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A commonly asked question by patients that have been diagnosed with a rotator cuff tear is: “Should I get surgery or not?”. This is not a simple question to answer as each rotator cuff injury is unique and we must look at the entire shoulder complex to answer this.
Shoulder Anatomy
The shoulder or pectoral girdle consists of 4 joints:
glenohumeral joint
acromioclavicular joint
sternoclavicular joint
floating scapulothoracic joint
Directly surrounding the glenohumeral joint or commonly referred to as the “ball and socket joint” are 4 distinct muscles known as the rotator cuff. These four muscles not only provide strength to the shoulder joint but together they act to stabilize the shoulder joint and ensure that the “ball” stays centred in the “socket” during upper extremity movements. The, commonly referred to, SITS muscles (Supraspinatus, Infraspinatus, Teres minor and Subscapularis), arise from the scapula and connect to the head of the humerus, forming a cuff around this glenohumeral joint. These muscles can be used in initiating or assisting with abduction (supraspinatus), internal rotation (subscapularis) or external rotation (infraspinatus and teres minor) of the shoulder joint.
Common Rotator Cuff Injuries
There are many reasons that a rotator cuff muscle can be injured, including:
poor biomechanics
overuse/repetitive load
degenerative/aging tissue
high velocity trauma
poor mobility
In clinic, rotator cuff injuries are seen most commonly in individuals over the age of 40. With aging, muscles lose blood flow and with this decreased nourishment, tendons and muscles are more likely to be injured. Postural issues also become more pronounced with age which puts exaggerated forces on the tissues surrounding the shoulder joint.
The other commonly seen injuries in clinic are as a result of: repetitive overuse with throwing (eg. baseball pitcher) or hitting (eg. volleyball), or as a result of a fall with an outstretched hand (high velocity trauma).
Surgery vs Rehabilitation
There are many types of rotator cuff injuries. They can be identified as partial or full thickness tears, as well as by the number of tendons affected. A partial tear only goes partway into the tendon and is generally described as how deep it goes, not by the width or length. Partial tears can range from 1 mm (10% of a tendon) to many millimetres (>50% of a tendon). A full-thickness tear is when the wear goes all the way through the tendon creating a hole or gap in the tendon and the tendon has pulled away from the humeral head.
On considering which clients are appropriate candidates for surgery, a surgeon must consider many factors including age, overall health/tissue health, smoker or non-smoker, strength of tendon/surrounding tendons, shoulder function, life/work/sporting demands, and biomechanical factors. If there are factors that would diminish the likelihood of a rotator cuff surgery being successful, then a surgeon would likely suggest the individual focus instead on a specific rehabilitative program under the supervision of a physiotherapist.
If surgery is an option, then dependent on the type of surgery and tendon(s) repaired, the client will be given a specific post-operative protocol which can include a period of immobilization and a very specific rehabilitative program. Following surgery, it is very important to try to maintain the health and mobility of the joint and surrounding tissues as much as possible to maximize the likelihood of a successful long-term outcome. Typical post-operative rehabilitative programs range from 6 to 12 months in length.
Other than specific initial restrictions as outlined by the surgeon, the principles of rehab are identical whether the patient undergoes surgery or not. Individuals that do not undergo surgery, can often advance through the rehabilitation process more quickly as they are limited only by pain and function.
If the source of the injury was a result of poor biomechanics and/or repetitive overuse, the physiotherapist will need to address the causative factors. Often a lack of strength or control around the scapulothoracic complex is to blame and thus it is critical that this control be maximized to ensure that the surgical site and/or other structures are not further compromised. It is also important to ensure that the tissue length of all muscles crossing the shoulder joint are maximized to minimize further stress to the rotator cuff. Often pec major and latissimus dorsi are culprits in affecting maximal shoulder mobility. Tightening of the posterior or inferior capsule can also decrease shoulder range of motion and must be specifically addressed. In athletic movement, proper mechanics must be addressed which includes both upper and lower extremity assessment. This includes a comprehensive look at neuromotor patterning/timing, core strength as well as mobility and control of all contributing joints.
In Summary
To conclude, each rotator cuff injury presents with a unique biomechanical picture and contributing factors. In many individuals, specific rehab aimed at improving the overall biomechanics as well as specific strengthening of the shoulder complex can work well to return the individual to full function. In other cases, surgical intervention may be required to ensure the individual is able to regain sufficient shoulder strength and function. A comprehensive rehabilitation program specific to the individual will maximize the likelihood of surgery having a successful long-term outcome.
Karen Nichol, founder of Royal City Physio, graduated from the University of British Columbia with a Bachelor of Science in Physiotherapy. She is currently the head physiotherapist for Coquitlam Adanac Sr A's. She is also a member of the Canadian Physiotherapy Association, and the Physiotherapy Association of B.C. Book with Karen today.