You have fallen, you can not move your arm, and you have been told that you have a rotator cuff tear. Do you need to consider surgery to repair your rotator cuff?
Types of Rotator Cuff Tears
In our first Expert Series post we explored the cause of rotator cuff tears. What explained that the majority of rotator cuff tears are due to degeneration or attrition of the rotator cuff. Simply put- your rotator cuff tendon simply wore out.
Alternatively, trauma, such as a fall, or an accident can also cause a rotator cuff tear. When it comes to managing patients with traumatic rotator cuff tears most Orthopedic Shoulder surgeons are in agreement. There is a significant difference in the management of acute traumatic tears of the rotator cuff, versus the more common degenerative or attritional tear that we see. As discussed in our last Expert Series post, the initial treatment of a small degenerative tear is nearly always non-surgical.
Do We Recommend Surgery for Traumatic Rotator Cuff Tears?
In this post, our experts will discuss their thoughts on the management of traumatic rotator cuff tears.
Marty Leland, MD: Website, Twitter, Facebook
This depends on the activity level of the patient, how much pain and weakness they have, how long has it been since the tear and if they are starting to see any improvement or are things staying the same or getting worse. Night pain is also a sign that a patient has a higher likelihood of needing surgery. Also, the larger and more retracted the tear, the more I worry that they will not get better unless they have surgery. If I have a patient in their early 40s that works in heavy labor with a traumatic rotator cuff tear that has not shown any signs of improvement in 4 weeks, I might get an MRI right away and then discuss arthroscopic surgery. However, if I have a 70 year old retired patient of low physical activity that tore their rotator cuff slipping on the ice, I definitely want to try a significant course of non-operative treatment before discussing surgery.
Jeffery Berg, MD: Website, Twitter
I always try to fit the treatment to the patient…not the patient to the treatment, so I don’t have absolute rules. If the patient is younger than 65 yo healthy and active, I will almost always recommend surgery. If they are older and active, I will also usually recommend surgery. In patients that are less healthy, older and/or less active, I will consider nonoperative treatment but counsel them that their symptoms are likely to persist, progress or, even if improved over the short-term, could recur in the future. At that time, the tear may not be repairable or if repairable, will likely have a poorer prognosis for healing.
Scott Slattery, MD: Website, Twitter
When an acute, traumatic rotator cuff tear occurs and creates a sudden loss of function, I generally recommend surgical treatment. Patients do not tolerate sudden, significant tears as well as the slow, progressive degenerative tears. Several studies have shown that the best results, with acute tears, occur if the tendon is repaired within three months of the injury.
Derek Ochiai, MD: Website, Twitter
For acute, traumatic rotator cuff tears, I would recommend surgery. Typically, these tears can be more extensive and retracted away from the bone, making non-surgical intervention less likely to be successful. Also, acute traumatic rotator cuff tears in patients over the age of 40 years old can occur in combination with shoulder dislocations. If a patient over 40 has shoulder pain following a shoulder dislocation, I would have a high index of suspicion for a rotator cuff tear.
If you are a healthy, active individual who has slipped, fallen or have been in an accident and you have suffered a traumatic tear of your rotator cuff then your surgeon is likely to recommend a repair to give you the best chance at having a pain free, strong shoulder.
Once again I would like to thank our experts for their contribution to your education on the management of rotator cuff tears and shoulder pain.
Mark Kotte
I am an active 59 year old male who slipped and fell on the ice and injured my left shoulder. An MRI showed the following:
1. Full thickness tear of the supraspinatus tendon with tendon retraction. Partial thickness tear of the infraspinatus and subscapularis tendons.
2. Superior and posterior labral tear.
3. Large glenohumeral joint effusion with debris.
4. Mild osteoarthrits of the glenohumeral joint.
I am currently trying physical therapy for 30 days to avoid surgery. I am reluctant to have surgery since I developed a DVT when I had ACL replacement surgery 17 years ago. I am fearful of developing a blood clot again. Are my fears warranted? Is there anything that can be done either pre or post operative that can reduce my chance of a blood clot?
Hi Mark … yes. In patients at high risk for a recurrent DVT we will often start “blood thinners” or aspirin therapy after surgery and continue for a few weeks. It doesn’t bring the risk to zero, but it does diminish the risk. It also adds the risk of bleeding to the risks of surgery…
Maria
I am an active 54 year old woman. I was pulled off a golf cart by my dog in August (I know – don’t ask!) and landed on my shoulder. I had severe shoulder pain. I saw an orthopedic surgeon in October, who did x-rays to make sure that there were no breaks, and administered a cortisone shot. As I was uninsured until January 1, he suggested an MRI in early January if the shot/time/rest/NSAIDs did not work. I still have constant ache and very limited mobility.
I had an MRI done yesterday. 1. Extensively thickened and edematous joint capsule consistent with adhesive capsulitis. 2. Mild partial subscapularis tendon tear with partial longitudinal biceps tendon tear and partial medial subluxation of the long head biceps. I have a follow-up with my local ortho, and went ahead and scheduled an appt with a shoulder specialist at Duke.
Do these types of tears typically need surgical repair? Would just the arthroscopic repair fix all the issues that are listed on the MRI report? Or does the capsulitis and the subluxation of the LHB require different repairs?
Thanks so much!
The primary goal is to get your range of motion back. Surgery on an already stiff shoulder is not the best idea. In addition, your tears are not severe at all. Many people live long happy lives with those findings without surgery.
Most shoulder docs would agree that you should start with aggressive therapy to get the shoulder moving… and only consider surgery if your pain persists after a few months if therapy doesn’t alleviate your symptoms.
But please keep in mind… only you and your doctor can make that decision. Please understand that I post for educational purposes and can not offer treatment advice as a physician in this forum.
Good Luck
Gail Minnaar
I have a full thickness supraspinator tear with a 1.5cm retraction, no fatty infiltration, and a full thickness infraspinator tear with a 1.7cm retraction, no fatty infiltration, along with a 4cm superior larbral tear. All confirmed on Ultrasound, and MRI arthrogram. I have had 10 months of intense physio, and NSAID’s, with no improvement, – My night pain is probably the most debilitating as I am not sleeping for longer than 2 hours at a time. My husband does not want me to have surgery. Will I heal with out?
Thank you.
Probably not… that’s a large tear.
Greg
It will be two weeks tomorrow since I had a bike accident. I fell on my right shoulder with arm against body, not outstretched. Right clavicle was broken and has been in a sling. I have a deep ache in my shoulder and cannot lift my arm from my side more than a couple of inches. Could the shoulder pain and immobility be related to the broken clavicle or does there sound like there is more at play? I see an ortho in four days. Should I press for an MTI if there is no improvement in the pain and mobility by then? Thank you.
Each case is different Greg… some people can have injuries to both the rotator cuff and the clavicle, although that is usually rare.
When they examine you they should be able to determine if you need an Ultrasound or MRI to study the rotator cuff too.
Good Luck
Ellen
Seeking clarification. Surgery only recommended for traumatic tear if significant loss of function right away? I’m an active 50 year old who slipped and fell backwards onto a titled floor. Saw primary 12 days after and told no MRI without trying PT first. 4.5 weeks of PT have restored almost full range of motion with just slight discomfort – no pain medicine needed. No weakness. Still pain sleeping on that side so I don’t do that. If traumatic and PT seems to be doing the trick is there still a recommendation for surgery?
Ellen… There are many variables that go into the decision making about whether or not to have a rotator cuff repaired.
– size of the tear
– location of the tear
-acute (traumatic) vs. chronic (atraumatic)
– patient based quality of life complaints.
In my position I can only give information, I can not offer treatment recommendations. But the aforementioned variables and their effect on decision making can be reviewed with your surgeon to help you understand your options.
Elizabeth Moore
Thank you, we did not get past his primary care provider – though he did say he wanted to see what therapy would do. We do have good insurance so that is not the issue, something I realize figures into the decision part of the time.. His physical therapist recommended another orthopedic surgeon whose patients she had worked with in therapy for the same injury.
Elizabeth Moore
Elizabeth Moore
Dr. Luks,
My husband, Chuck, is 86. He walks briskly 2 to 3 miles a day about 5 days a week. He enjoys working at household tasks in our new condo. We travel, and hiked around the Pompeii remains in Italy this fall. He wants to go back to riding his bike.
He has low blood pressure and sees the doctor annually. He is on no medications, but does take supplements.
He has some sleep apnea, and a c-pap which he does not use.
He comes from a family of 8 children. Of those who have died, 3 were in their 90’s, one died in her 70’s of cancer. Of the 4 still living they range from mid 70s to 93.
On Christmas Eve day he slipped on the ice while walking the dog. He fell hard and could not get up. The left shoulder was dislocated and he was put under briefly to put it back in place. He had an MRI Dec. 28th.
Because they could not contact us by phone, we did not get the mri results until we saw the orthopedic surgeon on the 4th. The doctor told us he had a rotator cuff tear. Then he began warning us that surgery at his age carried too much risk, that infection was more likely at his age, that his shoulder might never heal, and asked how often Chuck would need to lift his arm over head. So we asked if he would not recommend the surgery and he said he would not care to do it.
So we came home and later in the afternoon we got the letter from the MRI clinic saying: “1) he has a complete tear of 2/4 of his rotator cuff muscles. 2)this requires surgery in for him to have shoulder function again, 3)please follow up with orthopedist Kiesau on 1/4/17 as scheduled.
Since then I have followed up to schedule a new opinion.
I have read your complete column found on this site. Chuck is reading about the surgery itself. Would you dismiss the surgery out of hand or proceed with getting another opinion. Do 86 year old men ever successfully opt for this surgery?
Dr.Luks, I am coming up on age 77 and I would do this in a heartbeat, so I need perspective.
Elizabeth Moore
There are so many variables that go into surgical decision making. His age is just one consideration. A second opinion seems logical.
jacur morris
Dr Luks. I am a 75 year old woman, not very active and live alone. Several months ago i tore bith rotator cuffs. My orthpod did not feel that i was a. good candidate for surgery Due two other health conditions . for safety purposes my son-in-law would like for me to learn to shoot a handgun but I’m concerned that recoil might hurt my shoulders again. they are still both moderately painful especially at night and I don’t want to do anything that will retear or cause more problems. I think my hand strength may be a problem Also. Am i bring foolish to want to do this?
Fixing rotator cuff tears at your age does carry with it a much lower success rate. Health issues can impact your recovery from anesthesia and the overall surgery as well.
P Lopez
Hi Dr Luks,
I am a 55 y/o woman working as a caregiver. My job requires a lot of heavy lifting. I had an on the job injury of my shoulder Jan 2015, had an MRI on July and seen by doctor in August. MRI results are High grade partial tear and tendinopathy of supraspinatus wit bursal side fraying as well. Insertional tendinopathy of infraspinatus and tendinopathy of subscapularis tendon. Also type II SLAP tear.
I had cortisone shots, PT and manipulation under anesthesia. I still have pain and I am going under surgery in two weeks.
My questions are:
Should I go ahead with surgery? Will surgery be effective for me to recover? Will my shoulder be fine after surgery? Please, give some advise, since I am still not sure if I should have surgery.
Thank you in advance for your words.
I can’t offer treatment advice since I haven’t examined you. Sorry. But second or even third opinions are often worthwhile.
Ngaire Jury
I am a reasonably fit 70 year old female. 18 months ago I had an accident and presented with painful shoulder when I reached in front on myself. I had some trouble sleeping at night. After MRI it was found that I had near full-thickness tear of the suprasinatous with delamination noted.
Partial tear of the subcoracoid tendon.
Moderate subcoracoid bursal effusion present. Normal inferior glenohumeral ligament complex. Biceps pully is intact.
This has been a long process and I finally have a date for May for repair. The problem is my pain level is now almost nil and I have almost full ROM . No pain at night now. I have spoken with friends of mine who are GPs and they have advised me not to go ahead as they feel I don’t need the surgery and could be more disabled afterwards. What do you think, and what should I say to my surgeon, he is a very respected sugeon and I don’t want to upset him.
Don’t worry about our feelings :-) We have tough skin.
Ronald Tolls, MD FACS
Very informative article, but I still have some questions, please. I am a retired Army general surgeon, surgical oncologist, and some orthopedic experience in residency and as a missionary surgeon, buy my knowledge is superficial.
Some 47 years ago when doing a lot of swimming,(Australian crawl), I first developed right bicipital tendonitis. It was temporarily relieved by injections of a depot cortisone and local anesthetic. Over the next 40 years on several occasions I persuaded a colleague or I self-injected. Finally about seven years ago a highly respected Houston orthopedic surgeon did a rotator cuff repair with only partial success in that an osteophyte remains and with abduction and external rotation I feel the tendon snap over the osteophyte.
Tussling with cattle and a feed bucket some two weeks ago there was a forced abduction/external rotation after which I developed severe shoulder pain, inability to abduct arm more than 15 degrees, tolerable passive abduction, and only worsening. Next week I will have an MRI.
1. How is it as I have been told that a strain of the long head of the biceps is a part of a rotator cuff injury?
2. How important if at all is it that the osteophyte I still see on xray be removed as a part of the rotator cuff repair?
3. As a fit 75 year old who still wants to be active on our hobby farm and accustomed to several hours
of heavy work daily, is a 2nd repair a consideration? The joint space is reduced from a normal of 10 mm to only 8 mm, suggesting degenerated soft tissue.
I thank you in advance for your advice.
Hi Dr. Tolls…
In response to your questions …
1. How is it as I have been told that a strain of the long head of the biceps is a part of a rotator cuff injury?
The biceps runs from the arm up through the rotator cuff in a region we call the rotator interval. When people develop degenerative rotator cuff disease — or tendinosis — the biceps, due to it’s close proximity to the rotator cuff is often involved. Experienced shoulder surgeons understand this and often times can alleviate significant residual rotator cuff pain with a biceps tenotomy or tenosdesis.
2. How important if at all is it that the osteophyte I still see on xray be removed as a part of the rotator cuff repair?
The concept that bone spurs cause rotator cuff disease was actually never a peer reviewed concept. It caught on in the 70’s. Was disproven throughout the 90’s and well into the early 2000’s. The bone spur is not the cause of your pain … nor the cause of rotator cuff disease. Tendinopathies exist throughout our body … the achilles, tennis elbow, the patella tendon in a jumpers knee etc. So why should tendinopathy in the shoulder be thought of differently :-) Anyway… I have a few posts in the blog section near the top on rotator cuff tendinosis you may want to read.
3. As a fit 75 year old who still wants to be active on our hobby farm and accustomed to several hours
of heavy work daily, is a 2nd repair a consideration? The joint space is reduced from a normal of 10 mm to only 8 mm, suggesting degenerated soft tissue.
Particularly for someone with a cuff that is degenerating… the article on the treatment of rotator cuff tendinosis might appeal to you. The distance between the acromion and humeral head is not static. If the shoulder girdle is tired from exercise, activity or injury — and the rotator cuff is weak, the distance will decrease. If we exercise athletes with normal rotator cuffs their distance will narrow transiently as well.
I hope this clarifies some of your questions !
Thank you for your service ! :-)
Howard Luks
Blakeley Southern
This is a very interesting article on rotator cuff surgery. You mention that night pain is a sign that the patient has a higher likelihood of needing surgery. I wonder if that is because at night we do not use our shoulders as much and therefore should not be experiencing pain. What is the chance of recovering if one is experiencing night pain in their shoulder?
People with night pain can recover with PT, etc… I said that they are more than likely to consider surgery because the night pain significantly impairs their quality of life.
SophieCA
Dr. Luks,
Thank you for spending time to run a very informative site and to read this comment. About a year ago, the backside of my right shoulder was overstretched while I was handling a heavy object with one arm. Pain continued so my doctor went inside to see (I begged him as it was very painful). He said he saw a tiny labral tear and torn joint capsule. Rotator cuff looked fine. He removed the scar tissue from the capsule and cleaned out. Then, after 3 months, I did something really stupid! Because of tight muscle, I saw a massage therapist. After one session, I felt my shoulder got loose. Pain started again. I saw my doc and he ordered MRI. MRI results say partial rotator cuff tear (supraspinatus tendon) and subtle type IV slap tear. The pain is on the back side of the shoulder. My Q is, can a massage really cause all these tears? Before the massage, I was recovering well.
Thank you again for your time and care for people.
Sophie
Nope .. it can’t
Mark Phelps
I have seen a second specialist doctor today in whose opinion the muscle retraction and atrophy are far too advanced for surgery which would be of no help in fact could exacerbate the problem. As you said his advice is that degeneration of the joint(s) is most likely, however currently strength and mobility are good. I am looking at possible PT to strengthen the remaining muscle and management of the joint through reduced physical activity and possibly leaving the fishing industry for a less physical occupation such as cruise boat captain. I was relieved not to have to go through with surgery but also disappointed that I am going to live with the consequences of not having the surgery many years ago when the problem first arose.. I was advised at that time that management was the better option….perhaps a second opinion then would have been a wise move….lesson = always seek a second opinion and don’t procrastinate.
Is there any other advice or treatment you would recommend.
Finally Dr Luks, thanks very much for your time through providing the information on this site – it has been much appreciated and of great assistance.
regards
Mark Phelps
Nelson Bay
Australia
There are more heroic options such as a graft with a “graft-jacket” … but you should find a good shoulder specialist and have a long sit down with them to see if it is worth it.
Good Luck to you.,
Howard Luks
Mark Phelps
Hello Dr Luks,
Firstly, thanks so much for a great source of information. Beat I have seen.
I have had supraspinatus full thickness tears both shoulders for over 10 years and have experienced some pain over that period in my work as a fisherman. Recently (six months ago) that pain increased to a new level after some sustained and heavy physical activity. Since that time and cessation of that activity both shoulders have settled down and I again only have little discomfort. I have seen one doctor who recommended surgery and am due to see another tomorrow for a second opinion. Bothe tears are over 30 mm and there is moderate atrophy on both muscles. My question is what happens in the longer term if I don’t have the surgery given that I am not in serious discomfort at the moment and have full movement of both shoulders as I have for most of the past 10 years. I can currently work and of course will be out of work for an extended period if I go ahead with the surgery. Do these tears usually degenerate to a seriously restrictive level and what may be the long term prognosis given I have managed O.K. thus far.
Regards
Mark P
Nelson Bay
Australia
Thank you for your kind comments. You are not in an enviable position. 30 mm tears are considered large, and the early fatty infiltration will only continue to progress. Most shoulder docs would consider fixing them if they have not retracted far and have a reasonable chance of healing. Yes, a tear this size will likely progress over time or become larger. This is a difficult decision for you because you rely on your arms to make a living and you will be out for 5-6 months. No one can give you a 100% crystal clear prediction on what will happen if you do or do not have surgery… but the odds favor progression of the tears and a poorer prognosis if the tears do become larger.
I hope this helps.
Good Luck
Char Wipff
Should I allow a reverse artificial joint replacement. I am 74 years old and active. I have had 3 major tears in 20 years. First was from repeative work. Second was 5 mo.s ago after a car accident. two tears. After repair felt better with PT. then after an exercise at pt putting my hand on my hip and moving my elbow forward I buckeled to the floor. Now with a MRI it shows the Supraspinatus tendon is torn complete. They want to either fix it again, do steriod or replace it. Help!!. Now I see that muscale could be turning to fat. What should I do
Char .. I would seek out many opinions. A reverse for a shoulder that is only missing the supraspinatus (one of four rotator cuff muscles) is not a great idea. Many people have non-repairable supraspinatus tears and live long happy lives. The success rate of revision repairs is not very good. The chance of success with a third repair is very poor, and a fourth — no comment. Nothing wrong with trying PT and seeing how you respond.
Howard Luks