Shoulder pain is a very common problem, affecting as many as one in every three people. Many people with shoulder pain have problems with their rotator cuff, which is the common term for the four muscles that support your shoulder joint. Billions of dollars are spent annually in the treatment of shoulder pain in the United States. Your first move might be to reach for the ibuprofen, but chronic use of NSAIDs has many associated risks, including gastrointestinal bleeding, kidney impairment, and even increased risk of death from cardiac diseases. Because there are a multitude of variables surrounding the issue, there is not a simple solution to shoulder pain. During an initial physiotherapy evaluation many of my patients ask me, “How will I know if I need surgery?” I am asked this for injuries to all parts of the body, but most often it is for shoulder pain. There are so many factors that go into whether or not someone will need surgical intervention. Age, overall health, employment, hand dominance, and amount of disability are all things that should be considered. Given the risks associated with anesthesia and invasive procedures, it is not a decision to take lightly.
Give Physiotherapy a Try
This is always my first recommendation, even if diagnostic imaging shows there is a tear in the rotator cuff. Interestingly, there is no significant difference in the presence of rotator cuff tears in groups of people with and without shoulder pain. If you opted for surgery and the tear that showed up on MRI was not what was causing your pain, the results would be poor and you would have put yourself at risk of the many post-surgical complications, including infection, blood clots, and even death. A large systematic review found that exercise is effective for improving long-term function in shoulder pain. The study even showed that 2.5 years after treatment the group treated with exercise was still better than the control group. This can be compared with corticosteroid injections, which had better results than physiotherapy in short-term follow up, but not long-term follow-up. Additional conclusions were not drawn because the sample sizes were small and there was too much variability in treatment. Additional research has found the results on the efficacy of physiotherapy to be mixed but largely attributed this to a difference in treatment approaches. There is considerable variation in exercise intensity, volume, and type based on the needs and goals of each patient, so it is very difficult to quantify. In a given course of treatment you may get exercise, manual therapy, ultrasound, iontophoresis, electrical stimulation, and neuromuscular re-education, and what you receive can depend on the your physiotherapist’s training and bias instead of evidence. Physiotherapy for rotator cuff tears that are not a result of acute trauma has proven to be effective in relieving pain and restoring function. The worst possible outcome is that the treatment doesn’t allow you to avoid surgery. However, you go into the surgery with more mobility and strength than you had before, which leads to better outcomes.
Research for corticosteroid injections for rotator cuff tears in inconclusive, mostly because of poor methodology. If you are considering injection to avoid surgery, your doctor may personalize his advice to you based on your demographic and medical history. Injections should be combined with physiotherapy, which should address the poor movement patterns that contributed to rotator cuff tear. Other injections, like platelet-rich plasma (PRP), are fairly new in medicine and therefore limited research is available. As with the corticosteroid injections, your doctor can advise you in his or her success rates in patient cases similar to yours.
What a Surgeon Might Tell You
Unfortunately there is no research that definitely shows when a patient should have surgery. Continued pain is the main indication for surgery. If someone has had pain for 6 to 12 months without relief from conservative methods, then surgery is often the next step. After an acute traumatic injury you can sustain a large rotator cuff tear (3 cm or greater). If you have sustained a complete rupture you are at risk for retraction, which means the tendon is pulled away from the attachment. It can retract far enough that surgery is no longer an option. This is a time-sensitive matter and delaying surgery may result in long-term disability.
After You Have Tried Physiotherapy
When conservative treatments fail and you don’t have the quality of life that you want, surgery might be an option. Surgery should not be thought of as the quick repair as the recovery post-surgery is rather lengthy, including anywhere from 4 to 12 weeks in a sling, and 3-6 months of physiotherapy to restore range of motion, strength, and function. Even with a successful surgical outcome, moderate pain may persist for many months. There are certain instances in which surgery is not an option, and here are some reasons not to have surgery:
- You haven’t tried conservative treatment, under most circumstances.
- The tendon has retracted too far to be repaired.
- Advanced age of the patient; in this case you may be a candidate for a more complicated surgery if conservative treatment has failed. Some surgeons are now performing reverse total shoulder replacements to manage poor tissue quality as is seen more commonly in older populations.
- You have many other medical problems that make surgery a huge risk
Conservative treatment is always best, and physiotherapy has minimal risks and is less expensive than other treatment methods. Although there is limited evidence supporting the success of physiotherapy, a positive attitude toward your recovery is helpful. Research has shown that those patients who felt like conservative treatment would fail did not achieve good results with conservative treatments. This leads me back to the famous quote from Henry Ford:
“Whether you think you can or you can’t, you’re right.”
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Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2):CD004258.
Frost P, Andersen JH, Lundorf E. Is supraspinatus pathology as defined by magnetic resonance imaging associated with clinical sign of shoulder impingement? J Shoulder Elbow Surg. 1999;8(6):565–8.
Abdul-Wahab TA, Betancourt JP, Hassan F, et al. Initial treatment of complete rotator cuff tear and transition to surgical treatment: systematic review of the evidence. MLTJ. 2016;6(1):35-47.