If you tear something in your body, does it always need to be fixed?

Hearing the words, “you have a torn rotator cuff” can be pretty scary, and often the patient believes that surgery is required to repair a torn rotator cuff. I have met many patients who were simply told “you have a torn rotator cuff” and that it will be a quick surgical fix, without being told any more specifics. But the rotator cuff is a complicated part of the body, and a ‘tear’ can take many different forms, so it is helpful to learn a bit more about this important part of the body! In most cases, there are actually several potential treatment options for a torn rotator cuff, and surgery is not a guaranteed fix nor is it necessarily always the best option!

What is the rotator cuff, and what does it do?

The rotator cuff is actually a group of four muscles and tendons. In the video below you can see these muscles and tendons and how they cover and wrap around the shoulder joint and the capsule that surrounds it. The shoulder is a ball-and-and-socket joint.  The rotator cuff helps to move the joint; while your bigger muscle groups (delts, traps, lats, pecs) are responsible for the ‘heavy lifting’, your rotator cuff fine tunes these motions by keeping the ball relatively centered in the socket. When people think of muscles and tendons they think of ropes, so you might be thinking that there are four ropes that keep the ball in place in the shoulder socket. However, this is not quite the case: instead, a great analogy for the rotator cuff and the capsule is that of a blanket covering the shoulder joint.

When someone is suspected of having a rotator cuff tear and has an MRI, we can see which of the four rotator cuff tendons is torn, to what extent, and to some degree the overall health of the shoulder tissue. In our blanket analogy, when there’s a tear in one of the muscles it is similar to a snag or a hole in a knitted blanket. The blanket still has a continuity; it still has the ability to function. In the case of the rotator cuff, where one tendon has a tear, the others can make up the difference. This is the beauty of the human body, the fact that it is adaptable, and can deal with a large range of circumstances without the assistance of medication and surgery.

What about my painful, torn, rotator cuff?

So, you might be reading this blog with a painful shoulder and are the recent recipient of an MRI that showed a rotator cuff tear. You may have been recommended a surgery and may have been given varying information about the expected recovery time. In this situation, there are two questions that we should try to find answers for:

1. Is my shoulder pain definitely being caused by the torn rotator cuff?
2. If it is, is surgery definitely required for pain reduction/healing?

Let’s consider these one at a time.

Is my shoulder pain definitely being caused by the torn rotator cuff?

The instinctive answer to this question is ‘Of course! I have pain, and I can see something torn, so that must be the problem!’ Historically, this has been the assumption of doctors and medical science in general. But research is now showing that it’s not necessarily true! Consider some recently published research:

• A study of people entering their 50s found that for every person with a torn rotator cuff and shoulder pain there were two people who had a rotator cuff tear without pain! Twice as many people had rotator cuff tears without pain (non-symptomatic) as those with a rotator cuff tear with pain (symptomatic).
• Research has found similar trends for other pathologies that are often seen in imaging and have historically been surgically repaired, including knee meniscus tears, disc degeneration, and hip labrum tears. In general, this is an area where our medical understanding and best practices are rapidly changing!

The problem is, most of those people who have non-symptomatic rotator cuff tears never know they have a tear, unless/until they develop shoulder pain, because we don’t tend to do imaging of non-painful body parts. So if you develop shoulder pain and find out you have a rotator cuff tear, there usually isn’t any way to know whether the tear has been there for a while or not, or why the shoulder has become painful now when it wasn’t before.

Is surgery definitely required for my torn rotator cuff?

Again, the gut response (including that of many doctors) is, ‘Yes! There is something torn in there, we need to go in and fix it!’ And the assumption that goes along with that is ‘If something is painful and torn, and I repair it with surgery, then that will fix the problem and resolve the pain’. But again, research is showing that it just isn’t that simple. For instance, a recent study found that 40% of surgical rotator cuff repairs actually fail to heal, BUT the people in this situation are actually happy with their outcome both in terms of pain and function. On the other hand, I have also treated many patients (like Pearson) who have had shoulder surgery that either failed to resolve their pain, or their function, or both. In many cases, therapy can help these patients heal and recover so that they are pain-free and can return to the activities and sports they enjoy EVEN THOUGH the tear may still be present!

So what gives? The problem is that as humans, we tend to think of our bodies as a mechanical system – if something is ‘torn’, that means it’s broken and it needs to be fixed. Our bodies are so much more complex than a mechanical system like a car or a house, with amazing self-healing and coping abilities that medical science doesn’t yet completely understand. More and more, we are finding that pathologies we can see on an MRI (or other imaging) may be more a normal product of aging than something that requires surgery for repair. Even when there is pain in the joint, research is proving that in many cases we can achieve better pain reduction and restore function with non-invasive physical therapy than with surgery – and avoid the risks and complications inherent to surgery! Even if therapy doesn’t resolve the problem, it is a low-risk treatment, and you can always opt for surgery later if needed (whereas a surgery, once done, cannot be undone!).

That said, there are absolutely situations with a surgical rotator cuff repair is needed, and some in which it is not helpful to delay surgery for a long period. So, when you are in pain and your MRI shows a tear, how can you know whether you need a surgical repair or if you should try physical therapy first? Here are the factors I consider when working with a patient with shoulder pain, and these are good questions to ask your doctor before deciding to schedule a rotator cuff repair:

How is the injury affecting your shoulder function?

This is a question that you can consider before even requesting an MRI of your shoulder! Unless there has been a significant trauma that has led to notable disability with lifting the arm, an MRI should not be the first thing you wish for as it can actually cloud decision making and hamper recovery. What if you’ve already had an MRI that shows a tear? It’s human nature to focus on that diagnosis, but remember that lots of people are walking around with rotator cuff tears and NO SYMPTOMS. It is entirely possible that you can heal and regain full function without pain, without having surgery.

Is your tear a result of trauma, or is it a degenerative tear?

• • Most rotator cuff tears are degenerative. This means they have occurred gradually over time, usually as a result of repetitive overload of the tendons. The quality of the tissue will be variable depending on how long the tear has been developing.
  • Degenerative tears have been shown to do well with therapy. A recent study showed that 75% of people who have a full-thickness rotator cuff (all the way through the tendon) recovered with rehabilitation and did not need surgery.
  • Traumatic tears happen during an instant where the load capacity of the tendon is drastically exceeded. The quality of the tissue is likely to be better as it has only just occurred, and is perhaps more amenable to surgical repair.
  • There are no studies that clearly show a clear benefit in conservative (PT) over surgical care for the traumatic tear. However, this is not to say that you should not consider conservative management for a period of time; this is something you can discuss with your orthopedic doctor and your PT.

What is the size of the tear?

Tear size is measured in two dimensions. Again, visualizing the muscles/tendons of the rotator cuff as a blanket (wide and flat) wrapping around the shoulder, the tear will have a depth (thickness) and a size/length. The depth of the tear is how far through the blanket (tendon/muscle) material the tear extends and will be described as ‘partial’ or ‘full thickness’.

Categories of the size of rotator cuff tears

The size of the tear is how much of the area of the blanket (tendon/muscle) is involved in the tear: is it just a few strands of the blanket, or does the tear go across the whole blanket?

As noted above, many people with a full-thickness tear can recover with physical therapy alone and do not need surgery, but the size of the tear is important. In general, surgery is recommended for tears that are 1.5cm or greater.

Which tendon(s) are torn?

Tears involving more than two rotator cuff tendons, or involving the subscapularis tendon have been shown to not respond well to conservative measures and are more likely to need surgery.

What is the quality of the tissue?

• • As a tendon degenerates, it is infiltrated by fat cells, collagen breaks down, making surgery less likely to succeed. Severe Fat infiltration, Gd III (scale is I-V), is considered a contraindication for surgery.
  • Smoking and diabetes can cause tendon degeneration and will slow healing from surgery.
  • A specific group of antibiotics has been shown to increase the risk of rotator cuff repair failure because it weakens the tendon structure – check out more at this blog for more info!

If I have surgery, what restrictions will I have afterward, and for how long?

• • Many times, patients undergo a rotator cuff repair and are surprised afterward to find that they are restricted from activities such as driving for a period of time. If you are considering surgery, make sure to ask and consider what activities you might be restricted from afterward, and for how long. Also, consider whether the surgery will affect your dominant hand. These factors may influence when you choose to have surgery if you do need to go that route.

What are the risks if I choose not to repair the rotator cuff at this time?

• • If you have a degenerative tear, there may be little risk to delaying a possible surgery in order to try physical therapy first. The risks will depend on the specifics of your tear. If your tear is the result of a trauma or if your function is severely affected, the risks of delaying surgery many outweigh the benefits.
  • Research does show that rotator cuff tears have a tendency to worsen over time if not repaired. However, this does not necessarily mean that your shoulder pain or function will worsen, as we know that many people unknowingly have rotator cuff tears and no pain or lack of function.

Ok, so once you’ve gathered the answers to these questions, what are your options?

If your tear is not large (less than 1.5cm in size), not the result of a trauma, and doesn’t involve multiple tendons or the subscapularis tendon, in most cases you can find relief from shoulder pain with physical therapy alone. The key is to make sure your therapy treatment is done over a long enough period of time, with appropriately dosed treatments.

For the typical rotator cuff tear that is degenerative, that injury has been developing slowly over a long period of time; likely months or even years. In the US it’s common for a PT plan of care to last 4-6 weeks, with visits 2-3 times per week. But for an injury that’s been developing over such a long time period, 4-6 weeks may not be nearly enough time to allow that body to respond to treatment and heal itself. There is no consensus on how long this should be, but a recent paper found surgeon recommendations across the US varied between 4 and 24-months. But this doesn’t mean that you need to go to therapy 2-3 times per week for this entire period! There is no research showing that such an intense schedule is beneficial. Therapy might be more intense in visits at first (maybe the first week or two) if manual therapy is found to provide relief, but the main treatment that has been shown to provide benefit is exercise, and if well taught, this can be done from the comfort of your own home and progressed in the clinic, with appointments increasingly spaced out as treatment progresses.

In my practice, as a patient is progressing and is doing well performing their exercises on their own at home, I might space out their appointments to once a month or more (even up to three months in some cases!). This is after the initial few visits, and only once the patient feels comfortable and confident that they are performing the exercises correctly and understanding their body’s pain signals. What is important with this treatment approach is to maintain good lines of communication between the patient and therapist, and to make sure that the exercises load the injured tissues enough to promote healing. That is why I do everything I can to promote easy communication with my patients in between in-person appointments – via phone, email, or even video conferencing when needed. If you have a question about your treatment or how you’re feeling, I want to answer that as quickly as possible so that we keep you on the road to healing and prevent any further injury. I know this approach isn’t for everyone, but for those who are willing to put in some work and stick with the course of treatment over a series of months, I have seen healing from injuries that patients have struggled with for years, even after surgery! Pearson’s story (video below, blog here) is a great example of a shoulder patient who “failed” rehab, but then also “failed” surgery, but through diligent, consistent work with me was able to get pain free and back in the boxing ring!

This is why it frustrates me when I hear of patients who are told to go to therapy for a four-week period, return to the doctor with a small amount of recovery and are told therapy has failed and they should consider surgery! Four weeks – even eight weeks – is not enough to assess the potential success of rehabilitation. When rehabilitation truly fails, or if you are unfortunate to have suffered a trauma and have lost the use of your arm, then imaging and possibly an appropriate surgery should be considered. Seeing a surgeon who is well respected and who clearly answers your questions is important. Understanding the specifics of the surgery and the rehab process is also important – In my 15 years of practice, I have been amazed how many patients come out of surgery and are surprised by restrictions placed on them and the amount of time they are told they will be out of action recovering. Whatever route you end up following, make sure that you ask questions and understand expectations. As a healthcare provider, I am happy when patients engage me in this way as it lets me know the patient is interested and engaged in their recovery, and can also challenge me to keep looking for better answers and results!

As you can see, there are many factors that need to be taken into account when you have shoulder pain. It is not as simple as having a scan, finding a damaged structure and repairing it. In a town full of engineers who like to fix and make things this is a little counterintuitive, but it speaks to the amazing resilience of the human body compared to the machines humans create!

If you are struggling with shoulder pain and wondering whether you might need a rotator cuff repair, consider scheduling a free ‘Discovery Consultation’ with me. I will discuss your history and examine your shoulder to determine whether physical therapy might be a helpful treatment in your individual case.

References:

• Somerson JS, Hsu JE, Gorbaty JD, Gee AO. Classifications in Brief: Goutallier Classification of Fatty Infiltration of the Rotator Cuff Musculature. Clin Orthop Relat Res. 2016;474(5):1328-32.
• Cancienne JM, Brockmeier SF, Rodeo SA, Young C, Werner BC. Early postoperative fluoroquinolone use is associated with an increased revision rate after arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2017;25(7):2189-2195.
• Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. EXERCISE REHABILITATION IN THE NON-OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS: A REVIEW OF THE LITERATURE. Int J Sports Phys Ther. 2016;11(2):279-301.
• Collin PG, Gain S, Nguyen huu F, Lädermann A. Is rehabilitation effective in massive rotator cuff tears?. Orthop Traumatol Surg Res. 2015;101(4 Suppl):S203-5.
• Christensen BH, Andersen KS, Rasmussen S, Andreasen EL, Nielsen LM, Jensen SL. Enhanced function and quality of life following 5 months of exercise therapy for patients with irreparable rotator cuff tears – an intervention study. BMC Musculoskelet Disord. 2016;17:252.
• Littlewood C, Rangan A, Beard DJ, Wade J, Cookson T, Foster NE. The enigma of rotator cuff tears and the case for uncertainty. Br J Sports Med. 2018;