Failed 3 Months of Rehabilitation: What Next?

So, you’ve slogged through three months of shoulder rehab and that bloody shoulder still isn’t playing nice. You’ve stretched, strengthened, and maybe even cursed a little, but the pain’s hanging on like that last guest at a party. Now what? Is it time to call the surgeon? Let’s break down the latest evidence and options for both the weary patient and the concerned clinician.

The Study Recap: Rehab vs. Surgery

Let’s start with a key study that explored this exact scenario. In 2021, Cederqvist and colleagues ran a pragmatic trial with 417 adults suffering rotator cuff related shoulder pain (RCRSP). They all went through a structured 3-month rehabilitation program. After those three months, more than half the cohort improved so much they tapped out of the study’s next phase. Only 190 patients (about 45%) were still symptomatic enough to move on.

Those 190 last standing patients were then randomly split into two groups: one group got shoulder surgery (tailored to their rotator cuff issue), and the other continued with non-surgical care (extended rehab and other non-surgical treatments).

Fast forward two years. Both groups improved in pain and function on average, and the difference between surgery and continued rehab was… trivial. Pain levels differed by only a few points, and shoulder function scores by even less, essentially a tie.

There was one important exception: patients with full-thickness rotator cuff tears. Surgery showed modest improvements in pain and function for these individuals. Still, we’re talking about improvements in the “helpful” range, not the “life-changing” one.

The key message? Start with rehab. Reassess after three months. Consider surgery only if symptoms persist and there’s a confirmed full-thickness tear.

Most Shoulders Settle with Rehab (No Scalpel Needed)

Here’s some good news: most people improve with non-surgical care. In that study, over half the patients found relief with just three months of structured exercise and therapy. That’s significant, especially considering these were people with chronic shoulder pain.

So, if you’re a patient frustrated after weeks of diligent rehab, hang in there. Progress is often gradual, not dramatic. And if you’re a clinician, it’s worth helping your patient stick with it just a bit longer, especially when there is no evidence of a full thickness rotator cuff tear.

Surgery: A Small Benefit for Big Tears (After Quality Rehab)

When rehab doesn’t hit the mark, it’s natural to consider the “next level” of care. But before scheduling time in the operating room, here’s what you need to know.

If there’s no full-thickness tear, surgery doesn’t provide a meaningful benefit over continued non-surgical care. Procedures like subacromial decompression or general clean-up often don’t outperform placebo.

But if there is a full-thickness tear and rehab hasn’t helped? Surgery might offer modest gains, including slightly less pain and slightly better function. Just remember, these gains aren’t massive, and surgery is far from a magic fix. It comes with its own rehab journey, risks, and time investment.

Bottom line: surgery is only worth considering if you’ve done the work with rehab and if imaging confirms a full-thickness tear.

When Rehab Hasn’t Helped: Your Next Steps

So, you're three months in and still struggling. Here’s a practical guide for what to do next:

•  Re-evaluate the Diagnosis and Rehab:Was the rehab truly individualized? Did you stick to it consistently? Could another condition be mimicking shoulder pain? Consider a second opinion.
•  Set Realistic Expectations:If you’re considering surgery, understand what’s involved with the procedure, the rehab, and the expected outcomes. Improvement is likely to be modest (for some) not miraculous.
•  Keep Exploring Non-Surgical Options:A tweak in the exercise program, a new physiotherapist, an injection. There’s often still room to improve without surgery.
•  Make a Shared Decision:Surgery or not, the decision should align with your goals. Want to get back to lifting heavy or playing tennis? That’s valid. Okay living with some pain as long as you avoid surgery? That’s valid, too. Discuss your goals with your clinician and decide together.

Final Thoughts: Shoulder On

If your shoulder still hurts after 12 weeks of rehab, don’t panic. Most shoulders get better with time and movement. And even if you’re in the unlucky group who didn’t improve right away, you’re not out of options, you’re just at a fork in the road.

Surgery isn’t the villain here, but it’s not a hero either. It’s simply one tool in the toolkit, best used selectively.

So, what’s next? Reassess, talk it through, and make a choice based on your situation, not fear, not frustration, and definitely not outdated assumptions.

Sources

•  Cederqvist S, Peolsson A, Björklund M, Bernfort L, Johansson K. Surgery versus non-surgical care for subacromial shoulder pain: a randomized clinical trial. Ann Rheum Dis. 2021;80(10):1252–1259.
•  Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329–338.