Rotator cuff surgery involves stitching or reattaching your torn rotator cuff tendon back to the humerus. The surgery to repair your rotator cuff is performed arthroscopically or with a small camera and other small incisions. With modern techniques rotator cuff surgery has become relatively easy to perform for Orthopedic Surgeons who specialize in shoulder injuries. But, this begs this question… do all rotator cuff tears require rotator cuff surgery? The answer might surprise you.
Whether or not you should consider rotator cuff surgery depends on a number of factors:
- your age
- the cause of your rotator cuff tear
- traumatic
- no injury
- the size of your tear
- if you have failed a trial of non-surgical management.
- physical therapy
- injections
- anti-inflammatory medications
This post and the answers below by our five Orthopedic Surgery experts deals with the topic of degenerative rotator cuff tears. That means that your rotator cuff wore out. If you had a severe injury which caused your rotator cuff tear, then I suggest you read this post. Rotator cuff surgery is usually recommended for nearly all traumatic tears.
Degenerative rotator cuff tears are very common. Many of you will not recall having an injury. You simply noticed your shoulder hurt one day. Some of you may have felt a snap while lifting up something like a suitcase. These are all common presentations for patients with degenerative rotator cuff tears. Many small degenerative rotator cuff tears will not require rotator cuff surgery. After 40, many people will have a rotator cuff tear and not even know it. You may wish to review our first Expert Series post where we discussed the cause of rotator cuff tears.
Remember:
- The rotator cuff is the most likely source of pain after 30
- Most rotator cuff issues, including tears are due to degeneration or attrition
- Most patients with small degenerative rotator cuff tears can be treated without surgery.
- Surgery for degenerative rotator cuff tears is generally considered after failure of a non-surgical regimen of physical therapy, possible injections and oral medications.
As accomplished shoulder surgeons, when do we consider rotator cuff surgery for a small degenerative rotator cuff tear?
Our Expert Series continues today with an answer to your question:
Do I Need Rotator Cuff Surgery?
Derek Ochiai, MD: Website, Twitter
Surgery is an option for degenerative rotator cuff tears that fail to respond adequately to non-surgical treatment, such as physical therapy and cortisone injections. Also, if the rotator cuff tear is inhibiting the patient’s quality of life.
Scott Slattery, MD: Website, Twitter
There are many options for the treatment of a small degenerative rotator cuff tear. I give all patients with small degenerative tears the option to treat them non-surgically with anti-inflammatory medications as well as physical therapy to improve flexibility, strength, muscle balance and coordination. This can work quite well. If the patient has good function and minimal pain, surgery is not absolutely required. If the tear is degenerative, chronic and large with associated muscle atrophy, initial non-surgical treatment with oral medications, injections and physical therapy is almost always the best option.
Marty Leland, MD: Twitter, Facebook
When I first see a patient over 40 with shoulder pain, my first treatment is anti-inflammatories, physical therapy, and frequently a subacromial steroid injection. I will then see the patients back 6-8 weeks later. If they are much better, there is no need for any further treatment. If they aren’t much better, I get an MRI to evaluate their rotator cuff. I usually do not order an MRI the first time I see them because, even if they do have a small rotator cuff tear, I would like to see if non-operative treatment would help them. If it does, GREAT! They may have avoided a surgery. I only order MRIs if they aren’t getting better. However, if I have a patient with a long history of shoulder pain and weakness and they are very weak on examination, I sometimes do order an MRI after the first office visit.
Jeffery Berg, MD: Website, Twitter
Degenerative rotator cuff tears are extremely common. Often these tears can be asymptomatic and incidentally diagnosed. So the first component of my “treatment” for these tears is to determine if they are symptomatic or not. If not felt to be symptomatic, I direct my treatment towards the suspected source of the patient’s symptoms and I advise observation of the tear. The observation primarily consists of clinical evaluations (history and exam) yearly if they remain asymptomatic or sooner if symptoms worsen, since these tears can progress and that progression usually is associated with an increase in symptoms. Depending on the office evaluation, I might also suggest serial ultrasounds or MRIs to evaluate for progression.
If these tears are felt to be symptomatic, I typically will start with nonoperative treatment. I find this to be the most reasonable treatment as degenerative tears often respond favorably to “conservative care” and although the symptoms can often respond well to surgery, they often don’t fully heal following the surgery. My nonoperative treatment consists of oral anti-inflammatories to treat the frequently associated bursitis as well as the pain that often brings the patient to the office. I will almost always include physical therapy as there usually is associated shoulder dysfunction and finally I suggest avoiding aggravating activities. Typically, I try this for 4-6 weeks, looking for any improvement. If improvement is seen, I will suggest continued nonoperative treatment until symptoms resolve or stabilize at an unacceptable level. If the latter, I will recommend an arthroscopic repair. If there is some retraction (lateral to mid humeral head) seen on the MRI, and depending on some specific patient characteristics (ie. young health, high activity level, etc.), I may suggest surgery on initial diagnosis, as I am concerned that if there is any further retraction, the tear may become unrepairable.
How we as physicians manage certain injuries may not always seem logical to patients. Many will not understand why we do not MRI every painful joint and many do not understand why we do not need to operate on everything that is “torn”. It is our obligation to educate you.
Our last post … When Should We MRI Your Shoulder will help you understand that we can make a reasonably good diagnosis and establish a treatment plan that should work without expensive, time-consuming imaging. In addition, many of our parts wear out. Like your favorite pair of jeans … Not all rotator cuff tears require rotator cuff surgery. The American Academy of Orthopedic Surgeons produced a document to assist surgeons in evidence-based management of rotator cuff tears. In this document, they find limited evidence to support surgery for degenerative rotator cuff tears without a trial of non-surgical management first. That said, some rotator cuff tears might continue to hurt after nonsurgical treatments … and you might be offered surgery as an option to improve your pain and thus your quality of life.
Jennifer
Hi Dr Luks: I am a fifty seven year old female with a demanding job of grinding concrete. Am extremely fit and do tons of extra activities. Fell four months ago and tore my rotator cuff. Had X-ray, ultrasound and MRI. Result is full thickness tear of the suprsaspinatus extending as a high grade partial tearing of the infraspinatus with substantial tendon retraction but only mild muscle atrophy. I have been doing physio excercises since March with no improvement. I cannot touch the back of my neck, nor raise my arm past my waist. I have had several incidents with my shoulder popping out and in since the tear I was asked if it affected my daily living and yes it most certainly does. Today my doctor received a letter from the specialist saying I should go to moonshoulder.com and excercise more and maybe he would check again in a few months. I am not one to sit on my butt and am a very quick healer so yes I do my exercises and more. I have adjusted my work so I can handle the pain and using other methods to cope with chores at home. I am just a simple lady but if something is broken it needs to be fixed before it can heal or am I wrong. I live in Alberta Canada but if you have any ideas about what to do I would appreciate it very much. I would love to have my life back. Thank you so much for your time.
Howard J. Luks, MD
Your tear seems to be fairly large. It also sounds like you fit into the acute rotator cuff tear category… waiting further could jeopardize your ultimate result.
Kathy
Husband has full thickness tear of the supraspinatus tendon with retraction of the tendon, dr said surgery, but he has no pain in shoulder, no lack of usage of arm, in fact does a lot of hard manuel labor and no pain , the only pain he has is every so many days he has bad neck pain that causes him not to be able to turn head. They did tey strong inflamation pills and they do help but not to tske for long period of time, really doesnt want surgery but has heard if you dont get it things can get worse and is 65 in age already! What would you recommend? Can he rake pills or get shot and wait on surgery or better done before getting older? He also has full range of his arm usage! Thank you for any adivce!
Howard J. Luks, MD
Without seeing him or his images i can not answer that. The right questions to ask your surgeon include what can happen over time? – Many, but not all tears become larger. What is the chance the surgery will be successful? Once retraction has started the success rate goes down… a lot.
What is his recovery? It’s probably a lot longer than you think. The most likely time to re-tear your rotator cuff is 20-24 weeks after surgery… so no heavy repetitive lifting until after that… many people can not afford that much time off work. There is no easy answer here. Even the American Academy of Orthopedic Surgeons agrees with that.
Rebecca
Hello Dr. Luks, Thank you for sharing this informative series on RC injuries and treatment options. I have a RC problem, a small tear where the bicep attaches in the front. I’m 53. I’ve been in pain for over 1 year (woke up with it one AM after sleeping on that arm the night before,) but I have only recently sought medical help with the issue. I’ve done PT and am now swimming laps. Steroids, anti inflammatory meds, and surgery are all out because of pre existing conditions. My question is, why is the ROM for my arm so limited (and can it return to normal?) and why do small, insignificant jarring motions to the arm cause such extreme pain? It’s also interesting to me that my upper back is painful although the tear is in the front of my shoulder, particularly the muscles behind my armpit. Living with the pain and limited ROM may be easier if I have a better understanding of what is causing it. Again, thank you for all the good you do.
jim Middleton
I am an 80 year old very active man- walk 45 minutes each day and played golf 3-4 times a week until recently
6 weeks ago had a fall in the bathroom and after x-Ray and MRI I have a slight tear in rotator cuff with a small bone chip. I have been in PT 3 weeks and have regained a lot of motion— just want to get back to golf. Should I avoid surgery at all costs?
Howard J. Luks, MD
Sounds like a good plan… best to avoid if you continue to improve
Robert
I am a 68 year old male going in for rotator cuff surgery in 2 days. I think I’m getting cold feet because of the time it takes to heal and the loss of my right arm for a significant time period. My pain is nominal during the day and I am able to do much to include golf but activities that require me raising the arm much causes some significant pain. Like Kayaking and casting a fly rod. At night, there is significant pain while lying down and it does keep me awake or wakes me early in the mornings. I had seen one doctor who gave me injections in the shoulder which didn’t help at all. My new doctor ordered an MRI and it told him I have a complete tear and he recommended surgery. I agreed to this and of course it is scheduled. My thoughts are should I have asked for alternatives or gotten a 2nd opinion? I guess I’m just unsure of the outcome and need reassurance that I’m doing the right thing.
Howard J. Luks, MD
Tough to say Robert.. so many variables. At 68 you likely have a degenerative tear and surgery is not the first option for treatment. Most people respond to physical therapy. But there may have been other issues other issues at play that I can not comment on since I did not examine you. This is certainly not an urgent procedure, so a second or third opinion won’t hurt.