When Not to Have Rotator Cuff Surgery

Rotator cuff tears may require surgery to repair, but they can often heal with rest, physical therapy, and medication when needed. Discuss with your orthopedist when to have or not have rotator cuff surgery.

Your healthcare provider will consider the type of injury, the degree of pain, and other factors when looking at treatment for rotator cuff injury.

This article explains types of rotator cuff tears and disorders, non-surgical treatment options, and when surgery may be necessary.

What Is a Torn Rotator Cuff?

The rotator cuff is the group of muscles and tendons that surround the ball-and-socket shoulder joint. It is comprised of several muscles and three shoulder joint bones: the humerus, scapula, and clavicle. When a rotator cuff tears, one of the tendons connected to the head of the humerus is either partially or completely detached.

Most people with symptoms of a rotator cuff problem develop pain around the shoulder. Other common symptoms include weakness of the muscles and limited joint mobility.

Healthcare providers diagnose rotator cuff problems through an exam and imaging. Tests such as X-rays, magnetic resonance imaging (MRI), and ultrasound can help determine the extent of damage to the rotator cuff.

There are several causes of rotator cuff tears. Causes include:

• Normal wear and tear (impingement) from aging
• An acute injury such as from a fall
• Repetitive wear and tear from sports or occupation (e.g., baseball pitchers, tennis, painters)

Due to normal aging, individuals over 40 are at increased risk of rotator cuff tears, and most individuals over 80 have some degree of tearing. Part of natural aging is reduced blood supply to the tendons. A reduced blood supply decreases the body's ability to heal an injured tendon, making eventual tearing more likely.

Types of Rotator Cuff Tears

There are two main types of rotator cuff tears: partial and complete tears.

Partial tears: In a partial tear, the tendon is still attached to the bone. However, the attachment has weakened from a thinning of the tendon.

Complete tears: In a complete tear, part or all of the tendon is completely detached from the bone.

A partial tear may progress to a complete tear over time.

Other Rotator Cuff Injuries

Other rotator cuff injuries include tendonitis, bursitis, impingement syndrome, and calcific tendonitis.

• Tendonitis is inflammation in the tendons of the rotator cuff.
• Bursitis is inflammation of the fluid-filled sacs called bursa. The bursa acts like a cushion between the rotator cuff and shoulder bone. When they become inflamed, they cause pain.
• Impingement syndrome is when the space between the acromion (a bony point on the top of the shoulder blade) and rotator cuff narrows. This narrowing causes the acromion to rub against the tendon and bursa when the arm is lifted, leading to inflammation and pain.
• Calcific tendonitis is a specific type of tendonitis caused by calcium deposits in the rotator cuff tendons.

Non-Surgical Treatments for Rotator Cuff Injuries

The majority of rotator cuff injuries do not require surgical intervention. If a recent, acute injury caused the tear or the tear is large, your healthcare provider may recommend surgery. Your healthcare provider may also recommend surgery if you have experienced symptoms for longer than six to 12 months or if your shoulder pain and reduced mobility are significantly impacting your daily life.

There are several non-surgical interventions that healthcare providers often try first to repair the rotator cuff.

Physical Therapy

A physical therapist can tailor a regimen to reduce pain and improve shoulder mobility. The physical therapist will likely focus on exercises to strengthen the muscles around the shoulder joint, which can help stabilize the joint.

Additionally, you and your physical therapist may incorporate flexibility exercises. Improved flexibility can help reduce pain and increase range of motion.

Rest

Resting your shoulder can improve pain and allow you to better participate in other treatments, such as physical therapy. Your healthcare provider may instruct you to avoid the activities that likely caused the injury in the first place.

For example, if you compete in rowing, you may need to take a break from the sport for some time. Or, if you work in construction, you may need to take time off of work to allow the injury to heal.

Pain Medication

A healthcare provider may recommend that you take various over-the-counter pain relievers to reduce the pain associated with a rotator cuff tear.

• Ibuprofen (e.g., Advil) helps with pain from inflammation.
• Acetaminophen (e.g., Tylenol) affects your perception of pain.
• Aspirin (e.g., Bayer Aspirin) also helps with pain from inflammation.

Both ibuprofen and aspirin are considered non-steroidal anti-inflammatory medications. Ensure you understand your healthcare provider's instructions for taking pain medications. For example, they may not want you to take aspirin and ibuprofen together since it can increase the risk of adverse effects. However, it may be ok to take them spaced far enough apart.

Steroid Injections

It is recommended that you try rest, medications, and physical therapy first. However, if these measures do not provide adequate pain relief or a return of shoulder mobility, your healthcare provider may recommend steroid injections.

Steroid injections reduce inflammation in the joint. However, they do not work for everyone. If they do work for you, the length of time they last varies between individuals. You may find they work for just a few weeks or are so effective that you never need another injection. Generally, steroid injections work for most people and last around three months.

When Surgery Is Necessary

Conservative treatment, such as physical therapy, is typically the first-line treatment for most tears. However, if the patient is young or an acute injury caused the tear, surgery may be the ideal first option.

The main goal is to decrease pain and restore function to the shoulder joint. Some degree of tearing is expected with advanced age. However, if conservative treatments do not provide relief, your healthcare provider may recommend surgical intervention.

In most cases, a healthcare provider can perform a less invasive type of surgery called arthroscopic repair. Additional treatments, such as platelet-rich plasma or mesenchymal stem cells, may help aid in recovery. Tendon transfers from another part of the body may be considered a surgical option if the rotator cuff tendons are too damaged to repair.

After surgical repair, your healthcare provider will immobilize your shoulder joint with a sling or wrap. You will then work with a physical therapist to progress from passive to active range of motion exercises. Recovery is long and lasts several months.

Summary

Most rotator cuff tears don't require surgery, and many people find relief with non-surgical treatments. Patients who are told they need rotator cuff surgery should understand the reason for the surgery.

In most cases, non-surgical treatments provide relief, with the exception of younger patients who have rotator cuff tears resulting from traumatic injuries. If you are unsure of the necessity of rotator cuff surgery, a second opinion can be helpful.