Shoulder pain and cuff tears.
Rotator cuff tears are a common source of shoulder pain and disability in adult shoulders and can be very limiting. Often people feel that the only option is either injection or surgery and are unaware that actually there is a lot you can do for yourself.
These are very common finding on imaging and can be divided into partial thickness tears or full thickness tears. The good news is that you can have a tear and no pain.
Around 25% of 50-year olds have a tear in the rotator cuff but have NO pain and for every decade older we get the incidence of tears get higher in people with NO shoulder pain.
That’s awesome news as it shows we can have a healthy fully functioning shoulder that may not be in pristine condition under the surface, (a bit like a car I used to own!).
What is the rotator cuff ?
The rotator cuff is classified as a group of 4 muscles that surround the ball and socket joint of the shoulder. The shoulder is made up of the humeral head, (the ball) and the glenoid fossa,(socket), of the scapula.
The muscles of the rotator cuff are :
- Supraspinatus, often thought to be the ” villain” of cuff related disorders
- Teres minor
Here’s a quick guide to shoulder anatomy and the rotator cuff.
We often imagine the rotator cuff tendons to be like cords or ropes that are distinct from each other and attach the muscles to the bone. However nothing could be further from the truth.
The tendons of the rotator cuff all blend together to form a blanket like structure around the joint. This means that even if you have torn part of this tendon unit there is plenty of healthier tissue to take over and do its job. It’s more like a hole in blanket rather than a torn rope !
Check out this article by Adam Meakins the sportsphysio who describes this beautifully here.
Are there different types of rotator cuff tear ?
When looking at rotator cuff tears its a good place to start is to take into consideration the following factors;
- If the tear occurred due to an injury, (traumatic tear), or gradually developed, (non-traumatic).
- Size of the tear. Tears can be categorised into partial tears,( < 1cm in size), or full thickness tears, ( >1-1.5cm in size).
- The location of the tear can also be an influencing factor. The insertion of the cuff tendon on the humerus has a very thickened portion to it that is referred to as the cable. The tendon tissue behind it is referred to as the crescent. It appears that if we tear close or through the CABLE this results in a shoulder that struggles more from a functional perspective than if we tear the CRESCENT.
- It appears to be true that a tear in the rotator cuff will not repair itself like a ligament or muscle tear but Fun fact – you can have a tear but not have pain.
- Last but not least is the impact that your shoulder is having on your lifestyle and what you have done already to try and help it. These may be as big a factor as the anatomy of your shoulder.
Do I need surgery to repair my rotator cuff tear ?
This is not an easy question to answer as everyone’s shoulder and circumstances are different and but there are some good guidelines;
Full thickness rotator cuff tears:
Full thickness tears are usually > 1 – 1.5cm in size and often lie close to the thickened cable in the cuff.
Here is a classic full thickness tear and how it moves. The lack of strength due to the cuff tear in the left shoulder demonstrates the classic hitch up to try and move.
Surgical approach for full thickness rotator cuff tears.
Acute tears that are traumatic in origin in individuals that are less than 60 years old appears to offer a very good outcome from surgery.
Interestingly there was no difference if the individual left it for 3 months or 3 weeks in terms of long term outcome.
You are still going to need to rehab the shoulder after surgery though. Just fixing the hole in the blanket isn’t going to ensure the blanket still works most efficiently.
Exercise rehabilitation for non trauma related full thickness rotator cuff tears
Non- traumatic full thickness tears are usually found in the over 60 population. They typically do better with a physio and exercise based approach and studies have shown that an exercise based approach will reduce the need for surgery by up to 75%.
However there may be a question about full these full thickness tears in a younger population (<60 years old), as their muscle and tendon quality may be better and in the long term may prevent further increase in the size of the tear.
Partial thickness rotator cuff tears
Certainly the evidence suggests that taking the physio/exercise based approach is as effective as surgey and at a fraction of the cost, especially in tendons that have less than 75% of the tendon torn.
Just as important to know is that the risk of the tear increasing in size without surgical intervention is realtively small. In fact progression of the tear by greater than 5mm was found in less than 10% of individuals.
Previous treatment for your rotator cuff tear
Another important factor in determining of surgery is a consideration is what have you done before hand with regards to getting better.
Exercise based rehabilitation takes time, especially with tendons. It has been estimated that if muscle takes a minimum of 14 -21 days to get stronger a tendon will take up to 3 months. So it takes time, effort and persistence.
More often than not the non traumatic type rotator cuff tears are related to a lack of strength and endurance in the muscles and tendon units. There may be associated movement restrictions that are the body’s way of protecting the shoulder.
By improving the strength and movement at the cuff we can often avoid the need for surgical intervention by getting the remaining healthy intact tissue more resilient and stronger.
Will the rotator cuff tear get worse without surgery ?
In the younger traumatic full thickness tear group there is a risk of the tear exetnding further and impacting function and that is why surgery may be recommended earlier in the story. The good thing about these tears is that the muscles and tendons are generally very healthy and respond well.
Even if surgery is in the future for your shoulder that still means that you will require some form of long term exercise based rehabilitation to get the best from it.
So what should I do now about my shoulder ?
My best advice if you have been diagnosed with a rotator cuff tear is:
- Get a good diagnosis to what is happening.
- Why it is happening or happened.
- Where you fit in with suitability for surgery or rehabilitation approach.
- Work with your physio to reduce the symptoms and build a strong healthy shoulder and upper limb. Check out our shoulder exercise blog
I hope that clears up some of your cuff related questions. If you need any more help please feel free to get in touch or book in to see one of us here.
Lewis, j: Course notes. The shoulder theory and practice ( 2017-Edition 12).
Lo et al; Partial thickness rotator cuff tears: clincal and imaging outcomes and prognostic factors of successful non operative treatment. Journal of Sports Medicine 2018.
Kukkonen et al; Treatment of non-traumatic rotator cuff tears. Bone & Joint journal 2014