Do all rotator cuff repairs need surgery? How can doctors predict who needs surgery?

A rotator cuff tear is an injury to the shoulder (read more here).  

Its most common in middle age to elderly people.  Tears usually result from long-term wearing out of the shoulder, and must less commonly occur because someone falls and tears the whole cuff in one instant.  The analogy is looking at your favorite pair of blue jeans with rips in the knees.  Those rips didnt occur over night, the occurred because you wore the jeans for weeks at a time for many years, and slowly the fabric over the knees just wore away.  Same goes for rotator cuff tears.

But nonetheless, people come in with a tear, diagnosed by MRI, and they want to know what the treatment should be.  You would think that a tear is a tear is a tear, and that all rotator cuff tears get treated the same way.  But a recent article showed that the physical nature of the tear (how big it is, what shape the tear is, etc) is the least important factor in determining whether someone needs surgery.

The most important factors are all mental, and specific to how the patient feels.  If the patient doubts that physical therapy will help and if the patient is very active and has high expectations for their arm function...they are most likely go get surgery.

I think this shows that even in the era of great diagnostic tools like advanced MRI imaging, 3-dimensional CT scans, and other fancy tests...the most important thing for a doctor to do, when deciding the best course of treatment, is to listen to the needs of their patients. 

References. 

1. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. Dunn WR et al. J Shoulder Elbow Surg. Aug 2016. see full article. 

2. The rotator cuff quality-of-life index predicts the outcome of nonoperative treatment of patients with a chronic rotator cuff tear. Boorman RS et al. J Bone Joint Surg Am. 2014 Nov 19;96(22):1883-8. Chronic Rotator cuff repairs success is 75%, 89% remain successful by 3 years.  RC-QOL test is most predictive of success. see full article. 

3. Kweon C et al Am J Sports Med. 2015 Oct;43(10):2368-72. 2015 Aug 12.Surgical Versus Nonsurgical Management of Rotator Cuff Tears: Predictors of Treatment Allocation. see full article. Factors for nonop treatment: younger age, pain < 1 year, low BMI.

4. Harris JD et al.  Predictors of pain and function in patients with symptomatic, atraumatic full-thickness rotator cuff tears: a time-zero analysis of a prospective patient cohort enrolled in a structured physicaltherapy program. Am J Sports Med. 2012. full article. factors determining good outcomes with chronic RC treated nonop: Age, tear retraction, duration of symptoms, and humeral head migration were not statistically significant...scapulothoracic dyskinesia, active abduction, and strength in forward elevation and abduction which can be modified through PT, did help pain function.  atrophy of supraspinatous infraspinatous also affected outcome but is not modifiable. 

5. Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. Dunn WR et al. J Bone Joint Surg Am. 2014. symptoms of RC tear do not correlate with size of tear.