Shoulder: 65% of rotator cuff tears do not hurt

What the two trials measured

CSAW had three arms: decompression, investigative arthroscopy alone, and no treatment. It is that third arm which makes the trial decisive.

Read the third row. Opening the shoulder and doing nothing beats doing nothing at all by 4.2 points, more than the real operation does. The minimal clinically important difference is 4.5 points: none of these values clearly reaches it, and the authors explicitly call these gaps not clinically important. At 12 months, decompression against placebo gives +0.3 points, with a p of 0.86.

FIMPACT measured pain at 24 months, in patients whose rotator cuff tear had been excluded by contrast MRI.

The clinical relevance threshold was set in advance at 15 points. No difference reaches it, including the two that are statistically significant against exercise. At 5 years nothing is left: +1.0 point against exercise at rest, with a p of 0.77.

The Cochrane review (2019), pooling these two placebo-controlled trials, concludes on high-certainty evidence to a gain of 0.26 points of pain out of 10 and 2.8 points of function out of 100, which is 3% in both cases.

What ultrasound finds in people who are not in pain

The Japanese population screening study by Yamamoto (J Shoulder Elbow Surg, 2010) scanned 1,366 shoulders. The prevalence of full-thickness rotator cuff tears is 20.7%, and 16.9% in people with no symptoms at all.

In the same village, Minagawa (J Orthop, 2013) established the decisive proportion: 65.3% of all tears are asymptomatic. A tear that does not hurt is twice as common as one that does, and beyond 60 it accounts for two thirds of cases.

Sher (J Bone Joint Surg Am, 1995) had found the same on MRI in 96 strictly asymptomatic people: 34% had a tear, and 54% of those over 60. The authors already wrote that these tears were compatible with a normal, painless shoulder, and warned of the potential dangers of using MRI alone as the basis of an operative decision.

The review by Teunis (J Shoulder Elbow Surg, 2014), across 6,112 shoulders, quantifies the slope: 9.7% of cuff abnormalities before 20, 62% after 80, odds ratio 15 with an interval from 9.6 to 24. Its conclusion is that cuff degeneration is a common aspect of normal human ageing.

Repair a cuff tear, or rehabilitate: the answer depends on the horizon

This is where most articles go wrong, by picking whichever horizon suits them.

Kukkonen (Bone Joint J, 2014) allocated 180 shoulders in people over 55, with a non-traumatic supraspinatus tear, between physiotherapy alone, acromioplasty with physiotherapy, and repair with acromioplasty and physiotherapy. At one year the Constant scores are 74.1, 77.2 and 77.9, with a p of 0.34. No difference between the three.

Moosmayer followed 103 patients with a tear of 3 cm or less, randomised between immediate repair and physiotherapy with optional later repair.

The gap is nil at one year, marginal at five, and crosses the threshold of clinical relevance at ten. In other words the right answer depends on how long the shoulder still has to serve, not on a general principle. At fifteen years, 29% of the physiotherapy arm had eventually gone to surgery. And in a third of the unrepaired patients the tear had enlarged, with a worse result.

On retear after repair, a range of 11% to 94% circulates. The solid figures are tighter: 26.6% across more than 8,011 shoulders (McElvany, Am J Sports Med, 2015), 19.9% median with an interquartile range of 10% to 30% (Holtedahl, Arthroscopy, 2022), 17% at six months across 1,000 consecutive repairs (Le, 2014), of which 27% for full-thickness tears and 5% for partial ones. We do not repeat the 94%, which comes from old series of massive tears in very small numbers.

The most uncomfortable finding in this literature is that the improvement patients feel does not track the state of the tendon. McElvany and Holtedahl both note it: scores improve whether the repair is intact or not.

Frozen shoulder, and three figures that need correcting

That it clears up by itself in 18 to 24 months is false, not merely imprecise. The review by Wong (Physiotherapy, 2017) concludes in as many words that the theory of a progression through phases to complete resolution is unfounded, and that most of the improvement happens early, not late.

Range of motion almost always returns. Symptoms persist in 41% to 50% of patients, almost always at a mild level. That is a more nuanced story than it goes away, and a more reassuring one than it is permanent.

What the studies do not allow us to claim

That frozen shoulder affects 2% to 5% of the population traces back to a 1969 work we could not consult, and no modern population study establishes it. That 10% to 20% of people with diabetes develop it is attributed to a 1972 work, unverified. What is documented is that incidence is higher in diabetes, and that range of motion recovers just as well.

That shoulder pain is the third most common musculoskeletal reason for consulting is widespread and we found no primary source for it. The same goes for figures above 50% attributing shoulder pain to the cuff: the only verified exhaustive census, across 35,150 registered patients in Dutch general practice, gives 29% cuff tendinitis among diagnoses.

Finally, no official published waiting time exists for shoulder surgery in Ireland, the United Kingdom, the Netherlands or Canada. The figures in circulation come from individual providers or from extrapolation, and we do not cite them.

In practice, if this concerns you

Three questions structure the discussion. Is the proposed procedure an isolated subacromial decompression, since that is the one a strong recommendation exists against. If a tear is involved, how large is it and what horizon of use is in view, since the gap between repairing and rehabilitating only appears after five to ten years. And was the image read alongside the clinical examination, since a tear is present in one person in two after 70 without meaning anything at all.

Noria Health arranges a full shoulder work-up near Brussels within 24 to 48 hours: clinical examination and cuff testing, range of motion measurement, dynamic ultrasound, and MRI where the examination justifies it. The report is issued within 24 hours, follow-up is structured at D14, D30 and D90, and surgery is considered only around day 10 if it is needed.

What Noria Health does not do: propose an isolated subacromial decompression for shoulder pain without a tear. Sudden loss of use after trauma, a hot and feverish shoulder, or a motor deficit are matters for the emergency services in your country, immediately, not for an appointment.

Further reading

• Joint replacement: 82% of knees are still in place at 25 years
• Spine: at 50, 80% of people with no pain have a degenerate disc
• Pain that waits

Sources

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2. Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement, FIMPACT. BMJ, 2018;362:k2860. https://pubmed.ncbi.nlm.nih.gov/30026230/
3. Paavola M, Kanto K, Ranstam J, et al. Subacromial decompression versus diagnostic arthroscopy, 5 year outcomes. Br J Sports Med, 2021;55:99-107. https://pubmed.ncbi.nlm.nih.gov/33020137/
4. Karjalainen TV, Jain NB, Page CM, et al. Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev, 2019;1:CD005619. https://pubmed.ncbi.nlm.nih.gov/30707445/
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See also: all our articles on musculoskeletal and pain.

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