Do Traumatic Rotator Cuff Tears Really Require a Different Approach?

In shoulder surgery, it is often believed, almost as a rule, that acute traumatic rotator cuff tears should be treated differently from degenerative (atraumatic) tears. The rationale is compelling: previously healthy tendon, better healing potential, and the prospect of superior structural, pain, and functional outcomes with early repair. This logic underpins many clinical guidelines and surgical decisions.

However, compelling logic is not the same as compelling evidence.

A recent comparative study examined traumatic versus atraumatic tears following repair and found no meaningful differences in tendon integrity, pain, or function between the two groups at follow-up. Healing is not better in traumatic rotator cuff tears.

The Ranebo et al. (2020) randomized controlled trial provides further weight to this challenge. In this study, 58 patients with small, traumatic full-thickness supraspinatus tears, all with previously symptom-free shoulders, were randomised to early surgical repair or structured physiotherapy without repair. After 12 months:

• Function and pain scores (Constant-Murley and WORC) were high in both groups, with no statistically or clinically significant differences.
• Pain at rest, during activity, and at night was similarly low.
• Quality of life measures were equivalent.
• The healing rate after repair was high (93.5%), but 29% of unrepaired tendons increased in size by >5 mm. Despite this, functional outcomes remained comparable at one year.

These findings are important because they undermine the assumption that traumatic tears inevitably benefit more from surgical repair, at least in the short term, and particularly for small tears in otherwise healthy shoulders.

Why might this be? One explanation is that small traumatic tears in a healthy rotator cuff may be well compensated for by the surrounding rotator cable, allowing near-normal function despite a persistent defect. Another is that improvements following surgery may relate as much to the postoperative rehabilitation process as to the mechanical repair itself, a process that physiotherapy can emulate without surgical risk.

Of course, caution is warranted. The Ranebo et al. trial was small, limited to one-year follow-up, and focused on small tears. Tear progression was observed in some nonoperative cases, raising questions about potential longer-term consequences. Longer follow-up studies have shown that differences can emerge over a decade, with unrepaired tears demonstrating more progression and worse outcomes. Although, we do have 10 year outcome data for non-operated full thickness tears showing 75% of people do really well.

The key point is that the “traumatic” label alone should not be a reflex trigger for surgical repair. Decision-making should integrate tear size, patient age, activity demands, comorbidities, and preferences, alongside the understanding that, for some small traumatic tears, nonoperative care can yield excellent results, at least in the medium term.

Clinical dogma thrives in the absence of strong evidence. This is one area where it’s worth pausing, questioning the narrative, and acknowledging that “it makes sense” is not the same as “it’s been proven”.

References

• Guevara-Alvarez A, Valencia-Ramon EA, Bothorel H, Collin P, Zbinden J, Guizzi A, Lädermann A. Traumatic and Atraumatic Rotator Cuff Tears Have the Same Rates of Healing. Arthrosc Sports Med Rehabil. 2024 Feb 13;6(2):100867. doi: 10.1016/j.asmr.2023.100867. PMID: 38379596; PMCID: PMC10877195.
• Ranebo MC, Björnsson Hallgren HC, Holmgren T, Adolfsson LE. Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial. J Shoulder Elbow Surg. 2020 Mar;29(3):459-470. doi: 10.1016/j.jse.2019.10.013. Epub 2020 Jan 7. PMID: 31924516.