World Spine Care clinics provide quality, evidence-based spinal care to those in under-served communities. While we focus on the spine, our clinicians are also qualified to assess and address complaints throughout the musculoskeletal system, including ankles, knees, wrists, and hips. Outside of back and neck pain, shoulder complaints are one of the most common reasons for people to visit a World Spine Care clinic.
Rotator Cuff Injury
There are various causes for shoulder pain, whether due to accident, injury, or overuse. In this article, we’ll discuss one of the most common painful conditions of the shoulder – rotator cuff injuries. We’ll cover some of the basic information about rotator cuff injuries, what causes them, the best treatment for them, and whether surgery should be considered.
Rotator cuff injuries are the most common painful condition of the shoulder and are responsible for 4.5 million physician office visits a year.1 Not only are they painful, but they can result in a significant lack of mobility and loss of function. The rotator cuff consists of a group of four muscles–supraspinatus, infraspinatus, teres minor, and subscapularis–and their tendons, that surround the “ball and socket” shoulder joint. Although these four muscles are involved in shoulder movement, their main function is to stabilize the head of the humerus (upper arm bone) in the joint.
What Does a Rotator Cuff Injury Feel Like?
The most obvious sign of a rotator cuff injury is pain in the front, side, and/or back of your shoulder. Sometimes the pain comes on quickly but, perhaps more often, the injury may be silent at first, with pain becoming progressively worse as damage to the rotator cuff progresses.
In addition to shoulder pain, rotator cuff injuries can be accompanied by a feeling of weakness in the arm, snapping or popping of the shoulder, limited range of shoulder motion, pain with raising the arm above the head, and in some cases pain that refers down the arm. It is often worse at night. Between 70-90% of people report difficulty sleeping when they have a rotator cuff injury.2
If you’re experiencing any of these symptoms, a rotator cuff injury should be suspected, especially since it is one of the most common causes of shoulder pain.
Causes of Rotator Cuff Injuries
There are two primary categories of rotator cuff injuries: acute and chronic repetitive injuries. The symptoms can vary significantly depending on which is causing the shoulder pain.
Acute rotator cuff injuries are caused by an abrupt injury, and you’ll usually remember the movement or moment when you injured your shoulder. Common motions that cause acute rotator cuff strains include falling, pushing, pulling, throwing, and lifting. You’ll sometimes notice a popping or snapping sound with this mechanism of injury as well.
More commonly, a rotator cuff strain (commonly called a “pulled muscle”) develops over time, and you can’t identify a specific moment when you injured your shoulder. These injuries develop after chronic and repetitive minor or micro-injuries to the muscles that build upon each other over time.3 They may resolve initially, but over time the pain can become progressively worse. Additionally, a related condition called impingement syndrome may precede a rotator cuff injury in 95% of chronic injuries.4
The most common rotator cuff muscle to be injured is the supraspinatus muscle, a muscle that primarily lifts your arm to the side. It may be difficult to perform this action after injury. Injuries come in a variety of severities from muscle strains to partial- or full-thickness tears of the tendons and ruptures in the more severe cases. Sixty percent of them can be progressive and start as a partial tear that progresses to a full tear within a four-year period.
There are a few health conditions that might make it more likely to experience rotator cuff strain injuries, including obesity, high cholesterol, diabetes, steroid injections, and genetics. Common conditions that can mimic a rotator cuff injury include shoulder labrum injury, biceps tendinitis, AC joint injury, and cervical radiculopathy, among others.5
Treatment for Rotator Cuff Injuries
The great news is that conservative care, such as offered at World Spine Care clinics, is recommended as the first choice of treatment for rotator cuff injuries that are non-traumatic.6 In fact, when we look at the large volume of studies on rotator cuff injuries, the data show that somewhere between 33-92% of patients who are treated with conservative care will improve.7 From what we know, you’re more likely to respond positively to conservative treatment if you meet these three criteria8:
- You have a rotator cuff tear that is less than 1 cm in size,
- Your shoulder pain has been bothering you for less than 1 year,
- You don’t have severe functional limitations and weakness when using your shoulder.
Although some severe cases may warrant a surgical consultation, it’s encouraging to know that even some partial and full thickness rotator cuff tears respond well to conservative management.9 There can be many reasons why surgery isn’t an option. Even in these cases, many significant rotator cuff injuries will benefit from conservative care.10
How Can a Chiropractor or Physical Therapist Treat a Rotator Cuff injury?
The most important reason to see a chiropractor or physical therapist for your rotator injury is that they’ll be able to do an examination and determine if the pain is a rotator cuff injury and its severity. This is the first step and allows your provider to design an effective treatment plan so that the recovery process can begin.
After examining and determining your shoulder injury is a rotator cuff strain, your provider will help you modify your activities during the recovery process. Typically, this means advice to avoid these three activities:
- overhead activities that worsen the pain,
- lifting or carrying heavy objects, and
- sleeping on the injured shoulder (especially with your arm outstretched over your head.)
Avoiding these movements and postures can help speed up your recovery time and prevent aggravating the injury.
Stretching and strengthening exercises for your shoulder, applied in a strategic manner, are also an important part of rehabilitating a shoulder injury. Chiropractors and physical therapists are knowledgeable in designing therapeutic exercise plans that can help decrease shoulder pain and improve your movement and strength. The great thing about rehabilitation exercises is that once you learn them, you can do them daily at home. However, it is important that you let your provider guide you through this process. The exercises you should be doing vary depending on where you are in the recovery process.
Addressing the muscles and soft tissue involved in your rotator cuff strain may also be beneficial. Your chiropractor or physical therapist can use techniques such as myofascial release or instrument-assisted soft tissue mobilization (IASTM) to reduce pain, promote blood flow to the area, and support the healing process.
Manual therapy, also called a chiropractic adjustment, joint manipulation, or joint mobilization can also provide relief. Many times, joint stiffness and restriction develop in the lower cervical and upper thoracic spine, glenohumeral (shoulder) joint, and scapulothoracic region. In fact, research has shown that manual therapy to the thoracic spine may help decrease your shoulder pain while also improving the movement and function of your shoulder.11,12,13,14
What You Should Not Do When You Have a Rotator Cuff Strain
There’s one thing you should not do when you suspect you have a rotator cuff injury–rest your shoulder. Avoiding all movement for extended periods of time isn’t supported by research.15 It’s better to avoid movements that aggravate your injury and see a chiropractor or physical therapist who can examine it and apply treatment appropriately.
Taking certain medications like non-steroidal anti-inflammatories (NSAIDs) may help relieve pain in the short term, but evidence suggests that long-term use may have some negative effects. Ibuprofen and high doses of aspirin may inhibit collagen synthesis (that your tendons and cartilage are made of) and disrupt the natural healing response.16
Do I Need Surgery for a Rotator Cuff Injury?
It’s natural to worry that you may need to have surgery if you’ve injured your rotator cuff. In the western world, surgical rotator cuff repairs are common interventions. Despite this, you should know that most rotator cuff injuries will show improvement with conservative care.
Numerous studies have shown that surgical repair of the rotator cuff has no advantage over conservative care.17,18,19,20 A Cochrane review of published studies also concluded that “[surgery] may provide little or no clinically important benefits with respect to pain, function, overall quality of life or participant-rated global assessment of treatment success when compared with non-operative treatment.”21
You may be a candidate for a referral to an orthopedic surgeon if your rotator cuff injury doesn’t respond to conservative care but know that for the vast majority, conservative care is the best place to start. More invasive procedures like rotator cuff surgery will still be available later if needed.
What Should I Do If I Injured My Rotator Cuff?
The overall message is that conservative care, such as chiropractic and physical therapy, is the best treatment option for most rotator cuff injuries. The therapy provided at the World Spine Care clinics is not only less invasive but is safe, more cost-effective, and will provide positive outcomes for many people.
Just like shoulder injuries, back and neck pain respond well to conservative treatments. World Spine Care’s mission is to provide high-quality, evidence-based spine care to underserved communities. We currently have clinics in 4 countries and have ongoing volunteer opportunities for healthcare providers. Learn more or donate today.
- Oh LS, Wolf BR, Hall MP, Levy BA, Marx RG. Indications for rotator cuff repair: a systematic review. Clinical Orthopaedics and Related Research®. 2007 Feb 1;455:52-63
- Keung WW, Yan LM, Hang YP, Teng LH. The effect of psychological factors on pain, function and quality of life in patients with rotator cuff tendinopathy: A systematic review. Musculoskeletal Science and Practice. 2020 Apr 29:102173.
- Kibler WB, Chandler TJ, Pace BK. Principles of rehabilitation after chronic tendon injuries. Clinics in sports medicine. 1992 Jul;11(3):661-71
- Neer CE III. Impingement lesions. Clin Orthop. 1983;173:70–77.
- Oh JH, Lee YH, Lee TH, Jang SI, Kwon J. The natural history of high-grade partial thickness rotator cuff tears: The conversion rate to full thickness tears and affecting factors. Clinics in Orthopedic Surgery. 2020 Dec;12(4):514.
- Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Äärimaa V. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. The bone & joint journal. 2014 Jan;96(1):75-81.
- Longo UG, Franceschi F, Berton A, Maffulli N, Droena V. Conservative treatment and rotator cuff tear progression. InRotator Cuff Tear 2012 (Vol. 57, pp. 90-99). Karger Publishers
- Bartolozzi A, Andreychik D, Ahmad S: Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Relat Res 1994, 308:90-97.
- Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clinics in sports medicine. 2012 Oct 1;31(4):589-604.
- Shepet KH, Liechti DJ, Kuhn JE. Nonoperative Treatment of Chronic, Massive Irreparable Rotator Cuff Tears: A Systematic Review with Synthesis of a Standardized Rehabilitation Protocol. Journal of Shoulder and Elbow Surgery. 2020 Dec 1
- Crosbie J, Kilbreath SL, Hollmann L, York S. Scapulohumeral rhythm and associated spinal motion. Clinical biomechanics. 2008 Feb 1;23(2):184-92.
- Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. Journal of Manual & Manipulative Therapy. 2009 Dec 1;17(4):230-6
- Walser RF, Meserve BB, Boucher TR. The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: a systematic review and meta-analysis of randomized clinical trials. Journal of Manual & Manipulative Therapy. 2009 Dec 1;17(4):237-46
- Muth S, Barbe MF, Lauer R, McClure P. The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy. Journal of orthopaedic & sports physical therapy. 2012 Dec;42(12):1005-16.
- Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Practice & Research Clinical Rheumatology. 2019 Mar 8.
- Al-Sadi O, Schulze-Tanzil G, Kohl B, Lohan A, Lemke M, Ertel W, John T. Tenocytes, pro-inflammatory cytokines and leukocytes: a relationship. Muscles, ligaments and tendons journal. 2011 Jul;1(3):68.
- Ranebo MC, Hallgren HC, Holmgren T, Adolfsson LE. Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial. Journal of shoulder and elbow surgery. 2020 Mar 1;29(3):459-70.
- Cederqvist S, Flinkkilä T, Sormaala M, Ylinen J, Kautiainen H, Irmola T, Lehtokangas H, Liukkonen J, Pamilo K, Ridanpää T, Sirniö K. Non-surgical and surgical treatments for rotator cuff disease: a pragmatic randomised clinical trial with 2-year follow-up after initial rehabilitation. Annals of the Rheumatic Diseases. 2020 Dec 3.
- Karasuyama M, Gotoh M, Tahara K, Kawakami J, Madokoro K, Nagamatsu T, Imai T, Harada N, Kudo Y, Shiba N. Clinical results of conservative management in patients with full-thickness rotator cuff tear: a meta-analysis. Clinics in Shoulder and Elbow. 2020 Jun;23(2):86.
- Kozono N, Takeuchi N, Okada T, Hamai S, Higaki H, Shimoto T, Ikebe S, Gondo H, Senju T, Nakashima Y. Dynamic scapulohumeral rhythm: Comparison between healthy shoulders and those with large or massive rotator cuff tear. Journal of Orthopaedic Surgery. 2020 Dec 22;28(3):2309499020981779.
- Karjalainen TV, Jain NB, Heikkinen J, Johnston RV, Page CM, Buchbinder R. Surgery for rotator cuff tears. Cochrane Database of Systematic Reviews. 2019(12).