Rotator Cuff Tear: Surgery or Physio?

A rotator cuff tear sounds serious - and for large acute tears in young athletes, surgery is often the right choice. But for the majority of cuff tears, which are partial-thickness or full-thickness degenerative tears in people over 50, the evidence supports trying physiotherapy first.

What the research shows

Several high-quality randomised trials have compared surgery with structured physiotherapy for degenerative rotator cuff tears. The consistent finding is that at one and two years, outcomes are equivalent. Many patients who were randomised to the physio group never needed surgery. Those in the surgery group who didn't improve could still have surgery later - and their outcomes were no worse for the delay.

When surgery is more likely to be the right choice

• Acute full-thickness tear in a patient under 60 following a specific injury
• Dominant arm tear in a high-demand overhead athlete or manual worker
• Complete failure of 3-6 months of quality physiotherapy
• Significant weakness that isn't improving with exercise

What quality physiotherapy looks like

Physiotherapy for a rotator cuff tear is not heat packs and gentle stretching. It involves progressive rotator cuff strengthening, scapular stabilisation, and gradually increasing load - including overhead work when the shoulder is ready. Programs that produce good outcomes typically run for 12-16 weeks.

Making the decision

The decision should be made in consultation with both a physiotherapist and an orthopaedic surgeon who is willing to support a trial of conservative management first. Be sceptical of any clinician who recommends surgery without a trial of good rehabilitation. Many surgeons now actively advocate for this approach.