tendon was “normal” prior to the incident. In cases of attritional or degenerative tears the tissue is not normal and simply wears away. IN those situations PT has been shown to be as effective as surgery for small tears.
If you have no atrophy or fatty degeneration of the muscle, and the tendon appears healthy and thick then surgery is an option… but not the only option. These are just recommendations… not absolutes :-)
I just had my exam with my Doc and the MRI and he says I have a small tear (I’m 62) with a bone spur.
He says it will not heal by itself and that I “must” have surgery since it will get worse and then I will need a shoulder replacement.
I’m scared and I don’t have a lot of money and I have a high deductible BCBS plan that pay nothing.
Your thoughts?
Hi Al …
Bone spurs are not the source of rotator cuff tears… that was proven quite a while ago. Some tears will become larger, some may not. Even the American Academy of Orthopedic Surgeons doesn’t recommend surgery for small degenerative tears. The average time frame that the recent science shows it takes for a tear to become larger is 2 year. In addition… some tears do not heal and could re-tear anyway. It’s a complicated topic. I hope this helps stimulate a conversation with your doc or a second opinion doc.
Thank you for your response:
Will a tear get worse over time? I would think it would. Then what?
I forgot to mention that they say it is a “full thicknes” tear and they plan to drill in pins, Ugh. Does all this sound consistant to you? I want my shoulder to be as “normal” as possible and will opt for surgery if the outcome over the next 20 years is better than NOT. I know it is a very educated guess, but with what limited information, is it YES or NO?
Sorry AL … without examining you and seeing your studies I can not comment more specifically on your case.
Dr Luks
I’m 63 female, gym 5x a week, golfer. MRI – full thickness defect in cuff measures approx 1cm AP by 9 mm medial to lateral. Tendinopathy in 3 of the 4. My Dr said I need rotator cuff surgery, I’m do not want it – frightened. Will get 2nd opinion from surgeon in the same practice (16 Ortho docs). Is it worth the try to try PT for at least 4 wks to see how that works out. Thank you for your time.
The literature is pretty clear in this area… PT has been shown to be nearly as effective as surgery for degenerative rotator cuff disease – and small tears.
I m a young 69 years old and very physically active. I have a partial tear and I have been dealing with this for 2 years. Steroid shot was no help. I just started physical therapy, but as yet no relief. I can manage pain except a night when it is about a 9. I get very little sleep.
How long should I expect to do physical therapy and take my Etodolac before I see any results. Should I refrain from physical activities and rest shoulder or keep it moving. I’m very confused whether to have surgery or keep plugging along with this physical therapy. Anything that can help the nights. I can manage if I could get some relief there
I usually give the therapy a month to work. If it is unsuccessful you can look into the Rotation Medical technology which appears to reverse the rotator cuff degeneration and heal partial tears. This is far different then just going in and “cleaning out” the shoulder.
Good Luck
This is so confusing because my doctor is going straight with surgery for a small tear of the labrum and a 6mm tear of the suprspinatus. He thinks at 47 I should. I work out (not really heaving lifting) and don’t want to put myself though this. How can physical therapy benefit such a thing?
you havent mentioned if you have pain or whether or not PT has been of benefit.
I haven’t had PT. My doctor just said surgery. I am only in pain when I move my arm certain ways: Behind my back, reaching straight to the side and up. It boils down to risking making it worse or getting it done while it is considered a small tear. I don’t understand how PT helps. I excercise my arms and can do some shoulder work outs (dumbell rows) but the tear is still there. If I leave it won’t I just end up ruining my shoulder when I am too old to have the surgery done?
Hi Doc! I’m a 40 year old healthy male. I had a traumatic fall in July of 15. Its now 10/15 and I recently visited a surgeon for a consult. My MRI results reported 2 full thickness tears and some bony bankart leisions( I think I’m spelling it correctly) anyway, the surgeon told me, after a 2 minute exam, that the radiologist was exaggerating the report and I didn’t have a lot of damage despite my chronic pain. He said I had too much strength to have that much damage. Perhaps he didn’t consider that I was a 6’5 350 lb logger? But I’m no sissy by any means. Should I seek a second opinion or should I follow through with his injections and pt?
Hi Jamie… sounds like a second opinion might help you sort out your options.
Dear Doc,
I am 45 male Asian with 50% thickness and 1.6cm partial tear. There is a bone spur. Should I go for surgery? If not will the tear heal by itself? If surgery can we just remove the bone spur? Thank you.
This is a very very very common finding on the MRI of a middle aged man .. or woman. If physical therapy fails to improve your pain AND you feel that your quality of life is poor then surgery is an option. The theory that bone spurs are the cause of shoulder pain died many years ago ! Your rotator cuff is the likely cause of your pain. Read my posts on partial rotator cuff tears and rotator cuff tendinosis.
Hi, I am a 27 ear old man weight lift 5x times a week. I suffered a rotator cuff tear about 6 months ago. I got an MRi and it revealed I had partial tear of my supraspintious with bursitis. I have been doing PT for about 5 months and have seen a huge difference in my range of motion. However, I do not have complete range of motion and experience pain whenever I lift anything above my head. is it possible the PT has reached its peak and surgery will be the only true way to complete regain full movement? Thank you for your time.
It’s possible … but it’s also possible that surgery can make you worse off :-( Not common, but it does happen. The more focused and limited our upside is … or the more lofty our goals are, the more likely that you may not be pleased with the results of surgery.
Timothy I am the same boat as you. How are you doing today? Did u have the surgery
Thank you for your quick response and insight. If i do get surgery will the 4 months of pt have any impact on recovery time
What a great website! Thanks for using your valuable time to send helpful info to all of us strangers across the internet. It is very generous, given that the vast majority of readers are in other states and not able to benefit you directly in return.
I am a 55 year old woman, in perfect health and physical form with a darned rotator cuff tear. It came out of nowhere and it’s maddening!! I had a cortisone shot a couple weeks ago to no effect. I just started PT yesterday and am hoping to regain full range of motion. I only have pain when I reach behind my back or reach for a very high shelf, so I definitely wouldn’t resort to surgery.
I’m relieved to see that you believe PT really works (at this point, I find it sort of hard to believe). I will give it a month (2 x per week) and will keep my fingers crossed. Thanks again!! You’re a real mensch!
:-) Thank you… and good luck with your rotator cuff rehab.
Hi. I have a complete partial tear rotator cuff injury from a car accident 2 and half years ago. Doctors have known about the tear for the past two years. Between tendonitis, complete atrophy of every muscle, frequent dislocations,winged scapula, scar tissue and nerve damage; I have been in physiotherapy for the last seven months. Winged scapula, most of the nerves have come back, regaining muscle, has improved, but the tendon is still inflamed, and the deep muscle pain is still very painful. I have seen 2 surgeons, but no one wants to operate to find out if there is something more going on. With everything my 55 year old shoulder has been through, I don’t know where to do go next to find help with my problems. Any suggestions would be most helpful?
You may need to see a shoulder specialist at an academic center… e.g.. JP Warner at Harvard, Brian Cole in Chicago, Jeff Abrams in NJ, Buddy Savoie in New Orleans, Steve Burkhart in TX, etc.
Hello, I would appreciate your thoughts.. I am a 62 year old female and recently caught myself with my arm on stair and heard a tear in bicep area. This brought me to doctor. After MRI, four large tears are shown, some full thickness which they couldn’t tell if they were old or newer, due to this event. I had had issues with this shoulder for many years and am very active, my thoughts, it’s old and the bicep new.
They want to do surgery asap saying time is very important incase it’s newwer…and my gut says no surgery. Is there a decent chance, with PT and being mindful, and of course not falling on it..that it won’t get worse, and may stabalize well enough to go on with life? I understand they don’t heal themselves.. just equally concerned with surgery and no guarentees. Thank you..Pam
A good shoulder doc can usually tell if a large tear is acute or chronic. It’s impossible for me to speculate which treatment is right for you without seeing you and the scan
Dr. Luks,
I am a 61 years old male. I have a full thickness tear measuring 1.1 x 1 cm in the distal and anterior supraspinatus tendon. Teres minor tendon is intact. I also have mild infraspinatus tendinopathy and moderate subscapularis tendinopathy, and a superior labral tear. I believe the immediate cause of at least some of these was playing golf. I felt a sharp pain on my first drive at the course. I did this on a Saturday. I could not raise my right arm in an outward fashion to even parallel to the ground. I got maybe a little more than half way there. However, when the arm was at rest, there was little to no pain. Minor movements produced minor twinges. Sharp movements sometimes produced a little more pain. Two days later, I received a cortisone shot (and had the MRI). For two more days, there was no change. Then one evening, I realized my right arm was above my head while putting on a shirt. I could raise it straight up. I could raise it in an outward motion above my head. There was some slight discomfort, but not a lot. That is how it is now. My orthopedist indicated physical therapy is the next step, but I believe (based on previous visits for the left shoulder) that he expects to perform surgery. Honestly, I am fine with the way the arm is right now, especially if a few more cortisone shots over time can keep it this way. More than that, my wife and I will be moving in 8 months, and there are all kinds of projects involving physical labor that need to be done. Lastly, I know I could play golf right now the way I feel, and I want to be able to do that for at least the next 5-7 years. I am trying to decide if it would be a mistake to decline surgery. I’d appreciate your thoughts and comments.
I am a very active 52 year old female. By very active, I train and compete in half and full ironman triathlons. About 5 weeks ago, I had a fall that resulted in a high-grade partial tear,of my rotator cuff in my dominant arm. Since I had a bucket list race 4 weeks out, the doctor gave me a cortisone shot and referred me for PT. And, we’d discuss complete treatment after he had the written MRI and my race. I got thru the race (and swim) but overused my arm dragging my suitcase and bike box across continents. I had the follow-up,today and based on my activity level, he wants me to have surgery to repair it. Based on what I’ve read, the acute nature of my injury suggests surgery is appropriate. The recovery will have a huge impact on my life and activity since I will have to time it around upcoming business travel and cancel my Ironman race this fall. What do you think?
There’s not a lot of literature on the treatment of acute partial tears. Besides, given your lifestyle and age, you could have had that tear all along .. but the injury, pain and subsequent MRI simply found it. MRIs of normal individuals with no pain find a lot of partial and full rotator cuff tears after we reach our 50s and 60s.
There is no general consensus on how to treat these injuries, but most of us would likely observe it and follow you if you are currently able to remain competitive. Can these tears become larger with time? yes… but it can take years. Also, there is very little proof that operating now prevents progression of rotator cuff disease. You do not have an easy decision before you… but before you decide to spend a 6-12 month chunk of your life on the sidelines I would consider a few more opinions.
Hi Doctor, a very interesting piece to read indeed. I’m a 41 year old Paramedic and about 3 months ago suffered a right shoulder injury whilst stretching overhead (felt shrp pain and experienced a ‘crack or snap’). After a few weeks of PT, my condition worsened and after 8 weeks had an MRI. Degenerative changes were noted but nothing else. I’m still in severe pain especially at night and cannot abduct my arm greater than about 20 or 30 degrees. What should I be saying to my doctor as I currently cannot work like this and need to get back?
Look up the posts on rotator cuff tendinosis
Your information is invaluable . I am a 66-year-old woman in excellent health and have a full thickness .8 cm tear in my rotator cuff . The first service and I Saul said I had to have immediate surgery or it would tear more . this was a gradual onset tear. Having difficulty metabolizing drawings I became fearful of the pain medication given after the surgery and sought a second opinion . He second surgeon was from a big city Hospital and said I did not need surgery only physical therapy and 90% of patients with this small the tear will recuperate even with it being a full tissue tear .
He gave me a script for a one time consult with a physical therapist to teach me the exercises correctly . Fortunately I went to a therapist that changed everything he had written down and pull and yanked on my shoulder and I started to be in more pain then when I initially went .
I called back surgeons office and was given another script to see a much better therapist . Is it possible the first therapist could have ripped my tear more? I was told not to do any exercises until seeing the next therapist so I have been icing it and hoping that the pain will go away before my next encounter with PT .
Any input that you could give would be so much appreciate it .
Unlikely that they injured it further. And your second surgeon sounds like the better of the two :-) Surgery for these very small degenerative tears is rarely indicated.
Thank you, Dr. Luks,
Please forgive all the typos I was using my microphone .
Your answer made my day !
I crashed my bicycle and landed on my right arm. I immediately had severe pain in my upper arm just below the shoulder. I went to the ER and they took an xray. Said it wasn’t broke and sent me home. That was 2 months ago. I am still having a lot of pain and popping. When it pops it REALLY hurts. My doctor has me doing physical therapy. Therapy seems to be making it more painful. Do you think I have a tear somewhere
It’s possible. A good exam and perhaps an MRI will be useful
Hello Doctor Luks. I’m 50 year old male in good health and very active. I had a rotator cuff repair medium size in 2013. Six months later no pain and most of motion restored. Very satisfied. My original rupture was traumatic and once again I tore it up by pulling someone into my boat. Same tear same place same amount of pain. Lots of discomfort. I tried therapy prior to the first surgery which went on for 6 months and just seemed to agrevate the situation. Looking for options …. Is there any chance a second surgery will fix it for good?
Sadly… no. Revision surgery is possible, but many advanced shoulder docs would consider a graft or augmentation since the results of revision surgery tend to be inferior. As I mention often, rotator cuff tears are often the result of rotator cuff disease. Our rotator cuff wears out over time, like your favorite pair of jeans. Therefore, over time, and as the degeneration progresses, the chance of it tearing again increases too.
Hi – I have read your blog with great interest. I am a 56 year old female with shoulder pain in my non-dominant shoulder. I have a decent amount of arthritis in other parts of my body, but I am not sure what exactly is going on with my shoulder. Although I did not have an acute injury, I do tend to exert myself beyond what is practical for a woman my age (landscaping work, moving docks in and out of water, etc.). After two months of chronic pain, I mentioned the situation to my doctor during a routine physical. I asked if he could refer me to PT, as I have great faith in the benefits from past experience with other issues. The problem is, after six weeks of therapy, I see no improvement. I actually may even be feeling a little worse. I am certain that I have degenerative changes, and probably multiple small tears much like my right shoulder. However, I wonder if maybe something else is going on. My pain is most evident whilst pulling blankets up over and across my body while lying on my right side, or trying to switch from laying on my right side to my left. Also, swinging a car door closed behind me while walking away has proven excruciating. A few other tweaking moments have occurred, but overall I experience a fairly constant dull ache. And, my bicep muscle seems to always feel tender and “knotted” in several places. Do these symptoms seem to indicate a specific malady to you? I suppose obtaining an MRI would be most helpful at this point, but I was just curious about your opinion based on my symptoms, and the fact that Physical Therapy has not been helpful. Also, I do take about 300mg of Tramadol each day for arthritis pain, and I would tend to think that would help the pain in my shoulder – maybe it has! Maybe I would be even worse off without it.
HI Dr. Luks
Thank you for making all this information available!!! I just had an MRI done and have found out that I have a bone spur and a rotator cuff tear. I have really no reason for it other than possibly from lifting weights. I t had been hurting for a while but original x-ray didn’t show anything. I’m now looking into therapy versus surgery as my Dr. has recommended. I’m still confused how therapy will help but will definitely look into it. I happen to remember your name as you were friends in high school with my sister!! Yours was the first sight I clicked on and couldn’t believe it!! Thanks again for all the wonderful info!!
Too funny… tell Carolyn I say hi :-)
PT is usually the way to go with most small degenerative rotator cuff tears. They are very common at our age :-( But thankfully most people do not have pain. If PT, etc does not improve your quality of life then surgery is a consideration.
Be well !
HL
Hi Dr. Luks, My doctor is recommending surgery for my left shoulder , after my MRI showed a 10 by 11-mm complete tear of the supraspinatus at the insertion with proximal tendinopathy . There is also a 5-mm cyst at the humeral head, diffuse capsular thickening and degenerative tear of the superior labrum with bicep tendinopathy. I am a 59 year old female and am experiencing pain (mostly at night ) in my left bicep. I have pretty good range of motion but the pain is waking me up at night. My shoulder has been achy for a couple of years already, did PT last year, but things seem to be getting worse. Is it time for surgery? I really appreciate any advice and your posts are invaluable.
HI Lynn… I’m glad the posts are helping you. I can not guide you though… that’s between you and your doc.
Good luck !
I fell playing indoor soccer and have a near complete full thickness tear of my supraspinatus tendon (90%). I am 43, very active with a physical job (lifting, heavy work, repetitive work). I am otherwise fit and strong and want to regain full strength and ROM in my shoulder. Is it worth trying PT or is surgery indicated considering this was caused by a traumatic event? Have to wait 3 weeks to see a surgeon, on ‘light duties’ at work and taking pain killers and anti-inflammatories to get by in the meantime.
As I write about in other posts, if you have an acute (recent), traumatic rotator cuff tear, it seems that the best option is to fix it.
Hi Doc,
I have read all your articles on rotator cuff tear treatment. Really impressed by your advise to each and everyone on the comment section.
My MIL is 64 year old and been suffering from rotator cuff tear. She doesn’t remember of any incident that might have caused this tear but it is guess that is a result of aging. The below is the description from her MRI scan. Could you please have a look at it and let me know if is it possible to go for physiotherapy.
“Mild supraspinatus tendinosis with small 3mm partial tear of the anterior fibres. Synovial thickening in the rotator internal – suggestive of adhesive capsulitis. subacromial-subdeltoid bursitis ”
Thanks in advance for the help.
Shruti
No doubt .. PT should benefit her. Those are not concerning tears. The adhesive capsulitis or frozen shoulder needs to be addressed with PT.
Hi Dr. Luks;
I’m 58 yrs old and I had a motorcycle accident on August 6th, 2016. I sustained a Distal Humerus Fracture of the Elbow. I now have plates, rod and screws in the humerus as per surgical repair. I started PT approximately 6 weeks ago (2x a week) to try and regain motion to the elbow. I also sustained loss of feeling in both my ring and pinky fingers with minimal movement in each. The recovery seems very slow in those areas and throughout this period I have been experiencing severe shoulder pain (which the surgeon said was a rotator cuff tear) and extreme “cracking and/or popping” across the entire shoulder region including the blade, acromion, clavicle projecting towards the back neck area. The pain has worsened to the point where I cannot sleep and have much discomfort throughout the day. I also seem to be stiffer after therapy (I do ice and heat treat after and throughout the day)The therapist believes the cracking and popping are just due to scar tissue as is the pain and feels I need to up therapy to 3x a week. Any thoughts and/or advice would be most appreciated as I can’t seem to find any relief…
Thank you for your help.
Doug
Sounds like your shoulder needs to be evaluated further … I would consider a second opinion.
Dr. Howard Luks, Thank you for your article. I am a physiotherapy that works in Toronto Canada and have been sharing your article with my patients. I have a special interest in shoulders and my caseload has many shoulder injuries (including degenerative rotator cuff tears). From what I understand, 80% or more of the population over 65yoa will have a degenerative rotator cuff tear and many of them will not even know it. Obviously some will experience pain and dysfunction while others will not and this really intrigued me. I have been putting the pieces together over the years (through clinical practice and not research) and noticed that many patients that experience pain also have co-existing cervical spine or CT junction dysfunction. I noticed that many of my patients have excessive movement through C5 (where they hinge) and this may be affecting the C5 nerve root causing changes in the conduction to the rotator cuff (supra and infrapsinatus). I also recently got certified in GUNN IMS (a dry needling technique developed by Dr. Chan Gunn) that explores the relationship with neuropathic dysfunction and myofascial pain syndromes including tendonopathies. I have been getting great results with treatment and it further validates my finding that the neck often plays a role in the population of degenerative rotator cuff pathology that has a painful presentation. Thanks again for sharing your article and for supporting what we physiotherapists do.
Dr. Luks, I am a 65 year old woman, active for my age but not an athlete by any means. I have been having soreness and sometimes sharp pains in my shoulder and bicep area for several months. Three weeks ago,while raising my arms, I felt it catch or crackle and it was followed by an incredible amount of pain. As if my right arm from the shoulder upwards was electrified and the pain lasted three days despite constant icing. MRI a week later showed two tears, one full thickness of the supraspinatus and dangling just above it a bone spur. Surgeon says the spur is responsible for the recent tear and surgery would take care of the spur as well as the tear. Arm has little strength and very little range of motion unless I want to bring on the pain. Not sure how I can endure PT so I am wondering if surgery is my only way out.
So… the spur as a cause of tear concept is not longer considered valid by most surgeons. Aside from that, when we treat these degenerative tears we often place an injection into the shoulder to enable folks to get into therapy with less inflammation and pain.
Good luck
Hi Dr. Luks
I am hoping for an opinion as to whether or not I should have surgery or stick with PT. I own a small gymnastics company and recently partially tore one of my rotator cuffs and labra and something with my bicep. It hurts. I was spotting a kid doing back tucks and he was not going to make it and his full weight was on my arm and I felt a ripping sensation in my bicep. I figured it was a pulled muscle and I rested it for a few days. It was a little painful in my shoulder and arm but not terrible. This was 2 months ago. I have recently had a MRI because it is going downhill quickly. My shoulder pops here and there and feels loose and crinkly. It is getting harder to brush my hair and drive and reach up to get things. I have not done and handstands or cartwheels for weeks and this is my job and passion. I started PT last week and hope to continue for a few weeks before making a decision. A couple of the PT exercises are painful to the point of crying.
Continue? Surgery? What do you think? Will surgery completely heal it to the point of me being able to do gymnastics and fully spot kids again?
Your input is greatly appreciated.
Regards,
Kerry
HI Kerry …
Obviously without examining you it’s hard to say. The pain from many of these shoulder issues you mention will subside over time. We can inject various structures we feel may be causing your pain and that can improve the pain so the PT can work better.
Good luck
Hello Dr. Luks,
4 weeks ago I was in a motorcycle accident. I dislocated my left shoulder. I went to the ER x-rays showed no evidence of breaks/fractures. I literally just got an MRI yesterday which would make it 4 weeks later. Since the accident I didn’t use or move it for the first 2.5 weeks. After which I started to rehab it for range of motion. I am an active MMA fighter, Triathlete, etc. Very flexible and do a lot of acrobatic things (cartwheels handstands etc…)I normally heal rather quickly though I am not certain about rotator cuff tears (supraspinatus tendon). I still am having an Ortho look at it but the immediate physician stated it appeared to be a high grade tear. Is it possible to rehab without surgery? I am no stranger to pain and rehab and would be up for the fight. Is this something that is possible in your experience to have a full recovery without surgery and with dedicated rehab? Thus far I have gained 30% more mobility since started.
thank you so much for your time,
Josh
I assume you mean a high grade partial tear? We approach traumatic FULL thickness tears aggressively since they heal well. Many shoulder docs would agree that small partial tears can be managed non-surgically… but need to be re-imaged in 6-12 months to be sure the tear isn’t getting larger. https://www.howardluksmd.com/orthopedic-social-media/surgery-traumatic-rotator-cuff-tears-expert-series/
After reading ALL your blog, I don’t want to be repetitious, however, I’m a 74 year old healthy, flexible, youngish female who loves to golf, garden, and generally do physical work which keeps me in shape. No problems whatever, now or in the past, with joints, arthritis, etc. 3 months ago, I tripped over a restaurant’s loose mat, shot through their foyer onto hard cement on my right shoulder/arm/side. Resulted in a tendon tear in my shoulder with some form of tendonosis (sp?) in my arm muscle.. Did PT for past 2 months but pain prevented me from doing it to the fullest. ROM seems to be improving very slowly, but pain is the same day and night with shooting pain into my arm even when sitting quietly. Generally speaking, and knowing you haven’t examined me, is there any chance this will improve over time or is this my fate for the rest of my days? I am very afraid of frozen shoulder because PT isn’t working. Also, should I even push through the pain to do PT (concerned that it will make this arm situation worse); perhaps not even being able to golf again.
Sorry that you are having such a tough time. There are too many variables that go into surgical decision making — therefore I really can’t comment if it would be appropriate for you to consider.
Good Luck.
Thank you so much for your wise counsel and understanding. Perhaps you can read into this that I really want the ROM that I had prior to the accident and I’m guessing that may not be possible (even with surgery or long term PT). Golf is my special pleasure in life along with just feeling able to enjoy the many non-sporty activities my daily life provides. Having said all this, in your expert opinion, would it be foolish of me to even try golfing again this season? Our season here in the Toronto area is short and Dues payment is ahead; if this will delay rehab or further increase the tear, I’ll restrain myself….hard to do living on a golf course and playing 4 to 5 times a week. If I do try on one occasion and play through the pain to see “how it goes” is the likelihood of further damage a possibility? You have seen so many of these injuries and the results of over-doing; your opinion is so very much appreciated. What a wonderful blog. You provided me the opportunity to vent even if you can’t provide a solution with so little information and a first hand medical examination. Thank you.
I had a fall six months ago and landed directly on my shoulder. Immediate and significant pain in the shoulder. After an injection which did not help had an MRI which revealed large full thickness tear. Pain at night when sleeping on shoulder but not unbearable. I have weakness and tenderness when doing shoulder presses. I still have excellent range of motion. Shoulder is tender after golf. Orthopedic surgeon recommends surgery. He states that shoulder will increasing become unstable and increase arthritic condition which is seen on X-ray and MRI. At age 65, do you feel that repair of tear is recommended course of treatment? Thanks.
Hi William… AS you know I cannot offer a formal treatment recommendation in this format.
Treatment options are based upon the cause of the tear, the quality of the tissue, the presence or absence of retraction and “fatty atrophy” and your examination.
In general the shoulder community favors fixing traumatic tears vs degenerative tears. They also prefer to fix (sooner rather than later) large tears that cause weakness and pain despite PT, etc. Only the person looking at you and your MRI study can determine the repairability of your tissue and thus the likelihood of a successful repair.
Perhaps you have more things to discuss with your Orthopedist now?
HJL
Hello Dr. Luks,
I am a 43 year old male and have been in Martial Arts for over 35 years and have my own school. In 2004 I had a martial art injury to my right shoulder and put it off until now because I’ve started to have more pain with range of motion. I had an MRI a few day’s ago and my results were Rotator Cuff: Supraspinatus tendon intrasubstance tear at its
footprint involves 40% thickness and extends 1 cm in the anterior
posterior dimension without significant tendon retraction.
Infraspinatus tendinopathy is present. No supraspinatus or
infraspinatus muscle atrophy is present. Minimal teres minor muscle
atrophy and edema are present.
AC Joint: Type I acromion is laterally tilted with AC joint
hypertrophic changes that slightly indent upon the supraspinatus
myotendinous junction.
Labrum and Biceps Tendon: Long head of biceps tendinopathy of the
intraarticular segment is present. No labral tear is identified.
1. Right supraspinatus tendon low-grade partial intrasubstance tear.
2. Infraspinatus tendinopathy.
3. Early quadrilateral space syndrome.
4. Long head of biceps tendinopathy.
I have tried everything for pain including therapy, 800mg of ibuprophen and it hasn’t helped. Do you think the right thing at this point be to have surgery which I have not seen a shoulder specialist yet but I do have an appointment to see one in a couple of weeks
What surgery are you contemplating? There are a few different potential pain generators on that MRI. And that is a fairly typical MRI for an active 40 or 50 something. Before surgery it’s important to know which problem is bothering you, so we know what needs to be addressed. — e.g.. biceps, cuff, or quad space.
After a snow skiing accident, I’m scheduled for high grade rotator cuff repair, proximal bicep tear repair because of full rupture (tenodesis), and labral repair (doctor said also going to remove non-symptomatic bone spur ‘just in case’). Doc’s PA said no motion whatsoever of the arm (including passive and pendulums) for a minimum of 8 weeks (asked me not to shower or change shirt for first 5 days so the arm will stay totally immobilized), passive ROM of motion starting with initial physical therapy weeks 8-16, and progressing to light weight (no more than 1-2 pounds) for 4-8 months. Won’t release me to drive for minimum of 6 months. Also said my tennis, cycling and snow skiing days are permanently over because even a slight fall would cause the repairs to fail. After I saw the doc, but before I did the pre-op visit, my understanding of the recovery time was about 2/3 of what the PA said. And, seeing as I’m a very healthy (zero medical conditions), active person, the limitations on future activities are distressing. When I questioned the PA, he said that the limitations (also indicated that I’d only regain about 70% of pre-op strength and ROM) on activities and recovery were based on age and gender (I’m an extremely active female, 56, healthy weight, non-smoking and lift weights 4 times a week as well as run a couple of days a week). I currently have full (although painful) ROM of motion since the injury was less than 3 weeks again. No previous injury to the shoulder or bicep. The PA said a limitation of ever lifting more than 10 pounds with the repaired bicep was something I’d have to adhere to. Are these limitations and the schedule for rehab common? Not sure what to do since this doc is highly recommended and also takes my insurance. Second opinion doctor said just to live with the injury and accept limitations of the shoulder and bicep since I’m over 50. Guess I’m alarmed because the PA said I’d also have to have separate PT for my hand, elbow, and wrist because I shouldn’t use it at all for 8 weeks. Asked if I could move the wrist and fingers while using a squeeze ball during recovery if I didn’t move the arm or shoulder (will be in a sling) and he said absolutely not. Since this is my dominant side, it’s quite challenging. The PA also said to me that “People say that they’ll do PT and be compliant, but nobody is. That’s why you won’t recover fully”. The doctor had indicated that this surgery is not anything unusual for a bicep rupture and rotator cuff tear, so I guess I’m confused as to why his PA is taking a different stance on recovery and restrictions. Also not sure why I’m not allowed to move hand and wrist passively and/or without any weight load. Doc didn’t mention it during my visit and I didn’t injure hand, forearm or wrist. I won’t see that doctor until 16 weeks (interim visits will be with his PA with the first one at 6 weeks).
Well … that does seem a bit extreme… doesn’t it. I would talk with the surgeon… or perhaps a second opinion.
Thank you for your helpful comment! Second opinion was a recommendation of living with injury and limited range of motion and strength. Was hoping to continue active life style. Trying to find 3rd opinion before surgery on Thursday (insurance is an issue). Current surgeon’s office said need to talk to PA instead of doc. PA said no need to schedule time to talk with surgeon. PA acting as gatekeeper and staff will not let me talk to or make doc appointment. Extremely frustrating. My husband and I have had friends recover from rotator cuff surgery fully and have returned to all activities. Very worried and we’ve decided that there may be a gender issue with the PA after an enlightening conversation with a nurse over phone. PA is new and doc is letting him rework existing protocols as he sees fit. Have friend who is retired physical therapist that has worked with this surgeon before and said he’s good and his patients recover well. Friend is concerned with recovery protocol. PA has even recommended ‘no activity that makes me break a sweat’ for six months including no walking or riding stationary bike for exercise (I asked). Not sure what to do since bicep repair is recommended within three weeks of injury and am approaching that time frame.
Imagine how hard it might be to talk with the surgeon after the surgery ??? idk… but you need to be comfortable with the situation before surgery.
Great point! At this point, delay may be necessary until I do feel comfortable. Your comment made me think things through again. Too bad you’re not close enough for me to make an appointment to see you. :-)
My husband (78 years old) had a fall and landed on his left shoulder a month ago. MRI revealed a small tear. We were
told to do 2 things physical therapy and cortisone shot
He cannot raise his arm and if he attempts to do it he gets severe pain. What do you suggest shall he have the shot
first or physical therapy first? Thank you Dr. Luks
The PT is the most important… but the injection can be effective for many to diminish the pain. Not essential but often helpful .
Hi Dr. Luks
I enjoyed your articles and have a ? for you. I fell in November tripped on the tie out while putting my dog on it and flew and fell on my RHS on brick pavers. My MRI shows supraspinatus tendon intermediate grade partial thickness intrasubstsnce tear of musculotendinous junction insertion.
On the infraspinatus tendon I have near complete tear of insertion of tendon of numeral head with few residually intact bursal surface fibers. Went to two surgeons in MI. First one definitely surgery. 2nd one tried PT. Went around 14 times. Dr thought mobility not fast enough and now I scheduled surgery in April. Wondering if should get a 3rd opinion or just do it. Any thoughts?
Sorry Doreen ..I cannot offer specific treatment advice. But… If PT does not improve someone’s pain and confidence in their shoulder then surgery can become one of the options to consider.
Hi Dr Luks I don’t have pain except when I try to reach something or move my arm too much. Maybe I need more PT. in your professional opinion have you ever had a patient with my MRI results that returned to full mobility with PT?
Thank you. Doreen
Hi Dr. Luks,
I’ve read a number of your articles on rotator cuffs and labrum tears; they have been very informative- thank you!
My story/inquiry: I fell skiing Feb 4, my arm was outstretched and pulled outward as I rolled down this huge hill (I did not catch myself on my hand). Initially it was not very painful but within the first week, got much worse. I sought care February 12 with an orthopedist and initiated PT the next day. About 4 weeks later (once inflammation was down) I got an MRI-arhtrogram that revealed a partial thickness tear in my supraspinatus, another partial thickness tear in my subscapularis, and a detached labrum (anterior to posterior) that my physician is saying may be anatomically normal for me. I should also mention I was a swimmer and rower in high school and had trouble with the same shoulder. I had an MRI-A done then as well and it was determined I had a bad case of bursitis, but no sort of tear or labrum issue.
It is now April 7th. I have been going to PT 2x/week, taking diclofenac BID, and icing my joint throughout the day. To-date, I have received 2 hydrocortisone injections that help minimally.
My pain at rest has lessened, though recently has been coming on more frequently in strong, intermittent waves which is new (I attribute this to increasingly difficult exercises in PT). My ROM has increased since I initially injured myself, but when I extend my arm in front of myself at shoulder height, I have significant pain. At shoulder height, if I move my shoulder joint around (it feels like something inside is catching/pinching/in the way), I am able to achieve full ROM– coming back down I have to do the same (a painful wiggle dance when reaching shoulder level). The same is applicable when I raise my shoulder to the side but to a much lesser extent. Any rotation is painful and causes a feeling of instability as well as popping/catching/pinching.
I have been out of work since Februrary 10th- I am a Neonatal ICU nurse and currently am not able to work with my shoulder as it is.
My physician’s plan of care is to continue with PT bi-weekly and steroid injections PRN. He said the next step would be to consider a novocaine injection.
My questions:
(1) Does this plan of care seem reasonable to you or do you think I should seek out a second opinion?
(2) I know that partial tears can be treated with PT, but I am questioning the diagnosis of an anatomically normal detached labrum as it was not detached on my MRI in ~2005. Does this seem like a sound consensus that it is anatomically normal?
(3) At what point would one consider surgery in my case? It has been 8, almost 9 weeks and I am still unable to work. While there has been progress in some areas, some movements have remained just as painful (raising and bringing my shoulder down when shoulder height is reached and with rotation).
I truly appreciate your knowledge, time, and guidance in the matter.
Thanks in advance :)
Sorry… I simply can not comment on specific cases… I hope your shoulder pain starts to improve soon. It’s not unusual for it to take a number of months.
I am a 75 year old woman with a “full-thickness complete retracted supraspinatus tear probably extending into the fibers of infraspinatus. Surgical consultation is recommended.” I was referred to an orthopedic surgeon, waited 2 months for an MRI and then 2 months to see the surgeon who was an hours drive away. My age etc. was very clear on the referral but he announced after a consultation that he never did surgery on anyone over 60 because it would likely fail. I have been seeing physio for about 2 months and have exercises to do. But it is not really better. What would you do? Is he right?
There are other options… perhaps another opinion would be worthwhile.
Hi Dr. Luks,
Having seen my x-ray and MRI, my doctor has indicated I have partial tears in my supraspinatus and subscapularis and a bone spur. He seems to be eager to perform surgery, but I’m not so sure he has fully identified the problem. During 4 weeks of physical therapy, I’ve discovered that my shoulders seem to be rolled forward, my shoulder is frozen, and I experience impingement when I raise my arm (from the bone spur perhaps). The PT has helped a lot with my range of motion and the pain is not as bad as I recall. There seems to be alot of popping going on in the shoulder when I raise my arms.
The strangest thing I’ve found is when I reach behind my back, my right shoulder comes forward and my elbow points directly behind me instead of out to the side. Is this odd movement indicative of frozen shoulder or partial rotator cuff tears or do I have some other problem?
Thanks in advance.
Stiffness can cause that unusual motion pattern.
Bone spurs are not a reason for surgery. Most patients with partial tears will improve with therapy alone.
I am 52 and have “a full-thickness tear involving the infraspinatus tendon, which is retracted to the level of the mid humeral head. There is a fluid-filled tendon gap, measuring 18.” I had a bike accident 1 year ago that caused this. I’m still able to swim, play tennis and do yoga. I don’t care about the pain, only the longevity of the shoulder and being active now and into the future. Should I get surgery as was recommended by surgeon or should I carry on with my activities?
Hi Dr Luks
I am a 53 year old woman who is a veterinarian in my own single practice. For the last 6 months I have been experiencing shoulder pain (low grade dull pain most of the time and painful weakness when I try to lift things to the side with my right arm). I recently had an ultrasound on my right shoulder (this is my dominant arm) and was told that I have a partial tear of my supraspinatous at the insertion on the humerus measuring 23mm by 17mm. The Dr told me physio is the treatment for partial tears and if this does not work and the pain does not go away then I should get an mri and maybe surgery. Anyways my question is what percent of the tissue is torn (partially torn, but is it 50%, or is it more or less) and does it matter the size of the tear relative to the size of the muscle effect the prognosis and recovery? Your input is greatly appreciated. Thank you so much.
HI Barbara …
THickness appears to matter most… With partial rotator cuff tears, if > 50% of the footprint of the SST or IST (supra and infraspinatus) are torn the chance of progression increases, and the recommended treatments might change too. Most all partial tears- regardless of thickness- are usually managed with physio. If surgery becomes “necessary” due to lack of a response to PT, etc then the choices are a bioinductive patch or a more formal repair.
Good Luck.
Hi Dr. luks
I am 43 year old male firefighter with 2 should surgeries already on my shoulder. I have a 6mm rotor cuff tear. My Dr. said other repair sites look very good and not damaged. Been in physical therapy for about a month shoulder feels pretty good, some pain here and there but not like it was when injury occured. Not sure if i should keep going to PT. or have surgery at this point. This is the decision I am faced with. Your thoughts?
I doubt that many shoulder surgeons would consider surgery on a 6 mm rotator cuff tear in someone with very little pain.
Hi Doc,
After reviewing an mri for my shoulder, it is determined that I have a full thickness tear of the supraspinatus with 4 cm retraction. It looks to be an acute tear which likely occurred during a recent gym session. The muscle shows no fatty atrophy. My doctor recommended surgery but I am concerned about jumping in too fast. I am an active 45 year old and compete in road and trail running races. This will sideline me for sure, but I don’t want to be short sighted. One thing that surprised my Ortho was the amo7nt of strength and range of motion I still have. I have significant pain for sure, but I might be willingnto live with it if it is likely as bad as it’s going to get without surgery. Any thoughts?
Thanks!
HI Ben….
These are very tough decisions. If only the supraspinatus is involved then strength is not affected. Tears need to involve the infraspinatus in the back of subscapularis in the front to cause weakness.
I can not offer specific advice on what to do…. that discussion is for you and your doctor.
Good luck
Gotcha – thanks for the quick reply!
Best,
Ben
Doc: I am 65 active, gym, bicycle and tennis. Felt small disturbance in non dominant shoulder while doing seated military press . Continued and finished workout next morning mild pain in shoulder. Played tennis tossing with non dominant arm. Pain became much worse ROM less, severe pain at night.
MRI: Ac Joint moderate arthropathy with capsular thickening, minimal synovitis, minimal subacromial and subdeltoid bursal fluid. Mild downsloping of the lateral acromion.
Rotator Cuff: High grade partial and possibly a complete irregular tear of the anterior supraspinatus tendon near the footplate. Associated supraspinatus tendinopathy.
Labrum: Mild iffregular signalno evidence of tear.
G joint: small joint effusion, mild thinning of glenohumeral joint cartilage.
Bicepts Tendon: mild heterogeneous signalof the proximal bicepts tendon. No definate tear seen. Normally located.
Impression: High-grade partial or possible complete irregular tear of the anterior supraspinatus tendon near the footplate. Infraspinatus and subscapularis tendinopathy. Mild irregular signal within the superior labrum without evidence of a tear. Mild chondromalacia with a small joint effusion.
Ortho/Sergery: Arthroscopic rotator cuff repair, Subacromial Decompression. distal clavicularectomy including distalarticular surface and possible long tendon biceps tenodesis.
What is your opinion of this?
I am doing PT with pain, loss of ROM in mornings, stiff. Quality of life sucks.
If I have the surgery, 6-8-10 months rehab I will rest my arms and shoulders, still walk and work out lower body or not have surgery?
Most of us would suggest long (2-4 months) trial of PT before considering surgery. These are very typical age related “degenerative” changes on your MRI.
Good Luck
My doctor told me that physical therapy may be aggravating my degenerative torn rotator cuff, and I should simply stretch and do no other pt, yoga or shoulder exercises and see if i feel better, before i decide to operate. Is it possible that physical therapy with weights can actually make it worse?
Most shoulder surgeons suggest PT as a first-line treatment for small degenerative tears. I do not think they would do that if PT caused tears to become larger :-).
Some of these tears will grow larger over the years, yet some do not. Since biology plays a role here so you don’t need anything to cause some tears to grow larger.
Traumatic injuries and biology are the main causes of tears getting larger. PT would not be anticipated, under typical circumstances, to cause the tear to grow larger.