Degenerative rotator cuff tears are more common as we age and we may or may not have symptoms. Because of this, a common argument is, is the tear the actual source of the pain since people with NO pain may also have one? The older you are, the more likely you may see a tear on an MRI. Someone recently asked me what my thoughts were of surgery vs. conservative treatment, so I turned to the research. Below are quick conclusions of some recent studies that are out there with links to read more about each study if you would like. Scroll down to see my "two cents".
In a 2017 meta-analysis study:
"There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. Thus, a conservative approach is advocated as the initial treatment modality. Implications for Rehabilitation There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. There was no clinically significant difference between surgery and active physiotherapy in 1-year follow-up in improving Constant score or reducing pain caused by rotator cuff tear. As physiotherapy is less proneness to complications and less expensive than surgery, a conservative approach is advocated as the initial treatment modality to rotator cuff tears."
In a 2013 study:
"In conclusion, our survey of 664 residents in one village demonstrated that the prevalence of rotator cuff tear was 22.1% in the general population, which increased with age. Asymptomatic tear was twice as common as symptomatic tear."
In a 2020 study:
"The supraspinatus tendon is the most commonly affected tendon due to its anatomical location, tensile and compressive overload,2Â vascular changes and degeneration process associated with ageing."
"Degenerative tears in the rotator cuff is a common finding in imaging studies due to the natural ageing process. There is evidence that therapeutic exercises should be the first treatment option for these patients because the surgical approach is not clinically superior than the non-surgical approach in this population."
In a 2016 study:
"Tendinopathy and tears of the rotator cuff are age-related and commonly degenerative pathologies that can impact an individual's quality of life, and lead to surgical intervention. The economic and social burden associated with symptomatic rotator cuff tears is substantial, and population trends indicate this burden will progressively worsen. The role of exercise in treating rotator cuff tears has become increasingly popular as a means to treat and manage partial and full thickness tears of the rotator cuff, by addressing weakness and functional deficits that are commonly present in patients with symptomatic shoulders. Prolonged exercise rehabilitation and non-operative treatment should be considered in patients with rotator cuff tendinopathies, partial-thickness tears and potentially small full-thickness tears. Younger patients with acute tears >1cm will likely respond well to operative intervention, while older patients ( > 65 years) with chronic, full-thickness tears and associated muscle atrophy and fatty infiltration will not, and instead respond better to an initial course of exercise rehabilitation. According to reports in the literature, conservative treatment is effective in 73–80% of patients; however, not all patients will respond favorably or quickly. When opting for conservative treatment, it is important to understand that the responsiveness of patients and symptom recurrence will determine the potential for a successful outcome of exercise rehabilitation."
In a 2019 study:
"The findings suggested that strengthening exercises with or without associated techniques for manual therapy and use of electrothermal or phototherapeutic resources were the interventions with greatest power of treatment for individuals with this condition, over the medium and long terms. These approaches had greater therapeutic power than surgical procedures, which had previously been considered to be the standard treatment for many patients."
In a 2021 study:
"On the basis of this study, operative treatment is no better than conservative treatment regarding small, nontraumatic, single-tendon supraspinatus tears in patients older than 55 years. Operative treatment does not protect against degeneration of the glenohumeral joint or CTA. Conservative treatment is a reasonable option for the primary initial treatment of these tears."
In a 2020 study:
"Our data confirmed the effectiveness of conservative treatment in patients with full-thickness rotator cuff tears 12 months post-intervention. The results suggest that conservative treatment for patients with full-thickness rotator cuff tears should be the first line of treatment before considering surgery."
In a 2014 study:
"These results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition."
My "Two-Cents":
First of all, I wish when we got an MRI of one joint, we could get an MRI of the opposite side so we could compare results. Do you think insurance companies would go for that?? Ha! As far as this topic, the research speaks for itself. But also, think about how we may get a degenerative rotator cuff tear. Poor mechanics and/or strength and stability of the ribcage, thoracic spine, scapula, cervical spine, or even the arm itself can contribute to a rotator cuff tear over time. This can even be said for any other part of our body! Therefore, if the tear is surgically repaired but the other dysfunctions of the body remain, one could argue that symptoms will eventually return. Time is also something to think about. To rehabilitate a painful shoulder, it can take at least 6 months of consistent work (serious daily compliancy with home exercise program, lifestyle changes, etc), depending on how long the symptoms have been there, how healthy you are, and your age. After surgery, it is going to take at least 6 months to recover except now you are healing from surgery in addition to the rehab. Surgery has its risks that we're all aware of so I won't go into detail about that. I have heard doctors warn that if the tear isn't surgically repaired, it will get worse. I have not seen that in the research. I agree that if the dysfunctions in the body remain, a tear could get worse with continued faulty mechanics. But if the foundation is corrected, wouldn't it make sense that whatever capacity is left of the tendon(s) could be preserved? At the end of the day, no matter your diagnosis, if you don't put in the work, conservative treatment doesn't magically work for you. For those out there that are not very compliant with their exercise program and won't modify their activities while they are focusing on their rehab, sometimes surgery IS best because it makes them stop. I have seen this happen many times. Some people really have a hard time taking a step back for a bit so that they can focus on the basics.
There is no shame in surgery and in fact, surgery has given many people their lives back. We are lucky to have the technology that is available to us. This article was created to empower your decision-making and to be aware of what researchers are finding when it comes to degenerative rotator cuff tear prevalence and rehabilitation. Overall, the evidence is pointing to choosing physical therapist as the first line of defense for this condition.
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