Jared Powell (00:10):
In this episode, we're exploring a simple but important question. What makes rotator cuff surgery worthwhile? And today's guest is me and me alone. This episode is more of a one-to-one soliloquy between you and I discussing what I think is a really important concept in caring for people with shoulder pain. Let's get stuck straight into it. First of all, we're not talking about whether shoulder surgery works.
Jared Powell (01:04):
This question has been explored to death. We're talking about whether it works enough and who gets to decide that spoiler. It's the patient. It's not you or the surgeon. It's the person in pain, and that's where this new study from Harrison Hansford and colleagues comes in. Harrison is actually a former guest on the show, episode number 33, and I highly recommend you check out that episode to compliment this one. Harrison's latest study has just been published, which is the year 2025. In case you're listening to this in the future, in the journal trials, you'll find a link to the paper in the show notes. So let's start with some context. Rotator cuff surgery is common, but perhaps too common. It's often offered to people with persistent shoulder pain who haven't responded to non-surgical care. And this sounds fair and plausible, and sure there are trials showing some benefit, but we haven't always asked how much benefit patients actually need to consider the surgery worthwhile.
Jared Powell (02:02):
If surgery is 5% better than non-surgical care, is that sufficient? 30%, 50%, 70%, we actually don't know, and that's why Etal did this lovely study and they used a pretty clever method, a benefit harm trade-off study to determine the smallest worthwhile effect of surgery versus non-surgical care. And here's how it worked. They recruited people with persistent shoulder pain and gave them a clear scenario. Imagine you are offered rotator cuff surgery. How much improvement in shoulder pain and function would you need beyond what you might get from non-surgical care to say, yeah, shoulder surgery is worth it. So let me just repeat that bit. How much improvement in shoulder pain and function would you need beyond? And that's important beyond what you might get from non-surgical care to say, yeah, shoulder surgery is worth it. Hey guys, Jared here. I'm stealing you away from the pod for exactly 30 seconds.
Jared Powell (03:04):
And the answer is 40%. That was the median response. Participants wanted at least a 40% improvement in shoulder pain and function to justify the costs, the risks, and the recovery timeframe of surgery. In more practical terms, that translates to about 28 points on the Western Ontario rotator cuff index outcome measure, which is a commonly used outcome measure. Now, here's where I think it gets interesting.
Jared Powell (03:54):
That 40% figure isn't just pulled out of thin air. It's much higher than the usual thresholds. We talk about like the minimal clinically important difference, which might sit closer to 13 or 14 points on the same scale. Patients are setting the bar much higher than what we typically call clinically important, and maybe that's fair after all. Surgery isn't just a pill or a set of exercises. It's expensive both from a cost perspective, and it takes you out of action for a period of time. It carries risks and there are no guarantees of success. But let's not stop there. Let's ask the next question. Does the evidence show that surgery actually clears this bar, the 40% better bar? To answer that question, we need to turn to the systematic review and meta-analysis literature. And in particular, I'll talk about a 2019 systematic review by Lanin and colleagues.
Jared Powell (04:47):
This review compared rotator cuff surgery to non-surgical care across multiple studies, and what they found was pretty underwhelming. The benefits of surgery were small, sometimes statistically significant, but clinically modest at best. The effects didn't come close to the 40% improvement patients in the hand spent study said they needed. So what do we do with this tension or mismatch between the evidence and patient expectation? Well, first, we probably need to stop treating rotator cuff surgery as a default next step after nonsurgical care fails. Although this is a viable option for people, especially those with full thickness rotator cuff tears, we need to consider whether surgery will offer a clinically important effect beyond non-surgical care. If patients are expecting a major, a significant improvement and the evidence shows only minor gains, we have a responsibility to bring those expectations into the decision making process. This is what shared decision making should look like, not just outlining the risks and the benefits, but also exploring the patient's own values, preferences, and thresholds for recovery, asking what would make this treatment worth it to you.
Jared Powell (06:03):
And if the probable benefit doesn't match their answer, then maybe surgery isn't the right call, but maybe it is. There's nuance to consider here. There's one more point worth making. This study also challenges how we think about outcomes in musculoskeletal care more broadly, because what the handsman team is really asking is whose outcome matters? Too often we fall into the trap of thinking that statistical significance or small mean differences are enough to guide clinical decisions, but the smallest worthwhile effect flips that it says, let's not just ask whether something was, let's ask how much better a treatment needs to be for patients to actually care about whether it works. So to wrap up, people with rotator cuff related shoulder pain tend to want a 40% improvement in shoulder pain and function to consider rotator cuff surgery worthwhile compared to non-surgical care. The best available evidence suggests surgery rarely delivers that.
Jared Powell (07:00):
We need to align our clinical decisions with patient defined thresholds of recovery, not just P-values or tradition. Shared decision-making means being honest about this mismatch. Okay, guys, thanks for tuning into this solo episode. If you found this episode helpful or frustrating or enlightening, all three, I'd love to hear from you. Until next time, stay curious. Thank you for listening to this episode of The Shoulder Physio Podcast with me, Dr. Jerry Powell. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really does help the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
