Welcome to Hicksville Physical Therapy's patient resource about Rotator Cuff Tears.
Think of the shoulder as one of the most important meeting points for your bones. Its intricate design provides us with the ability to move our arm and hands in dozens of positions. But many don’t realize that although the shoulder provides us with a wide range of motion, it is not very durable compared to other joints of the body. This is why the shoulder, specifically the rotator cuff, is so susceptible to injury.
Because they are so prone to weakening or even degeneration over time, it is so important to pay close attention to the health and functionality of your rotator cuff tendons. A damaged rotator cuff would immediately weaken your shoulder, causing an exceptionally painful injury that will not heal on its own. Although it’s more common for one of these tears to occur in a patient’s late middle age (around 50-60 years old), it can really happen to anyone at any point in their life – regardless of their previous joint health.
Use this guide to learn about:
What is the rotator cuff, and what does it do?
The scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone) are the primary three bones that make up the shoulder.
Your arm is kept firmly in place within the shoulder socket by a group of four muscle tendons known as the rotator cuff. These muscles are: the supraspinatus, teres minor, infraspinatus, and subscapularis.
It may help to think of tendons as a glue-like material that joins muscles to bones. Muscles can initiate movement of the bones by pulling on the tendons. It’s because of this that the rotator cuff, a group of muscle tendons, can help to rotate and raise the arm.
As the arm is raised, the rotator cuff will maintain the position of the humerus within the scapula’s socket. The scapula’s upper portion forms a roof-like shape over the humerus that provides additional stability. This piece of bone is called the acromion.
Situated between the acromion and the tendons of the rotator cuff is a sac-like structure of tissue called a bursa. The bursa is extremely important to the functionality of the shoulder as it maintains a smooth, lubricated surface that will reduce damaging friction between the acromion and rotator cuff. There are bursae located all over the body in fact, all with the same purpose of maintaining smooth contact without damage.
What causes rotator cuff tears?
A general rule regarding the health of your bones, joints, and muscles is that an increased blood supply means faster recovery and more efficient self-maintenance. Unfortunately the rotator cuff tendons have several areas of low blood supply, which in turn makes these tendons especially susceptible to degeneration over time.
It’s this increased prevalence of low blood supply within the rotator cuff tendons that lead to increased risk of injury. Tears of the rotator cuff usually occur in tendons that had low blood supply even before degeneration had began, only to be worsened by degeneration over time.
Repeated motions of the shoulder over time such as occurs with overhand athletes like baseball pitchers can accelerate degeneration of the rotator cuff. However even seemingly mundane tasks like cleaning windows, painting, or washing cars can lead to weakening in the shoulder.
In addition to overhand motions, excessive force to the arm or shoulders can also increase the rate of degradation in the rotator cuff. This may include trying to catch heavy objects from falling, or catching a high speed baseball. In some cases, a minor injury to the rotator cuff can go undetected. In fact it’s estimated by researchers that up to 40 percent of people may suffer from a minor tear without being aware of it.
As stated above, the most common patient with a rotator cuff tear is in their late middle age, and has had previous issues with their shoulder. This patient typically suffered an injury that tore the tendon after trying to lift something heavy. After the initial tear, the patient will not be able to raise the arm above a certain point and will experience a significantly limited range of motion. However it’s important to keep in mind that excessive use or an injury at any age can cause a tear in the rotator cuff – even in young people.
What does a rotator cuff tear feel like?
A rotator cuff tear can cause varying levels of pain and weakness in the affected shoulder. Although not as common as a total tear, a rotator cuff may only tear partially. This would cause some discomfort and pain but you would still be able to achieve a normal range of motion. With a larger tear, however, you should expect increased weakness and discomfort.
In the case of a total rupture of the rotator cuff tendon, you will not be able to move your arm in a conventional range of motion. In fact, it will most likely be impossible to raise your arm away from the side of your body without assistance.
Some patients of a rotator cuff tear would describe the pain in the shoulder area as a catching sensation when moving the arm. It’s common for patients to want to avoid sleeping on the affected side because of this pain.
Upon your visit to Hicksville Physical Therapy, our in-house physical therapists will inquire about your medical history, your injury, and your specific symptoms of pain. This will be followed by a physical examination of the affected shoulder, which is the most important part in providing you with an accurate diagnosis. If our physical therapist can move the arm in a normal range of motion while you are unable to do this yourself, it is likely that you have a torn rotator cuff. With this diagnosis, a discussion of treatment options can commence.
Depending on the results of your physical examination, you may be referred to a doctor for further examination and diagnosis. After this, the physical therapists at Hicksville Physical Therapy will inform you of the various treatment options that are available, so you can return to your usual active lifestyle as soon as possible.
The main focus of your treatment at Hicksville Physical Therapy will be inflammation and overall pain management. Initial rehabilitation will typically involve short-term use of pain medications like ibuprofen or aspirin and lots of rest. Heating and icing sessions can also be used to lessen swelling and discomfort both during and after a medication regimen.
You will be given an individualized physical therapy program by our staff with the goal of restoring your shoulder’s mobility. Our hands-on treatments will include various assisted and individual exercises to improve your shoulder’s range of motion, while simultaneously strengthening nearby joints and muscles.
After you show signs of improvement, usually after several weeks of treatment, you will be instructed more strengthening exercises to expand your control of your rotator cuff and shoulder blade muscle. The purpose of these exercises is to restore your muscles ability to maintain the tight ball-and-socket formation of the humerus and scapula. This is what provides you with your arm’s wide range of motion.
Your daily activities and workstation may also be evaluated by our physical therapist in the early stages of treatment as to suggest improvements and avoid further complications.
The average length of physical therapy treatments for rotator cuff tears ranges from six to eight weeks. The majority of patients are able to return to their usual activities and unrestricted use of their arm during this time, however your time may vary as all physical therapy treatments are built around each patient’s specific case.
Unlike other joint surgeries, rotator cuff procedures can be a long process. Most patients will be instructed to attend two to three months of physical therapy sessions, with full recovery being achieved in up to six months. While restoring your shoulder’s mobility is an important part of your treatment, it is also crucial to avoid straining the healing tissues.
Ice and electrical stimulation along with massage therapy and other hands-on treatments may be used to control pain, muscle spasms, and swelling from the procedure. Along with these treatments, you should expect to wear a sling for four to six weeks after surgery in order to support and protect the shoulder.
While recovery may be a slow process, physical therapy can usually begin quickly after an arthroscopic surgical procedure. Your physical therapy routine will first target your range-of-motion and gradually work into active strengthening. However it’s important to be mindful of how much exercise your doing, and more importantly, how fast you are doing it.
Surgical procedures that involve incisions into the front shoulder muscles typically involve a longer, more gradual physical therapy treatment. At Hicksville Physical Therapy, our physical therapist will start your program out with passive movements, meaning your muscles remain relaxed while we perform movements on your shoulder joint. You may be instructed on how to perform these passive exercises at home.
Active physical therapy movements refer to using your own muscle power in range-of-motion exercises. This type of physical therapy will typically begin six weeks after your procedure, and include light isometric strengthening exercises that will strengthen your muscles without straining the healing tissues. Regular strengthening exercises may be pushed back until 12 weeks post-operation.
Although you may be given a physical therapy program with a wide range of exercises targeting different areas, the purpose of all of them is to strengthen your rotator cuff muscles and shoulder blade muscles. By following your custom exercise plan you will retrain the muscles of the shoulder blade to keep the ball of the humerus firmly in the scapula’s socket, maintaining a smooth and comfortable range of motion.
Because you are given a custom physical therapy program, you will most likely be performing exercises that are similar to movements you’d perform during work or other activities. Our physical therapist will help you identify certain activities and motions that exert too much stress on your shoulders, and instruct you on how to avoid any complications going forward.
If these non-invasive treatment options fail to improve your shoulder’s condition, you may be referred to another doctor for surgical evaluation. Muscle transfers and tendon grafts are two surgical options that are widely available, however they are complex procedures that are not usually necessary.
An X-ray will most likely be requested by your doctor to check for bone spurs, down sloping (hooked) acromion, or a loss of space in the shoulder joints. These are all signs of tears in the rotator cuff tendons, and are important indicators of a tear as an X-ray cannot show the tear itself. An X-ray will also show if you have a condition called calcific tendonitis, which involves calcium deposits in the affected tendons.
Related Document: Hicksville Physical Therapy's Guide to Calcific Tendonitis
Your doctor may also recommend an arthrogram test, which involves injecting dye into the shoulder prior to an X-ray. This test would indicate a tear in the rotator cuff if the dye leaks out of the shoulder joint.
You may also be recommended an MRI, or magnetic resonance imaging scan.
An MRI scan uses magnetic waves to create pictures of the shoulder in layers. The MRI scan is one of the most commonly requested tests because it is painless, non-invasive, and can show both tendons and bones.
While partial tears in the rotator cuff will usually heal with the help of non-invasive treatment options, complete ruptures will most likely require a surgical procedure if you are looking to completely restore your shoulder’s function. Elderly patients or those with any diseases that may increase the risks of a surgical procedure will typically be recommended non-invasive methods of recovery like physical therapy.
For some partial tears of the rotator cuff, you may be recommended to have surgeon evaluate the damage. This would involve observing how deep the tear is and where the tear is located. Using this information, the surgeon may recommend you consider a surgical procedure for your partial tear.
The MRI scan is the most common test used to observe a tear of the rotator cuff and determine whether a surgical procedure is necessary to restore function. Your surgeon will observe the rotator cuff’s tear while checking for other problems as a tear is usually the result of another problem. These problems include:
With the rise in arthroscope usage during surgical procedures, incisions have gone from three to four inches in length to about a quarter of an inch. The arthroscope is an instrument designed to give surgeons a close-up look into a joint or other space inside the body. The structure of this instrument is a thin metal tube even smaller than a pencil, with strands of glass called fiberoptics inside that allow the surgeon to view inside the space by looking into the other end of the tube – or onto an attached television screen via a camera. This is actually similar to how a microscope or telescope works.
This modern arthroscope setup allows the surgeon to carefully move around the joint with full view of what is happening inside. With the arthroscope in place, the surgeon can use other instruments to perform the surgery. The main benefit of the arthroscope is that it allows for a small incision, resulting in less damage to healthy tissue around the affected joint. This would mean a faster recovery, in some cases allowing the patient to go home the same day as the procedure.
The process of repairing the tear in the rotator cuff using the arthroscope would begin with several small incisions for the purpose of inserting the arthroscope into the body, along with any other instruments necessary to get the job done. Although these incisions are only about a quarter of an inch in length, it is common for the surgeon to make three or four of these incisions around the shoulder to allow for different views using the arthroscope.
A special pump will fill the shoulder joint with a sterile salt water fluid known as saline via a small plastic or metal tube that’s inserted into the shoulder. Another small tube will be used to remove the fluid from the joint, creating a constant flow of fluid that will remove any blood or debris from the joint during the procedure.
Other instruments that will likely be used during your rotator cuff surgery may include instruments to remove torn and degenerative tissue by chipping pieces away and vacuuming them out of the joint. By using these instruments, any bone spurs that create uncomfortable friction with the tendons of the shoulder can be removed to maintain a smooth under surface of the acromion and AC joint.
Suture anchors simplify this process as they are small enough to be put in place via the use of an arthroscope, and are typically made out of a dissolvable metal or plastic-like material. This anchor is drilled into the bone and threaded with the soft tissue that the surgeon wishes to reattach.
An open surgery, also known as an open repair, means that the surgeon will access the affected rotator cuff tendon by making an incision through muscles and tissues on the front side of the shoulder. Once the tendon is repaired, the front muscle is rejoined with the bone. This process may be necessary depending on your case.
Unfortunately, not all tears in the rotator cuff can be repaired. Tears that are especially old usually become contracted and cannot be stretched enough to make reattachment possible. This is when your surgeon may use the graft method where a length of tendon graft is used to span the distance from the stump of the torn rotator cuff to the humerus.
Although uncommon, the tendon tissue sometimes wears away so much that what is left is not strong enough to hold stitches. Your surgeon can still remove torn tissue and fix other problems in order to reduce your pain, however without stitches you will probably not regain your strength and range of motion. In fact, your range of motion may even be worsened.