Rotator cuff tear

What is a rotator cuff tear?

A rotator cuff tear is a condition characterised by partial or complete tearing of one or more of the rotator cuff muscles (figure 1).

The rotator cuff is a group of muscles which originate from the shoulder blade and attach to the upper arm bone (humerus) via the rotator cuff tendons (figure 1). Collectively, the rotator cuff act to provide stability to the shoulder joint and assist with elevation and rotation movements of the shoulder. The 4 muscles of the rotator cuff include:

• Supraspinatus
• Infraspinatus
• Subscapularis
• Teres Minor

During contraction of the rotator cuff muscles, tension is placed through the rotator cuff muscles and tendons. When this tension is excessive due to too much repetition or high force, damage to the rotator cuff may occur. This typically presents as a partial or complete rotator cuff tear and can involve any of the muscles listed above. Of the rotator cuff muscles, the supraspinatus is most commonly affected.

Causes of a rotator cuff tear

Rotator cuff tears often occur suddenly due to a high force going through the muscle and tendon beyond what it can withstand. This may be due to activities such as heavy or awkward lifting, a fall onto an outstretched hand, heavy pushing or pulling, or a forceful throw.

Sometimes a rotator cuff tear may develop over time due to repetitive or prolonged activities placing strain on the rotator cuff. This may cause gradual degeneration and weakening of the rotator cuff predisposing it to further injury. These rotator cuff injuries typically occur due to repetitive lifting, pushing, pulling, use of the arm in front of or away from the body (e.g. housework) or overhead activities and are most common in the older population. In athletes, rotator cuff tears are commonly seen in throwing sports (such as cricket or baseball), swimming, racquet sports (such as tennis), weight lifting or paddling sports (such as kayaking).

Signs and symptoms of a rotator cuff tear

Patients with a rotator cuff tear will often experience a sudden pain or tearing sensation in the shoulder during the provocative activity. In minor cases, patients may be able to continue sport or activity only to have an increase in pain upon resting later (particularly that night or the following morning). In severe cases the pain may be disabling, preventing the patient from performing further activity. Patients with a rotator cuff tear usually experience pain that is localized to the shoulder. Occasionally, pain may radiate into the upper arm, shoulder blade, upper back or neck. The pain associated with this condition is usually experienced as an ache that increases to a sharper pain with activity.

Patients with a rotator cuff tear will usually experience pain or difficulty when elevating the affected arm. Pain may also increase when lifting heavy objects (particularly overhead), using the arm in front of the body, during heavy pushing or pulling or when lying on the affected side.

In patients with a minor rotator cuff tear, little or no symptoms may be present. In these patients, a minor ache may be the only complaint. In severe or chronic cases, muscle wasting and weakness may be evident and night pain (regardless of position) may be present (especially in the case of a complete tear or rupture). This may be severe enough to keep the patient awake at night.

Diagnosis of a rotator cuff tear

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a rotator cuff tear. Further investigations such as an Ultrasound or MRI scan may be required to confirm diagnosis and assess the severity of the tear.

Treatment for a rotator cuff tear

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Surgery for a rotator cuff tear

In major tears to the rotator cuff, surgical intervention may be required to repair the tear and ensure an optimal outcome. This is then followed by an intensive period of rehabilitation, usually involving an initial period of 3 - 6 weeks in a sling whereby only passive movements are allowed (i.e. the physiotherapist moves the arm with the patient relaxed).

Following this period of rest, a graduated strengthening and flexibility program is indicated over the following months as guided by both the physiotherapist and surgeon. In cases where impingement or bony spurring is contributing to the rotator cuff tear the surgeon may also remove part of the bone to allow the rotator cuff tendon greater freedom of movement (this is known as a subacromial decompression).

Surgery is usually considered in those patients with severe rotator cuff tears, particularly in the following instances:

• If the patient is under 60 years of age
• If there is complete tearing of the tendon or muscle
• If there is failure of conservative management following a period of 6 - 8 weeks of treatment or longer
• In cases of young and active people, athletes, sportsmen and women
• If your occupation requires heavy, repetitive or overhead shoulder activities

Prognosis of a rotator cuff tear

With appropriate management, most minor cases of a rotator cuff tear that have not been present for long can usually recover within a few weeks. In chronic cases recovery can be a lengthy process and may take many months to achieve an optimal outcome. Those patients with larger tears to the rotator cuff including complete ruptures that require surgery usually need a period of rehabilitation of 3 - 6 months or longer before returning to full activity.

Contributing factors to the development of a rotator cuff tear

There are several factors which can predispose patients to developing a tear to the rotator cuff. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

• abnormal biomechanics (eg. poor throwing technique or stroke technique with swimming)
• neck, upper back and shoulder stiffness
• muscle imbalances
• muscle weakness (especially the scapular stabilizers and rotator cuff muscles)
• muscle tightness
• poor posture
• excessive or inappropriate training or activity
• inadequate warm-up
• poor core stability

Physiotherapy for a rotator cuff tear

Physiotherapy treatment is vital to hasten the healing process and ensure an optimal outcome in all patients with this condition. Treatment may comprise:

• soft tissue massage
• electrotherapy (e.g. ultrasound)
• joint mobilization
• dry needling
• ice or heat treatment
• the use of a sling
• progressive exercises to improve flexibility and strength (particularly the scapular stabilizers and rotator cuff muscles)
• hydrotherapy
• education
• training and activity modification advice
• technique correction
• postural correction
• anti-inflammatory advice
• devising and monitoring a return to sport or activity plan

Other intervention for a rotator cuff tear

Despite appropriate physiotherapy management, some patients with this condition do not improve (often developing into chronic rotator cuff tendinopathy). When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may include further investigations such as X-rays, ultrasound, CT scan or MRI, pharmaceutical intervention, corticosteroid injection (sometimes required in the case of secondary bursitis) or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition. Surgery may also be needed to repair the rotator cuff tear in those circumstances mentioned above.

Exercises for a rotator cuff tear

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 - 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

Initial Exercises

Shoulder Blade Squeezes

Begin this exercise standing or sitting with your back straight. Your chin should be tucked in slightly and your shoulders should be back slightly. Slowly squeeze your shoulder blades together as hard and far as possible provided it does not cause or increase symptoms (figure 2). Hold for 5 seconds and repeat 10 times.

Figure 2 – Shoulder Blade Squeezes

Pendular Exercises

Begin leaning forwards with your uninjured forearm supported on a table or bench. Keeping your back straight and your shoulder relaxed, gently swing your injured arm forwards and backwards as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch (figure 3). Repeat 10 times provided the exercise does not cause or increase symptoms. Repeat the exercise swinging your arm side to side provided it is pain free.

Figure 3 – Pendular Exercises (right side)

Pendular Circles

Begin leaning forwards with your uninjured forearm supported on a table or bench. Keeping your back straight and your shoulder relaxed, gently swing your arm in circles clockwise as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch (figure 4). Repeat the exercise swinging your arm counter clockwise. Repeat 10 times in each direction provided the exercise does not cause or increase symptoms.

Figure 4 – Pendular Circles (right side)

Foam Roller Stretch

Place a foam roller under your upper back as demonstrated (figure 5). Breathe normally keeping your back and neck relaxed. Hold this position for 15 – 90 seconds provided it is comfortable and does not cause pain.

Figure 5 – Foam Roller Stretch