Patient Information Sheet:
Rotator Cuff Tears (Conservative / Non-operative Management)
This information sheet is designed to give you a better understanding of shoulder rotator cuff tendon tears and the role of Physiotherapy treatment in managing this problem conservatively.
Incidence: Rotator cuff tears are a common shoulder problem with increasing age or trauma. MRI studies have found a low incidence of about 4% of rotator cuff tears in people less than 40 years of age. An increasing number of individuals over 60 years of age have significant rotator cuff disease including tears. By 70 years of age some 50% of individuals have partial or full thickness rotator cuff tear and by 80 years of age 100% of people have some degree of rotator cuff tear. So it follows that rotator cuff tears are essentially a degenerative tendon problem with increasing age, but may be worsened by certain activities and traumatic incidents.
Anatomy: The shoulder joint (glenohumeral joint) may be likened to a golf ball resting on a tee (see diagram at bottom of page), and is inherently quite an unstable joint. It relies greatly on the rotator cuff muscles (supraspinatus, infraspinatus, teres minor and subscapularis) and their tendon attachments to the capsule to provide support and control of shoulder movement. The area beneath the acromion of the shoulder blade contains the sub-acromial bursa, which helps protect and cushion the tendons as they passes through this space. This space is critical to tendon function as it is small and therefore leaves “little room for error” with functional shoulder movements.
Biomechanics: The rotator cuff and in particular supraspinatus acts to maintain stability of the glenohumeral joint and prevent unwanted or excessive translational movement (see diagram below). If the rotator cuff is inhibited by pain or torn it may result in problematic increased upward movement of the ball in the socket. This movement may also occur in a shoulder with a tight posterior capsule or weak scapula movement control. Excessive tension and strain may also be applied to the rotator cuff tendons when a person attempts to lift, lower, push or pull objects that they do not have adequate shoulder strength for.
Humeral head superior (upward) translation in the socket:
Pathology: Rotator cuff tendon degeneration occurs through a gradual process of tendon tissue compression, inflammation, overload and eventual tendon tissue failure. Rotator cuff tendon inflammation may progress to partial thickness tear and then progress to full thickness tear.
Symptoms: Shoulder pain due to rotator cuff tears often comes on gradually and insidiously. It may also follow a significant trauma, fall or due to heavy shoulder activity.
Common symptoms are of lateral shoulder and referred upper arm pain with any of the following activities:
- Reaching and elevation of arm (ie lifting heavy kettle, grandchildren, shopping)
- Washing your hair or reaching across to opposite shoulder
- Dressing (ie putting on a shirt, bra or belt)
- Cooking, cleaning, driving the car
- Night pain (especially in side lie positions)
Goals of Physiotherapy Treatment: The goal of Physiotherapy treatment is to reduce or eliminate inflammation of the rotator cuff tear and surrounding soft tissues to effectively reduce shoulder pain and improve function.
- This may firstly involve providing advice regarding appropriate shoulder function and activity levels. This sometimes means you may need to reduce the amount of shoulder activity in elevated or overhead positions, as well as loaded or strenuous shoulder movements.
- Improve shoulder range of motion through the use of passive manual therapy techniques and instruction in specific assisted-active rehabilitation exercises.
- Reduce posterior capsule tightness with stretches to enable improved centring of the shoulder joint.
- Optimise rotator cuff control, endurance or strength by instruction in specific rotator cuff control exercises using resistive theratube / theraband and light- weights.
- Enhance scapula stability by re-education of optimal scapula muscle control through exercises and proprioceptive awareness movements.
- Correction of any neck or mid back problems which may occur from a painful/weak shoulder utilising “hands on” manual therapy techniques and postural awareness exercises.
It is generally expected that a patient should attempt a minimum of four to six weeks of Physiotherapy and progression of a specific rehabilitation exercise program aimed at reducing tendon inflammation, decreasing shoulder pain and improving functional shoulder control. This time is needed as tendon problems are often slow to settle. This will give you a good understanding of whether you are likely to manage your shoulder condition with a conservative / non-operative approach. Some patients however do have a very symptomatic, functionally limiting or large tear and may require a surgical procedure to provide a better outcome.
Myers J. (2007). Rotator cuff tear (article in Sports Physio, APA publication), Issue 2, 8-9.
Ainsworth R, Lewis J (2007). Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. British Journal of Sports Medicine. 41(4): 200-210.
Lin et al (2006). Effects of shoulder tightness on glenohumeral translation, scapular kinematics, and scapulohumeral rhythm in subjects with stiff shoulders. Journal of Orthopaedic Research. 24 (5): 1044-1051.
Kelly et al (2005). Differential patterns of muscle activation in patients with symptomatic and asymptomatic rotator cuff tears. Journal of Shoulder and Elbow Surgery. 14 (2): 165-171.