In today’s modern world, if you’re middle-aged and feel a sudden stabbing pain in your shoulder and then it continues to ache, you get an MRI. If that shoulder study shows a big enough rotator cuff tear, you’re quickly spirited off to surgery. However, what would happen if you never had the surgery? Would it be a disaster or would it be OK? That’s what a new study set out to discover, and the results may surprise you.
The rotator cuff is a complex series of muscles and tendons that live in each shoulder. These muscles support the shoulder (a ball-and-socket joint), provide stability, and give you the ability to have a full rotational range of movement in your arms, especially when lifting. The rotator cuff muscles and tendons can tear. This can happen with an injury, especially with stress from an over-head motion (such as lifting) or in athletes, and it can also occur when wear and tear become more common in middle or older age. When we hear the word “tear” in relation to shoulder pain, our hopes of a nonsurgical treatment for rotator cuff tears often goes out the window and our first thought is that it must need to be sewn up, and indeed this is often what surgeons recommend. And if our MRI shows a full-thickness rotator cuff tear, this can even seem more in need of urgent surgical repair. But is it?
After rotator cuff surgery, not only is it common for many patients to still be in pain but oftentimes their full range of motion is also never realized. This can be particularly frustrating for athletes who rely on their shoulder range of motion to stay in the game (yet only about half actually return to their same level of play prior to their injury). Most of the time, the primary reason patients undergo rotator cuff surgery in the first place is to relieve their shoulder pain, so why are some patients still in pain? One reason could be what many studies have discovered—that the shoulder pain that patient has prior to surgery doesn’t necessarily have anything to do with the rotator cuff tear found on the MRI, especially if the patient is middle age or older and their tear is a result of normal wear and tear with aging.
If the rotator cuff is torn with trauma or perhaps while performing an exercise motion, clearly the tear could be the reason for pain; however, this still doesn’t mean surgery should be a given. There is too much research out there today showing that surgery is often no more effective for rotator cuff tears than no surgery at all.
It doesn’t stop here, even with the larger rotator cuff tears, there is a reason to be concerned about surgery as research has shown that 6 out of 10 of these large rotator cuff surgical repairs actually fail, resulting in retears. One reason could be that with rotator cuff tears, depending on our gene expression, fewer native stem cells may be available to help with healing. And in those over the age of 60, one out of every three patients don’t heal at all following rotator cuff surgery.
Now a new study finds that not only can nonsurgical treatment for rotator cuff tears be effective, but it can be effective long-term.
While we’ve seen many other studies showing that many rotator cuff tears can heal without surgery, today’s feature study not only confirmed these findings but also took it a step further, following up many years (5+) after the patients’ surgeries. The new study consisted of patients who’d had rotator cuff tears (full thickness) for greater than three months. All of the subjects took part in a “home-based treatment program” for a period of three months. Those who had successful outcomes were placed in the nonoperative group. Those who failed the home treatment underwent surgical repair. Both groups were followed for five years.
The result? At five years, 75% of the nonoperative group were still reporting successful outcomes (with a quality-of-life score of 83 out of 100). Of the initial nonoperative group five years prior, only 3 patients had gone on to require surgical repair. The operative group quality-of-life score was 89 out of 100 at five years, and researchers stated this was not a significant difference from the nonsurgical group. They concluded that patients can do very well long-term with nonsurgical treatment for full-thickness rotator cuff tears.
I think it’s important to emphasize the point here. Patients who opted for the surgery fared no better than those who skipped the surgery! Yikes, this study is going to piss off some surgeons.
The upshot? I love studies that question the status quo, and this one is going to be an issue for many surgeons quick to operate on shoulder rotator cuff tears. If 75% of these patients will eventually be out of pain, why are we taking the increased risk of a surgical shoulder rotator cuff repair? Said another way from a medical-legal standpoint, if there’s a complication with shoulder surgery and the patient was never informed of research supporting that there’s a 75% chance that they would eventually be mostly pain-free with good function without the surgery, is the surgeon directly liable for that complication? This is going to get interesting…
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About the Author
Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…