Can Physical Therapy for Rotator Cuff Tears Prevent Surgery?

Rotator cuff repair surgery and postoperative rehabilitation continue to be some of the most debated topics on the shoulder at orthopedic and physical therapy conferences.  Numerous studies have been published showing the failure rate of rotator cuff repair surgery ranges anywhere from 25-90%.

rotator cuff tearWhile this failure rate is certainly alarming, the term “failure” must be defined.  In traditional study models, success is defined as an intact rotator cuff, which makes sense.  However, one of the more interesting findings in most of these studies is that despite the “failed” repair, most patients are quite satisfied with their functional status and outcome.  This really does have to make you question how we define “failure” as patient outcomes and satisfaction seems more important than radiological findings.

These studies have sparked debate over the role of postoperative physical therapy follow rotator cuff repair surgery, with many physicians becoming more conservative and slowing down their protocols.  This obviously implies that some physicians believe that early physical therapy is the reason why failures occur.  This thinking may be flawed and factors such as tissue quality, tear severity, patient selection, surgical technique, and others may be more likely related to ultimate failure rates.

Another perspective to consider is that despite having a failed rotator cuff repair, patient satisfactions were good.  From experience, I can tell you that patients are satisfied when they:

  1. Have less pain
  2. Regain their mobility
  3. Return to functional activities

So the question really should be asked – if there is up to a 90% surgical failure rate but significant increase in satisfaction and outcomes, can physical therapy for rotator cuff tears alone without surgery be just as beneficial at helping patients reduce pain, regain mobility, and return to their activities?

 

Can Physical Therapy for Rotator Cuff Tears Prevent the Need for Surgery?

A recent study in the Journal of Shoulder and Elbow Surgery looked at this exact question.  The MOON Shoulder Group, which is a multi-center network of research teams around the country, followed a group of 381 patients with atraumatic full-thickness tears of the rotator cuff for a minimum of two tears.  The mean age of the patients was 62 years with a range of 31-90 years.

The patients performed 6-12 weeks of nonoperative physical therapy focusing on basic rotator cuff strengthening, soft tissue mobilization, and joint mobilizations.

At the six-week mark, patients were assessed and 9% chose to have rotator cuff repair surgery.  Patients were again assessed and the 12-week mark.  At 12-weeks, an additional 6% chose to have surgery.  In total, 26% of patients decided to have surgery by the 2-year follow-up mark.  Statistical analysis revealed that if a patient does not choose to have surgery within the first 12-weeks of nonoperative rehabilitation, they are unlikely to need to surgery.

Nearly 75% of patients avoided rotator cuff repair surgery by performing physical therapy despite having full thickness cuff tears. [Click to Tweet]

That is a pretty significant finding.

 

Keys to Nonoperative Rotator Cuff Rehabilitation

The results of this study could have a large impact on how we treat rotator cuff tears.  Physical therapy should be attempted prior to surgery, even in the case of a full thickness tear.  To maxmize these outcomes, a comprehensive rehabilitation program should be developed.  When working on patients with rotator cuff tears, I tend to focus on 3 key areas.

Restore Shoulder Mobility

This includes both passive and active mobility.  For passive mobility, it seems to me that shoulder range of motion is gradually lost as the rotator cuff symptoms increase.   Perhaps it is a pain avoidance strategy, disuse, or some other factor.  You’ll often find glenohumeral joint capsule hypomobility and soft tissue restrictions.  Soft tissue mobilization, joint mobilizations, and range of motion exercises should be designed based on the specific loss of motion exhibited by the patient.

Restore The Ability of the Rotator Cuff to Dynamically Stabilize

This is essentially the same as restoring active mobility of the shoulder.  The rotator cuff has to function properly to allow active mobility without restrictions.  In a previous article, I discussed the suspension bridge concept and how you can have a rotator cuff tear without symptoms.  You can see in this diagram that if you have properly functioning anterior and posterior rotator cuff muscles, you can often still elevate the arm despite a tear to the supraspinatus.

rotator cuff suspension bridge concept

Exercises designed to enhance strength and dynamic stability of the shoulder should be incorporated.  In my experience external rotation strength tends to be the most limited and needs to most attention.

Reduce the Impact of the Kinetic Chain

In addition to restore mobility and stability of the shoulder, you should also consider the impact of the kinetic chain on shoulder function.  Read my past article on the different types of shoulder impingement to understand some of these concepts.  Any dysfunctions of the scapulothoracic joint, cervical spine, thoracic spine, and lumbopelvic complex should be assessed.  These areas all have a significant impact on the alignment, mobility, and stability of the glenohumeral joint.

If you want to learn more about how I perform nonoperative rehabilitation for rotator cuff tears, I have a past webinar on shoulder impingement that discusses many of the same keys to treatment.

Using these principles, you can formulate a rehabilitation program that could potentially save 75% of people with rotator cuff tears from needed rotator cuff repair surgery.  Hopefully studies like this will continue to shed light on the impact physical therapy can have on the satisfaction and outcomes of patients with rotator cuff tears, with or without surgery.

 

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14 Responses to “Can Physical Therapy for Rotator Cuff Tears Prevent Surgery?”

  1. Thanks for sharing this, Mike. It’s very helpful to be armed with strong, current research when patients are often looking to their PT for guidance and an honest assessment about the need for shoulder surgery.

  2. Mike,

    This study was very interesting and very powerful for us as clinicians. In this study the majority of patients had tears isolated to the supraspinatus. I think this is an important point for clinicians. If we look at patients with larger multi-tendon cuff tears will we get the same result?

    Also we not only want to help patients in the short term but also in the long term. With that in mind we need to consider if rehab is not only improving the patients symptoms but also the joint mechanics. If we are not reestablishing normal joint mechanics with rehab but surgery is then that might change our decision since we also want to decrease the risk of early glenohumeral OA. A recent study looked at this following surgery and found that surgery doesnt reestablish the normal shoulder mechanics (http://www.ncbi.nlm.nih.gov/pubmed/21737834). If this is the case maybe the mechanics is domed either way and patients will be at risk for OA. At Penn we have done several recent basic science studies looking at the effect of overuse on the remain intact rotator cuff tendons and the glenoid cartilage following various rotator cuff tears (http://www.ncbi.nlm.nih.gov/pubmed/23280495 & http://www.ncbi.nlm.nih.gov/pubmed/23764174). When we look across tear size (supraspinatus only vs supraspinatus/infraspinatus) we see that the tears involving the infraspinatus have much more degradation of the remaining tendons and the cartilage. We also see a decrease in shoulder function. Based on the location of these changes in the cartilage it seems that the addition of the infraspinatus is affecting the anterior/posterior force balance of the shoulder thereby leading to less dynamic stability and more glenohumeral translations. Maintaining the force balance is very important to joint mechanics but also shoulder function. In patients with a combo tear of the supra/infra where the supra is too retracted to surgically repair patients can have great outcome with just a repair of the infra solely based on reestablishing the anterior/posterior force couple (http://www.ncbi.nlm.nih.gov/pubmed/21308755). This may have long term benefits to the overall health of the patients shoulder.

    • Stephen, thanks for sharing, as always! In the study quoted, 30% of subjects had tears that involved more than just the supraspinatus. I feel like this study did a good job of looking at a typical overview of demographics. I would like to see even more breakdown of specific groups to know the real outcomes based on age, tendon involvement, tissue quality, etc.

      Good thoughts on the normal mechanics and perhaps that is the last bit of the study, you need to rehab those rats next time!

  3. Mike–this is a great article and right on target with my experience, having a partial rotator cuff tear a couple years ago. Nice to see clinical data on it.

  4. Mike, this is an excellent article, thank you for sharing. It certainly raises a lot of questions about the approach to the management of rotator cuff tears. This will be great information to share with primary care physicians. Many patients who present to an orthopedic surgeon have been though conservative treatment and have had no improvements so it may be that we see a higher proportion of the patients who will not succeed with physical therapy. It arms us with good information to share with patients, however, and can give them encouragement that they may get significant relief without surgery.
    The article does not have a control group which raises the question, do patients have greater improvement with surgical intervention? This article (http://www.bjj.boneandjoint.org.uk/content/92-B/1/83.abstract) looked at the two groups and showed higher outcome scores with surgery – Constant Score, ASES, and Pain on a VAS were all higher in the surgical group. Also, patients who failed the initial therapy attempt and elected for surgery, had lower outcome scores than the patients who elected surgery initially.
    The article also did not look at patients who received no treatment. Perhaps time only in some patients could lead to a resolution of their symptoms to a satisfactory level. This points to the fact that the issue is complex and we still don’t have the answer to what exactly is the pain generator and why certain patients do well with certain interventions and others do not. Also, this article showed improvement in patients with full thickness tears – why then do so many patients with only tendinopathy or a partial thickness tear on MRI continue to have pain despite a reasonable attempt with conservative treatment? This paper does give us the opportunity to recognize that many factors need to be considered when outlining a treatment plan for a patient and in this case, non-operative treatment may be perfectly acceptable. Also, an MRI finding, in this case, is not an indication for surgery.

    • One other thought – the follow up for the study is 2 years – with longer term follow up and information about the long term sequelae of not repairing a full thickness tear, we may gather information that changes our thoughts as well. If we knew that a higher percentage of patients treated non-oepratively went on to develop clinically significant glenohumeral arthritis or if we knew that patients developed symptoms and elected surgery further down the road and their outcomes from surgery at that point were significantly poorer that those treated initially with surgery, we may have more info to make a different recommendation.

      • I do not have a subscription to this journal thus could not read the entire article but from the outset I have graeat concerns with saying “conservative therapy” did not help. What was the treatment provided? Can we measure the clinical and decision making skills of the therapists providing the care? and can we control for the compliance of the patient?

  5. this is a great article and the comments are great.

  6. To prevent rotator cuff prevent surgery it can only take few minutes if we listen, feel and remind ourself of who we are so the healing can take place.

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