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.
Doug
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
Howard J. Luks, MD
Sounds like your shoulder needs to be evaluated further … I would consider a second opinion.
Physiotherapy Toronto
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.
Ginger McKenzie
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.
Howard J. Luks, MD
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
Kerry
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
Howard J. Luks, MD
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
Josh
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
Howard J. Luks, MD
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/