Rotator Cuff Tears: To Operate or Not?
Far and away the most common shoulder injury we see in our clinic is pathology related to the rotator cuff tendons in the shoulder. The rotator cuff is made up of 4 tendons whose primary function is to provide stability to the shoulder throughout functional movement patterns.
When problems occur with the rotator cuff, common complaints include pain when reaching outward or upward, difficulty bringing the hand behind the back, difficulty with lifting/carrying, pain when sleeping on the affected side, or weakness with activities at or above shoulder height. Injuries to the rotator cuff commonly occur with overuse of the shoulder, with heavy lifting, with a fall on an outstretched arm, or when attempting to perform a quick, forceful movement with the upper extremity. However, the rotator cuff is most commonly injured over time through the body’s normal degenerative process which produces small microtears and inflammation around the tendons of the muscles. Small microtears in the rotator cuff tendons are often referred to as “grey hair and wrinkles on the inside.” Just as we expect some degree of aging to our outward appearance, we expect internal changes to our joints and muscles as we age. In the United States, 25% of people 60 years and older and 50% of people over the age of 80 have a full thickness rotator cuff tear.
Surprisingly, the presence of a tear does not guarantee pain or dysfunction of the shoulder and many people walk around every day possessing some degree of full thickness rotator cuff tears without knowing it. For this reason, we try not to make correlations between the presence of a rotator cuff tear on an MRI and the likelihood that physical therapy will or will not be successful for an individual. Research has shown in many instances that MRI findings do not correlate to the level or even presence of pain in the body.
Physical therapy is commonly prescribed as the first line of defense in rotator cuff pathology. Conservative management has been shown to be equally effective at long-term follow-up as surgery even for full thickness rotator cuff tears. Typically, physical therapy is trialed for approximately 8-12 weeks to determine its effect on pain, strength, and functional use of the upper extremity. If therapy is not successful, patients often inquire about the need for surgical management of the tear. What we know from the literature is that there are a few characteristics that can predict the surgical outcomes in patients.
Patients who may be poorer candidates for surgery are those who:
- Are over the age of 70
- Have degenerative tears that have happened over time
- Have partial thickness tears
- Have smaller tears
- Have a lot of fatty tissue in the muscles requiring repair
- Are smokers
Those who may want to consider operative management after a trial of physical therapy are those patients who:
- Are younger (
- Suffered an acute tear
- Injured their subscapularis muscle tendon
- Have multiple tendons involved in the tear
- Have large or massive tears
- Are still participating actively in overhead competitive sports
A trained physical therapist is a vital resource in determining the need for surgery and can help you to determine the best timeframe to seek surgical consult if necessary. Within 4 weeks of conservative treatment it is likely that you will see drastic improvements in your pain levels, strength, and use of the upper extremity. And at all costs, we will help you try to avoid surgery if it is not necessary. If your doctor has not recommended a trial of physical therapy for your shoulder pain, remember you can reach out and access your Willow Grove, Hatboro, and Glenside PTs through direct access for a full evaluation and assessment of your shoulder without a prescription from your doctor!
Written by: Courtney Dedda PT, DPT OCS, Vestibular-certified Specialist
Enseki K, Kohlrieser D, Mauro C, Kopka M, Ellis T. Postoperative Management of Orthopaedic Surgeries. La Crosse, WI: Orthopaedic Section, APTA; 2005.