The treatment of rotator cuff tears is far more nuanced and complicated than you think.
As with many Orthopedic Surgery topics, the treatments we offer people require far more nuance and are far more complicated than most realize. Do all rotator cuff tears need surgery? No. Should some be operated on? Yes! Which tears should be treated, and which shouldn’t? It’s not as easy as you might think it is. Besides… should we be using the word “tear” to describe the changes we see on an MRI when most people we see in the office have not had any trauma or serious injury?
On Twitter, I post these under the title— Orthopedic Truths. They are not meant to serve as a treatment recommendation; they are meant to serve as a learning tool and to help start a conversation about a topic that is complicated and over-treated in the general population. After all, it has taken decades of experience to get to this point.
Orthopedic Truths.
- Rotator cuff “tears” are common.
- Many rotator cuff tears tears don’t hurt.
- Don’t assume it’s the cause of your pain.
- But it might be the cause of your pain.
- Many tears aren’t even “tears.” The word tear implies trauma…
- Many “tears” are due to poor tissue health, loss of mechanical load, and other factors.
- Tears are not due to bone spurs.
- Tears can be partial or full-thickness. They can be small or large.
- Many adults with no pain have the exact same changes you have on an MRI.
- Some tears might grow larger over time. Others won’t.
- Some tears will become painful over the next few years. Some won’t.
- Some tears will cause weakness. That weakness might be due to guarding/pain… Or the weakness can be structural.
- Tears might be old and chronic. Some might be acute.
- Which tears should we fix?
- This isn’t as clear as you might think. Do all tears need to be fixed? No.
- Should some be fixed? Yes.
- Would I fix a painless partial or small full-thickness tear in my shoulder? No.
- Are the repairs of certain tears worthwhile? Certainly.
- Should all tears be treated surgically? No.
- Should we remove bone spurs to avoid tears? No.
- Confused? This decision-making isn’t easy.
- This is especially true if you provide for your family, need to work to put food on the table, and need your arm to work.
- Bottom line… It’s a FAR more complicated topic than most people think.
Howard Luks, MD; Twitter: 5/2024
Orthopedic Truths: Unpacking the Complexity of Rotator Cuff Tears
Few topics in orthopedic medicine are as intricate and nuanced as rotator cuff tears. As with many medical conditions, rotator cuff tears cannot be understood through a simple, one-size-fits-all lens. Instead, they require a careful and individualized approach. Let’s delve deeper into the tweet’s key points to unpack the complexity of rotator cuff tears and their management.
The Ubiquity of Rotator Cuff Tears
First and foremost, rotator cuff tears are exceedingly common. Some “tears” are considered to be age-appropriate changes. Many individuals, particularly as they age, will experience some form of rotator cuff degeneration. The term “tear” often conjures images of acute trauma or significant injury. However, the reality is that many rotator cuff tears are not the result of a single traumatic event. Instead, they often stem from gradual changes, leading to tissue degeneration. Many of you are out there playing ball, tennis, and swimming despite a rotator cuff tear you don’t know about yet.
Let’s say you have that tear that has been present for 5 years, but one day, your shoulder hurts. You decide to see someone; they order an MRI and a tear is seen. What are you going to do? Well, for starters, you will assume that the tear is the cause of your pain. But is it? Remember, you worked out, played tennis, etc, for years with this tear you didn’t know about. Now, you’re setting yourself up for an operation you may not need.
The Pain Paradox
A critical point raised in the tweet is that many rotator cuff tears do not cause pain. This paradox can be perplexing for patients and clinicians alike. The presence of a tear on an MRI does not necessarily correlate with symptoms. Many individuals with asymptomatic tears continue their daily activities without issue. Conversely, some people experience significant pain and dysfunction despite having similar or even less severe tears. In many cases, the tear might not be the cause of pain. Severe pain in the shoulder can be due to many issues. Some examples are the early stages of a frozen shoulder, calcific tendonitis, and bursitis. Night pain, a common complaint, is not due to a tear but inflammation in a bursa within the shoulder.
Misconceptions About Rotator Cuff Tears
One of the most common misconceptions is the assumption that a rotator cuff tear is always the cause of shoulder pain. While it is true that rotator cuff tears can be painful, it is essential to recognize that shoulder pain can also arise from various sources, including other soft tissue injuries, joint issues, or referred pain from the neck. Therefore, attributing shoulder pain solely to a rotator cuff tear without a comprehensive evaluation can lead to misguided treatment.
Understanding the Nature of Tears
The term “tear” can be misleading. It implies a traumatic event, yet many rotator cuff tears are due to poor tissue health, loss of mechanical load, and other degenerative factors. These “tears” are often more about the gradual breakdown of tissue rather than an acute injury. Additionally, the notion that bone spurs cause tears is a myth that needs debunking. While bone spurs can coexist with rotator cuff tears, they are not the root cause. We will cover these bone spurs in another article soon enough.
Rotator cuff tears can vary widely in their characteristics. They can be partial or full-thickness, small or large. Some tears are stable and do not progress, while others may enlarge over time. Similarly, the onset of symptoms can be unpredictable. Some tears become painful over the years, while others remain asymptomatic.
The Complexity of Weakness
Weakness associated with rotator cuff tears can be multifactorial. It might be due to pain and guarding, where the body subconsciously limits the use of the shoulder to avoid discomfort. Alternatively, the weakness can be structural, resulting from the loss of tendon integrity and function. Distinguishing between these causes is crucial for determining the appropriate treatment approach.
Chronic vs. Acute Tears
Rotator cuff tears can also be categorized as chronic or acute. Chronic tears develop over time and are often associated with degenerative changes. Acute tears, on the other hand, result from a specific injury or trauma. This distinction is important because it influences the prognosis and the treatment strategy.
To Fix or Not to Fix?
Deciding which rotator cuff tears to repair is not as straightforward as it might seem. Not all tears need surgical intervention. For instance, would I fix a painless partial or small full-thickness tear in my shoulder? No. The rationale is that these tears often do not impair function or cause significant discomfort. However, certain tears do benefit from surgical repair. Larger tears, particularly those causing pain or functional limitations, may warrant surgical consideration.
The Role of Surgery
Surgery is not a blanket solution for all rotator cuff tears. The decision to operate should be individualized, considering the patient’s symptoms, functional needs, and overall health. Removing bone spurs to prevent tears is another myth that should be dispelled. While bone spurs may be present, they are not the primary cause of rotator cuff pathology and should not drive the decision for surgery.
The Decision-Making Dilemma
The tweet underscores the complexity of decision-making in treating rotator cuff tears. This process is especially challenging for individuals who rely heavily on their shoulder function for their livelihood. Balancing the need to provide for one’s family with the uncertainty of surgical outcomes is a significant burden. Patients must be fully informed about the potential benefits and risks of both surgical and non-surgical options.
Conclusion: Embracing the Complexity
As we conclude, it is vital to reiterate that managing rotator cuff tears is far more complicated and nuanced than it appears at face value. Each patient’s situation is unique, requiring a tailored approach that considers all factors—symptoms, tear characteristics, functional needs, and personal circumstances.
Orthopedic surgeons must navigate these complexities with a blend of clinical expertise, patient-centered communication, and evidence-based practice. While the tweet provides valuable insights, it also serves as a reminder that medical conditions like rotator cuff tears resist simple categorization. They demand a thoughtful, nuanced approach to ensure the best possible outcomes for patients.
In the ever-evolving field of orthopedics, continuous learning and adaptation are key. As we gain more knowledge and refine our techniques, the goal remains the same: to provide the highest quality care that respects the intricacies of each patient’s condition and life. Understanding and embracing the complexity of rotator cuff tears is a step towards achieving that goal.
