Rethinking rotator cuff tears

There are over 26 million rotator cuff tears in the United States alone. That is not a metaphor. It is a quiet fact. These tears exist, largely unseen, and for the most part, unfelt.

We tend to imagine that anatomy is destiny. That a tear in a tendon must lead to pain. That pain, if significant, demands correction. But this linear thinking—tear leads to dysfunction, dysfunction requires repair—is beginning to falter. Dr. John Kuhn, an orthopedic surgeon and academic, has spent the last two decades studying this terrain, and the patterns he observes do not match our expectations.

The majority of full-thickness rotator cuff tears are not tragic injuries. They are part of the slow weathering of tissue with time—like lichen spreading across stone. Many are incidental, not consequential. Kuhn’s long-term studies show that, with structured physiotherapy and patient engagement, three-quarters of patients avoid surgery. Not for weeks or months, but for years—ten and counting.

What, then, drives the need for surgery? The answer is disarmingly human: belief. Patients who expect physical therapy to fail are the ones who abandon it. The implication is not that pain is imagined, but that recovery is entangled with cognition, with narrative, with the future the patient envisions for themselves.

There is a kind of humility in Kuhn’s approach. He is not dismissing surgery. He performs it when needed—especially when function is lost or trauma is recent. But he resists the surgical impulse when it is driven solely by imaging or fear. The image is not the experience. The tear is not the story.

There is a poetic tension in this: a structure can be torn, yet the person remains whole. The rotator cuff, it seems, is not a singular predictor of shoulder pain, but a piece in a larger system—one that includes the nervous system, the mind, the social context, and time itself.

This is the physics of clinical care: small forces add up, trajectories are unpredictable, and certainty is rare. But patterns emerge. And the pattern Kuhn offers is this: belief matters. Context matters. Surgery is not inevitable.

Science, after all, is not just about measuring what is. It is about understanding what matters.

Keen to learn more? Don’t miss Jared’s insightful conversation with Dr. John Kuhn — listen to the full episode here: