A Hole in the Blanket!

I see a lot of people with rotator cuff tears but unfortunately, many of them have been poorly informed or do not understand what this means. Many believe that a torn rotator cuff means either surgery or a life of pain and disability. But this just isn’t true and in this short blog, I want to explain why and give you one of my top tips that can help explain rotator cuff tears a little better.

The first thing to say is that tears of the rotator cuff are common, really common. In fact, they should be seen as a normal part of ageing just like wrinkles and grey hair. We start to see rotator cuff tears appear in those without any pain or other symptoms from around the age of 50 onwards (ref). One study found that if you are over the age of 50 a rotator cuff tear seen on a scan is TWICE as likely to NOT be giving you any symptoms, and this increases to FOUR times as likely NOT to be an issue when you reach the grand old age of 80 (ref).


These points are often not explained to those in this age range who have shoulder pain and a cuff tear seen on a scan. Clinicians need to be informing patients in this age group that their cuff tear seen on scans could have been there a long time before they had any symptoms, especially if there was no sudden onset or trauma, and that this tear may not be the cause of their current pain and problems.

There is also a very strong possibility that these patients will also have similar tears on their non-painful shoulders (ref). However, we need to be careful who and how we explain this to as the power of words can be very strong for some, and sometimes just by telling a patient they may have tears elsewhere could prime them to start to feel symptoms.

It’s not a rope!

Being told you have torn a rotator cuff tendon in your shoulder can be very unnerving and upsetting, especially if you’ve been told it’s a full-thickness, large or massive one. Even worse if you’ve been told it’s hanging on by a thread which is a horrendous explanation and should NEVER be used but unfortunately is.

To help those with rotator cuff tears understand them better we first need to explain that not all our tendons are the same. Many think all our tendons are rope-like structures like the Achilles or finger tendons. However, our tendons come in a wide variety of shapes and sizes from long thin ropey ones, to short fat stubby ones, and large flat board ones like the rotator cuff.

The four rotator cuff tendons are unique in that they are ALL connected together to form a large broad flat 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 the biceps, basically making it 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 broad large flat tendon, just like a hole in a large blanket. I often use this ‘hole in a blanket’ analogy to help patients visualise and understand a tear of their rotator cuff better. I often explain to patients that just because you have a hole in a blanket, it doesn’t mean the rest of the blanket is useless.

This hole in the blanket analogy is not much different from the other hole analogy we use with lower limb tendons of treating the doughnut and not worrying about the hole. I find the hole in the doughnut and/or blanket analogy often helps reduce the fear and anxiety of being told you have a torn tendon and can help patients realise that they can work on the rest of the tendon around the hole.

The blanket analogy can also help patients understand how it is safe for them to exercise with a tear of their rotator cuff as many are worried that exercise will make a tendon tear worse. When you explain that exercise can help improve the function and resilience of the rest of the blanket around the hole which can improve their movement and reduce pain many patients understand, as well as telling them that there is little evidence that many cuff tears worsen or increase in size with exercise (ref).

I am also aware that exercise can help tendon tears by doing other cognitive and psychological things to reduce pain and improve function such as improving confidence, reducing fear, as well as providing exercise-induced hyperalgesia and/or descending noxious inhibitory control (ref, ref).

Sometimes I like to do a simple practical demonstration of a cuff tear by using a piece of paper that I make a hole in and then pull on it showing how the paper doesn’t break or tear. A video of me demonstrating this can be watched below. However, just a word of warning please choose your paper carefully and practice this a few times as you don’t want to tear the paper in front of patients when you don’t mean to. It’s also worth remembering that our tendons are much, much more robust than paper, in fact, a fabric dishcloth would be a much better model to use if you can.

Not just the blanket!

Another point about rotator cuff tears that is not explained well is that it’s NOT as simple as ONLY the size and location of a rotator cuff tear that explains pain and weakness or decides who does or doesn’t need surgery. Research has found that there are many other factors to consider as causes of shoulder pain and disability other than the size and location of a cuff tear, things such as activity levels, general health, social status, and even education level (ref) along with patient’s beliefs and expectations have all be seen to affect pain and function, and are important considerations in our clinical decision making about who may or may not be best suited for surgery or rehab.


To put it as simply as I can when it comes to clinical reasoning around rotator cuff tears, or any other pathology for that matter, it is vital to step back and take a wider look at what shape the person is in, not just what shape their shoulder is in to help guide them towards the best treatment options for them.

So there you go a quick review of rotator cuff tears. I hope you find the analogy of a hole in the blanket useful to help patients understand cuff tears a little better and perhaps to act as an antidote to some of the nocebic information that patients often get. And remember that when it comes to assessing, advising and helping patients with rotator cuff tears, it’s not just the size of the hole in the blanket that matters, but also what state the bed, the bedroom, and the rest of the house is in that does.

As always, thanks for reading




  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. Nice one!
    How would you go about explaining a patient, that his blanket will have a hole for the rest of his life? Most blankets you can sew..

  7. 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

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

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