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.
KMLewis
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. :-)
Alicia
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
Howard J. Luks, MD
The PT is the most important… but the injection can be effective for many to diminish the pain. Not essential but often helpful .
Doreen Procopio
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?
Howard J. Luks, MD
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.
Doreen Procopio
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
Sarah
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 :)
Howard J. Luks, MD
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.
Shirley Campbell
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?
Howard J. Luks, MD
There are other options… perhaps another opinion would be worthwhile.