What criteria should I use to determine if a patient with a rotator cuff injury requires surgical intervention?

Determining whether a patient with a rotator cuff injury requires surgical intervention primarily depends on clinical features indicating an acute or severe tear, failure of conservative management, and significant functional impairment. Urgent referral for surgical assessment is recommended if there is a history of trauma accompanied by pain, weakness, or sudden loss of active arm elevation, as this suggests an acute rotator cuff tear ¹. Surgery is also considered when there is persistent pain and functional limitation despite adequate conservative treatment, including rest, physiotherapy, analgesia, and possibly corticosteroid injections ¹.

Conservative management is the first-line approach, involving rest in the acute phase, gradual activity resumption, analgesia, and physiotherapy focusing on strengthening and motor control ¹. If symptoms persist or function remains significantly impaired after a sufficient trial of these measures, surgical options may be explored ¹. Surgical intervention is more strongly indicated in cases of traumatic full-thickness tears, especially in younger or active patients, or when there is a failure of non-surgical treatment to restore function (Papalia et al., 2011; Longo et al., 2021).

Recent systematic reviews and meta-analyses support that surgery may provide better outcomes in terms of pain relief and function for patients with full-thickness tears or chronic symptomatic tears unresponsive to conservative care (Longo et al., 2021). However, for partial-thickness tears or calcific tendonitis, evidence suggests that non-operative management can be effective, and surgery should be reserved for refractory cases (Papalia et al., 2011; Angileri et al., 2023).

Shared decision-making is essential, discussing the potential benefits and risks of surgery versus continued conservative management, considering patient preferences, comorbidities, and functional demands ¹. Urgent surgical referral pathways exist for suspected acute tears caused by trauma, while elective surgery may be considered after failed conservative treatment ¹.