So you have a sore, painful shoulder and you’ve been told it’s a rotator cuff tear. But what does that mean? How do you treat a torn rotator cuff muscle? How do you know if your rotator cuff is torn? Let’s start with the basics…

What is a rotator cuff tear?

Rotator Cuff Muscles

A rotator cuff tear is a very common injury affecting one (or more) of four different muscles in the shoulder. A tear can be partial or complete and can sometimes involve retraction of the tissue. Rotator cuff tears can be painful but they don’t have to be. They can often be associated with a traumatic event…but they don’t have to be! Rotator cuff tears can occur after years and years of use and are much more common in those people over 60.

Symptoms of Rotator Cuff Tear

Rotator cuff tears typically cause local pain in the shoulder. The pain can also travel down the shoulder toward the elbow. Surprisingly though, you may have one right now and not even know! A 1995 study published in the Journal of Bone & Joint Surgery performed MRI’s on people without shoulder pain. They found that rotator cuff tears in 4% of patients under 40 and in 54% of those greater than 60. A similar study found tears in 40% of those older than 50.

How do you know if you’ve torn your rotator cuff?

A skilled practitioner with the appropriate knowledge to diagnose your condition is obviously essential. One benefit of seeing a chiropractor is that we can order the appropriate x-rays right away. Although a rotator cuff tear is a muscular injury, there are clues that can be found on plain x-rays. Combining this information with certain clinical tests performed during your examination can allow for an early diagnosis so treatment is not delayed.

What is the best imaging for rotator cuff tears?

MRI (magnetic resonance imaging) is known to be one of the most accurate tools for diagnosing rotator cuff injuries. In Ontario, the wait can be long so many patients are referred for a diagnostic ultrasound. Although this modality isn’t as accurate, the wait times are usually shorter and can usually provide an early diagnosis.

Surgery for Rotator Cuff Tears

Surgery is appropriate for some individuals, but there are many different factors to consider. Many rotator cuff tears “re-tear” after surgery. Despite this, surgery can still improve function and decrease pain. Delaying surgery can be a bad idea though; your tear can get larger (especially if you’re over 60 years old), it can retract, can become infused with fat tissue and it can also atrophy (shrink). Each of these events will make recovery more difficult. Surgery is usually a more obvious decision for younger patients with a new, severe tear. Older patients have to carefully discuss with their surgeon and weigh out the benefits and risks.

Should I try more conservative treatment first?

According to the evidence, it is usually a good idea to try conservative treatment (like chiropractic or physiotherapy) for approximately six to twelve weeks prior to choosing surgery. This approach is most suitable for those people who still have some strength in their shoulder. Thinking of waiting to see if it improves? It is generally understood that larger tears will not heal with time. In fact, it would be more likely to get worse and retract. Significant retraction can make surgery more difficult.

Physiotherapy for Shoulder Pain

Our Burlington Chiropractic and Physiotherapy clinic offers many different ways to treat rotator cuff tears. Exercise, interferential current, laser therapy, acupuncture, graston or hands on treatment (like Active Release) are some of our “tools”. The best treatment for rotator cuff tears depends on many factors. Age, the duration of your symptoms, your x-ray findings and clinical findings (like strength) all play a role in the decision making process. Give our clinic a call and start with a diagnosis…we’ll help you figure it out!
Email – info@burlingtonsportstherapy.com

References
Hansen M, Otis J, Johnson J et al. Biomechanics of massive rotator cuff tears: implications for treatment. The Journal of Bone and Joint Surgery 2008; 90(2): 316-325.
Keener JD, Wei AS, Kim HM et al. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. The Journal of Bone and Joint Surgery 2009; 91: 1405-1413.
Maman E, Harris C, White et al. Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging. The Journal of Bone and Joint Surgery 2009; 91: 1898-1906.
Sher JS, Uribe JW, Posada A et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. Journal of Bone & Joint Surgery 1995; 77:10-15.
Wolf B, Dunn W, Wright R. Indications for repair of full-thickness rotator cuff tears. Americal Journal of Sports Medicine 2007; 35: 1007-1016.
Zingg PO, Jost B, Sukthankar A et al. Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. The Journal of Bone and Joint Surgery 2007; 89: 1928-1934.

It’s always easier to understand a condition when we simplify it. This happens quite often in the world of physical rehabilitation. An example in the knee would be the diagnosis of patellofemoral syndrome. This is a term that many practitioners use to describe a patients knee pain, yet it doesn’t specifically distinguish between various causes of pain in this area. Quite often patients are diagnosed with a condition in the shoulder called impingement. Again, this is helpful for some patients so that they can understand their condition better, but it is still a very vague term.

Shoulder Impingement Causes

Impingement of the shoulder is much like the name implies; certain structures get pinched which causes pain. This is obviously a very simple explanation of a very complex topic. There are various different types and different causes of impingement in the shoulder. For the practitioners out there, we know there is internal and external impingement. Internal impingement involves compression of tendons (usually) between the head of the humerus and the glenoid labrum. External impingement involves compression of the rotator cuff tendons or the subacromial bursa between the humeral head and the acromion process.

Shoulder Impingement

Functional Shoulder Impingement

At this point I’ve probably already confused the average reader, so the rest of this blog will focus on something more interesting; the various causes of secondary or “functional” impingement. This category of impingement is somewhat fixable in a clinical setting with the help of a manual practitioner.

Decreased Shoulder Movement

For some people, their shoulder impingement is associated with a loss of movement in the shoulder. Specifically, it would be a loss of internal rotation (turning your arm inward). This is something we can detect clinically and can give us clues to various dysfunctions in a patients shoulder. Among other things, this loss of movement alters the axis of motion in the shoulder which can lead to impingement.

Altered Shoulder Blade Movement

The scapula (shoulder blade) can move in a sub-optimal pattern leading to impingement of the shoulder. Termed scapular dyskinesis, the altered movement has a cascading effect on various shoulder tissues. Scapular dyskinesis has various causes and types, but the take-home point is that it can eventually lead to internal impingement in the shoulder.

Rotator Cuff Dysfunction

The various rotator cuff muscles have different prime movements. Together they can serve to depress or hold the humeral head down during abduction. When there is dysfunction in the rotator cuff muscles you can lose this ability and the humerus can translate upwards (resulting in impingement). Of note, rotator cuff injury can also lead to external impingement.

SLAP Lesion

A SLAP lesion refers to damage in the cartilaginous labrum of the shoulder. The labrum lies directly against the head of the humerus, so damage in this area can “get in the way” when we move the shoulder.

Shoulder Instability

Some people have too much laxity in their shoulders. This can be from repeated trauma or can simply be the way they are “built”. In this case, the patient’s humerus translates upwards and compresses various tissues (which is impingement).

Treatment for Shoulder Impingement

In an effort to be more specific and delineate the various causes of shoulder impingement this blog may actually confuse many readers. The take-home point is that sometimes your practitioner may simplify things so you understand them easier. Impingement of the shoulder can be a very complex condition with various causes. Due to this, there are various different ways to properly fix it. For some people, manual treatment and the use of therapeutic modalities are necessary. For others, specific exercises and rehabilitation strategies are indicated.  Active Release Technique, Graston and Laser Therapy are all common methods for treating shoulder pain.  Unsure what to do? Give us a call!

To contact our Burlington clinic – info@burlingtonsportstherapy.com

References
Cools AM, Cambier D, Witvrouw EE. Screening the athletes shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. British Journal of Sports Medicine 2008; 42: 628-635.
Tate AR, McClure P, Kareha S, Irwin D. Effect of the scapula reposition test on shoulder impingement symptoms and elevation strength in overhead athletes. Journal of Orthopaedic & Sports Physical Therapy 2008; 38(1): 4-11.
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The supraspinatus, infraspinatus, teres minor and subscapularis muscles are often referred to as the rotator cuff muscles. Injury to the rotator cuff musculature is one of the more common conditions affecting the shoulder, ranging from mild strains to complete tendon rupture.

Symptoms of Supraspinatus Tear

Rotator cuff injury (including rotator cuff tear) can cause significant pain, weakness and reduced range of motion. Quite often, it causes difficulty with common daily tasks like putting your arm in a coat sleeve, putting your seat-belt on or reaching in the back seat of your car. Of course, there are many different conditions affecting the shoulder that can make these daily activities difficult and painful, so it is important to have this condition properly diagnosed.

Diagnosing Shoulder Pain

Soft tissue imaging (like diagnostic ultrasound or magnetic resonance imaging) is the optimal way to diagnose rotator cuff tears. Unfortunately, there is often a waiting list for these diagnostic tests so the preliminary diagnosis is made clinically in your health practitioner’s office. This is not always a simple step, since the commonly used clinical tests are not always easy to interpret. According to the scientific literature, there does not seem to be a reliable correlation between symptoms and tearing of the rotator cuff muscles. In other words, studies have found that many patients with minimal pain and normal function of the shoulder often have imaging results indicating partial thickness tear of the supraspinatus or full thickness tear of the supraspinatus.

Rotator Cuff Treatment

Consulting with a knowledgeable and skillful diagnostician can eliminate wasted time by deciphering which tissue is likely damaged and focusing treatment on the appropriate structures as quickly as possible.  That’s the first step as it helps to determine what avenue of treatment is best.  For some, surgery is necessary.  For most, conservative treatment like physiotherapy or chiropractic is the best choice.  What is right for you?  There are many factors to consider and we can assist you with that process.  For example, a recent injury might benefit from laser therapy or gentle exercises with our physiotherapist.  For others with more chronic rotator cuff injury (like supraspinatus tendinosis or tendinopathy) active release or graston technique with one of our chiropractors would be the best treatment.  Unsure?  Give us a call or send us an email…we can help you!  905.220.7858  email - info@burlingtonsportstherapy.com

References

Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. British Journal of Sports Medicine 2007; 41: 200-210.

Uhthoff HK, Sarkar K. An algorithm for shoulder pain caused by soft-tissue disorders. Clin Orthop Relat Res 1990; 254: 121-127.

Frost P, Andersen JH et al. Is supraspinatus pathology as defined by magnetic resonance imaging associated with clinical sign of shoulder impingement? Journal Shoulder Elbow Surgery 1999; 8(6): 565-568.

Schibany N, Zehetgruber H, Kainberger F et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J. Radiol; 2004; 51(3): 263-268.

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