Rotator Cuff Tear: Surgery or Physiotherapy?

22%Rate of full-thickness rotator cuff tears found among 664 people screened in a village in Japan

65%Share of these tears that caused no symptoms at all

37%Rate of full-thickness tears over the age of 80; 11% in people in their 50s

75%Patients who did not need surgery for 2 years with a physiotherapy programme

What is it?

The rotator cuff tendons get thinner and wear with age. Over time, a tear can form through part of the tendon (partial) or through its whole thickness (full-thickness). The supraspinatus tendon, at the top of the shoulder, is the one most often affected. Sometimes a tear is caused by an injury, such as a fall, a dislocated shoulder or suddenly lifting a heavy load.

Screening studies show that full-thickness tears become much more common with age and that most cause no symptoms. So a tear seen on an MRI does not, on its own, decide your treatment.

Symptoms

Pain on the outside of the shoulder when you lift your arm out to the side or forwards
Pain that gets worse at night, especially when you lie on that shoulder
Weakness when you lift or rotate your arm
Difficulty brushing your hair, reaching up to a high shelf or reaching behind your back
Suddenly being unable to lift your arm after an injury

Surgery or physiotherapy?

In the MOON study in the US, which followed 452 patients with a full-thickness tear not caused by trauma, about 75% of patients did not need surgery for 2 years after a physiotherapy programme. Those who chose surgery mostly did so within the first 6–12 weeks; after that, few patients went on to have surgery.

In a study in Finland of patients over 55 with small tears not caused by trauma, physiotherapy gave results as good as surgery at an average follow-up of 6 years; satisfaction was 88–92% in every group. However, another study in Norway, of small and medium-sized tears, found better results after 10 years in the group that had a repair.

That is why the decision is an individual one. Early orthopaedic assessment is important for tears that start suddenly, such as being unable to lift your arm after a fall or a blow, and for young, active patients. For tears caused by wear, a regular physiotherapy programme is usually tried first.

Treatment

ExerciseExercises that strengthen the healthy parts of the rotator cuff, the muscles around the shoulder and the shoulder blade muscles, and maintain your range of movement.
Adjusting the loadOverhead tasks and heavy lifting that clearly increase your pain are cut back for a while; the arm is not put in a sling, and you keep using it in daily life.
Pain controlCold or heat, and painkillers recommended by your doctor, make it easier to keep exercising.
Manual therapyHands-on treatment for the shoulder and upper back, combined with exercise, can help reduce pain and improve movement.
SurgeryAn orthopaedic specialist assesses the need for surgery for traumatic tears, for young and active patients, and when symptoms do not improve despite regular physiotherapy.

Exercises at home

Six exercises for the shoulder

Do the exercises within a pain-free or mildly painful range; if your pain is no worse the next day, carry on. Start with isometric exercises and move on to light weights as the pain eases.

Door frame external rotation

Stand with your painful side next to a door frame. Bend your elbow to 90 degrees and keep your arm against your side; you can put a small folded towel in between. Press the back of your hand against the door frame without letting your arm move. Hold for 30–45 seconds, pressing only as hard as you can without increasing the pain.

5 reps, 1–2 times a day

Side-lying external rotation

Lie on your pain-free side. Bend the elbow of your top arm to 90 degrees and rest it against your waist. Holding a light weight (a full water bottle will do), lift your hand towards the ceiling while keeping your elbow still, then lower it slowly.

10–15 reps, 2–3 sets

Scaption (angled arm raise)

Stand with your arms by your sides and your thumbs pointing up. Raise your arms forwards and slightly out to the sides, at an angle of about 30 degrees, up to shoulder height; you can hold a light weight in each hand. Lower them slowly, without lifting your shoulders towards your ears.

10 reps, 2–3 sets

Resistance band row

Tie a resistance band to a door handle or another sturdy anchor at chest height. Holding the ends of the band and keeping your elbows close to your body, pull back and squeeze your shoulder blades together. Slowly return to the start.

10–15 reps, 2–3 sets

Wall slides

Stand facing a wall and rest your forearms against it at shoulder height. Slide your arms up the wall as far as you can without pain, feeling your shoulder blades glide forwards and upwards. Slowly return to the start.

10 reps, 1–2 times a day

Shoulder blade squeeze

Stand or sit up straight. Without lifting your shoulders towards your ears, draw your shoulder blades back and slightly down towards each other. Hold for 5 seconds, then relax.

10–15 reps, twice a day

Video

Videos for the rotator cuff

From the YouTube channel of US physical therapists Bob Schrupp and Brad Heineck.

Three exercises for the rotator cuff

Basic movements to strengthen the muscles that rotate the shoulder.

Ten exercises for shoulder pain

Exercises used for impingement, bursitis and rotator cuff problems.

Videos belong to the Bob & Brad channel.

Frequently asked questions

My MRI shows a tear. Should I have surgery?

Not always. Shoulder tears are common with age, and most tears cause no symptoms. For tears not caused by a fall or a blow, physiotherapy is usually tried first; surgery is considered for tears that do not improve or that were caused by a sudden injury.

Will the tear heal with physiotherapy?

A full-thickness tear does not usually close up on its own. But once the healthy parts of the rotator cuff and the shoulder blade muscles get stronger, the shoulder can often become pain-free and work well despite the tear.

Which side should I sleep on at night?

Lying on the painful shoulder can make the pain worse. It may help to lie on your good side with your painful arm resting on a pillow in front of you, or to support your arm with a pillow when you lie on your back.

Can exercise make the tear bigger?

Controlled exercise, increased gradually, is considered safe and is the foundation of treatment. For a while, cut back on heavy lifting and overhead strain that clearly increase your pain; keep up your exercises as far as the pain allows.

When to seek help right away

See a doctor without delay if you have any of the following:

Being completely unable to lift your arm after a fall or a blow
A change in the shape of the shoulder, or a suspected dislocation
Redness or warmth in the shoulder, or a fever
Numbness, tingling or loss of strength spreading into the arm
Left shoulder and arm pain together with chest pain, shortness of breath or sweating (call 112)

Sources

Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: from mass-screening in one village. J Orthop. 2013;10(1):8-12.
Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22(10):1371-1379.
Kukkonen J, Joukainen A, Lehtinen J, et al. Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years: over 5-year follow-up of a randomized controlled trial. J Shoulder Elbow Surg. 2021.
Moosmayer S, Lund G, Seljom US, et al. At a 10-year follow-up, tendon repair is superior to physiotherapy in the treatment of small and medium-sized rotator cuff tears. J Bone Joint Surg Am. 2019.