“I had a scan and it shows I have a rotator cuff tear…….so I am probably going to need surgery’’’.
If I had a dollar for every time I heard a client tell me this, well I wouldn’t be worrying about winning Tattslotto any time soon. Many clients freak out at the thought of a tear in these muscle, thinking the only two options are surgery or a life of pain and disability. However, rotator cuff tears are incredibly common and rarely need surgery and with appropriate treatment, a pain free full range of motion should be achievable.
Firstly, rotator cuff tears are a normal part of ageing. In fact we start to see rotator cuff tears in people WITHOUT pain or any other symptom from 50 years onwards…..and one study published in 1999 on over 400 individuals with no pain (Templhof et al) found that 23% of them had rotator cuff tears. Another study by Minagowa et al suggested that if you have a rotator cuff tear on imaging and are over the age of 50 you are twice as likely to NOT have any symptoms, with that number increasing four times by the time you reach 80. So like it or not, the more grey hairs you get the more likely you are to have a rotator cuff tear.
But they do not just happen in older individuals. A study by Conner et al showed that up to 40% of elite overhead athletes had rotator cuff tears, with no reported pain or problems.
What about the pain?
Pain is a really bad indicator of rotator cuff tear severity and in fact if surgery is required. In fact, studies have shown that people report more pain with a smaller, partial thickness tear compared to a bigger one. Gotoh et al found that when the rotator cuff tendon is only partially torn there is more pain mediating chemicals than when it is fully torn. Another study by Carr et al found that the bursa above the tear is more likely to produce pain than the tear itself due to it’s rich innervation.
So if I have a tear, what does that mean?
We are often freaked out at the initial diagnosis of a rotator cuff tear, particularly a large one or a full thickness one. This is often because we imagine our rotator cuff tendons being a rope-like structure, not too dissimilar to an Achilles tendon but a lot smaller. Hence our mind conjures images of a frayed rope that has been cut and therefore with some extra force it will rupture. But this is not the case for the rotator cuff tendons.
Why are the rotator cuff tendons different?
The rotator cuff is made up of four muscles; supraspinatus, infraspinatus, teres minor and subscapularis that connect together to form a large, flat, broad tendon that has a relatively large insertion into the humerus. So rather than imagining your rotator cuff tear as a cut through a rope, it is more appropriate to think of it as a hole in a blanket.
Why is this important?
Lets think about it. I’m not sure I trust a cut rope and would most likely throw it in the bin. But a hole in a blanket doesn’t render it useless. It will still keep you warm at night and you can still pull it over onto your side of the bed after your partner steals it off you.
So is it safe to exercise a torn rotator cuff?
Absolutely. In fact the purpose of rehabilitation of a rotator cuff tendon tear is to improve the function and strengthen the area around the hole in the blanket, whilst improving the shoulder movement and reduce their pain. Contrary to popular belief, there is little evidence that rotator cuff tears worsen or increase in size with exercise (Kong et al).
In conclusion, rotator cuff tears are a normal part of our life. Their relevance to shoulder pain might not be as significant as you first thought.
Dr Vaughan Saunders
B Sc (Clin Sc) M Hlth Sc (Osteo)