Type into Google “Will My Rotator Cuff Tear Get Worse?” Here’s what you find.

I tried this recently wonderign what information will patients see if they ask this question.

Reputable sources from Cleveland Clinic to American Academy of Orthopedic Surgeons to individual surgeons with good SEO state, “rotator cuff tears do not heal without surgery and they get worse over time.” One search engine savvy surgeon says, “on average, a rotator cuff will enlarge within 2 years.” (That’s not true, doc: tears enlarge in about half of cases).

Is this scary prediction accurate?

Is it the full story?

Is it telling the patient everything they need to know to decide how to treat their shoulder?

This, at best, is simply curated, misleading information. At worst, well, it’s a fact a surgery center needs patients to make profit.

So what is the whole story?

What do patients deserve to know before they decide how and when to receive treatment for a rotator cuff tear?

There’s a lot we could say here, but, it makes sense to keep information simple.

So lets focus on one recent seminal study as a basis for debunking the incomplete conclusions surgeons sometimes generate in patients heads who are managing a rotator cuff tear.  

This study, published in JBJS in 2024, is titled “The Predictors of Surgery for Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears Change Over Time Ten-Year Outcomes of the MOON Shoulder Prospective Cohort.”  These authors saw there was no consensus on who should have rotator cuff surgery. So they wanted to assess the predictors of failure of nonoperative treatment, as defined by the patient undergoing surgery for symptomatic, atraumatic full-thickness rotator cuff tears.

Physical therapy is successful in >70% of patients with symptomatic, atraumatic full-thickness rotator cuff tears with10 year follow-up.

According to the internet knowledge spread by the surgeons, shouldn’t the tear size worsening be a major predictor of physical therapy (PT) failing? I mean, you’ll commonly read online the tear WILL worsen if not addressed by surgery.

The number one predictor of failing physical therapy and having surgery was low patient expectations regarding the efficacy of physical therapy (PT) . Let that sink in! If our patients believe PT won’t work, guess what? It doesn’t work.

How does this make you feel about the surgeons controlling the narrative for patients searching the internet for treatment information?

The belief “PT wont work for me” predicted early decision for surgery.  So how about the patients who went to physical therapy (PT) and then later decided to have surgery.  They allowed more time for the tear to worsen so were their predictors related to tear characteristics? Nope.  Workers’ Compensation status and activity level were predictors of later surgery. Nothing to do with rotator cuff tear size. Nothing about the anatomy of the rotator cuff tear (ie size, location) predicted surgery over 10 years. The anatomy, which is often the justification for surgery, just doesnt seem to matter that much.

So how about the patients that did PT and avoided surgery? After 10 years, their tears must have gotten worse and, subsequently, their pain was worse, right?  Nope. Physical therapy was successful in >70% of patients with symptomatic, atraumatic full-thickness rotator cuff tears at 10 years, with outcome measures improving, and not declining, over the 10-year follow-up period.

So who then, should have rotator cuff surgery? A high energy, traumatic rotator cuff tear might consider surgery relatively quickly. Otherwise, surgery is decided solely on function and not on pain.  Limited function that isn’t improving with extended PT should consider surgery.  Anatomy of the tear is not really a factor in this. So, in summary, most patients should try PT for 3-6 months and, if no change in their function is occurring, then consider a referral to a (good) surgeon.

Remember confirmation bias is a real thing for all humans. Confirmation bias is when you see evidence that supports your current set of beliefs, you tend to accept it. When, on the other hand, the evidence goes against your beliefs, you tend to reject it. This is the benefit of the scientific method and reduced bias research.

Source: Kuhn JE, Dunn WR, Sanders R, et al. The Predictors of Surgery for Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears Change Over Time: Ten-Year Outcomes of the MOON Shoulder Prospective Cohort. J Bone Joint Surg Am. 2024;106(17):1563-1572. doi:10.2106/JBJS.23.00978.