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.
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?
Howard J. Luks, MD says
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.
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?
Howard J. Luks, MD says
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.