“Almost all patients with shoulder complaints benefit from physical therapy.”
- Judy Chepeha1
What is the rotator cuff?
Healthy shoulders are very flexible joints. This flexibility is largely due to the design of the shoulder. Unlike other joints (such as the elbow or hip), the shoulder relies more on its surrounding muscles and less on its bony design for stability and function. A combination of four muscles are usually credited with providing stability to the joint. These muscles surround the joint from front, back and above, helping to keep the joint in place and aligned as it moves in different directions, as well as contributing to shoulder movement.2 The four muscles combine to form the rotator cuff, working together to stabilize and move the shoulder.2
What is a rotator cuff injury?
When one of the muscles of the rotator cuff is injured, it can affect the function of the entire rotator cuff and result in shoulder pain.2 Shoulder pain is very common. Some estimates suggest that as much as half of the population experiences shoulder pain in a year.2 Nearly half of these people have some form of rotator cuff problem, including tendinopathy (inflammation or pain in the part of the muscle that connects to the bone), impingement (when the muscles or tendons get caught between the bones that make up the shoulder joint), or a partial- or full-thickness tear of the muscle.2 Although these problems affect people of all ages, rotator cuff tears become more common with increasing age.2 In fact, it has been estimated that more than half of adults over 60 years of age have at least a partial-thickness tear of one of these muscles.1,2
What causes these injuries and how common are they?
When rotator cuff injuries affect young people, they are often related to participation in overhead or throwing sports, such as baseball.2 With older patients, the injury is often the result of repetitive overuse of the shoulder, and may have several contributing factors including poor posture, weakness of one or more of the rotator cuff muscles, and regular overhead work or overhead sport participation.2
My doctor just told me I have a rotator cuff tear. I need surgery, right?
Even though the name rotator cuff tear sounds scary, in reality many people have rotator cuff tears that don’t cause them pain or limit their ability to function.1,2 Signs of a tear or other damage on an MRI or other test do not necessarily correlate with pain or the inability to do daily activities.2,4 In fact, it has been found that 23% of "normal" shoulders (pain free, full movement) have rotator cuff tears.4
Researchers have tried to find out why some tears lead to pain and decreased function and others do not. There is some research suggesting that painful tears may relate to the size of the tear or to a recent increase in the size of the tear; however, other studies suggest that the location of the tear within the rotator cuff is what determines if a tear becomes painful or limiting.4
You might need surgery, but you also may not.2 This is a decision to be made after a discussion with your physician. How long you’ve had the tear, the quality of the remaining muscle, other health issues, the person’s expected level of shoulder use/activity, and other factors are all considered when the decision between surgery and conservative treatment is being made.2 Although some people benefit from shoulder surgery to repair a torn rotator cuff muscle, the first step is to complete a few months of conservative treatment, consisting largely of exercises to strengthen the shoulder muscles.2 In other cases conservative management (including exercise) can allow other shoulder muscles to make up for, or compensate for the torn muscle,4 meaning that surgery may not be necessary.
What about conservative management?
Conservative treatment for rotator cuff tears and other rotator cuff injuries includes treatment to help heal the injured rotator cuff muscle, pain management, education to avoid further/re-injury, and exercises to restore normal movement to the shoulder and normal strength to both the affected and unaffected muscles of the shoulder and rotator cuff.2 Physiotherapists provide treatment to address pain, improve flexibility, and gradually progress exercises. Exercises are prescribed to ensure that strengthening occurs gradually, without increasing pain and other symptoms, and without causing compensation from other muscles which can lead to future problems or poor quality movement.2
Pain relief is one of the main reasons that older adults seek treatment for rotator cuff injuries. However, some evidence suggests that there is no difference in long term pain and discomfort between people who are treated with surgery and people who are treated with conservative management only.3 This is one of the main reasons that conservative management is the first resort for treatment.1
What if I do have surgery?
Surgery is usually provided only after a patient has tried conservative management without success.2 Surgery usually does not result in a complete return to “normal,” and results tend to be better for younger patients without other medical concerns.2 A significant amount of active physiotherapy is also required after surgery to achieve a good recovery, continuing for up to 24 weeks.2,5
IgnitePhysio. Research highlight: Non-operative shoulder rehab study. An interview with Judy Chepeha, PhD. Available at: https://ignitephysio.ca/blog/podcast-episode-007-shoulder-new-developments/. Accessed on August 22, 2017.
Magee DJ, Zachazewski JE, Quillen WS, Manske RC. Pathology and Intervention in Musculoskeletal Rehabilitation. Elsevier Health Sciences, 2015. https://books.google.ca/books?id=-R3mCgAAQBAJ&dq=shoulder+surgery+chepeha&lr=&source=gbs_navlinks_s
Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Musculoskeletal Group, 2008.
Huisstede BMA, Koes BW, Gebremariam L, Keijsers E, Verhaar JAN. Current evidence for effectiveness of interventions to treat rotator cuff tears. Manual Therapy 2011; 16:217-230.
Shoulder Rehabilitation. Edmonton Region Shoulder Rehabilitation Guidelines-Standard Arthroscopic/Mini-Open Rotator Cuff Repair. Available at: https://cloudfront.ualberta.ca/-/media/rehabilitation/faculty-site/research/research-documents/shoulderrehabilitationguidelines-standardrcrepair.pdf. Accessed August 24, 2017.