Why Shoulder Rehab Should Be Like A Delicious Pizza

Rotator Cuff Related Shoulder Pain Rehab Should be Like a Good Pizza

Rotator Cuff Related Shoulder Pain Rehab Should be Like a Good Pizza

Okay, this is the pizza blog and you’re probably thinking: How is a pizza related to rotator cuff related shoulder pain?

In fact, the pizza model is a great analogy for the rotator cuff-related shoulder pain rehab.
And although this analogy is of course too simplistic to be transferred to all variables in human beings, I believe it’s a very good way to memorized complex knowledge.

1) Dough = Education

So, in the analogy of a pizza – first there is the dough, which i would like to compare to Education.
The basis of your rehabilitation strategy is education. There is no pizza without a dough. There is no rehabilitation strategy  without educating your patient. And okay, I acknowledge that there are different types of dough – there are also different ways of educating your patient.  Your patient will have other experiences and different knowledge about the problem, so also your education will be different in different patients.

Pizza dough
Tomato saus

2) Tomato saus = Healty lifestyle

Second in a pizza is the tomato saus and this is your advice for general fitness. Run, walk, bycycle – this is probably the healthiest part of a pizza, but this is also the healthiest part of your rehab program. Take advantage of your patient being in your practice to advise them to be more fit in general. This doesn’t only mean to prevent other co-mobidities, but also has an influence on your pain perception for instance.

3) Cheese = Progressive loading program

Third, you got the mozzarella/cheese. This will be your progressive loading program of the musculotendinous unit of the rotator cuff and also what really makes the pizza delicious.
And actually, you now have all the ingredients for a pizza Margherita – which is the most popular pizza world-wide by the way. You got your education, healthy lifestyle advice, and a progressive loading program.


4) Ham = Manual Therapy

But okay, but you can also pimp your pizza with ham for example. We could compare the ham to manual therapy. It’s not always necessary for all patients, but in some people adding ham can encourage your patients to eat it or in other words to motivate him/her to follow the progressive loading program you design for him/her.

5) Mushrooms, Onions etc. = Massage, Dry Needling, Taping etc.

At last, we could add mushrooms  or onions for example. This might be of added value: It’s completely again optional, but can convince your patient to eat the pizza, but absolutely not mandatory. I compare these extra ingredients to dry needling, massage, shockwave, taping etc.


6) Pineapple = Therapeutic Ultrasound, Laser etc.

Okay, we have to talk about pineapple of course. In my opinion, pineapple doesn’t belong on a pizza and you could compare it to your therpeutic ultarsound machine – in other words, it’s useless for your treatment success.
P.S. Physiotutors agree with the fact that ultrasound & laser doesn't belong in shoulder rehab, but a good pizza Hawaii can actually be very delicious!;)

Now this was a very rough overview about how a delicious pizza relates to rotator cuff related shoulder pain rehab. Maybe I could spark your appetite for pizza and you would also like a recipe on how to actually “bake” such a delicious pizza. All the details can be found in my newly released online courses Rotator Cuff Related Shoulder Pain: Separating Facts from Fiction.
If you would like to have a better idea of what you can expect in the course, either head to the following info page or feel free to subscribe to my FREE 5-day video-course below!

Thank you very much for reading!



Learn to Distinguish Shoulder Facts from Friction in This FREE Mini-Video-Series

Awarded World Leading Shoulder Expert Filip Struyf takes you on a 5-Day Video Course to Bust Lots of Shoulder Myths that Prevent you From Delivering the Best Care for your patients with Shoulder Pain

PT vs. Surgery for Rotator Cuff Tear

Major ? Alert!
A while back we posted about a randomized controlled trial comparing decompression surgery with physiotherapy in the case of lumbar spinal stenosis. The outcome: Physiotherapy yielded similar outcomes as surgery!
Inspired by these findings, I prepared an inservice during my last clinical rotation in the form of a critically appraised topic on the current evidence comparing surgical to conservative treatment of rotator cuff tears.

The results:

– A total of 3 RCTs were published between 2014 & 2015.
– Patientgroups amounted to 56 (1), 103 (3), and 180(2) Patients
– Follow-Up Evaluations at 1 (1) (2) and 5 (3) years

– No significant differences in age/gender across studies
– Symptoms since 1 (1) (3) and 2 (3) years
– Studies included degenerative, atraumatic ruptures (1) (2) (3) and traumatic ruptures (3)
– Affected tendons: Supraspinatus (2), supraspinatus + ≥1 additional (1) (3)

– Trauma as onset of symptoms (1) (2)
– local & systemic diseases (1) (2) (3)
– previously operated shoulder (1) (2) (3)
– cognitive impairments influencing participation (1) (2) (3)

– Surgical protocol:
Open/miniopen (1) (3) or arthroscopic (2) surgery followed by ≥12 weeks of Physiotherapy mostly identical to the conservative protocol

– Conservative protocol:
inconsistent description (2) (3)
4-6 weeks: Maintain Glenohumeral/Scapular Mobility
6-12 weeks: Stabilitytraining, Increase Strength

– Primary outcome across all studies:
Constant Murley Score: Combines Shoulderfunction (65 Points) with subjective evaluation of disabilites (35 Points)

– Secondary:
…MRT post (1) (3), VAS (1) (3), several questionnaires (1) (3), SF-36 (3), Costs (2),…

– Heerspink (2015) (1): No significant difference in the per-protocol analysis. Statistically significant difference in the intention-to-treat (Surgery better than Physiotherapy). Difference below Minimal Clinically Important DifferenceHeerspink et al

– Kukkonen (2015) (2): No significant difference

Kukkonen et al

– Moosmayer (2014): Statistically significant difference. Surgery better than Physiotherapy. Difference below Minimal Clinically Important Difference

Moosmayer et al


– Re-rupture rate 20-73% (1) (3)
– Rupture progression ≥5mm in 37% of conservative shoulders.
– Costs: 2417€ for Physiotherapy, 5709€ for surgery


– Patientgroups equal at baseline
– Appropriate randomization/blinding
– Intention-to-treat (1) (2) (3) and per-protocol analysis
– Subgroup analysis (intact vs. rerupture, rerupture vs. conservative)
– High follow up rate ≥95%

– Insufficient/inconsistent description of conservative Protocols (2) (3)
– Pragmatic Studies
– Cause and Extend of ruptures differ greatly
– Kukkonen (2015) (2): Included only well compensated, small, isolated ruptures. No info whether full-thickness or partial thickness tear. Patients had full ROM at inclusion => The CMS has great focus on ROM improvement. They have no follow-up MRI.

Clinical Bottom Line:
In practice, conservative protocols yield similar outcomes to surgical intervention. Patients with degenerative ruptures should be advised to start with a conservative treatment and only cross over to surgery if it doesn’t yield satisfactory results.
Concerning the re-rupture rate, further research should be done on prognostic factors indicating successful surgery.

This is again fairly recent evidence underlining the power of our profession. In the end, we CAN prevent surgery in many cases. Furthermore, patients received the same physiotherapy as their conservative counterpart. What made the improvement? Really the surgery? And once again, physiotherapy could save a tremendous amount of money. so #GetPT1st




Heerspink, F. O. L., van Raay, J. J., Koorevaar, R. C., van Eerden, P. J., Westerbeek, R. E., van’t Riet, E., … & Diercks, R. L. (2015). Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. Journal of Shoulder and Elbow Surgery, 24(8), 1274-1281.

Kukkonen, J., Joukainen, A., Lehtinen, J., Mattila, K. T., Tuominen, E. K., Kauko, T., & Äärimaa, V. (2015). Treatment of Nontraumatic Rotator Cuff Tears.J Bone Joint Surg Am, 97(21), 1729-1737.

Moosmayer, S., Lund, G., Seljom, U. S., Haldorsen, B., Svege, I. C., Hennig, T., … & Smith, H. J. (2014). Tendon repair compared with physiotherapy in the treatment of rotator cuff tears. J Bone Joint Surg Am, 96(18), 1504-1514.