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.
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
Howard J. Luks, MD
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
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
Howard J. Luks, MD
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
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
Howard J. Luks, MD
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
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
Howard J. Luks, MD
Nope .. it can’t
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?
Howard J. Luks, MD
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.