How are rotator cuff tears treated?

Dr. K M. Warnock, MD
Orthopedic Surgeon
Not all rotator cuff tears require surgery! Many patients can be treated non-operatively with excellent results. A combination of anti-inflammatory medications, steroid injections, and physical therapy can reduce the pain and increase the strength of the shoulder and thus avoid the need for surgery. Depending on age and activity level of the patient, non-operative treatment can be successful.

Tears will not heal on their own. If a rotator cuff tear causes ongoing shoulder pain and weakness then surgery is generally the recommended treatment. Avoid more invasive surgery later by considering arthroscopic rotator cuff repair. Arthroscopic rotator cuff repair is the state of the art in treatment for rotator cuff tears. The purpose of the surgery is to relieve the symptoms and to repair the injured tendon responsible for causing the symptoms.

A surgeon will evaluate your condition by in consultation, discuss your symptoms and medical history, and use diagnostic imaging tests such as x-rays and MRI (magnetic resonance imaging) or ultra sound to see soft tissue.
Dr. Bruce I. Prager, MD
Orthopedic Surgeon

Rotator cuff tears can often be treated with physical therapy.  If there is a complete tear in the dominant side with weakness and pain, then surgery may be necessary.  Most patients with rotator cuff injuries have pain at night, are unable to sleep on their side and have weakness raising their arms sideways. 

If your symptoms fit the above, I would recommend seeing an orthopedic surgeon to get the correct diagnosis.  Partial thickness tears often do NOT need surgery.

Dr. Kristofer J. Jones, MD
Orthopedic Surgeon

Treatment of rotator cuff tears is typically dictated by the severity of the tear. In the case of small, partial tears, symptoms can often be relieved by rest and activity modification, including avoidance of any activities that require repetitive overhead motion or heavy lifting. An anti-inflammatory medication can be used to reduce pain during everyday activities and help the person tolerate exercises that can be initiated with a specific physical therapy program designed to improve shoulder biomechanics. If an anti-inflammatory does not prove effective, a local cortisone injection into the area can often provide more substantial pain relief.

In the case of full thickness tears where the tendon is completely pulled away from its bony attachment, surgery is recommended to reattach the tendon to its normal anatomic location. Full tears can get progressively larger over time if left untreated, causing further tearing and the potential for muscle atrophy and loss of normal tendon elasticity, which can prevent future successful surgical repair.

Dr. Kristofer J. Jones, MD
Orthopedic Surgeon
Good results for a rotator cuff tear can be obtained through conservative treatment, which involves focused physical therapy designed to strengthen the rotator cuff and the scapular muscles. This will stabilize the glenohumeral joint and prevent any additional or future injury. Isotonic stretching and isometric strengthening work best, although plan to avoid exercises that require a lot of movement during the early phases of treatment, as this will make the shoulder sore. It’s better to hold the muscle and contract it to keep the muscle firing but minimize extreme movement, hence avoiding further irritation of the soft tissues and subsequent inflammation.
Dr. Ron Noy, MD
Sports Medicine Specialist
Most rotator cuff tears are partial or small, and usually do not require surgery. A proper strengthening program at the gym and/or with a physical therapist may be all that is needed to get rid of the pain in the shoulder and improve function. Occasionally, a cortisone injection may be necessary to keep inflammation down during the recovery process, but is an adjunct to the exercise program and not in lieu of it. I like to teach my patients what I call the “No Pain Principle Program” which is the opposite of the “No Pain, No Gain” mentality most of us were raised on as athletes. Essentially this had 3 components:
  1. Painless zone of motion strengthening in 3 planes of the rotator cuff (external rotation, internal rotation and abduction). If you are moving through a painful spot during the exercise, then you are potentially injuring the cuff further and causing more inflammation later, which weakens the cuff.
  2. Scapular (shoulder blade) stabilization exercises, but particularly anything that causes you to stick your chest out when doing them, such as rowing and reverse shoulder shrugs. This will move the acromion bone and/or subacromial bone spur (which are above the top of the rotator cuff and can dig into the cuff during reaching, sleeping and other activities) away from the cuff, thereby opening the space and potentially increasing the painless zone of motion exercises in step Ice the shoulder for 10 minutes afterwards. The reason an NFL quarterback ices his shoulder after a game is not for pain -- every bone in his body hurts after a game -- but rather to prevent the inflammation that will occur later from throwing a football for 3 hours. 
Follow these principles and surgery most oftentimes will be avoided. However, there is a simple test which I teach my students and patients that will predicts whether this will work. If the test is negative, arthroscopic surgery may be necessary. Likewise, if you have a large full thickness tear, surgery is often necessary to repair the tendon back to the bone. This will allow improved function, reduced pain, and promote proper mechanics to help avoid arthritis in the future.
After being diagnosed by a physician for a rotator cuff tear you may be presented two options. The first option is surgery. This will be determined by your physician based on the extent of the tear. The second option is rehabilitation with a physical therapist or athletic trainer. The rehabilitation will consist of basic shoulder strengthening and stretching techniques. The first area that I like to work on is the scapular stabilizers. This is a set of muscles located between your shoulder “blades” that offers the base of support for the rotator cuff. A strong base with these muscles will not only help gain strength in the rotator cuff but will help prevent any further issues.  

The second phase of the treatment plan would be to actually strengthen the rotator cuff. The key to strengthening these muscles is proper form.  

To see a description of how to perform these exercises please see my answer on how shoulder strength can help a libero in volleyball.

Please speak with your physician before beginning any exercise program and seek help from an athletic trainer or physical therapist if you are having trouble performing the exercises because they can watch your form and adjust the weight accordingly.

The "rotator cuff" is actually made up of 4 tendons—the tissue that attaches muscles to bone. When you hear the term "rotator cuff tear" it can mean many different things. A "partial rotator cuff tear" is typically an age-related change that is a very frequent finding on MRI and may not have much clinical significance (many people with no symptoms in their shoulder over the age of 40 will have "positive findings" on an MRI and so we have to be careful about correlating symptoms with MRI findings!).

If you have a symptomatic "partial tear" this is often treated successfully without the need for surgery. This includes instruction in home exercises, physical therapy, anti-inflammatory medicines, and occasionally a cortisone injection if the pain persists. The pain actually comes from associated "bursitis" not usually from the rotator cuff "tear" itself. The bursa is a fluid-filled sac that sits on top of the rotator cuff and is designed to help with smooth, gliding motion (we have bursa all over our body including the hip, knee, shoulder, elbow, etc...). When the bursa gets inflamed we call it "bursitis".

If you have a full thickness tear (tendon detached from bone) this will more often lead to the recommendation of surgery especially if you suffer an acute tear following trauma for example. Many surgeons perform rotator cuff repairs all arthroscopically today and this does minimize the associated trauma to the shoulder but does NOT change the time for healing and recovery. In fact, in many situations you will be asked to delay the onset of post-operative rehabilitation for 4-6 weeks if you have an arthroscopic large or massive rotator cuff repair to decrease the risk of re-tearing.

An important issue to keep in mind is that unfortunately rotator cuff tearing is associated with age-related degenerative changes meaning that you may have a rotator cuff tear and not even know it (especially as we progress beyond the 5th and 6th decades). This is sometimes very frustrating for patients and orthopaedic surgeons to discover that a patient who had no prior symptoms comes in and has a massive (sometimes irreparable) rotator cuff tear. When in doubt, you should always seek medical attention for pain around the shoulder and especially if you notice any associated weakness in the arm.

Rotator cuff tears are treated according to the size, location and chronicity of the tear. A partial tear may not require a repair, but a simple debridement (trimming) of torn tissue. A complete tear requires reattaching the torn tendon back to the humerus (upper arm bone). This is typically done with suture anchors, where an anchor is placed in the bone and the suture attached to the anchor is then looped around the torn edge of the tendon. The tendon is then positioned back to the bone and tied in place.
Both debridements and repairs are typically done arthroscopically. However, for very large rotator cuff tears, an open incision may be required for optimal visualization.

If you have a rotator cuff tear, you should perform a combination of flexibility and strengthening techniques to help your body heal and prevent further injury. Begin by foam rolling your pecs (chest) and latissimus dorsi (lats). Foam rolling is a form of self-massage that can help relax tight muscles before you stretch them. Hold the tender spots for 30 seconds to allow your muscle time to relax and release the knots that are causing tension in the muscle. After you have completed the foam rolling, statically stretch the chest and lats. Hold each stretch for 30 seconds to allow your muscles time to elongate. Next, perform strengthening exercises for the shoulder and core. This can be done by performing stability ball bridges (to help strengthen the muscles that stabilize the core and hips) and the ball combo I (to strengthen the muscles in your shoulder complex). Perform 1-3 sets of 10-15 repetitions of each of these exercises.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.