The shoulder is one of the most mobile joints in the body. That incredible range of movement allows us to throw, swim, lift, reach, push, pull and perform everything from high-level sport to everyday activities like getting dressed or reaching into a cupboard. But that mobility also means the shoulder relies heavily on the muscles and tendons around it to provide control and stability.
The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint. They originate from the shoulder blade and attach to the upper end of the humerus, helping to keep the head of the upper arm bone centred within the relatively shallow socket of the shoulder. The four muscles are subscapularis (attaches the front of the shoulder) supraspinatus, (at the top) and the infraspinatus and teres minor (sit at the back of the shoulder).
Rotator cuff problems are incredibly common, and they become more common as we age. But this is where things get interesting, as the presence of a rotator cuff abnormality does not necessarily mean that you have a painful shoulder.
Just like tendons elsewhere in the body, the rotator cuff undergoes changes throughout our lives. Tendons are living tissues and are influenced by the same metabolic, hormonal, genetic and loading factors that affect the rest of our musculoskeletal system. As we get older, it is increasingly common to see tendons that look different on ultrasound or MRI. There may be thickening, changes in tendon structure, partial tears or even full-thickness tears. And many of these changes are completely asymptomatic.
Studies have found that rotator cuff abnormalities are present on MRI in the vast majority of people over the age of 40. Full-thickness rotator cuff tears can also be found in a significant proportion of older adults who have no shoulder pain at all. So if you are over 40 and have a shoulder MRI, don't be surprised if the report doesn't say “normal”. This is important because we can easily fall into the trap of assuming that the abnormality on the scan must be the cause of the pain.
But an MRI shows us structure. It doesn't tell us exactly how that structure is behaving, how strong you are, how irritable your shoulder is, what activities you are doing, how your shoulder responds to load or what you need your shoulder to be able to do. That is why two people can have very similar MRI findings but completely different symptoms and functional abilities.
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So why does my shoulder hurt?
This is the question that matters. If a rotator cuff tear is visible on an MRI, it may be contributing to your symptoms. But it may also be an incidental finding. Your symptoms, strength, movement, training history, occupational demands, sleep, general health, previous injuries and response to loading all form part of the clinical picture.
This is why we don't want to look at imaging in isolation. Instead, we want to understand what your shoulder can currently tolerate and what you need it to be able to tolerate.
For an elite swimmer, that might mean repeatedly producing force overhead for hours each week. For a tradesperson, it might mean lifting and working above shoulder height throughout the day. For a parent, it might simply mean being able to pick up their child without pain.
The same imaging finding can have completely different implications depending on the person.
As Jo Gibson has highlighted in her work with rotator cuff-related shoulder problems, an important question is not simply “Is it torn?”, but “Does the tear matter?”
That shift in thinking is incredibly important. Rotator cuff tears aren't all the same. Rotator cuff tears can occur suddenly following an injury, or develop gradually as the tendon changes with age and loading. A traumatic tear may occur following a significant event, such as falling onto an outstretched arm or experiencing a sudden force while lifting, throwing or playing sport. Other tears develop gradually over time. As the tendon changes with age, it may become less tolerant of certain loads and a tear can develop without one specific injury. These two situations can require very different approaches.
Loading is part of the treatment
For most people with rotator cuff-related shoulder pain, rehabilitation is centred around progressive loading and symptom modification exercises.
This is important because rest alone does not build capacity.
Rest may calm an irritated shoulder in the short term, but if we want the shoulder to become stronger and more resilient, it needs to be exposed to an appropriate level of load.
How can Physiotherapy help?
Physiotherapy for rotator cuff problems is therefore about much more than treating the tendon itself. We look at the entire shoulder and the person attached to it.
We assess strength, movement, pain, function and the demands being placed on the shoulder. We then use progressive exercise and symptom modification exercises to address the areas that need improving. For some people, the focus may initially be on restoring comfortable movement and basic strength. For others, it may be about developing substantial strength and power so they can return to high-level sport.
And sometimes the most important part of physiotherapy is helping someone understand their diagnosis. Being told that you have a “tear” can understandably make people fearful of moving their shoulder. But a tear doesn't mean your shoulder is broken. It doesn't automatically mean you need surgery. And it doesn't mean you need to stop using your arm.
I am not completely opposing surgery, as surgery has a role and surgery is an important option for some people. Acute traumatic tears, particularly in younger or highly active individuals with significant weakness or loss of function, may benefit from surgical assessment. Some people also consider surgery when they have persistent symptoms and functional limitations despite an appropriately designed and sufficiently long rehabilitation programme. But surgery isn't automatically required simply because a tear appears on an imaging.
For many people, particularly those with degenerative rotator cuff tears, rehabilitation can provide substantial improvements in pain, strength and function.
If you are experiencing shoulder pain or have recently been told you have a rotator cuff tear, our physiotherapists can help you understand what your diagnosis means and develop a rehabilitation plan based around your goals.
Agout C, Berhouet J, Spiry C, Bonnevialle N, Joudet T, Favard L, Society FA. Functional outcomes after non-operative treatment of irreparable massive rotator cuff tears: Prospective multicenter study in 68 patients. Orthopaedics & Traumatology: Surgery & Research. 2018 Dec 1;104(8):S189-92.
Cavalier M, Jullion S, Kany J, Grimberg J, Lefebvre Y, Oudet D, Grosclaude S, Charousset C, Boileau P, Joudet T, Bonnevialle N. Management of massive rotator cuff tears: prospective study in 218 patients. Orthopaedics & Traumatology: Surgery & Research. 2018 Dec 1;104(8):S193-7.
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