While there are now safe, minimally invasive procedures that can decrease your shoulder pain and improve your shoulder motion; there are a number of variables to consider before deciding whether to have a rotator cuff operation. The first and most important factor to consider before having surgery on your rotator cuff is whether you need to have surgery at all. Sometimes there are lower risk options such as physical therapy or injections, which can treat your problem without surgery.
Not all rotator cuff tears are created equal. Not all need repair with surgery. To understand this better it’s best to briefly describe a few types of tears that may or may not need “fixing.”
Rotator cuff tears can be categorized in many ways. One of the main ways is as either full thickness tears or partial thickness tears. The two are quite different and the difference can impact your choice of treatment significantly.
A full thickness tear is a complete hole in the fabric of the rotator cuff tendon. Just as if you had a hole in your shirt and could see your arm through that hole, when you have a full thickness tear in your rotator cuff there is a communication between the inner and outer parts of your shoulder joint. In this case the tendon is typically lifted away from the bone where it would normally attach.
In contrast, a partial thickness tear is akin to your shirt fabric being threadbare in a specific location. It may have some torn fibers but there are still enough threads intact that there is not a complete “hole” in the garment.
Partial thickness tears tend NOT to be urgent problems. This is not to say that they are not painful. Some partial tears are more painful than full tears. It just means that because there is not a full detachment of the tendon from the bone, they tend not to demand immediate surgery.
Are all partial tears the same?
No. Like full thickness tears, partial thickness rotator cuff tears can vary in size. Some partial tears are shallow and occupy very little of the thickness of the tendon. Others are deep and occupy nearly all of the thickness of the tendon.
Whether you decide to have surgery for a partial thickness rotator cuff tear usually boils down to how painful you are and whether you’ve failed to get better with non-operative treatments. If you have a partial rotator cuff tear and haven’t had an adequate course of physical therapy (about 3 – 6 months) and/or injections you probably don’t want to consider surgery yet. Certainly there are exceptions to every rule, but this is a good rule of thumb.
What if your doctor tells you that you have a full thickness rotator cuff tear? Do you necessarily need to fix it with surgery? It depends.
The decision to have surgery for a full thickness rotator cuff tear is more complex. There are a number of factors that you must consider when deciding to have surgery including age of the tear, size of the tear, your overall health and your muscle quality.
When it comes to rotator cuff tears, size does matter
Unfortunately as many people age they develop full thickness rotator cuff tears without ever having had an injury. They just happen. Many of these tears start out small and slowly enlarge over time. The size of your full thickness tear is important because it may not only impact your function but also your ultimate chance of success after a surgery.
Not only are some large tears more technically challenging to fix they also have a higher chance of tearing again after a surgery than smaller tears. So treating them with surgery before they get too big may offer a better prognosis for some people.
This is not to say that you shouldn’t consider surgery if you have a large tear- in fact you often have no control over how big your tendon tear is when you finally discover it. But you should know large tears have unique characteristics that can influence your prognosis.
Don’t neglect your rotator cuff tear
With a full thickness rotator cuff tear, not only will the size of the tear affect how you approach it, but the timing of your injury may also influence your decision-making.
In general you should consider treating an acute rotator cuff tear differently than a chronic tear. An acute tear is one that you might have sustained in a trauma like a fall. One day your shoulder is fine, the next day you slip on the ice, fall on it and now you can’t lift your arm.
There’s good evidence now that acute tears are often best treated with more immediate surgery. If you wait too long in these situations, the torn tendon can sometimes pull away from the bone and then scar and shorten making it difficult or impossible to repair later. The problem is that the muscle acts like a spring and pulls a fully torn tendon away from the bone. The tendon won’t reattach itself at this point because the muscle force is too powerful and won’t allow it to return to its previous attachment site without help. This process can happen quickly-within a few months- with some large tears.
Whether a fully torn tendon will heal itself back to bone, is one of the most common questions I receive. And sadly, for the reasons mentioned above, it won’t.
Chronic full thickness cuff tears – ones that are more than 6 months old – are different. You can approach many of them more like partial thickness tears. You may be able to try more conservative measures like therapy and injections to see if you can reach your strength and comfort goals without surgery. Of course if those don’t work, then surgery might be a good option.
Making a final decision about your operation
Ultimately deciding whether to have surgery for a torn rotator cuff depends on a host of factors including your overall health, your lifestyle needs, and the feasibility of a good outcome. Determining these factors takes thoughtful consideration, time and good communication with a knowledgeable specialist.
Making a good decision about whether to have surgery for a rotator cuff tear can be complex. The previous discussion might seem long but it has only covered a few of the factors involved in the process.
If you are considering rotator cuff surgery and want help clarifying the decision making process for your personal rotator cuff injury, please feel free to call us to obtain a personal consultation.
Dr. DiPaola is adept at the proper non-operative rehabilitation and operative treatment of rotator cuff injuries. He has performed hundreds of rotator cuff operations and he routinely performs arthroscopic surgery for the majority of his rotator cuff repairs. He also has experience treating difficult to manage rotator cuff problems such as large tears, old tears, repeat tears and rotator cuff tears associated with arthritis.