Most Shoulders That Get Told They Need Surgery Don't
Most shoulders that get told they need surgery don't. That's the honest answer, and I want to give it to you straight away. But some genuinely do, and knowing which one you are is the whole point of this article.
Here's the quick version. Impingement on its own will almost always settle with physio — almost always — unless there's something structurally wrong in that space, a bone spur closing it down, in which case you might need a decompression. Partial tears very often settle with physio too, depending on how big it is and whether there's an impingement driving it. And full thickness tears — a big, complete tear — are the ones most often considered for a repair. But even then, it's not automatic. Some full thickness tears rehab perfectly well.
So it's not about what your scan says. It's about three things, and I'll take you through them at the end.
My name's Joe. I'm an ex-professional football head physio and multi-clinic owner here in the UK. As always, this is a guide to help you understand your options. It's not medical advice for your specific shoulder.
Impingement: Almost Always Settles With Physio
Let's start with impingement, because this is where a lot of people end up being offered something. If your problem is impingement — that tendon getting compressed as you lift — it will almost always settle with physio. I want to be really clear about that: the vast majority of impingement does not need an operation.
Remember what's causing it. Tight pecs, tight lats, a weak cuff, a shoulder blade that isn't moving. Sort those out, the space opens up, the tendon stops getting squashed, and it settles. That's a mechanical problem with a mechanical solution.
But — and this is the exception — sometimes there's something structurally wrong in that space. The space your tendons run through is bordered by bone, and over the years you can develop a bone spur, an extra bit of bony growth that grows down into that space. That's different, because no amount of physio is going to change the shape of a bit of bone. If that spur is genuinely closing the space down and catching that tendon, that's when a surgeon might do a decompression — going in and shaving that bone back to open the space up and stop it catching.
But notice the order there. You don't start with that. You treat it properly first, and if it hasn't responded, and there's a genuine structural reason showing on imaging, that's when a decompression comes into it.
Partial Tears: Very Often Settle With Physio
A partial tear means the tendon is damaged but hasn't gone all the way through — it's still intact. And here's the good news: these very often settle with physio, because the tendon is still doing its job. It's still connected, just irritated and compromised. Settle it down, load it progressively, strengthen it up, and a lot of these do really well.
It does depend on a couple of things. How big is the tear? A small partial tear and a large one that's most of the way through are different propositions. And is there an impingement driving it? If that tendon is still being compressed every time you lift, it's never going to get a chance to settle — you have to sort that out first.
So for a partial tear, the default position is physio, and most of them respond.
Full Thickness Tears: Most Often Considered For Repair — But Not Automatic
Then there's a full thickness tear, where the tendon has torn all the way through and is no longer attached where it should be. These are the ones that most often get considered for a repair, because a tendon that's completely detached isn't going to reattach itself. That's just the reality of it.
But — and this is the bit I really want you to hear — even a full thickness tear is not an automatic operation. Some people with full thickness tears do genuinely well with rehab. Remember, there are four muscles in that cuff. If one has gone, we can often train the other three, plus your shoulder blade, to compensate and share that load. I've seen plenty of people with a confirmed full thickness tear get their shoulder working perfectly well for what they need.
The Three Things That Actually Decide
So who does well with rehab, and who ends up needing a repair? It comes down to three things.
The first is how you're doing functionally. Not what the scan says — what can you actually do? Can you get on with your day, work, sleep, do the things that matter to you? Someone with a tear on a scan who's managing their life fine is in a very different situation to someone who can't lift a kettle.
The second is your strength. How much power have you actually got in that arm? Can you lift it, hold it, load it? If the strength is there, or we can build it, that tells us the shoulder is coping — that points towards rehab. If the arm is genuinely weak and isn't improving with proper strengthening, that's when a repair becomes more relevant.
The third is how you've responded to treatment. Have you actually had a proper go at rehab — not two sessions and a sheet of exercises, but a genuine, progressive strengthening programme given proper time? That's the test. If you've done that properly and you're still weak, still struggling, still not functioning, then you've got real information, and a surgical opinion makes sense. But if you haven't had a proper crack at rehab and someone's already talking about operating, I'd want you to have tried that first.
What This Means If You've Been Told You Need Surgery
So to bring it together: impingement almost always settles with physio, unless there's a bone spur structurally closing that space down, in which case a decompression might be needed. Partial tears very often settle with physio, depending on the size and whether an impingement is driving it. Full thickness tears are most often considered for repair, but some rehab really well. And the decision isn't made off the scan — it's made off how you're functioning, how much strength you've got, and how you've responded to a proper course of treatment.
If you've been told you've got a tear, don't panic and don't assume you're heading for an operation. Get it assessed properly, have a genuine go at rehab, and then make the decision with real information.
This article is a guide to help you understand your options. It's not medical advice for your specific shoulder. Decisions about surgery should always be made with a qualified professional based on a proper assessment of your function, strength, and response to treatment.
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