Author: Bryan Lang, PT, DPT, MHA, CSCS, Cert.DN: Doctor of Physical Therapy, Business Owner, Associate Professor, and Blog Contributor. Explores common client questions, helps find solutions for every day functional health concerns, and interprets difficult theories in healthcare rehabilitation. Committed to life-long learning and education. Learn moe about Bryan on Google+ .
I have seen hundreds of people come into our clinic complaining of shoulder pain. Often, the pain can make it difficult to find a comfortable position to sleep, reaching behind them can send shooting pains, and potentially the worst part of all is that the client usually doesn't know of any reason why the pain started occurring. Often I hear "it just started hurting and I didn't do anything differently."
They come to physical therapy because they want to know what's causing their pain and how they can fix it. Many of these non-traumatic shoulder issues can come from a rotator cuff tear or strain. Once I can conclusively rule in the rotator cuff tear being the culprit of the pain and rule out any other pain referral sources, I often give some facts about rotator cuff tears and many times this opens the dialog for questions from the client. Below are some great facts on non-traumatic rotator cuff tears and some answers to common questions I receive.
The secrets of shoulder pain:
There is NO correlation between the amount of pain someone feels from a non-traumatic rotator cuff tear and the severity of the injury.
A majority of people with non-traumatic shoulder pain are sedentary individuals. In one study, the researchers found that 70% of rotator cuff defects occurred in sedentary individuals doing light work. This implied that you don't have to be using your shoulders all day at work to get a rotator cuff injury and pain from it.
28% or more than a quarter of rotator cuff shoulder pain is on the non-dominant shoulder. Again, this implies that how much you use a shoulder doesn't correlate to if it will become damaged.
Should I get an X-ray or MRI immediately?
No. If the client is having non-traumatic shoulder pain from a rotator cuff tear, imaging will not give a physical therapist any additional useful information that a thorough examination didn’t already tease out. Physical therapy treatment protocols are not based on imaging, but on pain and function. If pain is decreasing and function is improving, we don’t need an image to tell us we’re on the right track. If things aren’t improving, then an image is warranted.
The other reason why I don’t like to get an image first for non-traumatic tears is that it can lead to false positives. The prevalence of rotator cuff tears in the general population is 22.1% and increases as we age. However, asymptomatic tears were two times more common than symptomatic tears. This means that you can have a rotator cuff tear and have no pain. In fact, it’s more of the norm to have a tear with no pain than to have a tear that causes pain. So just because you have something on an image, doesn’t mean it’s the true cause of your pain.
What if my tear doesn’t heal?
A study by Yamanaka and Matsumoto found out this exact answer. The researchers concluded that after 1 year of identifying a rotator cuff tear, 10% were healing due to the reduction in the size of their tear, 30% had no change in the size of their tear, and 50% of the subjects had an increase in their tear. However, those with increased tearing reported higher IMPROVEMENT scores in function and REDUCTION in pain. To answer the question, if your tear doesn’t heal, this study shows that you’ll probably have less pain and more function. What a weird concept because it’s the inverse of what you would expect.
Should I get surgery?
You can’t beat this study to give you an answer to this question. Here’s how the study went:
180 subjects with non-traumatic rotator cuff tears were placed into three groups
Group 1: Physical therapy only
Group 2: Physical therapy and acromioplasty (surgery but no rotator cuff repair)
Group 3: Physical therapy + acromioplasty + rotator cuff repair (surgery with repair of the cuff)
And guess what their conclusion was?
“Results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.”
Therefore, in my opinion, you need to give physical therapy 4-8 weeks before we even discuss surgery. If we aren’t seeing improvement in strength, range of motion, and pain after that long, then a consult with an orthopedic surgeon would be an appropriate next step.
If you wake up with shoulder pain for no apparent reason tomorrow morning, don’t worry. You’re in good hands with a skilled physical therapist.