Robert Shmerling, M.D., is associate physician and clinical chief of rheumatology at Beth Israel Deaconess Medical Center and an associate professor in medicine at Harvard Medical School. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program and has been a practicing rheumatologist for over 25 years.

Question:

I have a torn rotor cuff. What can I expect if I don't have surgery to repair it?

Answer:

The rotator cuff is a collection of four tendons that merge as they connect to the upper arm. They allow the shoulder joint to have the greatest range of motion of any joint in the body. However, the rotator cuff is also prone to injury. Inflammation, degeneration and tears are common.

Many people with rotator cuff tears do well without surgery. However, there are a number of factors that affect the success of non-surgical treatment:

• What demands do you place on your shoulder? If you are a competitive athlete who puts a great deal of stress on the shoulder, surgical repair may be most appropriate because non-surgical treatment does not reliably improve strength. Also, people tend to put more stress on their dominant arm, so if you are right-handed, doctors may be less likely to recommend surgery for rotator cuff tear of the left shoulder.

• How big is the tear and how long have you had it? Non-surgical treatment may not be as effective for a large tear (as demonstrated by MRI or other imaging tests). However, a partial tear or a small tear may respond very well without surgery. If the tear occurred years ago, it may be much more difficult to repair surgically than if it happened recently.

• What symptoms do you have and how bad are they? If the most prominent symptoms are pain and reduced mobility, non-surgical treatment may be effective. However, if your primary symptom is weakness, surgery may be a better option. A surgeon is more likely to recommend surgery for symptoms severe enough to limit normal function and daily activities, especially if other, more conservative treatments have failed.

• How good is your overall health? Some people are poor surgical candidates because of co-existing medical problems, such as heart disease and diabetes. For such individuals, non-surgical treatment may be the only reasonable option.

Of course there are advantages to avoiding surgery. By treating non-surgically, you avoid the risks of surgery, such as infection or complications of anesthesia. There's also a long recovery period after rotator cuff surgery. While rotator cuff surgery is reportedly successful in 80% to 90% of cases, each person has a unique set of risks, benefits and expectations. So patients and surgeons must be selective and thoughtful about when to pursue surgery and when to stick with more conservative treatment.

Non-surgical treatment includes pain medications, topical treatments (such as the application of cold compresses), corticosteroid injections and physical therapy. A sling may improve comfort, but use should be limited to avoid stiffness.