Posts tagged rotator cuff tear
Physical Therapy Accelerates Recovery From Rotator Cuff Tears
shoulder pain-rotator cuff tear-physical therapy-treatment

Rotator cuff tears are a common finding among middle aged adults with shoulder pain, but are also found among their peers without shoulder pain. Many of us will develop these tears as we age and as we have discussed in previous blog posts there is no difference in outcomes at 1 or 2 years if a patient elects for surgery or Physical Therapy for treatment of their symptoms. Our interventions in Physical Therapy are designed at optimizing shoulder function through manual therapy and strength training exercises allowing patients to return to their prior levels of activity without symptoms. Thankfully many rotator cuff tears improve over time due to the natural history of this injury, but a research study suggests Physical Therapy may accelerate this recovery if utilized early in a patient’s recovery.

Dickinson and colleagues studied 55 patients with rotator cuff tears for up to one and half years after the onset of their symptoms (J Shoulder Elbow Surg. 2019). Patients were broken into two different groups based on their utilization of Physical Therapy interventions. Authors reported patients who received Physical Therapy in the first three months after the onset of their symptoms reported greater improvements in pain and function compared to patients utilizing other interventions such as medication or a wait and see approach. Importantly, Physical Therapy was found most effective in the first 8 week of treatment with limited benefits after this 8 week time frame. Patients are encouraged to utilize Physical Therapy early in their recovery process to accelerate their recovery.

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Will The Bone Spur In My Shoulder Cause A Future Rotator Cuff Tear?
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One commonly sighted reason to perform surgery is to prevent a worsening of an existing pathology. In the shoulder, clinicians aim to preserve important structures such as the rotator cuff with early vs. late surgical interventions despite prior research showing little to no change in progression of tears of rotator cuff tears in patients with a high grade tear. Choosing to delay surgery, without risk of rotator cuff progression, allows a patient to benefit from Physical Therapy. Evidence shows equivocal outcomes between Physical Therapy and surgery for patients with rotator cuff tears. Another structure of concern on a shoulder x ray is a acromion bone spur. In theory, bone spurs on this structure could reduce space between the ball of the shoulder joint and the overlying end of the shoulder blade. New research demonstrates these bone spurs are not as problematic as first theorized.

It has been suggested that a bone spur can lead to shoulder impingement and eventual tearing of the rotator cuff. A recent retrospective study challenged this theory. Yoon et al. examined 119 patients with an intact rotator cuff, diagnosis of impingement, and a 3mm sub-acromial bone spur (Arch Ortho Trauma Surg. 2018). The patients received conservative care including Physical Therapy and received a follow up image to check the cuff integrity as early as 2 years, but as late as 5 years after their initial x ray. The authors found no progression of rotator cuff tears in the 2-5 years after the initial evaluation suggesting the lack of importance the spur relating to tears in the cuff.

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Physical Therapy Improves Pain, Strength, and Function Among Patients with Full Thickness Rotator Cuff Tears

Previous research has documented no difference in long term outcomes between Physical Therapy and surgery for patients with rotator cuff tears.  Many patients with rotator cuff tears, including massive tears, do well with conservative treatment of their shoulder injuries demonstrating improvements in pain, strength, and function.  Strength training makes up the foundation of conservative care for this injury.  A recent review of the evidence documents the power of strength training for patients with rotator cuff injuries.

rotator cuff tear-treatment-exercise-strength

A review of the available evidence in the International Journal of Sports Physical Therapy highlights the evidence of 35 studies examining the use of strength training for patients with rotator cuff injury (Jeanfavre et al. 2018).  The authors reported on the results of strength training on 2010 shoulder with a rotator cuff tear.  Further, they found 73% of these tears were greater than 1 cm and 37% were classified as massive.  37% of these tears were traumatic in nature and 58% of patients experienced symptoms greater than 1 year.  Authors reported 78% of patients improved their symptoms and 85% improved their strength and function after Physical Therapy.  Interestingly, only 15% of patients elected for surgery following a course of Physical Therapy highlighting the effectiveness of conservative management of this injury.  

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What happens to unrepaired full thickness rotator cuff tears?

In our previous blog post we described how few (16%) partial rotator cuff tears progress over time.  Understanding the non progressive nature of the injury allows patients an opportunity to explore non surgical options including Physical Therapy.  In this study they followed partial rotator cuff tears over time, but a more recent study followed patients with full thickness rotator cuff tears over a 5 year period.

Boorman and colleagues followed patients with chronic (> 3 months), full thickness rotator cuff tears (J Shoulder Elbow Surg. 2018).  All patients participated in a comprehensive, Physical Therapy home exercise program.  At 3 months, patients were categorized at successful (asymptomatic with Physical Therapy home exercises) or failure (continued pain and dysfunction).  These patients were then referred for surgical consultation.

At 5 years, 84% of all patients were contacted to determine their current symptoms and functional level.  75% of patients treated non operatively remained asymptomatic with their strengthening program.  Only 3 patients who were initially asymptomatic at 3 months required surgery over the 5 year follow up period.  Importantly, the authors noted no difference in functional outcomes at 5 years between those patients treated surgically or with a home Physical Therapy exercise program.  The authors concluded "non operative treatment is an effective and lasting option for many patients with a chronic, full thickness rotator cuff tear."  This study and our previous blog post challenge the belief that non operative interventions only delay eventual surgical interventions because very few tears regress and very few patients eventually undergo surgical repair.

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Impact of Posture on Rotator Cuff Injury

Posture has a controversial and complex role in musculoskeletal pain.  Some research studies have found zero to weak correlations between posture and pain while other studies have shown it can both impact pain and function.  One area of the body where posture may have a larger role is with shoulder function.  Individuals with limited mid back mobility often demonstrate increased rates of neck and shoulder pain.  A recent study examined the impact of posture on rotator cuff injury and symptoms.

A recent study in the Journal of Shoulder and Elbow Surgery examined 379 individuals during an annual physical (Yamamoto et al. 2014).  Participants were examined for posture, shoulder function, and also underwent an ultrasound examination of their rotator cuffs.  The average age of the participants was 62 years old and consistent with previous research 25% showed a rotator cuff tear in one shoulder and 12% showed a rotator cuff tear in both shoulders.  The authors concluded postural abnormalities were an independent risk factor for both symptomatic or non symptomatic rotator cuff tears.  This study highlights the importance of thoracic posture and mobility for patients with shoulder pain.

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Few Rotator Cuff Tears Worsen Over Time

Previous research has found no significant difference at either 1 or 2 year follow up between Physical Therapy or surgery for rotator cuff tears.  One disproven argument you may still hear against the conservative care of these tears is they may worsen over time including larger tear sizes or further movement of the torn ends (retraction) limiting surgical effectiveness.  This is a logical thought until we consider what the research shows on the progression of these tears.

An article in the American Journal of Sports Medicine followed 362 patients with high grade partial rotator cuff tears to determine the natural progression or regression of these tears over time.  These patients were followed with conservative care including Physical Therapy for up to one year before undergoing a second MRI scan to determine if there were any changes in the torn tendon.  81 patients underwent the second MRI scan.  The authors reported only 16% of patients had a progression of their tear.  Conversely, 60% of patients showed no change in the tear size and 25% of tears improved over time.  Authors stated "decisions to undertake surgery at the time of presentation may be excessive".  

This study highlights the importance of using Physical Therapy first for rotator cuff tears.  Schedule your first appointment with the experts at MEND now/