Rotator Cuff Tear – Surgery or No Surgery?

When you think “rotator cuff tear,” most brains jump to surgery. However, surgery isn’t always necessary for rotator cuff tears. Tears come in different shapes and sizes and symptoms vary greatly between individuals. When – or if – to get rotator cuff surgery is not a clear-cut decision. It is nuanced, gray, and an incredibly difficult choice.

We have worked with individuals who choose to get surgery, those who do not want to get surgery, and after individuals have had surgery. In our opinion, a lot more rotator cuff repairs are done in the United States than actually need to be done. We believe this is due to a combination of things. Insurance reimbursement regulations are difficult and surgeons lack time to stay up to date with research. Poor quality physical therapy also abounds in our country. We would like to change that.

Evidence to Support Conservative Management

Here is a little bit of evidence that reviews the effectiveness – or rather ineffectiveness – of rotator cuff tear surgery –

• Sham surgery for a rotator cuff repair is just as effective as actual surgery. (Challoumas, Clifford, Kirwan, & Millar, 2019)
• Outcomes for degenerative (no traumatic injury) rotator cuff tears are the same one year later for those who attend physical therapy compared to those who have surgery. (Kukkonen et al., 2014)
• In images of men 40-70 years old, 96% of individuals show abnormalities. These abnormalities include bursal thickening, arthritis, rotator cuff degeneration, and rotator cuff tears. (Girish, 2011)
• More specifically, 22% of men between 40-70 years old have a rotator cuff tear and absolutely no pain. (Girish, 2011)

We can continue – but we think you get the point. “Fixing” the rotator cuff by surgically repairing it isn’t always the best solution to the problem. Furthermore, one third to one half of the tears that are surgically repaired end up re-tearing. Ironically, a good chunk of these people do not develop pain even though they have re-torn their rotator cuff. Essentially, surgery is not always the answer.

When is Surgery the Answer?

We would be remiss though if we didn’t clarify when surgery IS the answer. There are a couple non-negotiables that no matter how biased you are, surgery is where you should go. These deal breakers fall into two categories – physical tests and emotional tests. If you fail any of these tests, you may want to see a surgeon instead of trying to manage things conservatively. Surgery may be necessary to get the outcome you desire.

Rotator Cuff Tears – Physical Tests

First, if you can’t lift your hand above your head with your elbow straight, you undeniably need surgery if you want to reach overhead again. If you are okay not reaching overhead and only want to decrease your pain, then surgery may not be indicated. It depends on what your goals are.

Second, have someone raise your arm directly to the side and let go. If your arm falls back to your side because you can’t hold it up, surgery may be the best route. If you do not want surgery, we would suggest attempting conservative management for at least 8 weeks. Current research suggests trying conservative management for a full year before deciding that surgery is the best route. Ideally, we would suggest conservative management for a full year, but we understand that this is not always practical for some. However, it is important to ensure that your conservative management is good conservative management. Rest, ice, a cortisone injection, and various exercises that are not designed specifically for you do not count as conservative management.

Rotator Cuff Tears – Emotional Tests

The main emotional test you need to pass to be able to manage things conservatively is Can you avoid doing what bothers your shoulder? If you are constantly increasing your discomfort above moderate, your shoulder will never receive the rest it needs to fully recover. For a bit more detail on how much discomfort is okay and how much prevents healing from occurring, see this blog post.

The physical demands of your life are also important to consider. If you are capable of restricting yourself to non-painful activities but have a job or are taking care of an elderly family member or child and this is not possible, surgery may be your best bet. An example of this is a self-employed landscaper who cannot do his job without his shoulder. Sometimes there are ways around this, but not always. Social responsibilities play large roles in our lives and they are important factors to consider when making this difficult decision.

Now What?

Say you passed all those tests and you want to manage your rotator cuff tear conservatively. That’s fantastic! Here is the thing though – you will want to do so with the guidance of someone who sees this on a daily basis. This will help prevent you from falling into common pitfalls that a lot of individuals succumb to on their own and speed up the process to getting pain-free. If you are more of a DIY person, we compiled a few tips to get you started here, but we strongly recommend reaching out to us for a free consultation.