Physical therapy for torn rotator cuff before surgery

For several years, Therese Glowacki had an unwelcome companion: nagging pain in her right shoulder. It was often quiet, but it barked when she threw, swam, reached out to clean a countertop, extended upward to wipe a window or other routine actions.

She recalls three incidents that could have damaged the shoulder. There was a quick fall while skiing, a slow tumble from a bike when her feet slipped out of the clips, and a sharp pull from the heavy lift of a beer keg at a CD release party for the band in which she plays marimbas.

In each case, the pain persisted for a couple of weeks, but Glowacki, now 60, lived with it. The discomfort didn’t hinder her from doing her job as natural resource manager for Boulder County Parks and Open Space. The position requires writing, speaking, typing, and periodic hiking around the trails and fields her department manages, none of which strains her shoulder.

“I never sought professional help for the pain,” Glowacki said.

Painful pull

That changed in May of 2018 when she tried to swim and felt shoulder pain too sharp to ignore.

“I said, ‘Okay, I need to get it checked out,’” Glowacki recalled. The decision led to her participation in a national trial examining the effectiveness of surgical non-surgical approaches to one of the most common orthopedic injuries: tears of the rotator cuff, a collection of muscles and tendons that stabilize the shoulder joint.

Her primary care physician referred her to Dr. Eric McCarty, an orthopedic sports medicine specialist and chief of Sports Medicine and Shoulder Surgery with the Department of Orthopedics at the University of Colorado School of Medicine, who practices at UCHealth CU Sports Medicine clinic and UCHealth Broomfield Hospital. McCarty examined Glowacki and ordered an MRI that revealed two tears in her rotator cuff.

It was a routine diagnosis for McCarty, who said he performs two to three rotator cuff repairs a week, many of them the result of stress caused by outdoor pursuits like skiing, biking, golfing and rock-climbing, or accumulated wear-and-tear from work that requires a lot of lifting, reaching and overhead work. Nationally, some 2 million receive treatment for rotator cuff problems each year.

“It’s a common shoulder problem in the general population,” McCarty said, “and it increases every decade after age 50.”

The surgical standard

For rotator cuff tears like Glowacki’s that don’t involve an acute, serious injury, McCarty said the most common fix is arthroscopic surgery. He inserts an instrument with a camera into the shoulder, examines the space, identifies the tears, restores the rotator cuff to its original position and fixes it to the bone with a series of small anchors. It’s outpatient surgery, but the recovery, which requires six to eight weeks in a sling and subsequent physical therapy, can take five to six months, McCarty said.

Some patients can recover with physical therapy alone, McCarty added, but there hasn’t been much evidence compiled to compare the effectiveness of the surgical to the non-surgical approach and identify the characteristics of patients who do better with one or the other.

That’s the goal of the ARC trial, now underway at 11 study sites across the United States, including the University of Colorado, where McCarty is the principal investigator. Patients 50 years and older with rotator cuff tears not caused by acute trauma are randomly assigned for either surgery or a prescribed physical therapy regimen. After treatment, study researchers assess patients’ pain levels, strength, range of motion and ability to perform their routine daily activities.

“It’s an interesting study that pertains to a lot of people and may change the way we treat people with rotator cuff tears,” said McCarty, who co-authored an earlier study by the Multicenter Orthopedic Outcomes Network that showed that 75% of patients who followed a prescribed physical therapy regimen for their tears and were followed for two years improved sufficiently to avoid surgery.

“Many people do fine with surgeries, but we want to identify candidates for non-operative management as well as those who do need surgery,” McCarty said. “The way it’s been taught in the past is, ‘You have a rotator cuff tear; you need surgery.’”

To PT or not PT?

Indeed, Glowacki said her sister and a work colleague both had rotator cuff tears and tried physical therapy but wound up having surgery.

“They both said PT won’t work,” Glowacki said.

Despite those warnings and knowing that she could be assigned to the physical therapy group, Glowacki decided to enroll in the trial. She had the assurance that if she committed to the regimen but didn’t improve, she still could choose surgery. She’d also recovered from a serious calf injury earlier in her life without surgery.

“With [the surgical option] out there, I thought, ‘Why not give PT a try, join the study and see if my experience can help broader science,’” Glowacki said.

McCarty acknowledged that finding patients, as well as providers, with her attitude has been a challenge.

“We need both patients and physicians who are willing to let go of any preconceived ideas that a rotator cuff injury needs to be treated one way or the other,” he said. “They need to be open to the fact that one may be better than the other for a particular patient.”

Let’s get physical

Glowacki began a four-month physical therapy regimen at UCHealth Family Medicine – Boulder late last summer. The sessions included massaging her muscles, moving the right arm and shoulder in different directions, and stretching with bands. She later progressed to lifting 1- to 3-pound weights. She also worked on assigned exercises at home five days a week for 20 to 30 minutes.

“I was pretty committed,” she said.

The effort paid off. By January of this year, Glowacki’s shoulder pain had subsided sufficiently that she was confident she could avoid surgery. To be sure, she kept up her home exercises two or three times a week for another three months and now does them periodically to stay on track. She’s back to pain-free swimming and throwing (a few recent snowball tosses didn’t cause a twinge).

McCarty noted that physical therapy doesn’t repair rotator cuff tears so much as teach patients to use uninjured muscles to move the shoulder efficiently and painlessly. Glowacki said she learned to maintain good posture, open her shoulders and work the muscles across her chest. She’s careful to avoid the all-too-common shoulder-straining habits of hunching over computer keyboards, cellphones and steering wheels.

“The physical therapy really helped me,” she said. “There is no surgery in my future.”

Toward personalized treatment

The experience of Glowacki and other patients enrolled in the ARC trial – the national enrollment target is 700 – could help orthopedists do a better job of tailoring treatment for rotator cuff injuries, McCarty said.

“We know there are people who can live with rotator cuff tears,” he said. “We want to try to identify the characteristics of those who get well with physical therapy. I’m an orthopedic surgeon, but that doesn’t mean I’m looking to do surgery every time,” he added. “I’m here to make people better. Sometimes I’m going to utilize my surgical skills, but sometimes I’m going to use my diagnostic skills to treat patients the right way. That sometimes means PT and avoiding surgery.”

The trial could have wide ripple effects that spread beyond the clinic and operating room, McCarty said. The study is co-sponsored by the Patient-Centered Outcomes Research Institute, which investigates the effectiveness of treatment options.

“There is no doubt there are financial implications,” he said. “Physical therapy costs something but not as much as surgery. There are potential ramifications on health care delivery and cost.”

For more information on the ARC trial, contact Jeff Wilson at 720-848-8228 or [email protected].