Numerous papers over the last few years have demonstrated a very significant increase in the number of patients being indicated for surgery on their rotator cuff tear. The latest paper came out of the Hospital for Joint Disease. Their findings are alarming.
- The investigators found a total of 168,780 rotator cuff repairs were treated with surgery in NYS from 1995 to 2009.
- In 1995, the population incidence of rotator cuff repairs was 23.5 per 100,000.
- In comparison, in 2009, the population incidence was 83.1 per 100,000, an increase of 238% .
- The percentage of individuals aged between 45 and 65 years undergoing surgery for a rotator cuff repair increased from 53.0% to 64.2% during this same period.
The rotator cuff are the muscles which enable us to move our shoulder. There are actually four of them. The most commonly torn tendon is the supraspinatus and the vast majority of those “tears” are degenerative or attritional. A degenerative or attritional rotator cuff tear is simply a portion of the tendon which wore out over time. Most patients do not have a single traumatic precipitating event which led to the tear. Recent studies have shown that the majority of these tears will not grow in size and that patients will have few if any issues if these rotator cuff tears are treated without surgery. So what’s going on here?
- Are more patients choosing surgery as an option ?
- Are more patients being told that surgery is their only or best option?
- Has the development of minimally invasive techniques led physicians to recommend surgery more often?
- Was the development of a surgical billing code we can submit for payment responsible for the rise?
- Are the patients being told that the science shows that surgery is not needed for many rotator cuff tears?
There are many patients who believe that if something is torn, it therefore must be fixed. It takes a while to convince them otherwise. It seems counter-intuitive to them that surgery is not necessary to fix a rotator cuff tear in order to alleviate their discomfort. Most patients, if you take the time to talk to them will understand. Some may not and will easily find someone to operate on them.
There are surgeons who are routinely treating the MRI findings and not necessarily the patient who will recommend surgery for a rotator cuff tear simply because it is present… despite their knowledge of the current literature. Why? Because fixing a tear surgically pays more than talking to a patient for 30 minutes about why the surgery might not be necessary.
The authors of the study mentioned in the opening sentence correlated the increase in rotator cuff repairs with the development of a billing code, called a CPT code, which allows the surgeon to bill the insurers for the repair. They found a direct correlation between the release of this code and the increase in the number of patients who had surgery for rotator cuff tears.
Bottom line… as we age, rotator cuff tears become very common. Most of them occur because our tissue simply wore out. Many small degenerative rotator cuff tears do not require surgery in order to alleviate your pain. Most small degenerative rotator cuff tears will not grow in size.
You want to be treated as a patient, not as an MRI finding or CPT code. Make sure you hit the books (Google) and look for meaningful information about the issue you suffer from. Make sure to question your surgeon. If your doctor isn’t willing to engage… walk.
Any questions?
NameKaren Leto says
Thanks for the article and the honesty. I wish everyone would take this serious.
Leon Walters says
Hello:
I am a barber and after working for 54 years I am having trouble holding my arm in the position I need when using the clippers. The muscle for that position is very weak. I have had an MRI and shows a tear, but I don;t know yet where the tear is located. (I see Dr. in about 2 weeks) I have full motion of my shoulder, very little pain and can do just about anything with the shoulder except cut hair…..Any advise would be appreciated.
Leon
Howard J. Luks, MD says
Tough to say Leon … when we determine the proper treatment for patients we need to consider their goals, occupation, etc…
Without knowledge of the MRI findings, and without examining and talking to you I can not provide you with a firm recommendation one way or the other.
Good Luck
Howard Luks
Leon Walters says
I saw the surgeon yesterday and he says there is only a 50/50 chance that the muscle would come back with the surgery…. I am in limbo as what to do.
Shelley says
30 years ago fell on my left shoulder on cement sidewalk. Young, did nothing about it. 2010, started working out, I could not lift that arm straight out in front of me. I couldn’t lift a two pound weight. Worked out for about 1 year, got up to 5 lbs. eventually. I moved forward in workout routine, and I was doing military push-ups off a aerobic’s step, right arm on step, left arm off step, then two arms on step, then left arm on step, right arm off step. 3 sets of 25 reps each time. Finished first 25, rested. Began 2nd set, on first rep left arm off step, right arm on, my left arm totally collapsed. Pain felt like I broke my shoulder. I could not move arm for at least one – two weeks. My massage therapist helped me with some, enablingobility again. I was in Physio at the time for another unrelated issue, Went to see MD, no ex ray, no MRI ordered, just prescribed Physio for shoulder pain. It was practically impossible to do. Not much progress, so when I completed Physio for other issue I stopped going. A year later I tried acupuncture a suction cup treatment. That helped with sleeping issues, but coverage ran out, so stopped that . Last winter finally got into see Orthopedic surgeon and had MRI, he said it’s only tendinitis, and gave me cortisone shot. I just started a job with a lot of heavy and overhead, continuous movement with shoulders . I’m back to pain at night, and pain during the day. Pressing extended arms outward, against resistance, upward and backward movements, etc. pain is constant, sharp and dull.
Can you suggest any thing I should do now. I feel like I’m just hotting a brick wall. I’ve been trying to seek approoriate treatment or surgery. I don’t know what to do. If pain and weakness continues, I may lose my job.
I want to see photos of my MRI, so I can see damage, I heard once that there is definite degeneration there.
Thanks, hoping you can respond.
Howard J. Luks, MD says
Hi Shelley … the rotator cuff is the most common source of pain in the shoulder … and a tear isn’t necessary for it too hurt. Search our site for Tendinosis and you can read more about it. Second… there are other structures which can bother you .. the biceps, rarely – the labrum, calcific tendonitis, etc… All those entities can be treated successfully if thought to be the source of your pain.
Good Luck
Angela says
Dr Luks, I fell at work on my left side about 3 months ago, I slipped and fell on ice covered porch. I’m having serious pain in my shoulder and elbow. Workcomp is slow to approve things as ypu know. So far they have X-ray my elbow and shoulder. Nothing showed up there, they approved a MRI of my shoulder, found put today there is a 8 millimeter tear near the humeral head. I was told surgery isn’t required and given a steroid injection. My next appt is in 2 weeks for the dr to look at my elbow again and ask for a MRI on it. He has ask before but was denied . It is really hard to bend this arm, I can’t sleep but a couple hrs at a time. In your opinion will a steroid shot help? Or do you think eventually I will need surgery? Thanks for your time.
Howard J. Luks, MD says
Hi Angela.. physical therapy for most tendon problems around the elbow and the shoulder can be very effective.
Michelle says
I have my MRI report in front of me. The impressions are as follows
1)Full Thickness tear unvolving the supraspinatus tendon retracted 3cm from the greater tuberosity.
2)Full Thickness tear involving the infraspinatus tendon retracted from the greater tuberosity.
I watched your video and it states. That retracted tears are harder to repair.
I see my Ortho next Friday.
What are your thoughts?
Howard J. Luks, MD says
It’s true … retracted tears are more challenging to fix and have a lower healing rate (or higher failure rate) after surgery. But each case is different. At least you now know what to talk to your surgeon about.
Good Luck
Nancy says
I have a large rotator cuff on my right side . I have been told that surgery is the only way that I can go. I have been putting this off as I am scared to have it done. How long can I go without the surgery and will it keep tearing? Also I live in the north country and the cold weather seems to make it unbearable . Any thoughts?