ATHLETIC EDGE
Sports Medicine
Sports Injury Prevention & Rehabilitation
 540 BRYANT ST, PALO ALTO, CA 94301
(650) 815-6552

Voted Best Sports Therapy Clinic in the San Francisco Bay Area 2010-2016!

Rotator Cuff Tear

(Also known as Torn Rotator Cuff, Rotator Cuff Strain, Supraspinatus Tear, Supraspinatus Strain)

What is a rotator cuff tear?

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. Collectively, the rotator cuff act to provide stability to the shoulder joint and assist with elevation and rotation movements of the shoulder. The four 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 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 tears typically occur due to repetitive lifting or overhead activities and are most common in the older population. In athletes, rotator cuff tears are commonly seen in throwing sports (such as football 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 rotator cuff tears, 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 a rotator cuff tear 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), 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 physician 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

Most minor rotator cuff tears settle well with appropriate physical therapy. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from any activity that increases their pain until they are symptom free. Activities which place large amounts of stress through the rotator cuff should be minimized, these include: overhead activities, throwing, heavy lifting, pushing or pulling and sleeping on the affected side. Resting from aggravating activities ensures that the body can begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
  • Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with a rotator cuff tear is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.
  • Patients with a rotator cuff tear will usually benefit from following RICE. RICE is beneficial in the initial phase of the injury (first 72 hours) or when inflammatory signs are present (i.e. morning pain or pain with rest). This primarily involves resting from aggravating activities (occasionally a sling may be required), regular icing and keeping the arm elevated (i.e. sleeping on the opposite side). Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
  • Patients with a rotator cuff tear should perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. The treating physical therapist can advise which exercises are most appropriate for the patient and when they should be commenced. Exercises to improve scapular stability and strength are a key component of the rehabilitation of a rotator cuff tear. Exercises to improve posture and upper back flexibility are also important, along with a graduated rotator cuff strengthening program (usually involving the use of Resistance Bands). If a rotator cuff tear is not adequately strengthened following injury, a poor outcome is likely.
  • In the final stages of rehabilitation, a gradual return to activity or sport is indicated as guided by the treating physical therapist.

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 physical therapist 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 physical therapist 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 physical therapist. 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

Physical therapy for a rotator cuff tear

Physical therapy treatment for a rotator cuff tear is vital to hasten the healing process and ensure an optimal outcome. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • joint mobilization
  • dry needling
  • ice or heat treatment
  • progressive exercises to improve flexibility and strength (particularly the scapular stabilizers and rotator cuff muscles)
  • 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 physical therapy management, some patients with a rotator cuff tear do not improve (often developing into chronic rotator cuff tendinopathy). When this occurs the treating physical therapist 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 be needed to repair the rotator cuff tear in those circumstances mentioned above.