Rotator cuff tears are common shoulder injuries and can present very different. Individuals with these injuries can range from being asymptomatic to being completely debilitating. Consequently, it is important to seek the opinion from a qualified health professional such as a physical therapist or sports physician to receive the appropriate treatment. This will be a comprehensive guide to what a rotator cuff injury involves and how it should be managed.
More...
ANATOMY
Before discussing the management of shoulder cuff tears, it is important to understand the anatomy of the shoulder. The rotator cuff is comprised of 4 main muscles which include the:
- Supraspinatus
- Infraspinatus
- Subscapularis
- Teres Minor
Image 1. Visual representation of the back of the shoulder blade where the rotator cuffs originate.
Source: https://commons.wikimedia.org/wiki/File:Shoulder_joint_back-en.svg
By observing image 1 and image 2, all the rotator cuff muscles attach from the shoulder blade (scapula) to the head of the shoulder bone (humerus). They play a significant role in stabilising the shoulder joint by fine-tuning its movement, particularly in the upper ranges. Some examples of these upper ranges include overhead activities such as reaching up for groceries or throwing.
Due to the location and orientation of these muscles, they are also heavily involved in the external and internal rotation of the shoulder girdle. These are the movements which help rotate the shoulder towards and away from the body. External and internal rotation is essential for both sporting and daily activities.
Rotator Cuff Tears
Overview
As the name suggests, a rotator cuff tear is a tear within one of the 4 rotator cuff muscles. Most commonly the supraspinatus (as seen in image 2). Generally, they will either be classified as either a partial or full-thickness tear. Depending on whether the rotator cuff muscle is either partially or completely torn, may determine how the shoulder is managed.
Image 2. Front view of the shoulder showing an intact subscapularis and torn supraspinatus. Modified and sourced from: https://en.wikipedia.org/wiki/Rotator_cuff_tear#/media/File:Rotator_cuff_tear.jpg
Mechanism of injury
Generally, rotator cuff tears are more prevalent in active individuals over the age of 50. These injuries can either be due to a traumatic event or age-related changes over time. Examples of common mechanisms associated with rotator cuff include:
- Falling on the outstretched hand
- Lifting a heavy item
- Excessive external force (e.g. arm getting pulled, high impact contact)
- Repetitive overhead movements (e.g. tennis, painters)
- Age-related structural changes to the rotator cuff muscles (e.g. rotator cuff tendinopathy)
Signs and symptoms
Due to the rotator cuff’s significant role with overhead movement, a commonly observed symptom is shoulder pain when attempting to lift the arms. Health professionals will often seek out the ‘painful arc’ sign as an indication of the injury. This sign will be further explored in the diagnosis section below. Additional symptoms which may accompany the ‘painful arc’ includes:
- Lying on the affected shoulder
- Pain during night times
- Reduced shoulder mobility
- Inability to perform overhead movements
- Difficulty lifting heavier items
Diagnosis
Like with any musculoskeletal injury or condition, it’s important to consult a relevant health professional such as a physical therapist or sports physician. Assessments such as thorough questioning and a physical examination will be conducted to determine the diagnosis. Usually, imaging will not be required unless there was trauma involved or if there are any other indications. There are 2 physical assessments which can be conducted without any assistance. Although these assessments will help guide the diagnosis, they are not always 100% accurate.
1. Painful arc test: During this test, you will be standing up and raising both shoulders to the side. If this reciprocates the shoulder pain when elevated between 60-120 degrees, this may indicate a rotator cuff injury.
2. Resisted external rotation test: During this test, you will stand with elbows bent at 90 degrees. In this video below, you are rotating the shoulder outwards and resisting a therapist. However, this can be performed against solid objects such as a wall or door. If pushing against the objective reciprocates the pain, this may also indicate a rotator cuff injury
Once again, these tests cannot be relied upon for a complete diagnosis. Visiting a health professional is important to see whether there could be other contributing factors for these positive shoulder assessments.
Management of Rotator Cuff Tears
A decision about the management of the injury should be made between a physical therapist, physician, and orthopaedic specialist (if required). Several factors will be considered such as:
- The age of the patient
- Whether the injury was non-traumatic or traumatic
- The severity of the injury (e.g. whether it was a partial or full-thickness tear)
- The goals of the patient (e.g. be able to perform recreational activities, return to elite-level sports etc.)
- Current occupation
When looking over the literature, there is inconclusive evidence to suggest that surgery is superior to physical therapy for rotator cuff tears. Two recent systematic reviews showed conflicting results when comparing surgery and physical therapy. A 2015 study by Ryosa’s team suggested that patient outcomes were similar between physical therapy and surgery. Conflictingly, a 2019 study by Schemitsch’s test suggested otherwise.
In my clinical experience, a joint decision should be made between the patient and the medical team. When deciding, the above factors should be considered to determine the most suitable management plan.
Under most circumstances, physical therapy would be recommended as the first-line treatment for at least 6-12 weeks. More invasive treatments, such as a rotator cuff repair, may be considered if there is a lack of progression.
However, there are situations where surgical intervention should be considered immediately. For example, a young elite athlete who has had a full-thickness supraspinatus tear after a traumatic injury may consider surgery first. Especially if the athlete is relying on their sport as a career and source of income.
Physical Therapy
As mentioned above, physical therapy would usually be recommended as the first-line treatment for most rotator cuff tears. Depending on the physical therapist, treatment modalities may involve pain management, reducing the load through the shoulder and exercise therapy. More specifically this may involve:
- A structured rehabilitation programme focussing on restoring shoulder function, strength, and mobility
- Home exercise programme
- Hands-on therapy such as soft tissue massage and joint mobilisation to reduce stiffness
- Electrophysiological modalities such as TENS/EMS machines to reduce pain
- Temporarily ceasing activities such as overhead movement and heavy lifting
As per table 1., the goals of the rehabilitation program will be to:
- Restore range of motion
- Improve shoulder stability and strength
- Sport-specific movement and function
Phases of Rehabilitation | Goals | Example Exercises |
|---|---|---|
Restoring range of motion |
| |
Improving shoulder stability |
| |
Sport-specific movement |
|
Table 1. Sample rotator cuff rehabilitation programme. Source: Edwards, P., Ebert, J., Joss, B., Bhabra, G., Ackland, T., & Wang, A. (2016). Exercise rehabilitation in the non-operative management of rotator cuff tears: a review of the literature. International journal of sports physical therapy, 11(2), 279.
Post-surgical Management
Surgery will usually involve repairing the rotator cuff of the tear. Initially, a sling may be used to assist recovery in the very early stages. Additionally, the surgeon will also set a few restrictions such as lifting and mobility limitations within the first few months. It will be important to adhere to these restrictions to protect the shoulder joint and help with recovery.
During the recovery process, the physical therapist will work with the individual for up to 12 months to help achieve the goals discussed with the patient. Rehabilitation will usually commence within the first week. Within this period, the physical therapist will tailor their treatment plan around the restrictions, goals and guidelines set by the surgeon.
As mentioned rotator cuff injuries will usually be managed conservatively before moving onto more invasive surgical treatment. In most cases, it is recommended to seek the advice of relevant health professionals for a faster recovery. For any further advice or support, please do not hesitate to send me an email at lmao@toptotoe.com.au.
Disclaimer: This article is not intended as medical advice or a treatment plan. All content such as text, images, videos and tables in this article is for general information only. Please seek the expert opinion of a relevant health professional for any advice, diagnosis or treatment.