When Not to Have Rotator Cuff Surgery?

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when not to have rotator cuff surgery

Are you wondering when not to have rotator cuff surgery? These days, more people are opting to skip this surgery. Who should do that and who really needs the surgery? I’ll also cover a patient here who decided to skip the surgery despite a rotator cuff tear and is back to full activities. Let’s dig in.

What is A Rotator Cuff Tear?

rotator cuff muscles

The rotator cuff muscles and tendons surround the shoulder joint and move it as well as stabilize it. There are four muscles which include, from front to back, the subscapularis, the supraspinatus, the infraspinatus, and the teres major/minor. The tendons can get injured or torn due to trauma or age. This can cause pain with shoulder movement and if physical therapy doesn’t help, surgery is often recommended.

How Does Rotator Cuff Surgery Work?

The tear in the rotator cuff tendon is often sewn together surgically. If the tendon has broken off the area where it inserts on the bone, anchors can be used to adhere the tendon back to the bone. Other procedures are often also performed such as acromioplasty. This is where one of the bones of the shoulder is shaven down to make more room for the rotator cuff.

When Not to Have Rotator Cuff Surgery?

rotator cuff tear

Rotator cuff tears come in a few different flavors.

  • Partial Tear (second image above). This is where a part of the tendon has been torn, usually the top (bursal side) or bottom (articular side). The partial tear can also be inside the tendon, in which case it’s called interstitial or intrasubstance.
  • Complete Non-retracted Tear (third image above). This type has many small tears throughout the whole tendon, but it’s still held together as one piece. Regrettably, many MRI reports don’t point this type out clearly.
  • Complete Retracted Tear (fourth image above). This is also called a massive rotator cuff tear. Basically, the tendon is completely torn and pulled back like a rubber band.

Traditionally, all three of these types of tears were surgical candidates. However, more recently, research has shown that surgery for a partial tear produces no better outcomes than just physical therapy (1).  Hence, if you have a partial tear, this is the clear definition of when not to have surgery.

Complete retracted or massive tears are tricky. One problem is that the retear rate is very high, with about 6 in 10 of these rotator cuff tendons tearing again after surgical repair (6). One way to avoid retears is by having your own bone marrow stem cells injected into the surgically repaired site (3). This seems to reduce that problem by about half.

Finally, the middle category of a complete non-retracted tear is really interesting. For this type of tear, many surgeons recommend surgery. However, research shows that surgery isn’t better than no surgery (2). In addition, there’s also information showing that injecting PRP or bone marrow concentrate into the tear can help avoid surgery (4,5). How does that work? By stimulating the tendon to heal itself. Below is a video that shows that newer procedure:

How Long Can You Wait to Have Rotator Cuff Surgery?

Generally,  after an acute tear, you can wait a few months before rotator cuff surgery. Having said that, many rotator cuff tears have been there for many years before they are surgically repaired.

This is a patient who injured his shoulder in 2016. His MRI is above and shows a very large supraspinatus tear that is shown at the yellow arrowheads. This is a complete non-retracted tear. In late 2016 he had the bone marrow stem cell procedure shown above. Instead of surgery, his own bone marrow stem cells were injected into the large tear. He reported being 85% better and had a simple booster shot at two years. He sent us this video at four years out:
That’s a 405-pound bench press! So while this is not recommended, it does mean to me that he successfully healed this tear above without surgery.
The upshot? I hope I answered the question of when not to have rotator cuff surgery. As you can see, in addition to the old surgical options there are newer non-surgical options.

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References

(1) Nazari G, MacDermid JC, Bryant D, Athwal GS. The effectiveness of surgical vs conservative interventions on pain and function in patients with shoulder impingement syndrome. A systematic review and meta-analysis. PLoS One. 2019;14(5):e0216961. Published 2019 May 29. doi:10.1371/journal.pone.0216961

(2) Khatri C, Ahmed I, Parsons H, Smith NA, Lawrence TM, Modi CS, Drew SJ, Bhabra G, Parsons NR, Underwood M, Metcalfe AJ. The Natural History of Full-Thickness Rotator Cuff Tears in Randomized Controlled Trials: A Systematic Review and Meta-analysis. Am J Sports Med. 2019 Jun;47(7):1734-1743. doi: 10.1177/0363546518780694. Epub 2018 Jul 2. PMID: 29963905.

(3) Hernigou P, Flouzat Lachaniette CH, Delambre J, Zilber S, Duffiet P, Chevallier N, Rouard H. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study. Int Orthop. 2014 Sep;38(9):1811-8. doi: 10.1007/s00264-014-2391-1. Epub 2014 Jun 7. PMID: 24913770.
(4) Rha DW, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil. 2013 Feb;27(2):113-22. doi: 10.1177/0269215512448388. Epub 2012 Oct 3. PMID: 23035005.
(5) Centeno C, Fausel Z, Stemper I, Azuike U, Dodson E. A Randomized Controlled Trial of the Treatment of Rotator Cuff Tears with Bone Marrow Concentrate and Platelet Products Compared to Exercise Therapy: A Midterm Analysis. Stem Cells Int. 2020 Jan 30;2020:5962354. doi: 10.1155/2020/5962354. PMID: 32399045; PMCID: PMC7204132.
(6) Murell G. American Academy of Orthopaedic Surgeons (AAOS) 2012 Annual Meeting: Abstract 062. Presented February 7, 2012.
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2 thoughts on “When Not to Have Rotator Cuff Surgery?

  1. John M Carbonniere

    Dr. C, I had my left rotator cuff surgically repaired in 2003. The surgeon described it as several small tears, which he repaired. While extremely painful (the most painful surgery I’ve experienced, including the TKR I had a year ago) and it taking what felt like years to fully heal (it was probably a year and a half before I felt it was truly healed and was able to use it as usual) it has been quite successful. Then I began having similar problems with my left shoulder three years ago. There was a big reduction in pain after I got a growth factor shot in my heel, as previously mentioned in a disk note, however I did nothing at the time to strengthen it, which was a big mistake. I have had two PRP injections in the ladt 8 months which resulted in the same healing as did the surgery but in vastly shorter amount of time and with a huge reduction in pain! I am also exercising it regularly this time. While stem cells are likely better than PRP, I can still highly recommend the PRP over surgery!
    Regards,
    Mike Carbonniere

    1. Chris Centeno, MD Post author

      Yes, Mike, PRP can heal small tears in the rotator cuff.

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