Why A Rotator Cuff Tear Happens & The 3 Phase Process To Naturally Fix It
/in Podcast/by dmiddaughHello El Paso! This is Dr. David specialist physical therapist from El Paso Manual Physical Therapy and I'm bringing you today the Stay Healthy El Paso Podcast. We are going to be talking about why a rotator cuff tear happens, and the three-phase process to naturally fix it.
Here in the clinic at El Paso Manual Physical Therapy we follow this three-phase process. There is a lot of detail to it, I'm just going to give you an overview about it. It is possible to adapt it for yourself at home. We teach our clients here, how to do it at home. And we will get into all the details about it.
But first, I want to answer the classic question that we get from every patient that comes into the clinic as we see them regularly. With a rotator cuff tear, they always ask, “How did this happen? Why? I was fine last month and now this is happening, and my shoulder hurt me a little bit, but now it hurts a lot and I can't do a lot. And we are going to go into that.
Let's get started with just talking about what the rotator cuff is and why it's important for your shoulder.
There are four rotator cuff muscles and tendons, and just to talk about muscles and tendons real quick, muscles I think most people get, is the part of your body that when you tighten it up, it gets harder and it moves your joints like in your in your bicep. Everybody thinks about that, the flexing muscle in your arm. The part that everybody wants to have bigger, the big biceps. That's the muscle.
What most people don't understand though, is the tendon is at the end of muscles and attaches the muscle to the bone so that when the muscle contracts and squeezes, it yanks the tendon which makes the bone and that's what causes movement out of joint. So up in the rotator cuff, you have four rotator cuff muscles, and they all have associated tendons that connect to the shoulder to the, what's called the humerus, the upper arm bone, and it pulls the ball into the socket. It is heavily important for the stability and fine-tuned movement of the ball and socket joint in the shoulder.
The four muscles really quick, are the supraspinatus infraspinatus, the subscapularis and the terry's minor muscle. All four of those come together to form the rotator cuff. Now when you get a rotator cuff tear, it's most commonly in the supraspinatus tendon, which is the one that's closest to the top of the joint. And there are different types of tears. If you have a tear out there, you'll be familiar with these terms. And the way they find these is usually with an MRI.
By the way, if you haven't had an MRI then chances are you haven't been told these terms. But if you have had an MRI then this is going to be familiar to you. You might have a partial thickness tear, also called an incomplete tear and a full thickness tear are, also called a complete tear.
Partial thickness tear just means that the way the tendon tore, it's almost always the tendon, that tears, by the way, when it comes to the rotator cuff. It's only partially torn or detached from the bone. It's not fully torn or detached. So it's still hanging on. It's still being used to do its normal function in the shoulder.
Now, a complete tear means it's just about nearly detached from the bone. What I see is that most people can still use the muscle when they have a complete tear. That indicates that it's still attached somehow. But it's probably hanging on by a thread is really what's going on.
You have to understand with MRIs, they are not the gold standard to an MRI. In other words, what's better than an MRI is going in with a surgical camera and observing or looking at the tendon. That's the true way to diagnose a tear. But of course, surgeons aren't going to say, well, let's just do surgery to stick a camera in there. Just to diagnose it, they are not going to want to do that. They are only going to do that if they are going to actually do something about it.
Then MRI is the next best thing because it is an invasive, it takes a picture of the inside of the body, but it's not as good. So that means that there is a possibility for the MRI to be wrong about how bad the rotator cuff is torn. In some cases, it's completely wrong where there isn't a tear at all. But the MRI is showing that there is a tear. That's called a false positive.
In the medical world, you can also have a false negative. But anyways, what a false positive is, you go get an MRI and the doctor says based off the MRI, you have a rotator cuff tear, whether it's full thickness or partial thickness. And the way that you find out that it's false is when you end up having a surgery for it and surgeon says there was nothing wrong, and they don’t know why your shoulder is hurting because your rotator cuffs is just fine. They usually just close you back up and maybe they cleaned up a couple things that they could find, but you really didn’t have a tear. Then you had a false positive MRI.
I just want to give you a heads-up MRIs are not always 100%. Right? But what they are good at is blatant problems. They do find blatant, huge issues, but smaller issues that aren't as, as significant they might have a false positive.
Some other differentiations to make within rotator cuff tear types is acute versus degenerative.
An acute tear means that it just happened because of some event, like you were in a car accident or you fell, or you had a bike accident, something like that. Some trauma that happened that caused you to tear the rotator cuff, versus degenerative. The way that typically comes on is, there was no trauma, there was no events that happened, a fall or accident. It just started hurting one day.
It might have been something trivial that set it off like, I went to go pick up that gallon of milk or that full coffee pot, or I was picking up the laundry while doing chores at home, or I worked a lot at home, I did a bunch of gardening or this project outside. And by the end of it, my shoulder was just killing me. And the next day it was hurting even worse, and that's when I decided to go to the doctor and then they said that I have a tear.
So very likely wasn't just that coffee pot that you picked up, or the six hours that you spent doing that project at home. It was an accumulation of problems that were minor. It just happened that you passed the threshold of pain and activity to really set it off. And further tear the tendon and make it worse.
But most often these people have had some shoulder issues here and there. They may not even be painful. By the way, some rotator cuff tears are completely painless, but they just can't pick up their arm all the way, or they lose function. The way that most people lose function by the way, when I say that, it means they can't raise their arm all the way up overhead like the candle or their arm.
Reaching out ahead or at an angle, or you just can't even reach all the way out there, you don't have the actual strength or ability to get there. Reaching behind the back is very commonly limited as well like if you are trying to scratch an itch in your back, or fish the belt or the belt loops behind your behind your back. Or for ladies reaching for a bra strap behind your back is painful or just not possible with these rotator cuff tears.
Those are the different types, there are full thickness, partial thickness, and then there are acute and there are degenerative. Now as you probably already thinking, a full thickness tear is worse and an acute tear is going to be worse, and those are the ones that are more likely to have surgery. Obviously, if you have a partial thickness tear, then you have a better shot at getting better without surgery. And if it's degenerative, then usually you can fix things and prevent it from getting worse, because it wasn't some trauma that was out of your control, it wasn’t an accident.
There are cases though, and we've seen them here in the clinic where people come in with MRIs, it's a full thickness tear, and they look pretty bad. And it turns out to be degenerative. It's been going on for a while, and they get better. They get completely better, completely escaped their surgery. We've had it consistently, I'd say a few times a year, three, four, maybe five times a year, we get people that are actually scheduled for surgery. When we talk to them on the phone, I hear this from the staff that answers the phone. They'll say, Hey, you know, we booked so and so for a visit with you with you next week. And be careful with this person, because they are actually booked for surgery at the end of the month, and they are just seeing you for a second opinion.
Once we see them in person, and we talk to them, I do all the testing and we find out that they are actually a great candidate to do therapy before surgery. And I always tell them, Look, if it's that urgent for you, please go get the surgery. I'm not going to tell you not to. Obviously, it's your decision. It's your shoulder. But if you can wait maybe a month and see how this goes as far as physical therapy. Then if it's getting better gradually you have an excellent shot at rehabilitating this problem naturally, without exposing yourself to the side effects and the risks of surgery.
Plus, the big factor for that person is that they are going to learn what to do to keep their shoulder healthy for the long term. Which surgery just doesn't teach you, you just show up for a surgery date and they take care of the rest, you lie on the table and they do everything for you. And they do a great job. By the way, if you have to have a rotator cuff surgery, all the ones that I've seen, they are done so well they do a fantastic job.
There are some surgery cases that don't turn out too well as with every surgery, but I see that less with rotator cuff repairs and with certain other surgeries. It's not the worst surgery in the world to have but it's still surgery. You still might get an infection, there are still risk for other problems to happen.
Let's talk about the reasons for these degenerative tears. Obviously for an acute situation, where you fell, had a car accident, or something happened. The reason for it, there was an obvious problem. But when there is no accident, people are left wondering to themselves, what the heck, what did I do? There are four main components to this. Let me go into each one.
Posture is one, if you tend to be in a slouched posture because you work at a desk, or that's just been your posture, chances are it's not a hard and fast rule, but chances are within your shoulder joint ,within the ball and socket joint, your joint isn't properly aligned when you are in that posture. You tend to shut down some of the muscles in the area as well, which causes the ball and socket joint to not be most congruent, or the ball isn't in the socket as best as possible.
It's not out completely to where your shoulders and work but it's not seated in as best as it can be. And if you move like that if you live like that, if that's how your shoulders forced to work, then it begins to wear down on the rotator cuff tendons around it. Gradually over time, you wear it down. And when you wear it down, you begin to form a tear.
Occasionally, some people will say, yeah, my shoulder is kind of sore. When I pick it up, I just feel a little bit of pain, but I can do everything I need to, and it goes away after a while. I've lived like that for years. And then one day I was just miserable. I can’t sleep on that shoulder. I had trouble getting my shirt on and off or washing my hair in the shower. Simple things become very, very uncomfortable to do. So, posture is a big problem.
Weakness is the next one. If you just have a weak upper body, you are going to be predisposed to getting some sort of rotator cuff tear problem.
The shoulder itself the ball and socket joint. It's a phenomenal joint. The only other ball and socket joints in the body is the hip. And the difference between the hip and the shoulder is the bone structure of the hip. The socket is very deep relative to the shoulder. If you look at the bone structure of the socket in the shoulder, it's tiny. The socket itself is very tiny and surrounding the socket is a bunch of cartilage and other tissues, and the rotator cuff is a big stabilizing factor.
What you don't have to worry about in the hip is that it's more stable naturally because of the bone structure. But up in the shoulder, you have to rely on stability from these muscles. If you just are not strong overall in your upper body, you are very likely going to have stability problems in the shoulder, which leads to tears in the rotator cuff.
That's one of the first things that breaks down in the shoulder. So, if you are averse, if you don't like to go to the gym, and workout. I see this especially in females, because females just are more usually concerned about having strong legs and strong arms versus men are the opposite. They want to have strong arms or strong legs. Females tend to avoid working out their upper body which years down the road, can affect the rotator cuffs. We see a lot of these rotator cuff issues.
Now in men, when we see rotator cuff tears, it tends to happen in the jock type of person. The classic is somebody, It was a guy he's in his 50s now 60s even and very active. He has always played sports in high school, lifted weights, lovee doing bench press, because that's the guy lift the bench press. That's all the guys are going to be good at bench press. And usually they have developed some sort of big muscle imbalance within the shoulder that's causing that ball to not sit on the socket right.
It may not hurt at the very beginning, the first few years that is happening, but over time it can begin to cause a problem. And you can begin to get rotator cuff tears. Once you hit a certain threshold, that can be really painful. The degenerative type tend to happen when people hit their late 40s 50s. Usually, if they have had some shoulder problems leading up into their 40s and 50s, they definitely have them by their 60s.
So, if you are in your 30s or 40s, right now, you are already having some shoulder problems, you need to fix this issue before it's too late because you are going to end up getting a rotator cuff tear. You may already have a baby one going on, but it is possible to heal that. We will talk about that more here in a second.
Let's talk about genetics next. That's the third factor for a rotator cuff tear. Your shoulders index inside your shoulder, right above the ball and socket joint, there is a piece of bone from your shoulder blade that overhangs on top of the ball within the ball and socket joint. It's called the acromion. In the space between the acromion and the ball and socket joint, they call that the subacromial space. There are some structures in there, of course, were the rotator cuff tendons runs through there, the supraspinatus. There is a Bursa that commonly gets blamed for problems.
Everybody that has shoulder problems has some form of bursitis, shoulder bursitis. And some people go down the rabbit hole of trying to fix their bursitis when it's really a rotator cuff problem, or some other related problem. And the bursa just gets irritated because of it, but it's not the bursa's fault. It's other things fault, but people will go get injections for the bursa.
Anyways, that subacromial space can be reduced which can cause compression on the bursa. The rotator cuff tear or the rotator cuff, which can lead to a tear. And so, that space needs to be managed properly. Strengthening the muscles around the shoulder will allow the space to be more normal. Posture will also allow the space to be more normal, but some people have a different shaped a chromium which can genetically reduce the space, so they just have less margin for error. Those people with a certain type of a chromium shape need to just be extra careful that they have good posture and strength and they can manage just fine.
The fourth factor related to this chromium, the bone shape within their shoulder, is that if they are getting some rubbing on the rotator cuff tendon from that acromion of the degenerative changes within the joint is that they might get bone spurs on the bottom part of the acromion. A bone spur is just an increase growth on the bone. There are all these theories and why they occur. I'll just give you my take on it.
One of the principles in the body, one of the things that’s always true, is that the body adapts to forces. So just like if you get calluses, for instance, people get calluses on their feet, on their hands, other parts of their body, depending on what activities they are doing. A callus is a response to some sort of increased repetitive force on the skin. In order for the skin to avoid tearing and breaking down, it gets thicker, and it gets thicker to protect itself from when you go back to do that activity it won't tear.
The other parts of the body do that too. Just like if you go lift weights, if you are picking up weights to strengthen your muscles, your muscles feel the force of the weight that you are having to lift, and so they adapted by getting thicker and stronger. So that you can pick up the weights again easier and maybe even pick up more weights.
Tendons do the same thing. We know that bones do the same thing if you have osteoporosis for instance, it's recommended that you go do resistance exercise or body weight bearing exercise, because it tends to make the bones thicker so that they can be better able to sustain forces and not break as you get more active. Those bone spurs develope to protect the bone from breaking or becoming irritated or injured somehow. It's a sign that something's not right. In the overall mechanics, the way that you move your posture, your strength as well.
There is some imbalance somewhere, somehow, that's causing this bone spur to develop. If you have bone spurs on the bottom of your acromion it's going to decrease that subacromial space. And it can directly put pressure on your rotator cuff tendons, and just cause a tear to come along faster than other people. So that's just a genetic thing that some people have.
That covers the four reasons for getting a tear.
Let's talk next about how to naturally fix it. I'm going to give an overview of our three-phase process for naturally fixing rotator cuff tears. It's quite complicated. Whenever we take a rotator cuff patient on, we have to first see if we can help them or not, or if they really are the best candidate for surgery and they should go there first.
We always educate them. We say, Hey, if you are going to go have surgery, that's cool. That's your decision, or it's very appropriate, I recommend it too. I think you should go. You are not going to do too well, if we try to skip out on surgery, it’s just that far gone, unfortunately. But I tell them, you still need to go through physical therapy after. It's almost always the case. Whenever you have a rotator cuff repair surgery, you get sent to physical therapy. And the point of that physical therapy is to just get your motion back. Because you are going to be all stiff and swollen from your surgery, you are going to have to be wearing a special sling. You have to wear that thing at night, it's miserable to sleep with it, you are going to be in pain for a long time, usually three or four months after surgery.
That's just normal for everybody going through rotator cuff surgery. But all the physical therapist is going to get you to do, is begin to raise your arm up, move it out to the side, and move as your shoulder allows. They have to follow protocol and get it back to normal. When I say normal and air quotes because most people that have finished rotator cuff repair physical therapy after the surgery, they are not normal. They'll tell you, when I pick up my non-surgical arm, my good arm, they'll say, look you can come up and look at my other arm and they are lacking, good 20-30 degrees. They are not normal yet.
But they have made a lot of progress. Obviously, they couldn't do anything near that after surgery. So it's more functional for them, they can get through life, but they may still not be able to sleep on that shoulder, they may still have trouble using the arm and may be weak. Doing housework around the house is still a challenge for them.
There is still a lot of rehab that needs to happen on their own. Or they may still go to therapy for a while. And really, it takes the better part of a year to recover fully from a rotator cuff repair surgery. Then I tell these people that are going to go get surgery, that they still have to fix the underlying problem. If you think about it, if you had a degenerative tear, there is something about the way that you are moving, the strength of posture. Maybe your genetics is a factor, but there is something that you can modify, so that you don't have to have a surgery again. Because we see that happen.
We see people to get a rotator cuff tear, they go get a surgery, and then a couple years later, they are back at the surgeon's office because their shoulder hurts again, and the surgeon is saying you are developing another tear in the same area, I'm going to have to go do a double repair. And I always tell them, there is something that wasn't fixed. That wasn't the surgeon’s responsibility. They likely did a fantastic job. It wasn't the surgery coming undone. It’s that there are issues that are unresolved here that need to be strengthened or moved better.
If we get somebody who's a good non-surgical candidate, they should have physical therapy like we have here, the specialized type of physical therapy that we offer, then I start telling them great, I'm glad you decided to start physical therapy with us, you are going to learn how to manage this, so you don't have to have surgery. And if for some reason you have surgery, you are going to know how to manage this beyond that, so that you are not having to have a second surgery.
Let's get into the three-phase program that we take people through.
Phase One, The Healing Phase.
We sometimes skip this phase, but it just depends on where the individual is at. If we get somebody in here, let me use our last case for example. Or the last one that we had in here, she is in her mid-60s, very active, loves to garden, loves to do projects around the house. She is a retired teacher and loves spending time with her family, loves baking, loves cooking, she just loves life and loves taking care of her family and her home.
It just slowed her down tremendously. Once she hurt her shoulder. She wasn't sleeping well because you couldn't lie on that side. It was a right shoulder and even if she turned over on her left side, she just couldn't get as comfortable as normally before the surgery. It just impeded her sleep so much. Of course, her everyday activities were affected too, she couldn't shower, or do her hair. She couldn't put on her clothes comfortably. Putting on her bra was just extremely difficult with her right shoulder.
Her complaint was pulling up her pants. She said, once I get my pants up to my thighs and have to put some effort into it to get them all the way up. It really hurt her shoulder. So that was a big deal, whether she had to get her husband to help her out and that's tough. Having to get help to put on your clothes when normally you don't need it. She was definitely flared up and probably had a very acute situation.
But let me back step on that. She did have a degenerative tear, but it was very flared up right now. In other words, it was hot. It wasn't like she had some accident. Because we get some people that on their own before they get to us, they, they flare down when they are flared up. so they are not as as acute as we call it. They are not in as much pain, they can move a little bit better, but the tear is still there and needs to be fixed.
Well, this woman was definitely flared up when she came in, she couldn't pick up her arm very much, and she was having trouble with all that stuff. So one of the first things we will do with these people is we tell them, we need to get that tissue under control, it's just like a cut your skin and you got some bleeding happening, the first thing you got to do, whenever you get a cut on your skin, is to control the bleeding and bandage it up. It's probably going to bleed a little bit throughout that first day, maybe even into the next day, until enough healing occurs, that it stops bleeding and then you just have to baby it for a while so that it scars down and becomes normal again.
Same thing in the shoulder within these tendons. So, we told her is to get a sling, the type of thing that you get if you went to the hospital with a shoulder problem. Just a basic sling one that they sell like at Walmart, or like a CVS or Walgreens, a lot of grocery stores even have them, they shouldn't cost them more than 20 bucks, some are as little as 10 or even less. It doesn't have to be a hardcore sling. Get yourself in that sling and you need to cinch it up really good so that it shoves your shoulder up.
Because what I want to have happen and I'll show people here in the clinic, I need that ball shoved up into the socket so that it's not tensioning the rotator cuff. Because if you don't have that ball shoved up into the socket, then essentially, it's hanging out. Gravity is pulling it down, especially if you have a tear, a full thickness tear, and you are just not going to bring the edges of the tendon together as easily to facilitate healing. So, you need to have that sling on for most of the day.
We tell these people, you can sleep without it, as long as you can get decently comfortable, but during the day, you need to use it and it serves two purposes, that first one that I talked about to bring the ball up into the socket. But the second one is to reduce your usage of it, because automatically when you are in that sling, you are just going to use that arm less, you are going to have to open the door with the other hand, you are going to have to not do that chore the same way that you were doing it before. It's also going to tell other people as well that you are hurt, so they'll be more likely to help you out so that you can baby that shoulder and let it flare down.
Once you flare it down, then we are in a position where we can work some of the other muscles and start rolling into…
Phase Two, The Cleanup The Motion Phase.
That's what I call it. When I say clean up the motion, we are looking at the way that all the muscles work together to control the ball and socket joint. Usually there is an imbalance between those two and we have to clean up that motion, clean up that imbalance so that the forces are normalized and you can take pressure off that tendon that was torn. Then you can begin to heal a bit faster.
We also have to look at the shoulder blade, and all the muscles that attach to it and move it around. Because that's a big deal. If your shoulder blade is moving properly, the outer part of the shoulder blades serves as the socket for the ball and socket joint. All those rotator cuff muscles attach on to the shoulder blade and then they connect out through the rotator cuff tendons to the ball part of the joint and they bring them together and stabilize them. We have to make sure that the shoulder blade is moving well.
Then what gives stability to the shoulder blade is the spine, the upper back and the neck. We have to look at the muscles that give stability there and the posture that's going on within all three of those areas, the spine, the shoulder blade, and then the ball and socket joint. We have to clean up the motion. There are some simple logic exercises to do. They need to be done quite repetitively.
Sometimes we need to hang out between the healing phase and the cleanup motion phase for a while. Once the healing phase is pretty much over and there isn't much pain in the shoulder at all except with a few motions. Then the motion is cleaned up. Largely people are learning how to move better, then we can enter the third and final phase.
Phase Three, The Strengthening Phase
This is the longest phase typically, because most of the time people that have this degenerative type of tear, have chronic weakness, they have avoided working out their upper body or they just haven't worked out in such a way that's helpful for their shoulder.
We have to begin undoing a lot of weaknesses that have been going on for years, maybe even decades. Strengthening muscles just happens slowly and just need lots of reps over time. We start out people with some daily exercise and then, as they go gets stronger, we can reduce it to every other day. Then usually it's just a couple times a week as they start maintaining the last kind of lesser reach phase, a fourth phase, if you will, as a maintenance phase.
Which I'll tell people about, but I don't typically see them throughout that process. That's what they keep up on their own. And that maintenance phase is critical, by the way, because if they don't do it, if they don't stay in that maintenance phase. They don't keep up the exercises that they are supposed to, which are usually some sort of overhead lift, some two basic exercises, then they can begin to regress and get their rotator cuff tendon injured again or irritated again.
Those are the three phases, the healing phase, the cleanup the motion phase, and the strengthening phase. Then the bonus extra phase that you should hang out in, is the maintenance phase. But the first three are the ones that we carry people through here in physical therapy all the time.
That’s everything that I wanted to talk to you about for the podcast here. I wanted to answer the question of why a rotator cuff happens, what are all the details surrounding the muscles, the types of full thickness versus partial thickness, acute versus degenerative, and all the reasons that a rotator cuff tear can happen, and then how to go about naturally fixing it.
Just one last thing about the natural fix, we see people with full thickness, degenerative tears here all the time, and they get better. What we know in the research is that, it is possible to fully recover, and maybe not even have your rotator cuff tendon attached again. But to move your arm normally, you can compensate with other muscles. It's my belief that the tendon does actually regenerate and heal. We just don't have solid research for it. Hardly anybody that gets better goes back when they are feeling great and doing everything that they were doing before. That nobody ever says hey, can you go get him another MRI just to see if it's connected or not.
I've never heard of that happening. Maybe it's happened here and there. But I haven't seen any research studies about that. It's just not studied. A lot of people in the medical field will say, Oh, well, it's torn and you are not going to get it back. But we don't have any hard evidence to say that. I think it's really a false statement, but it's a common belief, and it's imparted on patients a lot.
But I've seen it happen here in the clinic over and over again, where people get better, but they don't want to spend the three or four grands to go get another MRI. They just say you know what, I'll pass, I’m back to normal anyway. So, think about that whenever you are considering surgery or considering how to go about fixing your rotator cuff problem.
Anyways, I hope this has been helpful for you. If it has, please share this with somebody that you know needs to listen to this. Somebody else who also has shoulder problems, possibly rotator cuff tear, if you think that this information was helpful for you, I encourage you, actually let me request that you leave a five star review for our podcasts that would really help to get visibility out there, to get more people to learn more about a rotator cuff problem and see other ways to help their shoulder besides medications, injections and surgery there.
There are natural solutions out there for rotator cuff problem. Subscribe to our podcast if you want to keep getting more information about this, I highly encourage that. We put out content every week about different body parts. Right now, we are talking to all about shoulder and neck problems. But please I love the review. I’d love for you to subscribe and share this as well. Thank you and I hope you have the best day.
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