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    Physical Therapy As Effective As Surgery for Rotator Cuff Tears

    A recent study from Finland asserts that when it comes to treatment of nontraumatic rotator cuff tears, physical therapy alone produces results equal to those produced by arthroscopic surgery and open surgical repair. According to the study's authors, follow-ups of 167 shoulders treated show that "conservative treatment should be considered as the primary treatment for this condition."

    The research, published in the January issue of Bone and Joint Journal (abstract only available for free), was built around treatment of 173 patients aged 55 and older (mean age 65) with supraspinatus tendon tears. Patients were assigned to 3 groups: the first group received physical therapy only; the second group received acromioplasty and physical therapy; and the third group was treated with rotator cuff repair, acromioplasty, and physical therapy. Each group contained similar age ranges and equal distribution by sex. After exclusions and drop-outs, 167 shoulders were available for assessment.

    Components of the physical therapy treatment remained the same across groups: patients were given guidance and information on home exercise that focused on glenohumeral motion and active scapular retraction for the first 6 weeks, with increases during the next 6 weeks, followed up by increased strength and resistance training for up to 6 months. Participants were also referred for 10 physical therapy sessions in an outpatient clinic.

    When patients were assessed using the Constant score at 3 months, 6 months, and 1 year, researchers found substantial similarity in rates of improvement. "Contrary to our hypothesis, surgical repair of a supraspinatus tear does not improve the Constant score when compared with acromioplasty only or conservative treatment," the authors write. Additionally, the patients' subjective satisfaction ratings were the same for all 3 approaches.

    The findings even seemed to contradict the placebo effect often associated with surgery. Authors noted that participants were aware of the treatment path assigned to them, yet the surgery group did not report markedly different perceptions of improvement. The results led authors to speculate that the similar Constant scores among groups "may simply be due to the similar physiotherapy [regimens]."


    Based on the prior research regarding the strong correlation between bursal/articular tears and when surgery is appropriate, I find this study to be a possible starting point, but may be misleading in the headline. As the abstract is the only thing I can access, can someone with greater access please assess and report on the power or lack of power in regards to the statistical analysis?
    Posted by sean on 3/13/2014 1:07 AM
    I need to access the full research article to see what the criteria was for improvement, and how long the patiets had the tears before receiving treatment as well as the degree of fatty infiltration of muscle at initiation of treatment. The title is misleading and should read "non-traumatic rotator cuff tears"
    Posted by Julie Hagigeorges on 3/13/2014 10:49 AM
    I had my rotar cuff surgery three years ago for a torn rotator cuff and some calcium deposits on my shoulder. It still hurts I went to an orthopedic surgeon and he said the way my arm bends the bone to bone is hitting together I don't know what to do
    Posted by Liza Perry on 3/14/2014 12:15 PM
    Years ago I worked for a large well-known orthopedic group. Yes, I was employed by a POPTS - respected as a colleague for my skills, experience, and my professional judgment. I treated many patients with definitive partial rotator cuff tears - some traumatic, some attritional or of other non-traumatic origin. Unless findings and symptoms were so overwhelming indicative of necessitating specialized imaging and subsequent surgery, the conservative rehabilitation approach was almost universally tried. The treatment plan, progression, and rehabilitation management of the patient was entirely my responsibility. Most patients that myself and colleagues treated were able to proceed to a successful outcome, never requiring surgery. Of course, this is all anecdotal and reported by a pariah who worked for a POPTS, and unless one's supreme sensitivity to my reportage is an anathema- I am certain many of us do not find this report at all surprising. Conservative care of partial cuff tears has been one of the most rewarding experiences for orthopedic physical therapists for years. Personally, I experienced a definite partial cuff tear in my dominant arm at age 50. My shoulder ER strength was 2/5, flexion 3+/5, ABD 3/5. Pain level at rest 6/10, ROM WFL. Sleep was close to nil unless in reclining position. MRI and probable surgery recommended. Despite my pain and strength deficits, I self-treated for months, continued to practice, continued to exercise - albeit carefully - and avoided all pain reproducing movements/functions/activities. I was able to return to full and uninhibited activity - including racquetball - in six months. Again, an anecdotal report, but an example of a common story we can all probably relate from our own practices. As an aside, I am now 74 and continue to play racquetball with no recurrence of RC injury.
    Posted by Herschel Budlow P.T. on 3/14/2014 9:35 PM
    How many of us have treated non traumatic rotator cuff tears that were referred to us as "bursitis or tendinitis" and had no imaging for diagnosis but had all the clinical signs? Some recovered and some had significant enough pain to be referred back for imaging and sometimes ultimately surgery. I guess the pain issue is what drives most of my patients to get the surgery. Not everyone can tolerate a rotator cuff tear and the sleep deprivation. I did have the pain and sleep disturbance and I did debate having the surgery but did not. I think it depends on the individual sometimes.
    Posted by J W Corwin PT on 3/17/2014 10:35 AM
    The MRI is "the tool of the devil" according to Ned Kuhn, MD, orthopedic surgeon from Vanderbilt. I say it typically is the key to the cash register. RCTs are quite common, especially in men over 50, and most of them don't have pain or weakness prompting a visit to their doctor who then refers them to the surgeon; hence the trap has been set and they have walked into it. Dr. Kuhn reported that about 10% of folks over 60 have RCTs - this is about 5.7 million people. They do about 250,000 shoulder surgeries/year in the US and assuming these are all RC surgeries, that amounts to about 4% of the RCTs out there. What do the other 96% do? Research shows that failed repairs are very likely to have a good outcome - so why are so many operated on? In my opinion and that of many others, if he patient does not have frank weakness and/or intractable pain then DO NOT get the MRI! I predict in 10 years or less the shoulder MRI will go the way of the NSLBP MRI and will not be covered - too many false positives that just lead to harms (and of course a transfer of wealth). Asymptomatic full thickness tears are quite common. I suggest PTs do some research in this area and they will find this to be very true.
    Posted by Ed Scott PT, DPT, OCS on 3/20/2014 11:10 AM
    An impartial review of patient care across all health professionals is not possible when we all work under the umbrella of the medical Profession. They have louder, richer voices than the rest of us. Thanks for studies like this one, we need more of them. If all other Allied Health workers combined, forgot their differences and shared their common interests they would become a more effective lobby. Otherwise we will remain the poor relations.
    Posted by Clare O'Hagan on 3/26/2014 7:18 PM
    Posted by JOEDAN CAVENAUGH on 5/22/2014 9:59 AM
    In answer to Sean, there were 180 patients originally included in the study, and they were divided evenly between three groups. The study was structured on the hypothesis that the repair surgery would have the best outcomes. So a lack of a statistically significant difference between the outcomes triggered the null hypothesis. When comparing the Constant score between the three treatment groups, p = 0.34.
    Posted by Gary Brazzell on 5/28/2014 5:50 PM
    I have completely torn 3 tendons in my rt. shoulder (superspinatus and intraspinatus. ) I was told that surgery would not be successful and therapy was prescribed . I play golf left handed and now am unable to finish my follow thru due to the pain. I need advice on whether to continue therapy or go thru the surgery. I would be willing to continue physical therapy if I can play without pain. Please advise. Tony Lamonica
    Posted by Tony LaMonica on 6/24/2014 7:07 PM
    I have an old AC dislocation from a car accident 25 years ago and 6 months ago fell and had severe shoulder and upper arm pain - an MRI showed a full thickness rotator cuff injury and an x ray significant arthritis. After 6 weeks of very limited shoulder use and heat i felt good and had fair ROM. Now with more activity -i.e gardening and some lifting my shoulder is more painful but no tendenitis as I originally had. Hot showers seem to help. What next?
    Posted by Laurie on 7/5/2014 12:44 AM
    I am finding the information on this Web site to be very helpful. It is difficult to decide whether or not to have the surgery. There is often tremendous pain with the rotator cuff injury, and, of course, restrictions in one's lifestyle. (Especially at the outset.) However, it is my understanding that this may be considered "elective surgery"...which adds to the dilemma for a retiree (re. medical coverage).
    Posted by Donna McCusker on 8/5/2014 12:58 PM
    Can someone tell me what exercises I should do to strengthen my rotator cuff and I am willing to do it. I will really appreciate as I have been dealing with pain and pain and I don't want surgery. GOD BLESS YOU and Thank you email: rajpura@yahoo.com
    Posted by Raj on 9/2/2014 8:07 PM
    I am avid tennis player, and my guess is that I have a partially torn infrapinatus with a full thickness tear due to serving. I do not have any pain when doing normal,physical activities or problems with sleeping. I am now in physical therapy. Overhead activity, mostly trying to serve in tennis is something that definitely hurts. I am of course not playing tennis. I have some interior pain on the right side of the shoulder which is minimal. The MRI showed the partial tear. I do,not want surgery, but am wondering if I will be able to play tennis again. I can serve underhand without pain . Has anyone tried soft tissue therapy? By the way I am 70 years old.
    Posted by Liz on 9/6/2014 1:53 PM
    I tripped and fell catching myself with my right arm, and my shoulder hurts; sure that I have a possible tear in one of the tendons. Also, my primary physician refered me to a surgean. Through my on method of physical therapy with a "green" band, I'm improving. I believe that your body and good oxygened blood flow can produce the ability to heal itself without surgery.
    Posted by Jim on 9/18/2014 9:46 PM
    My follow suffers of rotator cuff injuries. Go to website for the American Academy of Orthopedic Surgeons and download the exercises for rotator cuff injuries. They do help!
    Posted by JOHN LOHERER on 9/27/2014 7:37 AM
    I fell and was in so much pain. I had an mri and tore 2 tenant Have received in a year about 5 injections and PT . After I get an injection I feel fine. I'm 51 and I schedualed for surgery in 1 month from now. Getting really nervous now and don't know if I want surgery now. I'm so confussed.
    Posted by Denise golfis on 1/13/2015 8:07 PM
    Confused what I should do. Have surgery or not
    Posted by Denise Golfis on 1/13/2015 8:28 PM
    I slipped on the ice and tried unsuccessfully to catch myself and hit my shoulder. Doctor did exam and MRI, torn rotator cuff and a hairline fracture on one of the bones, not the big one. Wondering if fracture will make nonsurgical route still possible.
    Posted by Tom on 1/24/2015 9:25 PM
    If the tear is full thickness supraspinatus tendon and the medial tendon margin is retracted to the mid acromial is it possible for complete healing with PT alone. My surgery is scheduled for March 9th. My pain is manageable and does not affect sleep.
    Posted by Paula on 2/23/2015 1:38 PM
    Was dx with bursitis but after more than a year of pt, shots & trigger point therapy I eventually could not use my arm. Finally got an mri, had a massive full thickness tear, tendonosis, and went to surgery followed by more pt. 18 months later I have two complete full thickness tears in the same place and now have arthritis in the joint capsule. Doc insisted it was healed when I complained of pain and limited motion. Had a doc get angry with me when I didn't give him the right responses he expected on exam. He thought I should have carpal tunnel. After xray confirmed arthritis of the thumb, I went to another surgeon. Frankly, the conservative approach has meant misery for me. I also had three cspine surgeries after the doc finally did an mri on my neck. I have permanent nerve damage now. I did not fit into anyones neat little criteria (age of onset 35-now 49) so I received the "conservative" treatment. Now I face possible disability. My comment is a question: what about those folks who don't fit inside the research box, table or graph? I can't find answers because my problems extend beyond the medical communities' graphs and outcomes. Mind you, the doc I speak of is not one but many. I don't trust anybody anymore. Good luck to those folks deciding on surgery or "conservative" treatment.
    Posted by Kristen on 3/13/2015 11:15 PM
    I agree from the above statement as I also have experience in physiotherapy.
    Posted by Muhammad Tariq on 3/23/2015 8:26 AM
    I've had 4 RC surgeries (1 full tear, 2 Partials on my right shoulder along with bursitis and one partial on my left). I have since developed severe pain in my neck that prevents me from moving it normally. I also have herniated disc's L4,5 and i think S1. As far as the surgeries unless it disables you from doing daily activities I would recommend PT for a while and see if that helps. I have been unable to work for over 2 years and was terminated from employment in Feb. I do have a disability case pending but I really wish i could've returned to work. I have been miserable physically and emotionally for years now. I don't wish this on anyone. Stay away from the knife as long as possible
    Posted by Anthony Sacco on 4/24/2015 10:58 AM
    I am 74 years old. I have always been into heavy exercise. I tore my right rotator cuff at age 60. Everything healed perfect with no pain and no ROM problems. It took a year of careful PT and exercise before I was back to normal. However, I was as good as new and went back to my old exercise program. Everything was fine for 14 years. I have now messed up my left shoulder. I was very stupid. I felt so Good that about five years ago I started doing Dips again (the same exercise that messed up my right shoulder 14 years ago). I had an MRI and the results were: 1. Acromioclavicular Arthropathy. Large joint effusion dissects into the acromioclavicular joint indicating the inferior capsule is torn. 2. High-grade tear and retraction of the supraspinatus. 3. At least partial tear and tendinopathy of the subscapularis with mild retraction not excluded. There are a few other things mentioned such as moderate arthritis but I am not worried about these things. I have decided it is best that I give up my exercising as I guess I am just too old. I am now faced with the decision of having the surgery or not to have it. I remember how long it took me to heal the first time. My arm was completely immobilized for six weeks. It took me several months after the cast was removed to have full ROM. The Doctor did not even offer any alternatives to surgery. That worries me. Any comments on rather I should or should not have the surgery without trying PT, meds, etc first? Thanks
    Posted by Louie Calaway on 5/9/2015 11:34 AM
    I have had a shoulder problem for a few months, cannot raise arm from the side higher than 45 degree angle. Dr. thinks it's tendinitis/rotator cuff. I had a cortisone shot and then PT for about three weeks now. I'm confused, because the PT has been telling me repeatedly not to do any exercise/movement that hurts my arm. Then he suddenly said I need to push it and unless the pain is unbearable, to just do it and then treat with heat or ice. So I'm not really sure what is best to do! Any advice would be appreciated.
    Posted by Kay on 5/9/2015 5:49 PM
    I have 80% torn rotator cuff, bursitis, and calcific tendinosis. I've gotten two dr opinions - one says I need surgery, the other says I don't. I don't know what to do. I've tried PT off/on and have been dealing with the pain for about 4 years. To complicate things my left arm was amputated at birth so if I have surgery the recovery will be complicated.
    Posted by jean on 5/14/2015 8:35 PM
    I have full thickness tear in the rotor cuff.doctor recommends surgery. I do not want surgery I'm 64 with arthritis in the joints and low bone density. I can sleep and I'm exercising the arm.what advice can you help me with to continue without surgery. thanks, Eileen Huettl
    Posted by Eileen Huettl on 8/12/2015 10:33 AM
    Hi Herschel Budlow, it was good to read your encouraging post. I have a full-thickness tear and 6mm wide in A-P dimension on the anterior side of my supraspinatus. I would like to avoid surgery if not a must. Have you or your coworkers seen full-thickness supraspinatus tear heal without surgery? Thanks.
    Posted by David on 8/13/2015 2:21 PM
    I am no Doctor but from what I have heard doesn't after a while your body become amune to the med's along with the fact they can also cause damage to other oranges in your body. I have been on 3 different types of pain med's and 2 different muscle refels along with physical thearphy and have had every bone scan, MRI, XR and other EMG along with anything run to find out with is wrong with my shoulder down to my hand on my left hand since Dec and I am still in a lot of pain. I don't let if stop me because of little ones. Now they have decision to do the surgery. So not every case is different with different issues.
    Posted by Eustacia Odle on 8/14/2015 4:27 AM
    The study is enlightening but I would like to see the results after 2 years or 5 years long after the PT has stopped and patents shoulder exercise regimens have faded.
    Posted by Paul on 8/17/2015 10:29 AM
    Any time that you can avoid surgery it is for the best. It's exciting news to hear that surgery isn't always the go-to option for a shoulder injury now. Physical therapy is a great way to reduce pain and heal without surgery. Thanks for sharing!
    Posted by Drew on 8/24/2015 9:58 AM
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