PathologyThe rotator cuff is a collection of muscles (musculus subscapularis, musculus infraspinatus, musculus supraspinatus, musculus teres minor), which together form the main stabiliser of the shoulder joint. A tear in one of these muscles t.h.v. the tendon can undermine the functions of the rotator cuff. When one of the muscles ruptures, it is a rotator cuff tear and is often but not always accompanied by functional impairment and pain deep in the shoulder. A rotator cuff tear is the most common cause of shoulder pain (Longo et al., 2021). In a study by Minagawa et al, it was shown to occur in 22% of the population (Minagawa et al., 2013). Moreover, the same study showed that as many as 65.3% of all tears were present without symptoms. Another study also showed that 7.6% of the population showing no symptoms in the shoulder could be diagnosed with a tear via an MRI scan (Moosmayer et al., 2009). Symptomatic rotator cuff tears account for only 34.7% of all rotator cuff tears. The prevalence of symptomatic and asymptomatic tears increases significantly with age, but with age, asymptomatic tears become more common. You can speak of full and partial thickness tears; in full thickness tears, the tear runs across the entire diameter of the tendon, while a partial tear runs across only part of the thickness of the tendon. Partial tears are the most common, but again you can see an evolution as age increases, as full-thickness tears are more common in an older population than in a younger population (Minagawa et al., 2013). |
Cause of rotator cuff tearsBroadly speaking, there are two main origins of a rotator cuff tear:
The degeneration tear is the most common and develops over a longer period of time. A tear can occur due to overuse and overload of these muscles. Thereby, reduced blood supply can also play an important role in the development of a tear. After all, the tendons recover slower than the muscles after strain so they do not get time to adapt. Consequently, this makes them weaker. The recovery time required after strain also increases with age. A good relationship between load and load capacity is therefore important! However, it is also possible for a rotator cuff tear to occur acutely. This is usually the result of a dislocation (dislocation), a fracture or a fall (Keener et al., 2019). There are also risk factors that increase the likelihood of a rotator cuff tear such as:
If one can identify these risk factors early, your physiotherapist can take them into account. This will ensure a more favourable rehabilitation (Zhao et al., 2021). |
Evolution of the rotator cuff tearBoth pain in the shoulder and reduced range of motion of the arm are major symptoms of a rotator cuff tear. Decreased muscle strength can also be a consequence of a rotator cuff tear. It is possible for the rotator cuff tear to become larger if left untreated. The biggest risk factors for this are the size of the tear and hand dominance. In most patients, symptoms increase as the tear gets larger but this is not always the case making it difficult to describe a general course of symptoms (Keener et al., 2019). Specifically adapted exercise therapy can gradually reduce these symptoms. If one has suffered an acute tear, it is beneficial to start therapy as soon as possible, as this can ensure a faster functional recovery (Houck et al., 2017). Surgery is also a possible treatment strategy but is used less and less. The choice of surgical treatment is mostly related to the age of the person and the severity of the injury, as it has been shown that a higher age and a larger tear involves significantly more relapse and risk of a post-surgical tear. As many as 21% of individuals who undergo surgery experience a new tear within 2 years of surgery (Longo et al., 2021). |
SymptomsGenerally, the symptoms of a rotator cuff tear are a gradual onset of pain, weakness and impaired function of the shoulder (Micallef et al., 2019). However, when the tear is caused by trauma, these symptoms will be acute. |
Articular symptomsJoint mobility will possibly show the following symptoms:
Neurological symptomsNeurological symptoms are usually not present with a rotator cuff tear. |
Muscular symptomsThe tear may reduce the strength in the shoulder. Usually, both the external and internal rotator muscles are affected. Reduced strength may also be present with overhead movements. Touching or applying pressure to the affected tendon may be painful (Longo et al., 2021). If the injury has persisted for some time, it is also possible that the muscle mass of the affected muscles and the muscles around them may decrease. One can possibly observe this by looking at the contours of the shoulder (deltoid muscle) and of the scapula (infraspinatus muscle) (Di Benedetto et al., 2021). Additionally, discomfort may also be present at night when lying on the affected shoulder. OtherWe often also see a deviation from the normal movement pattern to avoid the pain. This is typically the case in athletes. Baseball is a sport where this typically occurs. Because the tear usually occurs in the supraspinatus muscle, baseball players show a deficit when turning the arm inwards (internal rotation) and that they can turn their arm further outwards (external rotation) (Ishigaki et al., 2022). |
Role of physiotherapy and your physiotherapistYour physiotherapist will try to identify the symptoms and the cause of occurrence as best as possible and, based on this, an appropriate treatment will be drawn up. This will be done during the anamnesis. To begin with, your physiotherapist will explain the origin and nature of the injury. This is important preventively to avoid relapses. In this way we reduce the chance of a similar injury to the other shoulder or a recurrence to the same shoulder. During treatment, your physiotherapist will also explain why certain treatment methods are used. The aim is to progressively regain mobility and strength of the shoulder without overstraining the muscles and tendons. Slowly, functional, daily activities are integrated. Physiotherapy examinationThe aim of the physiotherapy examination is to confirm a suspected rotator cuff tear. Your physiotherapist will examine muscle atrophy or observe an antalgic (=pain-avoiding) posture. Next, active and passive movements of the shoulder will be examined. A restriction of certain active movements indicates an (incipient) tear. If passive movements are also restricted, this may indicate a problem other than a rotator cuff tear. It is important to check this already during the 1st consultation to build the right treatment pathway. Depending on which active movement is restricted, one can identify which part of the rotator cuff muscles is most affected. Finally, it is also necessary to do a differential diagnosis to exclude overlapping conditions thv the shoulder. Indeed, there are other lesions at other sites of the body that may elicit similar symptoms. It is certainly important to check whether the cervical spine can be identified as the cause. It is possible that the joints in the neck may radiate to the shoulder, and it is also possible that nerves may be compressed as they exit the spine, which may also radiate to the shoulder. To test this, for example, a spurling test can be performed, in which more compression is applied to the cervical spine to see if this triggers the symptoms. The mobility of the cervical vertebrae is also checked to rule out the presence of a local joint problem in the neck. Finally, it is checked whether the second rib is a cause of the symptoms. Possibly, a movement disorder in the joint between this rib and the spine also causes radiation around the shoulder. By testing the mobility of this joint and any sensitivity it causes, this can be ruled out. Only when the examination is complete can one choose the right treatment strategy. |
Physiotherapy treatmentExercise and manual therapy under the supervision of a physiotherapist is the most common first-line treatment in patients with rotator cuff tears (Micallef et al., 2019). The main goal of physiotherapy is pain relief and functional improvement. This means improving strength and mobility and being able to translate these improvements into activities of daily living. Broadly speaking, treatment can be divided into three parts:
EducationEducation includes information about load structure, progress of treatment and possible reduction/stop of certain activities to optimise recovery. As a patient, it is important to recognise and be able to adjust the balance between load and load capacity yourself. Manual therapyIn manual treatment, we will aim to normalise the range of motion of the shoulder through mobilisations. The physiotherapist moves the shoulder passively in limited directions with the aim of systematically restoring the range of motion. Pain-relieving techniques such as traction of the shoulder joint are also used. Tonus lowering (muscle relaxing) techniques may also be indicated with the aim of avoiding a muscle contracture. |
Exercise therapyProperly structured exercise therapy is the most important part of rehabilitation and includes improving muscle recruitment, scapular stabilisation, coordination of muscle contraction and improving proprioception (Micallef et al., 2019). Being able to actively stabilise and control your scapula with good coordination will optimise the load on shoulder structures. Strength exercises of the rotator cuff are also an important aspect of exercise therapy. An important part of strength training are eccentric exercises, which are exercises where the muscle actively resists extension. These types of exercises have already been shown to be effective in tendon-related injuries in terms of shoulder pain (Dejaco et al., 2017). In particular, they have a good impact on strengthening the tendon. This strength training is given within the pain-free range of motion of the arm. To track the progress of strength in the shoulder, we can use hand-held dynamometry, which is a device that displays your strength through a simple test. The exercises will evolve to functional, sport-specific or job-specific exercises as progression occurs to promote a safe return to activities of daily living (Plancher et al. 2021). |
Revabilitation pathwayWithin each rehabilitation, we always distinguish short- and long-term goals. Depending on the type of pathology, this will differ. |
Short termIn the short term (first month), the goal is to minimise pain and improve range of motion so that one can resume daily functional tasks. |
Long termIn the long term (month two to month four), the goal is to be pain-free over the full range of motion of the shoulder and while performing exercises (Wulf, s.d.). Recovery is not yet final here, though, because the tendon needs further strengthening. After all, remember that you can have a tear even without pain and so it is best to continue building up the load capacity. |
Multidisciplinary approachThe use of analgesic medications, specifically NSAIDs (anti-inflammatory drugs), are recommended at the beginning of treatment if a lot of pain symptoms are present. (Plancher et al. 2021). It is important that your physiotherapist has a clear picture of any medication you are taking. If you continue to overuse the tendon due to pain medication, this can negatively affect recovery. Corticosteroid injections are also sometimes considered but there is no evidence that this gives better long-term results (Lin et al. 2018). If injections are used after rotator cuff surgery, there even appears to be a risk that the tendon will tear again and require revision surgery (Puzzitiello et al. 2020). Thus, if the pain can be controlled by physiotherapy or less aggressive medication, this is preferable. Medical imaging (MRI) is usually not necessary in patients who have a rotator cuff tear. Determining the exact location of the tear will not change the treatment because every muscle of the rotator cuff is included in the treatment. Communication with the doctor is an important aspect of treatment. Indeed, it is important for a physiotherapist to be aware of any medical conditions that increase the risk of a rotator cuff tear, examples include diabetes, high blood pressure and hyperlipidaemia (Giri et al., 2023). In most cases, conservative treatment is the first choice, but surgery may also be more appropriate. This is more likely to be the case with a complete tear. Non-invasive conservative treatment is therefore preferable. If rehabilitation does not progress as expected, then surgical intervention can still be considered. However, it is important to mention that there is no scientific evidence showing that surgery has a better outcome than conservative treatment (Fahy et al., 2022). Clear communication with the doctor is also important in this case. If you are a member of a sports club, communication with the club's coach/physiotherapist is important. This way, we can inform the club about the condition of the injury and discuss possible 'return to sport'. |
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