Shoulder pain is one of the most common musculoskeletal issues we see first hand in clinic and for many people, this pain is caused by an issue with their rotator cuff. For lots of people, being told that they have a ‘rotator cuff tear’ immediately causes alarm and concern regarding surgery. However in reality, surgery is often not always the case and many rotator cuff tears can be managed successfully with physiotherapy.
What is the rotator cuff?
The rotator cuff is a group of four muscles, and its tendons, in the shoulder [1]. It is made up of the:
- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis
They work together to provide stability to the shoulder and enable rotation and lifting of the arm. Injuries to the shoulder in which one or more of these tendons become damaged or torn, can lead to pain, reduced mobility and weakness.
What is a Rotator Cuff Tear?
A rotator cuff tear occurs when one or more of the tendons becomes damaged. This ranges from a minor fray of the tendon fibres to a complete tear in which the tendon detaches from the bone. Symptoms vary depending on the size and location of the tear, but common symptoms include [2]:
- Reduced range of motion
- Pain when lifting the arm
- Weakness in the shoulder
- Pain when dressing
- Disturbed sleep, especially when lying on the affected side / unable to lie on the affected side
- Difficulty completing overhead tasks
- Unable to carry heavy objects
Types of rotator cuff tears
Rotator Cuff Tears vary significantly in severity and presentation. It is important to recognise the type of tear to guide treatment decisions and expectations for recovery. Tears are classified as partial or full thickness tears according to the amount of damage that has occurred to the tendon fibres [3].
A partial-thickness tear means only part of the tendon has been damaged. A full-thickness tear means the tendon has completely been torn through. As the rotator cuff is made up of 4 muscles, tears can either involve one tendon or multiple of the tendons. A multiple tendon tear is usually classed as a more severe injury with associated greater loss in shoulder function and weakness. Research has identified the supraspinatus tendon as the most commonly torn rotator cuff tendon, involved in 70-85% of rotator cuff tears [4].
What causes a rotator cuff tear?
Rotator cuff tears can occur suddenly, referred to as an acute tear, or develop gradually over time, known as a degenerative tear.
Acute tears can occur following:
- A fall
- A sporting injury
- Heavy lifting
Degenerative tears occur slowly and over time as result of:
- Age related wear and tear
- Repetitive overhead activity
- Long-term tendon irritation
- Poor shoulder mechanics
Can rotator cuff tears heal naturally?
No, it is very rare for a rotator cuff tear to heal naturally by themselves due to its weak healing ability which is impacted by low blood supply and high mechanical stress on the shoulder. It is also affected by individual factors such as diabetes, age and smoking which can negatively affect healing [5]. Despite the tendon not having the capability to heal naturally, symptoms can improve over time to reach a similar pre-injury level of function which does not require a fully ‘healed’ tendon. Adjuncts such as platelet rich plasma (PRP) and corticosteroid injections can be used alongside physiotherapy rehabilitation to accelerate recovery through pain relief and range of motion improvement [6].
Do all rotator cuff tears require surgery?
Simple answer; no. Not all rotator cuff tears require surgery despite the above paragraph which states that the tear will not naturally heal. Research has shown that many rotator cuff tears improve greatly with physiotherapy and activity modification. One specific study review which compared the functional outcome for surgical vs non surgical management for rotator cuff tears at a two year follow up found no significant improvement in the surgical group [3].
It is important when reviewing surgical options that the decision is not just based upon the location and size of the tear which is shown through scans. Clinical symptoms, functional limitations, strength and patient goals are also at the forefront when making this decision.
However, on some occasions rotator cuff tears do require surgery. Surgical intervention is often considered when there is one or more of the following [7]:
- There is a large traumatic tear
- Multiple tendons are involved
- Shoulder function is severely limited
- First line non surgical treatment has not been successful, and symptoms persist
- The patient is young and highly active, an athlete or works a very manual job
On occasions in which surgery is required, physiotherapy remains to plays a huge role for both pre- and post-surgery rehabilitation to regain range of motion and strength.
How does physiotherapy help?
Physiotherapy plays an essential part in rotator cuff tear rehabilitation for both surgical and non-surgical treatments. However, this will focus on our non-surgical patients in which research consistently supports exercise-based rehabilitation as an effective first-line treatment for many rotator cuff conditions.
Early treatment focuses on pain management control, to reduce irritation and improve comfort. This is accomplished through supervised physiotherapy including education, application of ice, activity modification, gentle range of motion exercises and manual therapy [8].
Our next goal is to restore movement back into the shoulder. Post rotator cuff tear it is common for pain to alter shoulder mechanics due to avoidance of movements in an attempt to reduce pain. Guided assisted mobility exercises help to restore normal movement patterns in a safe way without applying excessive strain to the injured tendon.
We then move onto strengthening exercises for the shoulder and the surrounding musculature including the rotator cuff muscles as well as the upper back muscles, deltoids and shoulder blade stabilisers (serratus anterior, rhomboids, trapezius) [9]. Increasing strength in the surrounding musculature helps to reduce stress on the injured tissues and improve shoulder function. This aids patients to return and complete their activities of daily living.
Rehabilitation then takes a step up for patients specifically returning to sport or demanding, manual jobs such as construction work to ensure the shoulder has sufficient strength, good neuromuscular control and proprioceptive capacity to tolerate higher loads and dynamic functional demands safely and efficiently.
Conclusion
Rotator cuff tears are a common musculoskeletal injury, making it important to understand the impact physiotherapy can have on a patient’s quality of life. Although physiotherapy does not directly heal the torn tendon, evidence and experience shows targeted rehabilitation significantly improves shoulder function and reduces pain. Successful management is achieved through a combination of understanding a patient’s goals, setting an individualised exercise programme, patient education and load modification to regain confidence and control.
Therefore it is clear to see the vital role that physiotherapy plays in conservative management of rotator cuff tears by optimising functional capacity in support of a long-term improvement.
Our Barnet, Cockfosters & Enfield Physio’s have tons of experience and are specialists in treating rotator cuff injuries. Have confidence that our specialist Physiotherapists will closely assess, diagnose & treat you in the correct & evidence-based way for all injuries. You can book an appointment here.
Blog By: Jess Simmons (Specialist Musculoskeletal Physiotherapist at Crouch Physio).
References
- Akhtar, A., Richards, J. and Monga, P. (2021) ‘The biomechanics of the rotator cuff in health and disease – A narrative review’, Journal of Clinical Orthopaedics and Trauma, 18, pp. 150–156. doi:10.1016/j.jcot.2021.04.019.
- Abdelwahab, A. et al. (2021) ‘Traumatic rotator cuff tears – current concepts in diagnosis and management’, Journal of Clinical Orthopaedics and Trauma, 18, pp. 51–55. doi:10.1016/j.jcot.2021.04.013.
- Longo, U.G. et al. (2021) ‘Conservative versus surgical management for patients with rotator cuff tears: A systematic review and meta-analysis’, BMC Musculoskeletal Disorders, 22(1). doi:10.1186/s12891-020-03872-4.
- Bedi, A. et al. (2024) ‘Rotator cuff tears’, Nature Reviews Disease Primers, 10(1). doi:10.1038/s41572-024-00492-3.
- Zhang, C. et al. (2021) ‘Current biological strategies to enhance surgical treatment for rotator cuff repair’, Frontiers in Bioengineering and Biotechnology, 9. doi:10.3389/fbioe.2021.657584.
- Petri, M. et al. (2016) ‘Non-operative management of Rotator Cuff Tears’, The Open Orthopaedics Journal, 10(1), pp. 349–356. doi:10.2174/1874325001610010349.
- Pitt, L., Mazuquin, B. and Littlewood, C. (2024) ‘What influences the decision to undergo rotator cuff repair surgery: A survey of clinician’s perspectives’, Shoulder & Elbow, 17(3), pp. 341–347. doi:10.1177/17585732241281743.
- Longo, U.G. et al. (2023) ‘Conservative management of partial thickness rotator cuff tears: A systematic review’, Sports Medicine and Arthroscopy Review, 31(3), pp. 80–87. doi:10.1097/jsa.0000000000000372.
