Choosing the Right Shoulder Surgeon for a Rotator Cuff Tear

Rotator Cuff Tear: A Patient’s Guide to Choosing the Right Treatment

A rotator cuff tear is one of the most common causes of shoulder pain and weakness. However, because these injuries can vary greatly in severity, not every tear requires surgery.

The right treatment approach depends on many personal factors, including the type of tear, your symptoms, your age, activity level and the physical demands you place on your shoulder.

The information in this article is designed to help you understand your options for repairing a rotator cuff injury and guide you in choosing the right orthopaedic shoulder surgeon for your care.

What is the rotator cuff?

The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint. Together they are responsible for keeping the ball of the shoulder centred within the socket, and it is one of the structures that allows you to lift, rotate and move your arm.

Tears of the rotator cuff often follow a traumatic injury, such as a fall or physical blow. However, some injuries occur more gradually over time due to tendon degeneration and age-related wear.

Partial-thickness vs full-thickness tears

Whether your rotator cuff tear is full-thickness or partial-thickness will determine what treatment is best for you.

Partial-thickness tear
A partial-thickness tear means only part of the tendon has been damaged while some fibres remain attached to the bone. These tears may respond well to:

• Physiotherapy
• Activity modification
• Strengthening exercises
• Anti-inflammatory medication

Full-thickness tear
A full-thickness tear means the tendon has completely detached from the bone. These tears do not fully heal naturally. Treatment for these more severe tears depends on:

• Symptoms
• Age
• Activity level
• Occupation
• Tear size
• Tendon quality
• Muscle quality
• Duration of the tear

Can a rotator cuff tear heal by itself?

This is one of the most common questions patients ask.

Unfortunately, a full-thickness rotator cuff tear will not heal back to the bone without surgery. Once the tendon has completely detached, there is currently no evidence that more conservative approaches — such as physiotherapy, exercises, injections or medications — can cause it to reattach naturally.

Some partial-thickness tears may settle with non-operative treatment because some of the tendon remains attached. While it’s unlikely that the tendon will fully heal, many patients experience significant improvements in pain and function with physiotherapy and by modifying their activity.

Symptoms are more important than the MRI

An MRI scan is an important and necessary part of diagnosing rotator cuff tears, but it should never be interpreted in isolation. Many people have rotator cuff tears that can be seen on MRI yet they experience little or no pain. Others have relatively small tears but experience significant weakness and loss of shoulder function.

Treatment decisions should always consider:

• Clinical examination
• Shoulder strength
• Pain levels
• Functional limitations
• MRI findings
• Your goals and expectations

The MRI is only one part of the overall assessment.

Symptomatic vs asymptomatic tears

Asymptomatic tears
It’s not uncommon for some rotator cuff tears to be discovered incidentally during scans performed for another reason. Surgery is often unnecessary if there is:

• Minimal pain
• Good shoulder function
• Preserved strength

Symptomatic tears
Patients with the following symptoms are much more likely to benefit from specialist assessment and, in selected cases, surgery:

• Night pain
• Weakness
• Difficulty lifting the arm
• Pain affecting work or sport
• Ongoing symptoms despite physiotherapy

When is surgery recommended for a rotator cuff tear?

Every rotator cuff tear is different, and treatment should always be tailored to a patient’s needs. Factors such as your age, activity level, occupation, symptoms, tendon quality and MRI findings all influence the most appropriate treatment. The table below provides a general guide.

A simple rule of thumb

Although every patient should be assessed on an individual basis, a younger (under 65 years of age) or more physically active patient with a symptomatic full-thickness rotator cuff tear will usually be advised to consider surgical repair. This is because these tears do not heal back to the bone and may enlarge over time.

On the other hand, partial-thickness tears and some full-thickness tears in older patients (over 70 years of age) or those with lower activity demands can often be managed successfully without surgery. In these cases it’s important that shoulder strength and function remain satisfactory and that symptoms improve with rehabilitation.

However, it’s important to note that age and physical fitness are not the only factors determining the best treatment approach — you are best to talk to your shoulder surgeon about the options available to you.

Why early surgery can matter

As tendon injuries generally get worse over time, early surgical intervention can greatly improve longer-term outcomes. Over time:

• The tear may become larger
• The tendon retracts away from the bone
• The muscle undergoes fatty degeneration
• The tendon becomes progressively more difficult to repair
• In some patients, the tear may eventually become irreparable

Early repair of an acute full-thickness tear often provides the best opportunity for successful tendon healing.

Can physiotherapy heal a rotator cuff tear?

Physiotherapy is one of the most important conservative treatment options for shoulder pain. However, it is important to understand what physiotherapy can and cannot achieve.

Physiotherapy can:

• Improve shoulder movement
• Improve strength
• Reduce pain
• Improve shoulder function

However, it cannot reattach a full-thickness rotator cuff tendon back to the bone. Instead, it helps many patients compensate for the tear and may allow them to avoid surgery if symptoms remain manageable.

What about cortisone injections?

While cortisone injections can be very effective at reducing inflammation and temporarily relieving pain, they cannot repair a torn rotator cuff tendon. Current evidence suggests repeated corticosteroid injections may:

• Reduce tendon quality
• Contribute to tear progression
• Affect tendon healing
• Increase the risk of infection if surgery is performed soon afterwards

It is important to note that many shoulder surgeons avoid subacromial cortisone injections within three months prior to surgery, due to the increased risk of postoperative infection and concerns regarding tendon healing. If you are likely to require rotator cuff repair surgery, it is advised you consult your shoulder surgeon before receiving a cortisone injection to prevent any delays to your surgery.

Myths vs facts

Experience matters

Rotator cuff surgery is highly specialised. Successful surgery depends heavily on a number of factors, including an accurate diagnosis, selecting the appropriate patients for surgery, surgical technique and a robust rehabilitation programme.

Orthopaedic shoulder surgeon Dr Sushil Pant has performed more than 5,000 shoulder operations over more than a decade of dedicated shoulder practice. His practice is exclusively focused on shoulder conditions, including arthroscopic rotator cuff repair, complex tendon reconstruction, revision shoulder surgery and sports-related shoulder injuries. He has also been involved in the care of elite athletes, including players from NSW rugby and AFL programmes, where restoring shoulder strength, function and stability is critical for returning to competition.

Why choose Dr Pant at Sydney Shoulder Unit?

Patients with rotator cuff injuries choose Dr Sushil Pant at Sydney Shoulder Unit because of his dedicated focus on shoulder surgery and evidence-based care. Dr Sushil Pant’s experience includes:

• Over 5,000 shoulder operations, frequently treating both straightforward and complex rotator cuff tears
• Exclusively operating on shoulder conditions
• Expertise in arthroscopic (keyhole) rotator cuff repair and complex tendon reconstruction
• Management of traumatic, degenerative and revision rotator cuff tears
• Advanced MRI assessment to determine tear size, tendon quality and muscle degeneration
• Evidence-based treatment recommendations tailored to each patient’s needs
• Comprehensive rehabilitation pathways designed to maximise recovery after surgery

Questions to ask at your consultation

Suspecting or receiving a diagnosis of a rotator cuff tear can be incredibly daunting. When meeting your shoulder surgeon, consider asking the following questions to help understand your injury and determine the best path forward:

• Is my tear partial-thickness or full-thickness?
• Is my tendon still repairable?
• Will my tear heal without surgery?
• Is physiotherapy likely to be enough?
• What happens if I delay surgery?
• Is a cortisone injection appropriate for me?
• What are the chances of a successful repair?
• How long will recovery take?
• When can I return to work, the gym or sport?

Comprehensive rehabilitation

For both surgical and non-operative treatment approaches, rehabilitation is essential for rotator cuff repairs. Recovery typically includes:

• Guided physiotherapy
• Progressive strengthening
• Activity modification
• Return-to-work planning
• Sport-specific rehabilitation where appropriate

It takes several months for your tendons to heal following surgery, therefore it is essential that you adhere to your rehabilitation programme for the best possible outcome.

The bottom line

Rotator cuff tears are common, but that doesn’t mean treatment should follow a “one size fits all” approach.

Partial-thickness tears and lower-activity patients often respond well to physiotherapy and non-operative treatment. Symptomatic full-thickness tears in younger, active patients are much more likely to benefit from early surgical repair. In these cases, early surgical intervention — before the tendon retracts, the tear enlarges and muscle degeneration occurs — can greatly improve the long-term outcome.