Rotator Cuff Tear
Written by Daniel Manoso Hernando - Physiotherapist at ProPhysio
It has been well known in the medical world that there are a lot of people with tears in their rotator cuff tendons functioning normally with no pain or issues… IS IT TRUE? ABSOLUTELY YES.
According to Templhod et at who published a study in 1999 that investigated over 400 people with no shoulder pain or reported problems, found evidence of a rotator cuff tear in 23% of the patients, furthermore in patient which age is older than 80 they found a incidence of 51% of rotator cuff tear. They concluded that a rotator cuff tears must to a certain extent be regarded as “normal” degenerative attrition, non necessarily causing pain and functional impairment. (1)
More recent studies support these findings, in 2016, Schwartzberg et al concluded that superior labral tears are diagnosed with high frequency using MRI in 45- to 60-year-old individuals with asymptomatic shoulders. These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population. (2)
And Bonsell et al found that radiological analysis in conditions such as subacromial impingement, pathology of the rotator cuff, and acromioclavicular degeneration should be interpreted in the context of the symptoms and normal age-related changes. (3)
Ruptured but functional… how is it possible?
It depends on the location of the tear!!
There is an important part of the rotator cuff called the rotator cable.
Even in the case of tear in the B area, an intact rotator cable helps to maintain the function, the problem is when the tear is in the rotator cable. (4)
What about pain? Surely the amount of pain in the shoulder gives us a clue if its small or large cuff tear?
Well actually NO it doesn't. Pain is a really bad indicator of the amount of cuff damage, in fact it is a bad indicator for most things. Gotoh et al found that when the cuff tendon is only partially torn it releases more pain mediating chemicals than when fully torn, also Carr et al found that its more likely the bursa above the cuff that generates the pain than the cuff tear itself due to its rich innervation. (5,6)
Holmgren et al developed a specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, which was statistically effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three months timeframe used in the study. (7)
Kuhn et al concluded that a non-operative treatment using physical therapy protocol is effective for treating a-traumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years. (8)
You can have a rotator cuff tear and no pain, or you can have pain and a rotator cuff tear, but that a rotator cuff tear could not be the source of your pain.
The amount of pain is not relevant in order to know if there is small or large damage.
Physiotherapy approach has shown scientific evidence on decreasing the pain in patient with a rotator cuff tear.
1. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J shoulder Elb Surg. 8(4):296–9.
2. Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthop J Sport Med. 2016 Jan 11;4(1):2325967115623212.
3. Bonsell S, Pearsall AW, Heitman RJ, Helms CA, Major NM, Speer KP. The relationship of age, gender, and degenerative changes observed on radiographs of the shoulder in asymptomatic individuals. J Bone Joint Surg Br. 2000 Nov;82(8):1135–9.
4. Burkhart SS, Esch JC, Jolson RS. The rotator crescent and rotator cable: an anatomic description of the shoulder’s "suspension bridge". Arthroscopy. 1993;9(6):611–6.
5. Dean BJF, Gwilym SE, Carr AJ. Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain. Br J Sports Med. 2013 Nov;47(17):1095–104.
6. Gotoh M, Hamada K, Yamakawa H, Inoue A, Fukuda H. Increased substance P in subacromial bursa and shoulder pain in rotator cuff diseases. J Orthop Res. 1998 Sep;16(5):618–21.
7. Holmgren T, Björnsson Hallgren H, Öberg B, Adolfsson L, Johansson K. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ. 2012 Feb 20;344:e787.
8. Kuhn JE, Dunn WR, Sanders R, An Q, Baumgarten KM, Bishop JY, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J shoulder Elb Surg. 2013 Oct;22(10):1371–9.