Do I Need Surgery for a Rotator Cuff Tear?

The short answer

Most rotator cuff tears do not need surgery right away, and many never need it at all. Dr. Raynor repairs two kinds: tears that keep hurting or keep you weak after a real effort at therapy, and tears that happen suddenly in an active person whose shoulder was fine the day before. Everything else starts with physical therapy, and it often ends there.

Is it normal to have a rotator cuff tear and no pain?

Yes, and it is far more common than most people think. In an MRI study of adults with no shoulder pain at all, 54% of those over 60 had a rotator cuff tear, and about half of those tears went all the way through the tendon (Sher et al., 1995). When 664 residents of a Japanese village had both shoulders screened by ultrasound, full-thickness tears rose from about 11% of people in their 50s to 27% in their 70s and 37% in their 80s, and two out of three tears in people over 60 caused no symptoms (Minagawa et al., 2013).

So a tear on an MRI report is a finding, not an automatic operation. The real questions are whether the tear is causing your problem, and whether the shoulder will settle down.

Which rotator cuff tears does Dr. Raynor fix?

Dr. Raynor sorts tears into two groups, because they are treated differently.

Worn-in tears. These develop slowly over years and often go unnoticed until something, like a weekend of yard work, irritates the shoulder. Most can be calmed back down. As he tells patients, "the ones that are pesky and annoying and won't go away are the ones we fix."

Acute tears from an injury. These happen to a shoulder that worked normally until a fall or a hard yank. The arm is suddenly weak and often cannot be lifted to shoulder level. In Dr. Raynor's experience these tears tend to be larger, and he recommends repairing them early rather than waiting to see. Timing matters: in a prospective study of painful traumatic tears with weakness, results were not compromised when the repair was done within 4 months of the injury, while the largest tears repaired after 4 months had the worst results (Petersen & Murphy, 2011).

He also leans toward repair when a shoulder keeps getting weaker, or when a young, active person has a full-thickness tear.

What should I try before rotator cuff surgery?

Dr. Raynor lays out the same options with every patient, starting with the one that leaves you the most control.

• Do nothing and live with it. Always a legitimate choice for a worn-in tear that is not limiting you.

• Physical therapy. In Dr. Raynor's words, "PT is never the wrong answer." In a multicenter study of 452 people with full-thickness tears that were not caused by an injury, a structured therapy program was successful for about 75% of them over two years, and those who chose surgery generally did so between 6 and 12 weeks (Kuhn et al., 2013). In the same group of patients, the strongest predictor of ending up in surgery was not the size of the tear but low expectations that therapy would help (Dunn et al., 2016). How you feel about therapy shapes the decision more than the MRI does.

• Anti-inflammatory medicine for a flare, if you can safely take it.

• A steroid injection to calm the shoulder down so therapy can do its job.

Dr. Raynor is comfortable with one or two injections. What he avoids is a standing schedule of shots in place of a plan, because, in his view, repeated steroid can weaken the tendon. Injections also matter if surgery is ahead: in a systematic review, two studies found that patients who had two or more injections in the year before a cuff repair had roughly two to three times the odds of needing revision surgery (Cimino et al., 2020). If repair becomes the plan, he schedules it with some distance from the last injection.

Do I need an MRI for a rotator cuff tear?

Usually, yes, before any decision about surgery. X-rays of a torn rotator cuff tend to look normal because the tendon is soft tissue; they are taken to rule out arthritis and fractures. An MRI shows how large the tear is, whether the tendon has pulled back, and how healthy the muscle behind it looks. If the first step is going to be therapy or an injection no matter what a scan shows, Dr. Raynor may hold off. He orders an MRI when it will change the plan, and always before a repair.

What does recovery from rotator cuff repair look like?

The surgery is arthroscopic and outpatient: a few small poke holes, small anchors in the bone, and sutures that hold the tendon down so it can heal back where it belongs. The rotator cuff repair page walks through it step by step. In Dr. Raynor's practice, the calendar looks like this:

• Sling for 6 weeks. For most people the hardest part is having to ask others for help.

• About 3 months: strengthening begins.

• About 4 months: the tendon is healed to the bone. As Dr. Raynor puts it, "it's totally healed... you get permission to go load it."

• About 6 months: most people are doing what they want, though they still notice the shoulder.

• About 1 year: full recovery.

That long road is part of why he does not operate on every tear he sees. "That's why I don't rush in." The rotator cuff repair recovery roadmap walks through each stage.

The Bottom Line

A rotator cuff tear is common, and many never cause trouble. Dr. Raynor repairs the ones that will not settle after a real effort at therapy, and he moves sooner on sudden tears that leave an active person weak. If an injury has left your shoulder weak, or you already have an MRI showing a tear, the Fast Track page explains how to get in front of him quickly. More on tear types and treatment is on the rotator cuff tears page.

References

1. Sher JS, Uribe JW, Posada A, et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10-15. doi:10.2106/00004623-199501000-00002 PMID: 7822341.

2. Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: from mass-screening in one village. J Orthop. 2013;10(1):8-12. doi:10.1016/j.jor.2013.01.008 PMID: 24403741.

3. Petersen SA, Murphy TP. The timing of rotator cuff repair for the restoration of function. J Shoulder Elbow Surg. 2011;20(1):62-68. doi:10.1016/j.jse.2010.04.045 PMID: 20675154.

4. Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22(10):1371-1379. doi:10.1016/j.jse.2013.01.026 PMID: 23540577.

5. Dunn WR, Kuhn JE, Sanders R, et al. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2016;25(8):1303-1311. doi:10.1016/j.jse.2016.04.030 PMID: 27422460.

6. Cimino AM, Veazey GC, McMurtrie JT, et al. Corticosteroid injections may increase retear and revision rates of rotator cuff repair: a systematic review. Arthroscopy. 2020;36(8):2334-2341. doi:10.1016/j.arthro.2020.04.044 PMID: 32389769.