As we learn more about pain, we realize surgery often isn’t the answer.
A 2019 research review found surgery is a poor treatment choice for chronic pain. The study found surgery is no better than a sham procedure — going under anesthesia and receiving cut on the skin but nothing else — for multiple regions of the body. Whether you are receiving surgery for low back pain, knee arthritis, angina, abdominal pain, endometriosis, biliary colic, or migraines, surgery does not appear to be the answer.
Add rotator cuff tears to the list.
Multiple studies have shown surgery is not necessary for rotator cuff tears. A recent study found physical therapy alone can do the trick.
A 2021 study divided patients with confirmed supraspinatus tear (one of the four rotator cuff muscles) on MRI into three treatment groups.
The physical therapy group received 10 outpatient sessions. In addition to the in-person sessions, the patients were provided instructions — written and verbal — for at-home exercise.
“The first six weeks of the exercise protocol aimed at improving glenohumeral motion and active scapular retraction, after which static and dynamic exercises to improve scapular and glenohumeral muscle function were gradually increased until twelve weeks. After this, the patient increased resistance and strength training up to six months.” — study protocol
Group two received an acromioplasty — a procedure where part of the top part of the shoulder blade is shaved. Some people in group two also receive a biceps tenotomy, acromioclavicular, or both if indicated. Physical therapy was started immediately after the surgery.
Group three received the acromioplasty (and tenotomy and/or AC resection when indicated) and a rotator cuff repair. Physical therapy was started after three weeks of immobilization in a sling and three weeks of active shoulder motion.
The average rotator cuff tear was 10.1 mm in group 1 (PT only), 9.6 mm in group two (PT and acromiopasty), and 8.5 mm in group three (everything). Following a 5-year follow-up, there were no differences in pain or function between the three groups. All three groups had high and similar satisfaction scores.
This research builds off previous research that concluded surgery is not the answer for rotator cuff tears. How is that possible?
Surgery doesn’t ‘fix’ pain
Surgery does not address the causes of chronic pain. Pain is more complex than tissue damage. Pain is the result of biological (e.g. tissue damage, genetics, etc.), phycological (e.g. mood, personality, etc.), and social factors (e.g. cultural, socioeconomic, etc).
Pain in “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” — International Association for the Study of Pain
Even when damage is present, pain may not be. This is why studies show MRI results are decent chance it will show with the presence of pain. Many people with pain have clean MRIs and vice versa. This is true in the back, neck, hip, and shoulder.
So, even when a rotator cuff is present on imaging, pain may not be present. If both a tear and pain are present, addressing the tear won’t address the pain.
Surgery only affects one component of pain
Surgery doesn’t change the psychosocial drivers of pain such as anxiety, fear, and stress. Our emotional state and overall health play a large role in the pain we feel.
Rehabilitation can restore strength lost following a tear. Surgery doesn’t grow muscle or restore tendon and ligament integrity. Only activity can do that. In some cases, when a tear is large enough, surgery may be the answer. But even ACL tears are being rehabbed successfully without surgery.
The sham surgery studies mentioned at the beginning of the article provide an interesting piece to the puzzle. The reductions in pain were obtained without making actual repairs. This highlights the power of the mind and expectations. The positive improvements after surgery are largely driven by expectations followed by movement. The patients thought the damage was dealt with and so they continued their lives.
Before going under the knife, be sure to explore all of your options.