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Is Shoulder Pain a Rotator Cuff Tear? Don’t Trust Your MRI

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I have been treating people with shoulder pain for what feels like forever. In most cases, they can’t remember a specific incident that caused their pain or when the pain even began. But as time passed, the pain grew worse and eventually it ended up limiting their ability to perform many to most of their functional activities—like driving, hair care (combing, blow drying), securing a bra, tucking in a shirt at the back of their pants, reaching behind them in the car and lifting objects over shoulder height. Lots of things that most people take for granted.

Then they sought medical attention. The proverbial MRI (magnetic resonance imaging) was taken and a rotator cuff tear was found. For the lucky ones who saw me before making an appointment for surgery, I worked with them to resolve their symptoms and their function fully returned. Those who had surgery for that rotator cuff tear that was supposedly the cause of their symptoms did not fare so well.

As I explained in my earlier blog on MRIs, they are not a reliable way to determine the root cause of most pain. If the rotator cuff tear only occurred at the time the pain began, say two weeks ago, and you can’t remember a specific traumatic incident that occurred two weeks ago, isn’t possible that that rotator cuff tear that was found actually occurred more than two weeks ago? If an MRI were taken a few months prior to your pain beginning, the very same rotator cuff tear—the one being called the cause of your pain—would be present. And if it has existed for months or years prior to when your pain began, how can anybody assert that is causing your pain now?

Here is a little study that clearly illustrates this point. As reported in The New York Times, sports orthopedist Dr. James Andrews conducted MRI scans of the shoulders of 31 professional baseball pitchers with absolutely no shoulder pain or injury. He found that 87% had rotator cuff tears and 90% had labral (cartilage) tears.

Now let’s talk about the rotator cuff tear itself. Tears are classified as acute or degenerative…

An acute tear is due to a trauma—like falling off a ladder and trying to stop yourself by stretching your arm behind you.

A degenerative tear is due to wear and tear and progresses very slowly. This occurs because the mechanics of the shoulder joint are not preserved as you lose strength and balance of the muscles associated with shoulder function.

If you are troubled by shoulder pain, ask yourself which of these scenarios is more like yours:

  • Can you identify a specific trauma associated with your pain? It would have to be something pretty dramatic. Prior to the event, you had no pain and you now have severe pain. Prior to the event you had full range of motion and now you have almost none. In this case, surgery to repair the tear is often advisable.
  • Is yours a case where nothing dramatic happened? Degenerative tears create no immediate symptoms because they develop over years. And they also can be treated without surgery.

Let’s talk about how the shoulder works and what part of the rotator cuff does what. The two primary aspects of the rotator cuff are the supraspinatus and infraspinatus. You will feel a bony portion running from the inside to the outside of the shoulder blade. This is called the spine of the shoulder blade. Above it (and above the shoulder joint) sits the supraspinatus. Its purpose is to support the weight of the arm bone when the arm is hanging at your side. It cannot help to keep the head of the upper arm bone in the right position when the arm is raised. That is primarily the job of the infraspinatus, which sits below the spine of the shoulder blade.

With this understanding, you can determine which muscle is eliciting your pain. If you have no real problem holding your arm at your side but you can’t raise it even to shoulder height, the infraspinatus is involved. If you can raise your arm without much difficulty but just letting your arm hang at your side elicits the pain, then the pain involves the supraspinatus.

In pretty much every case I have treated where the rotator cuff was leading to shoulder-region pain, the person could not raise his or her arm; hanging it down was not a problem. Hence, the pain was from the infraspinatus. Yet in every case I have seen where an MRI indicated a tear of the rotator cuff, it was in the supraspinatus. This means that the tear had nothing to do with the pain.

The rotator cuff works with several other muscles to achieve normal function. If these other muscles are strained, it can cause the rotator cuff to overwork and strain. The key to resolving pain at the shoulder in most cases is physical therapy to teach you how to strengthen all the appropriate muscles associated with shoulder function, such as the exercise in this article to strengthen the posterior deltoid.

I hope this blog has helped you determine whether that rotator cuff tear found on your MRI is truly the cause of your pain…and whether surgery is the right option or you simply need to strengthen the right muscles.

Be warned—having an unnecessary surgery will only prolong your chronic pain and dysfunction.

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