 A rotator cuff tear is quite simply a tear of your shoulder’s rotator cuff tendons. A rotator cuff tear can occur in two ways:
Traumatic rotator cuff tears occur quickly or under heavy load eg a fall or lifting a heavy weight. However, the most common cause of a rotator cuff tear is repeated micro-trauma, which can occur over several weeks months or years. Repeated rotator cuff injury from straining or pinching the rotator cuff tendons will injure the soft tissue resulting in bruising or swelling. Since there are only a few millimetres separating your rotator cuff tendons from a bony hood (acromion), the additional swelling causes a quicker impingement, catching or squeezing of the rotator cuff tendons. What are Rotator Cuff Tear Symptoms?Your rotator cuff tears may be partial or full thickness tears. You will will notice that your shoulder pain and weakness increases with the severity of your rotator cuff tear. More importantly, it is a reduction in your shoulder function that is important. Partial rotator cuff tear may only present with mild shoulder pain, clicking during shoulder elevation and mild shoulder weakness lifting your hand above shoulder height or reaching behind your back. Full thickness rotator cuff tear will normally present with severe shoulder pain and an inability to lift your elbow away from your body. However, in some cases the rotator cuff tear is so severe that a significant number of your pain fibres are also torn, which can make them less painful but very weak. When you have a small rotator cuff tear you can often still raise your arm with or without pain. Moderate tears are usually very painful and you’ll have difficulty moving your arm. Most patients can’t sleep due to the relentless pain. When a large rotator cuff tear occurs you may find that you are unable to lift your arm at all. What is the Rotator Cuff?Your shoulder’s rotator cuff are a very important group of four small shoulder muscles that stabilise, control and move your shoulder joint. When your rotator cuff muscles work in isolation they exhibit rotational motion at the glenohumeral (shoulder) joint, which is why they are termed the rotator cuff. Your subscapularis, supraspinatus, infraspinatus and teres minor muscles are the four muscles collectively known as the rotator cuff. How is a Rotator Cuff Tear Diagnosed?Your physiotherapist or sports doctor will suspect a rotator cuff tear based on your clinical history and the findings from a series of clinical tests.A diagnostic ultrasound scan is the most accurate method to diagnose the size and location of your rotator cuff tear. MRI’s may show are rotator cuff tear but have also been known to miss a tear. What is Rotator Cuff Tear Treatment?Small and medium size rotator cuff tears usually heal successfully with appropriate conservative management and physiotherapy treatment.Unfortunately, large rotator cuff tears may require rotator cuff surgery if physiotherapy treatment fails to assist. Early rotator cuff tear treatment is important. Delay will result inretraction of your rotator cuff tendon, which can make healing or rotator cuff repair surgery more difficult and less successful.The best rotator cuff tear treatment results occur when the rotator cuff injury is fresh. Rotator Cuff Tear TreatmentRotator cuff tears are a common problem. Rotator cuff injury deteriorates further if you return to sport or work too quickly – especially if a thorough rehabilitation program is not completed. They are also regularly poorly treated by inexperienced shoulder practitioners. Your rotator cuff is an important group of control and stability muscles that maintain “centralisation” of your shoulder joint. In other words, it keeps the shoulder ball centred over the small socket. This prevents other shoulder injuries such as rotator cuff impingement, subluxation and dislocation. Researchers have concluded that there are essentially 7 stages that need to be covered to effectively rehabilitate rotator cuff tears and prevent recurrence. These are: Phase 1 - Early Injury Protection: Pain Relief & Anti-inflammatory TipsAs with most soft tissue injuries the initial treatment is RICE - Rest, Ice, Compression and Elevation. In the early phase you’ll most likely be unable to fully lift your arm or sleep comfortably. Our first aim is to provide you with some relief from pain-provoking postures and movements. This means that you should stop doing the movement or activity that provoked the shoulder pain in the first place and avoid doing anything that causes pain in your shoulder. You may need to be wear a sling or have your shoulder taped to provide pain relief. In some cases it may mean that you need to sleep relatively upright or with pillow support. Your physiotherapist will guide you. Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot. Anti-inflammatory medication (if tolerated) and natural substances eg arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reducing medication. Your physiotherapist will utilise a range of pain relieving techniques including rotator cuff deloading taping, joint mobilisations, massage, acupuncture or dry needling to assist you during this pain-full phase. Phase 2: Regain Full Shoulder Range of MotionIf you protect your rotator cuff injury appropriately the injured tissues will heal. Inflammed structures eg (tendonitis, bursitis) will settle when protected from additional damage. Rotator cuff tears may take several weeks to heal while you await Mother Nature to form and mature the new scar tissue, which takes at least six weeks. During this time period you should be aiming to optimally remould your scar tissue to prevent a poorly formed or lumpy scar that may re-tear in the future. It is important to lengthen and orientate your healing scar tissue via joint mobilisations, massage, muscle stretches, and light active-assisted and active exercises. These should all be pain-free. Researchers have concluded that physiotherapist-assisted joint mobilisations will improve your range of motion quicker and, in the long-term, improve your shoulder function outcome. In most cases, you will also have developed short or long-term protective tightness of your shoulder joint capsule (usually posterior) and some compensatory shoulder muscles. These structures need to be stretched to allow normal movement. Signs that your have full soft tissue extensibility includes being able to move your shoulder through a full range of motion. In the early stage, this may need to be passively (by someone else) eg your physiotherapist. As you improve you will be able to do this under your own muscle power. Phase 3: Restore Scapular ControlYour shoulder blade (scapula) is the base of your shoulder and arm movements. Normal shoulder blade-shoulder movement - known as scapulo-humeral rhythm - is required for a pain-free and powerful shoulder function. Alteration of this movement pattern results in impingement and subsequent injury. Your physiotherapist is an expert in the assessment and correction of your scapulo-humeral rhythm. Researchers have identified poor scapulo-humeral rhythm as a major cause of rotator cuff injury. Any deficiencies will be an important component of your rehabilitation. Plus, they have identified scapular stabilisation exercises as a key ingredient for a successful rehabilitation. Your physiotherapist will be able to guide you in the appropriate exercises for your scapular control. Phase 4: Restore Normal Neck-Scapulo-Thoracic-Shoulder FunctionYou may find it difficult to comprehend, but your neck and upper back (thoracic spine) are very important in the rehabilitation of shoulder pain and injury. Neck or spine dysfunction can not only refer pain directly to your shoulder, but it can affect your nerve’s electrical energy supplying your shoulder muscles and cause weakness. In addition, painful spinal structures from poor posture or injury doesn’t provide your shoulder or scapular muscles with a solid pain-free base to act upon. In most cases, especially chronic shoulders, some treatment directed at your neck or upper back will be required to ease your shoulder pain, improve your shoulder movement and stop pain or injury returning. Phase 5: Restore Rotator Cuff StrengthIt may seem odd that you don’t attempt to restore the strength of your rotator cuff until a later stage in the rehabilitation. However, if a structure is injured we need to provide nature with an opportunity to undertake primary healing before we load the structures with anti-gravity and resistance exercises. Having said that, researchers have discovered the importance of strengthening the rotator cuff muscles. Rotator cuff exercises need to be progressed in both load and position to accommodate for your specifically injured rotator cuff tendons and whether or not you have a secondary condition such as bursitis. Your physiotherapist will prescribe the most appropriate rotator cuff exercises for your injury. Phase 6: Restore High Speed, Power, Proprioception & AgilityIf your rotator cuff tear has been caused by sport it is usually during high speed activities, which place enormous forces on your body (contractile and non-contractile), or repetitive actions. In order to prevent a recurrence as you return to sport, your physiotherapist will guide you with exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance. Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepares you for light sport-specific training. Phase 7: Return to Sport or WorkDepending on the demands of your chosen sport or your job, you will require specific sport-specific or work-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport or employment. Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete return to sport or work. Work-related injuries will often require a discussion between your doctor, rehabilitation counsellor or employer. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a through rehabilitation program has minimised your chance of future injury. SummaryThere is no specific time frame for when to progress from each rotator cuff treatment stage to the next. Your rotator cuff injury rehabilitation status will be determined by many factors during your physiotherapist’s clinical assessment. You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves. It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and frustration. For more specific advice about your rotator cuff injury, please contact your PhysioWorks physiotherapist. What about a Corticosteroid Injections?Corticosteroid injections are often administered to relieve pain and promote tendon healing. Cortisone’s primary function is to increase blood sugar, suppress your immune system, and aid in fat, protein and carbohydrate metabolism. There are side effects and corticosteroid injections should be used cautiously especially with diabetics. It also decreases bone formation and leave you vulnerable to future tendon rupture. Researchers generally find that there is a good short-term benefit from corticosteroids but there are some long-term side effects, which may be less desirable. Some patients report good initial relief before a recurrence of symptoms. As with all medications, a discussion with you doctor regarding the pros and cons should always apply to corticosteroid injections. Rotator Cuff Repair SurgeryRotator cuff repair surgery is considered for full thickness and partial thickness tears that do not heal with physiotherapy. Most shoulder surgeons will recommend at least six weeks of physiotherapy prior to contemplating rotator cuff repair surgery. They do this due to the high percentage of success under the guidance of a shoulder physiotherapist and the knowledge that the recovery from rotator cuff repair will commonly take between six to twelve months of post-operative physiotherapy rehabilitation. During rotator cuff repair surgery, your surgeon will attempt to sew your torn tendon back together. The best results occur when the tear is fresh rather than older tear. You will normally be in a post-operative sling for three to six weeks. Most rotator cuff repairs take approximately six months of rehabilitation to regain as full as possible range of motion, shoulder strength and function. It is important to follow your physiotherapist and surgeon’s post-operative guidelines for your best outcome. In our experience, 80-90% have an excellent outcome at 12 months post-operatively. As with all surgery there are associated risks or complications. These can include infection, stiffness, blood clot formation, and nerve injury. The risks of significant joint stiffness are less than 5% and the risk of nerve injury is very low - approximately 1 in 10000.
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