Physical Therapy for Rotator Cuff Tear
What is a rotator cuff tear?
A rotator cuff tear is an injury to one or more of the four muscles and their associated tendons that make up the rotator cuff in the shoulder. These muscles and tendons are crucial for shoulder stability and movement. The rotator cuff consists of:
Supraspinatus: Located at the top of the shoulder.
Infraspinatus: Located on the back of the shoulder.
Teres Minor: Located just below the infraspinatus.
Subscapularis: Located on the front of the shoulder.
What is a partial thickness rotator cuff tear?
A partial thickness rotator cuff tear involves damage to the rotator cuff tendons that does not extend all the way through the tendon. In other words, the tear only goes partially through the tendon’s thickness. This might mean that the tendon is frayed or has a defect on one side. This can lead to weakness and loss of function. The rotator cuff has four tendons that can be affected, and a partial thickness tear can occur in any of these tendons.
Partial thickness rotator cuff tears are categorized based on their location relative to the shoulder joint's anatomy. Two key types are articular and bursal tears:
Articular Rotator Cuff Tear
Location: Occurs on the side of the rotator cuff tendon that is closest to the shoulder joint (the articular side). This is the surface of the tendon that faces the joint cavity.
Characteristics: These tears often result from chronic wear and tear or degenerative changes. They can be associated with conditions like shoulder impingement syndrome, where the tendons get pinched or irritated during shoulder movements.
Bursal Rotator Cuff Tear
Location: Occurs on the side of the rotator cuff tendon that is closest to the bursa (the bursal side). The bursa is a fluid-filled sac that reduces friction between the rotator cuff tendons and the overlying bone (the acromion) of the shoulder.
Characteristics: These tears are often associated with impingement syndrome, where the tendons rub against the bursa and the acromion, leading to irritation and tearing. They are frequently seen in cases of acute trauma or repetitive overhead activities.
What is a full thickness rotator cuff tear?
A full thickness rotator cuff tear, also known as a complete tear, is a more severe type of rotator cuff injury where the tear extends all the way through the tendon, creating a gap between the torn edges. This means the tendon is completely severed in the affected area and no longer intact. This can lead to significant weakness and loss of function.
What causes a rotator cuff tear?
A rotator cuff tear can be caused by a variety of factors, including:
Repetitive Stress or Overuse: Engaging in repetitive activities or sports that require overhead movements, such as baseball, tennis, or weightlifting, can put excessive stress on the rotator cuff tendons, leading to wear and tear.
Acute Injury: A sudden trauma or injury, such as a fall or lifting a heavy object, can cause a tear in the rotator cuff. This type of tear is often referred to as an acute or traumatic tear.
Age-Related Degeneration: As people age, the tendons in the rotator cuff can become weaker and less flexible. This degenerative process can make the tendons more susceptible to tears, even with minor stress or injury.
Poor Posture or Mechanics: Improper posture or incorrect techniques during physical activities can contribute to strain on the rotator cuff muscles and tendons, increasing the risk of tears.
Genetic Factors: Some individuals may have a genetic predisposition to rotator cuff injuries due to the structural characteristics of their shoulder joints or tendons.
Underlying Conditions: Certain conditions, such as shoulder impingement syndrome or arthritis, can contribute to rotator cuff tears by causing inflammation or increasing mechanical stress on the tendons.
What does a rotator cuff tear feel like?
A rotator cuff tear can cause a range of symptoms, which might vary in intensity based on the severity of the tear. Common sensations and symptoms include:
Pain: The most noticeable symptom is often pain in the shoulder, which can be sharp, dull, or aching. This pain is usually felt in the upper arm or the front and side of the shoulder. It may worsen with specific movements or at night.
Weakness: You might experience weakness in the shoulder, especially when trying to lift objects or reach overhead. This weakness can make daily activities, like lifting or reaching, more challenging.
Limited Range of Motion: A torn rotator cuff can lead to a reduced range of motion in the shoulder. You may find it difficult to move your arm through its full range or perform tasks that require shoulder flexibility.
Clicking or Popping Sounds: Some people hear clicking or popping noises when moving their shoulder, which can be related to the tear or associated inflammation.
Difficulty Sleeping: Pain from a rotator cuff tear often worsens at night, which can make it hard to find a comfortable sleeping position. It is most painful when attempting to lay on the side of the painful shoulder.
Shoulder Instability: In some cases, the shoulder might feel unstable or like it could "give out" when moving it in certain directions.
Pain Radiating Down the Arm: The pain might radiate down the upper arm and sometimes into the neck or upper back, depending on the extent and location of the tear.
Can an x-ray show a rotator cuff tear?
X-rays cannot visualize soft tissue structures, so they won’t directly show tears in the rotator cuff tendons. For a clear view of these soft tissues, other imaging modalities are preferred. However, X-rays can help identify bone changes associated with rotator cuff tears, such as bone spurs or joint degeneration, which might contribute to rotator cuff problems.
What test is used to identify a rotator cuff tear?
Here are some tests that our physical therapists use to identify a rotator cuff tear:
Empty Can Test (Jobe Test): The patient extends their arms out to the side and then brings them forward to about 30 degrees with the thumbs pointing down (like emptying a can). The examiner applies downward pressure to the arms while the patient resists. Pain or weakness during this test can indicate a rotator cuff tear, particularly involving the supraspinatus muscle.
Drop Arm Test: The patient is asked to raise their arm to the side and then slowly lower it. If the arm drops suddenly or the patient has significant pain, it may suggest a rotator cuff tear.
For a definitive diagnosis, imaging studies such as an MRI or ultrasound are often used to visualize the rotator cuff and assess the extent of any tears.
Do rotator cuff tears heal on their own?
Rotator cuff tears don’t heal on their own. What matters most is the size of the tear. According to this study partial tears tend to enlarge over time and progress to a full thickness tear. One study found that in rotator cuff tears involving ≥ 50% of the tendon thickness, 55% had tear progression over 4.4 years; whereas, in patients with tears involving < 50% of the tendon thickness, only 14% had tear progression.
With full-thickness tears, there is a greater risk of tear enlargement, progression of muscle degeneration, and higher risk of pain development, according to this research review.
Full-thickness tears or more significant injuries often do not heal on their own and may require surgical intervention to restore function and alleviate pain. The healing process also depends on factors such as the size of the tear, the age of the individual, and overall shoulder health.
Can a partial rotator cuff tear heal on its own?
Anatomically, the tear itself usually does not heal due to poor blood supply to the rotator cuff tendons. However, pain and function can often be improved with conservative treatment.
According to this study, small or minor rotator cuff tears (<50% affected) are more likely to improve with rest, physical therapy, and modification of activities that stress the shoulder.
Can a rotator cuff tear heal without surgery?
As we mentioned, the tear itself usually does not heal but pain and function can often improve without surgery, especially when managed conservatively. This systematic review found that nonoperative management, including physical therapy and medications, can lead to significant improvements in pain and function in many patients with rotator cuff tears.
Can physical therapy help with a rotator cuff tear?
Physical therapy can help, especially if you have a partial rotator cuff tear where less than 50% of the tendon is affected, according to this article.
Physical therapy can help by improving strength, flexibility, and range of motion in the shoulder. It also addresses pain and can enhance overall function. The ultimate goal is to help you return to your daily activities with reduced discomfort.
Techniques often include stretching exercises, strengthening exercises, and manual therapy. Stretching exercises should target the shoulder's range of motion and flexibility of the posterior capsule. Strengthening exercises should focus on the muscles around the rotator cuff and shoulder blade. Other exercises should be included to address shoulder and scapular movement control and postural control. Manual therapy techniques include joint mobilizations and soft tissue massage to decrease pain, decrease tightness, and improve movement.
What are the best rotator cuff tear exercises?
The best rotator cuff exercises are determined based on where the individual is in their rehab process. We utilize the evidence from this study to guide us in our decision making process.
Here are some of our favorite rotator cuff exercises, with progressions:
External Rotation Isometric
Internal Rotation Isometric
Sidelying External Rotation (can add weight)
External Rotation Progression
Scaption
Quadruped T
Prone T
Scapular Push Up Progression
How to sleep with a rotator cuff tear
Sleeping with a rotator cuff tear can be challenging. Try sleeping on your back with a pillow under your affected arm to keep it supported. If side-sleeping is more comfortable, you can try sleeping on the unaffected side with a pillow to prop up your affected arm. Avoid placing pressure directly on the affected shoulder.
Closing Remarks
If you need treatment after a rotator cuff tear, contact us below to speak with a physical therapist.
Disclaimer: This is not intended to be formal medical advice. Your individual needs should be met by the appropriate health care practitioners. Please consult with a trusted provider.
Dr. Vincent Liu PT, DPT
Doctor of Physical Therapy
The Game Plan Physical Therapy