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.
Carole
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.
Howard J. Luks, MD
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.
Carole
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.
William
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.
Howard J. Luks, MD
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
John
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
Howard J. Luks, MD
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.
KMLewis
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).
Howard J. Luks, MD
Well … that does seem a bit extreme… doesn’t it. I would talk with the surgeon… or perhaps a second opinion.
KMLewis
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.
Howard J. Luks, MD
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.