Marc Darrow, M.D.
We will see many patients after a shoulder surgery with less than hoped for results. One reason the surgery was not thought to be a success was the patient’s over-expectation of what the surgery could do and how fast they could return-to-play their favorite activity.
A study published in the Orthopaedic journal of sports medicine (1) wrote: “In professional female tennis players, a high return to play rate after arthroscopic shoulder surgery is associated with a prolonged and often incomplete return to previous level of performance. Thus, counseling the patient to this fact is important to manage expectations.”
In this study, there was an over-expectation of what the surgery could do. The arthroscopic shoulder surgery could get the player back to the game in most cases, but could not get the player back to “their” game as quickly as hoped for. In fact it took years if at all. Here are more details from this study:
- During the study period, 8 professional women tennis players from the WTA tour underwent shoulder surgery on their dominant arm. Indications included rotator cuff debridement or repair, labral reconstruction for instability or superior labral anterior posterior lesion, and neurolysis of the suprascapular nerve.
- Seven players (88%) returned to professional play.
- The average time to return to play was 7 months after surgery.
- However, only 25% (2 of 8) players achieved their preinjury singles rank or better by 18 months postoperatively.
In total, 4 players returned to their preinjury singles ranking, with their peak singles ranking being attained at a mean of 2.4 years postoperatively.
This type of surgery was found to be so unappealing that doctors from the New York Football Giants and the Hospital for Special Surgery in New York highlighted these observations in their paper published in Current reviews in musculoskeletal medicine.(2)
“Conservative management of rotator cuff injuries continues to be the “gold standard” in the elite athlete. This includes a comprehensive rehabilitation program, anti-inflammatories, and corticosteroid injections. Newer treatment techniques such as intramuscular dry needling and the use of biologics such as platelet-rich plasma and stem cells demonstrate early promising results; however, these modalities require further investigation to determine their effectiveness. Rotator cuff injuries can range from contusions and tendinopathy to full-thickness tears. A comprehensive evaluation is needed to determine the extent of injury and appropriate plan of care. Management strategies can range from rehabilitation to operative intervention and are guided by the size of the tear, time of season, sport, performance limitations, and presence of concomitant pathology.”
These professional players showed these results while receiving the best in rehab, training opportunities, training equipment, personal trainers, etc. What about the average patient? Is there an over expectation of what shoulder surgery can do for them?
Surgery was not the answer for swimmers
Researchers have documented that surgical interventions for subacromial impingement syndrome (also called Swimmer’s Shoulder, inflammation and degenerative shoulder disease from repetitive motions as in swimming), show that no technique is convincingly better than another surgical technique or that surgery is superior is any way to conservative interventions.(3)
Further, when having arthroscopic stabilization, even in youth athletes, it must be emphasized to the patients and their relatives that the recurrence rate of surgery damage and need for more surgery could be expected. Younger athletes being more vulnerable than in the adult athletes.(4) That was suggested in a well cited 2012 study published in the journal Arthroscopy.
Here again is a discussion of expectations in the athlete. While studying surgical options, no procedure showed itself better than non-surgical procedures and there is a good chance for the need of a revision surgery to repair the previous surgery.
A patient with problems of the rotator cuff or shoulder impingement may think so, however surgery is a still an invasive procedure that requires lengthy recovery and physical therapy even if successful. Further, even successful surgery has been shown to not always relieve all the pain and that shoulder weakness can remain. Complications may also include nerve damage.
A more optimistic study in 2019 in the Journal of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (5) said this:
“Adolescent athletes who undergo Bankart repair for traumatic anterior shoulder instability have an 81.5% rate of return to sports to preinjury levels of play at an average of 5 months following surgery. The overall total mean incidence of recurrent instability in the adolescent population is 18.5%, while the mean incidence of revision surgery is 12.1%. The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery.”
Again these are optimistic results:
- 4 out of 5 will have successful surgery
- 1 out of 5 will not
- 1 out of 8 will have to have another surgery.
- Throw these numbers out when you consider athletes who participate in contact sports. “The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery.”
In the Journal of the American Academy of Orthopaedic, surgeons offered a realistic level of expectation of surgical complication. “Most patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms post-operatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge.” Your treatment options include another surgery to repair the first one. Surgery to transfer a tendon into the area, and arthroplasty.(6)
A September 2023 study (7) suggest these patients would have the greatest chance of a more successful outcome after arthroscopic shoulder surgery.
- Younger patients with small tears
- Shorter duration of symptoms.
- Were not engaged in a worker compensation claim.
- Did not have a particular physically demanding shoulder activity they were engaged in.
- Had a lot of pain before surgery.
Does Platelet Rich Plasma application during surgery help?
An August 2022 editorial in the medical journal Arthroscopy (8) wrote: “Studies investigating the effect of PRP on shoulder rotator cuff healing, clinical outcomes, and retear rates suggest that PRP has no effect on outcome and healing but potentially reduces retear rates. However, study quality is compromised by low samples sizes, inadequate randomization protocols, and heterogeneity. . . Until there are reliable and valid data available, the use of PRP in rotator cuff repair is not strongly supported and is at the discretion of the treating surgeon. The current evidence shows the superiority of PRP over hyaluronic acid and corticosteroids, and there is promise that PRP could be a useful adjunct promoting rotator cuff healing following surgical repair.”
Shoulder tendon repair without surgery
The shoulder tendons are main players in rotator cuff problems, shoulder impingement, shoulder osteoarthritis and disorders of pain and weakness that get worse over time.
The symptoms of tendon weakness and injury are many and include inflammation of the tendons (tendonitis), and/or bursitis, inflammation of the bursa (the protective sac that sits between the bones of the shoulders and allows the tendons the space they need to move.)
All would agree treating the tendons and allowing the tendons to function normally would be the optimal treatment in shoulder pain, but that is where the agreement ends. Surgeons will insist that surgery after failed conservative treatments is the way to go, other doctors are trying something else for faster results.
1 Young SW, Dakic J, Stroia K, Nguyen ML, Safran MR. Arthroscopic Shoulder Surgery in Female Professional Tennis Players: Ability and Timing to Return to Play. Clin J Sport Med. 2016 Jun 22.
2 Weiss LJ, Wang D, Hendel M, Buzzerio P, Rodeo SA. Management of Rotator Cuff Injuries in the Elite Athlete. Curr Rev Musculoskelet Med. 11(1):102-112. doi: 10.1007/s12178-018-9464-5. Epub 2018 Jan 13.
3 Tashjian RZ. Is there evidence in favor of surgical interventions for the subacromial impingement syndrome? Clin J Sport Med. 2013 Sep;23(5):406-7. doi: 10.1097/01.jsm.0000433152.74183.53.
4.Castagna A, Delle Rose G, Borroni M, Cillis BD, Conti M, Garofalo R, Ferguson D, Portinaro N. Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports. Arthroscopy. 2012 Mar;28(3):309-15. doi: 10.1016/j.arthro.2011.08.302. Epub 2011 Nov 30.
5 Kasik CS, Rosen MR, Saper MG, Zondervan RL. High rate of return to sport in adolescent athletes following anterior shoulder stabilisation: a systematic review. J ISAKOS. 2019 Jan;4(1):33-40. doi: 10.1136/jisakos-2018-000224. Epub 2018 Nov 10. PubMed PMID: 31044093; PubMed Central PMCID: PMC6487304.
6. Strauss EJ, McCormack RA, Onyekwelu I, Rokito AS. Management of failed arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2012 May;20(5):301-9.
7 Stojanov T, Audigé L, Modler L, Aghlmandi S, Appenzeller-Herzog C, Loucas R, Loucas M, Müller AM. Prognostic factors for improvement of shoulder function after arthroscopic rotator cuff repair: a systematic review. JSES international. 2023 Jan 1;7(1):50-7
8 Hohmann E. Editorial Commentary: Platelet-Rich Plasma Reduces Retear Rates Following Rotator Cuff Repair but Does Not Improve Clinical Outcomes. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2022 Aug 1;38(8):2389-90.