The rotator cuff is the name for the group of muscles and tendons in your shoulder. The rotator cuff starts on the shoulder blade, extending over your shoulder, with the tendons anchoring on the upper arm bone and surrounding the ball of the shoulder like a cuff—hence the term rotator cuff. The rotator cuff muscles are known as stabilising muscles, because they hold the ball of the shoulder in the socket by balancing the forces of the bigger shoulder muscles. The rotator cuff consists of the supraspinatus, infraspinatus, subscapularis and teres minor muscles.
Are rotator cuff tears common?
Rotator cuff tears are the most common cause of shoulder pain. Tears can be acute (sudden onset) or chronic (long-term fraying). The outcome of your injury can be influenced by the size and location of the tear.
The supraspinatus is the most frequently torn tendon. Partial tears here of just one tendon respond well to physiotherapy. When the tear involves a second or third tendon in the rotator cuff, the effect on the shoulder dynamics, pain and recovery are much worse. In these cases, surgery may be required followed by extensive physiotherapy rehabilitation to regain strength, movement and confidence.
What causes a rotator cuff tear?
Acute tears involve an injury or trauma, usually in people who have had no shoulder pain before (for example, a fall on the arm while skiing). Chronic rotator cuff tears occur gradually and are common as people age. This is because the tendons, which attach the muscles to the upper arm bone, degenerate and fray. Up to 40 per cent of people over 65 will have degenerative tears of their rotator cuff and most do not have pain. Instead, they will notice their arm is weaker with overhead activities.
Younger individuals participating in repetitive overhead activities for their job or sport (such as carpenters, painters, swimmers or throwers) are also more at risk of injuring their rotator cuff. A family history of rotator cuff tears, as well as poor blood supply (which is affected by smoking) can predispose you to a rotator cuff tear.
How do I know if I have a torn rotator cuff?
If you have torn your rotator cuff acutely, you will experience intense pain in the shoulder and upper arm. You may have difficulty lifting your arm or you may have a painful arc of pain between 60 and 120o when you lift your arm out by your side. Chronic tears don’t have that intense pain. However, in both acute and chronic tears, there is a deep, dull ache in the shoulder and you may have difficulty sleeping, particularly if you are lying on that shoulder or on your back. Your arm will feel weak and you’ll have pain reaching for your seat belt or trying to brush your hair.
To confirm whether you have torn your rotator cuff, your physiotherapist will ask you to lift your arm away from your body slightly and turn your hand down, as though you are emptying a can. Your physiotherapist will then push against your arm to see if it is weak and painful.
Your physiotherapist or doctor may send you for an ultrasound scan, which will confirm the diagnosis and determine the size of your tear.
How can physiotherapy help with a torn rotator cuff?
Pain and loss of function after a rotator cuff tear are not related to how long you have symptoms or the size of the tear. The main factors that will affect your recovery are related to your shoulder blade muscles, how these work and how strong they are. This means physiotherapy and sticking to the exercise program your physiotherapist gives you will be most effective in relieving some of your symptoms.
Initially, you may not be able to perform any exercises even if your arm is supported because the pain is too severe. To combat this, your physiotherapist may tape your shoulder to decrease the pain and support the torn tendons. Some of the larger muscles around your shoulder may be working too much to protect your injured shoulder. Your physiotherapist may use dry needling or trigger point therapy into these muscles to help decrease the over-activity.
Your physiotherapist will prescribe exercises and stretches that can be done easily at home and that do not provoke symptoms. The focus will be on the shoulder blade muscles, as 21st century lifestyles (driving a car, computer-based work, etc) mean that these muscles become lengthened and do not work optimally. An easy strategy to overcome this is to elevate your breast-bone (sternum) before you lift your arm. Your physiotherapist may try to loosen your upper and middle spine (thoracic spine) because if your thoracic spine is looser, your shoulder blade muscles will be easier to activate.
As part of your home exercise program, you may be given a light elasticised band or tubing to gently pull out away from your body, particularly with the elbows tucked into the side and the forearms moving out to the side. There are many other exercises that can be given to improve your shoulder’s function, but the main thing is that you need to do the exercises regularly, particularly in the acute phase.
How effective is physiotherapy for rotator cuff tears?
Physiotherapy is very effective in decreasing symptoms of rotator cuff tears. In fact, the outcomes of surgery for rotator cuff tears are no different to the outcomes of physiotherapy. If a patient does not choose to have surgery in the first 12 weeks of physiotherapy, they are unlikely to require surgery.
Taping has been found to be effective in improving range of motion and muscle strength. Strengthening of the shoulder blade muscles has also been effective. If patients stick with their exercise program and believe physiotherapy will be helpful, they are more like to have a successful outcome with physiotherapy.
What can I do at home?
You can improve your posture by elevating your breast-bone (sternum), which will help to activate your shoulder blade muscles and gradually strengthen them. You can also strengthen these by doing the exercise with elasticised tubing where you tuck your elbows into your side and pull your forearms out from your body. To begin with, you need to improve the range (ie, how far you can pull your forearms out), rather than working on the strength, because you want to make sure you stay in your pain-free range. This is not a question of ‘no pain, no gain’.
Initially, you need to minimise your usual activities around the house such as sweeping, putting the clothes on the line or making the bed, as these activities will be painful and may delay healing. Remember that you can use your other arm to help lift the sore arm up, which will keep the range of movement in your shoulder and minimise the risk of the torn rotator cuff becoming a frozen shoulder.
How long until I feel better?
During the first six weeks you will have difficulty sleeping, brushing or touching your hair and putting your seat belt on, as you will have a great deal of pain. In the following six weeks you will see some improvement, but you will still have problems with many activities. Generally speaking, you will be able to return to most activities after six months, but in some cases this may be up to 12 months.