Physical Therapy As Effective As Surgery for Rotator Cuff Tears

Rotator Cuff Tears

The shoulder is one of the most mobile joints in the body that performs many complex movements, including extension and flexion, abduction (moving the arm away from the body), adduction (moving the arm toward the body), medial rotation (moving the arm toward the center of the body, with the thumb pointing in the same direction) and lateral rotation (moving the arm away from the center of the body with the thumb pointing away from the body). The ability to perform a wide range of motion comes at the expense of decreased stability in both the bone and muscular structure.

The rotator cuff is designed to reinforce the shoulder joint and hold the head of the humerus, which looks like a ball in the socket of the scapula or shoulder blade. The socket is known as the glenoid fossa. The four muscles that comprise the rotator cuff originate on the scapula and insert on the upper humerus. These four muscles, the supraspinatus, infraspinatus, teres minor and subscapularis, form a tight layer of muscle that help hold the shoulder joint in place while facilitating movement.

Rotator cuff tears are generally attributed to a traumatic injury to the shoulder or progressive “wear and tear.” Activities that involve repetitive motion of the shoulder, such as throwing a baseball or those holding a bow in archery, construction work or activities that involve a significant amount of repetitive overhead heavy lifting can cause an injury to the rotator cuff. The standard care for a nontraumatic injury has been surgical repair.

In 2014, Finnish researchers released a study that compared the results of physical therapy to surgical repair of nontraumatic rotator cuff tears. Surgical repair included both arthroscopic and open procedures. The authors concluded that conservative treatment, such as physical therapy, should be the primary treatment for this type of tear.

The study was published in the January, 2014 issue of Bone and Joint Journal. The study group was comprised of 173 patients who were at least 55 years of age, with the mean age being 65. Each participant in the study had a confirmed supraspinatus tendon tear.

Patients were placed in three groups. The first group received only physical therapy. The second group underwent acromioplasty, followed by physical therapy. Acromioplasty involves removing a small piece of the bone surface, or acromion, which comes in contact with a tendon and causes damage by the friction of the movement of the bone against the tendon. The third group was treated with rotator cuff surgery and acromioplasty, followed by physical therapy. Each group contained a similar distribution of subjects by age and gender. At the end of the study, there were 167 participants whose shoulders were able to be assessed. The other six participants were either excluded or dropped out of the study.

The physical therapy regimen was the same for each group. Patients received a home exercise program from a physical therapist that centered on glenohumeral motion, since the glenohumeral joint is the most mobile joint in the body. Patients were also given exercise that focused on active scapular, or shoulder blade, retraction which focuses on moving the scapulae toward the spine. Patients did a set number of repetitions for six weeks, then increased the number of sets or repetitions for the next six weeks. Strength and resistance training was added as tolerated as were the number of repetitions for up to six months. In addition to the home program, participants were referred to an outpatient therapy with a physical therapist clinic for 10 sessions.

Patients were evaluated using the Constant score at three and six months, then again at one year. After reviewing the results, researchers discovered similar rates of improvement across all three groups. Patients’ also reported similar satisfaction with treatment across all groups.

Some studies report a “placebo affect” when comparing surgical and nonsurgical approaches with the surgical group tending to report higher satisfaction with their results. However, the results of this study challenge this idea. Researchers did inform the participants which group they were in, but the patients who underwent surgery did not indicate superior results when compared with the therapy only group.

For individuals suffering from nontraumatic rotator cuff tears, this study shows that physical therapy is a viable and successful option.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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