You’re middle aged or older and you do something like reaching out too fast, or lifting, or maybe just bracing yourself to prevent a fall and you tear your shoulder rotator cuff. Surgery seems to be the definitive treatment, but recent research on the efficacy of rotator cuff surgery has a dirty little secret that should alarm you. What’s the nasty secret hiding in the recent studies?
The shoulder rotator cuff is a collection of muscles around the shoulder that help to stabilize the ball in the socket of the main shoulder joint and help you lift your arm. Trauma in middle age or older patients can lead to a tear in one or more of the muscles or tendons of this complex. These patients often have shoulder pain. It would make sense that if the rotator cuff is torn that sewing it back together in a rotator cuff repair would mean that the pain would go away. It would also make common sense that if the pain was coming from the rotator cuff tear, then those who showed healing of the tears after surgery would have better outcomes than those who didn’t show healing. However, this little critical detail that should support the validity of operating in the first place (healed tears = improved symptoms) is the dirty little secret of rotator cuff repair surgery and of the question of rotator cuff surgery success.
A review paper on the outcome in rotator cuff surgery exposes this bombshell that has now been seen across several studies. Whether the patient reports success with the surgery or not has nothing to do with whether the rotator cuff tendon heals or has not healed. This is a huge issue that calls into question the face validity of whether the surgical repair of the tendon is the right thing to do, but so far has gone largely unnoticed by doctors or brushed aside as an interesting factoid. It should raise a shrieking alarm among those who look at healthcare policy as well as with patients who have rotator cuff tears. In addition, since rotator cuff tears are common in patients without shoulder pain, this finding likely tells us that many times we’re operating on phantoms (meaning the tear that was incidentally found on MRI wasn’t the cause of the shoulder pain). What else causes shoulder pain? Pinched nerves in the neck is one big alternative cause.
The upshot? There’s a huge issue with the validity of operating on a shoulder rotator cuff tear – the outcome has nothing to do with whether the tear heals or not, calling into question whether the tear found on MRI has anything to do with why the shoulder hurts. In the end, this is the dirty little secret of shoulder surgery that has largely been avoided by shoulder surgeons. Perhaps this quote by Margaret Atwwod is apropos: “The best way of keeping a secret is to pretend there isn’t one.”