A hole in the blanket…

I see a lot of people with rotator cuff tears, but unfortunately, most of them have been poorly informed or do not understand what this means. Many believe that a torn rotator cuff tendon means either surgery or a life of pain and disability. However, this just isn’t the case and so I want to discuss some of the issues that are not explained well to patients with rotator cuff tears and give you some of my top tips to help.

The first thing to say is tears of the rotator cuff are common, really common, in fact, they should be seen as a normal part of ageing, just like wrinkles on the inside. We often start to see rotator cuff tears appear in people without pain or any other symptoms from the age of 50 onwards (ref). In fact, one paper found that if you are over the age of 50 and have a rotator cuff tear seen on a scan it is twice as likely NOT to be giving you any symptoms, and this increases to four times by the age of 80 (ref).


However, this just isn’t explained well to patients of this age and so we need to start informing patients that once you get to a certain age these tears may have been there a long time before they had any symptoms. In fact there is a strong possibility that they may also have similar tears on their non-painful shoulder, but please be careful telling patients this as the power of words can be very strong. Just by tell patients they may have tears elsewhere it could prime some to start to feel symptoms no matter how well you word it.

It’s not a rope!

I want to next discuss how we can explain rotator cuff tears a little better to patients as it can be scary as hell to be told you’ve got one. Particularly when you are told its a large one, or a full thickness one, or one that it is hanging on by a thread, which is an often used but terrible explanation that should NEVER be used. To do this I first think we need to explain to patients that not all tendons are the same.

Many think of our tendons being like the Achilles, a rope-like structure attaching a broad muscle onto a narrow bony insertion. However, our tendons come in a wide variety of shapes and sizes from long thin ropey ones, to large flat board ones.

The rotator cuff group of tendons are unique in that they are ALL connected together and form a large continuous structure around the humeral head. Most clinicians are aware that the Supraspinatus, Infraspinatus, and Teres Minor tendons are connected, but many are not aware that the Subscapularis is also connected to Supraspinatus via the rotator cable across the long head of biceps, basically making the rotator cuff a continuous structure.

Screen Shot 2018-05-26 at 12.00.15

A lovely image of the cuff showing its continuous structure

So when someone has torn a rotator cuff tendon what they actually have is a hole in this large flat blanket like tendon, not a tear in a rope as most visualise. I often use this blanket analogy to help patients visualise how the rotator cuff is arranged but also help them understand it better.

I often explain to patients that just because you have a hole in a blanket, it doesn’t mean the rest of blanket is useless. A blanket with a hole in it can still keep you warm at night, and when you tug on one end of a blanket with a hole the other end can still move.

This blanket analogy is not that much different from the other analogy we use with lower limb tendons of treat the doughnut and not the hole. However, I find the hole in the blanket analogy helps de-threaten the fear and anxiety of being told you have a torn rotator cuff and helps patients realise that they can work on the rest of the blanket around this hole.

This blanket analogy can also help patients understand how it is safe for them to exercise with a tear of their rotator cuff. Many think that exercise or movement will make the tear worse, but when you explain how exercising can help improve the function of the rest of the blanket around the hole and help improve their shoulder movement and reduce their pain patients tend to understand better, and despite claims there is little evidence that many cuff tears progress with exercise and activity (ref).

I am aware however, that exercise may be doing other non-biomechanical things to help reduce pain and improve function, things such as inhibitory learning, fear exposure and descending noxious inhibitory control (ref, ref).

Not just the blanket!

Finally, I think this blanket analogy is useful for us clinicians as it can help us visualise who may or may not do well with rehab for a rotator cuff tear depending on the size and location of this hole in the blanket. There is some research that states that if the hole (cuff tear) is large (over 1.5cm) and/or involves multiple tendons (particularly Supraspinatus and Subscapularis) then perhaps surgery to repair it is warranted (ref).

However, it is not just this simple as using the size and location of a rotator cuff tear to decide who does or doesn’t need surgery. Other research has found that there are many other factors to consider such as patient’s activity levels (physical or sedentary) general health factors (co-morbidities) and social status (education levels) (ref). All these factors along with the patient’s beliefs and expectations are important to consider in our clinical decision making about who is best suited for surgery or rehab.


To put it as simply as I can when it comes to rotator cuff tears it is vital to assess what shape the person is in and not just what shape their cuff is in to help guide us to the best treatment decisions. And this goes for all the other issues we see, we need to recognise that we should be assessing and managing the people, not just their structure.

So there you go a quick review of rotator cuff tears and some of the issues I come across regularly. I hope you start to use this analogy of the hole in the blanket to help patients understand cuff tears a little better and perhaps to act as an antidote to the generally nocebic information that patients often get. And finally when it comes to assessing, treating and advising patients what to do with cuff tears, remember it’s not just about the size of the hole in the blanket, but also what shape the bed, the bedroom, and the rest of the house is in.

As always, thanks for reading


If you would like to learn more useful tips like this from me then my 2-day shoulder course ‘Complex doesn’t have to be Complicated’ is travelling around the world and may be coming to a place near you.

To find out more about dates and venues please click the image below


10 thoughts on “A hole in the blanket…

  1. Adam,

    I’ve been in ortho and home care 15 Years and have always used the rope analogy (got it from shadowing an ortho MD)! This as such a wonderful post and I will forward to all rehab professionals I know, as I I’ve pointed out our words do more than we know!

    Thanks so much for writing these I get so so much out of them, you are truly a gift to our profession :).

    -Chad Fait

  2. What a great article! Love the blanket analogy – I may even adapt it to a nice, thick fluffy duvet which I think will be even more comforting to patients.

  3. Dear Adam,
    I’m a physio student & I love reading your blog & this is a WONDERFUL post! It’s so useful for me to educate my patients during my clinical attachments & when I start working in the future 🙂 I have a quick question:
    You mentioned that it’s always important to look at the patient as a whole (comorbidities, physical activity levels etc). Could you give an example whereby someone sedentary could benefit from surgery? Meaning rehab would not be helpful. I met several sedentary patients during my clinical attachments. Despite education, some still do not do their exercises (prefer their sedentary lifestyle). Thank you!

  4. I get a painless snapping in my right shoulder and part of me has worried that there’s a tear of some kind that’s going to get worse over time. But the more I learn about shoulders, the less I worry and the more I feel confident continuing to lift weights to the best of my ability at the gym. Snapping gets no better or worse with training, but my confidence and overall shape improves continuously.

  5. Completely agree Adam – tears gain far too much focus and Sen to be an excuse not to load/ condition the cuff- normal tissue doesn’t tear except for excessive unexpected force.

    Analogy does break down however as you can’t get a new supraspinatus down the market !

  6. As a humble patient, what an excellent analogy – totally agree about the state of the rest of the blanket … a hole sounds more like a reasonable explanation as to why the pain sometimes radiates, as opposed to a linear damage point. Love this blog…Thank you

  7. Hi! Thanks Adam for a wonderful article. I’m definitely going to use this blanket analogy! Very helpful.

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