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I want to share a fictional story about a patient named Casey. Although Casey is not real, the questions and events in this story are drawn from my over ten years of experience as a physiotherapist. This story aims to illustrate how to manage rotator cuff tears effectively.
Meet Casey
Casey is middle-aged and recently retired after a career that involved a lot of physical activity, mostly at floor or waist level. Since retiring, Casey has started experiencing pain on the outside of their shoulder. This pain makes it difficult to put on a jacket, pull up blankets in bed, and, most importantly, hold their grandkids.
Will a rotator cuff tear show up on an x-ray?
Casey came into my office with a doctor’s referral and an x-ray report. Casey mentioned that their family doctor suspected a rotator cuff tear and had sent them for an x-ray. Casey asked if the x-ray would show a rotator cuff tear. I explained that x-rays are used to show bony changes and do not reveal changes to soft tissues like muscles or tendons. Ultrasounds or MRIs are more useful for diagnosing rotator cuff tears. I assured Casey that we did not need any imaging to diagnose the tear; a physical assessment would be sufficient to guide our treatment plan by showing how well Casey could move and how strong they were.
Why does my rotator cuff hurt at night?
Casey then explained that the pain was worst at bedtime and asked why they couldn’t sleep on their side. I told Casey that this is common for a variety of reasons. At the end of the day, the shoulder may be tired and swollen from daily activities, even if we can’t see the swelling. When we lie down and stop using the shoulder, the swelling can accumulate, causing pain. The added pressure from lying on the swollen area can make it even more uncomfortable. I noted that nighttime pain is a common complaint but also one of the last to resolve.
What caused my rotator cuff to tear?
During the assessment, Casey mentioned that although they had an active job, it did not involve much overhead lifting. They were confused about why their rotator cuff had torn despite not falling or overusing the shoulder. I explained that rotator cuff tears can happen from trauma, but they can also occur over time due to degenerative changes. Regular use of the arm, even without significant overhead activity, can cause the tendon fibers to wear away. It doesn’t always take a big event for the rotator cuff to tear; often, it’s just the result of aging.
Will my rotator cuff tear be permanent? Will it heal on its own?
As we began the physical assessment, I noticed a lack of range of motion at the end range, likely due to the rotator cuff tear. Casey asked if the tear would be permanent or if it would heal on its own. I explained that the answer varies from patient to patient. Most rotator cuff tears have the ability to repair themselves, depending on the severity of the tear. Healing takes time—about a year for the tissue to fully mature. The tissue also needs stress applied in the right way to build strength and repair. Finding the appropriate load and direction is crucial for a full recovery.
Do you think my rotator cuff needs surgery?
After the physical assessment, Casey asked if surgery would be necessary. I responded with another question: “Can you do what you want to do, even with some pain? Are you able to sleep, work, and enjoy your activities?” If the answer is yes, surgery might not be the best option. If not, trying physiotherapy for a few months before reevaluating is the first line of defense. If physiotherapy doesn’t work, then surgery can be considered. Casey nodded and left the room. I saw Casey a few more times before they were discharged.
Surgery isn’t always the best choice
Fast forward a year, and I saw Casey’s name on my schedule again. Casey walked in and said, “I should have listened. I went ahead with surgery anyway, and now I feel worse.” I wasn’t upset with Casey’s decision; I was more frustrated with myself for not explaining things better. Despite being 85-95% better when discharged, Casey thought surgery would make them completely pain-free. Instead, it set them back, causing more pain than before.
We continued to work together to get Casey back to where they were before surgery. Casey often said, “I wish I had listened and known the outcome.” Hindsight is 20/20, and we don’t have a crystal ball to predict the future. Casey did the best they could with the information they had. In the end, surgery is not always the best option and should be a last resort rather than the first line of defense.
Conclusion
Casey’s story illustrates that rotator cuff tears are common and can often be managed without surgery. With the right treatment and time, most people can make a full recovery. Remember, rotator cuff tears are not the end of the world, and with proper care, you can return to your normal activities.
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