Questions to Ask Before Rotator Cuff Surgery
For the appointment where an orthopedic surgeon puts your MRI on the screen and says whether the torn rotator cuff should be repaired. The list is in six groups, in the order that conversation tends to go: the tear, repairing it or waiting, the operation, retears and other risks, the weeks in a sling, then therapy and the way back to work and overhead reach. With a surgery date already set, start at the third group; if you are still deciding, spend most of the visit on the first two.
The questions
Each question, and why to ask it
The tear
How big is my tear, and which tendons does it involve?
Why ask it
Get a measurement in centimeters and the tendon names, then write both down. Nearly everything later in the conversation hangs on those two facts: the kind of repair, the length of time in a sling and the odds the tendon heals.
Is it a partial tear or a full-thickness tear, and how did you tell?
Why ask it
A partial tear goes part of the way through the tendon and a full-thickness tear goes all the way through, which is not the same as the whole tendon having come off. Find out whether the call rests on the MRI, an ultrasound or the exam, and how sure the surgeon is before seeing it with a camera.
Has the tendon pulled back from the bone, and how far?
Why ask it
The word you may hear is 'retraction'. Have the surgeon show you on the screen where the tendon end sits now and where it belongs, and say whether it should reach without being stretched tight.
What does the muscle behind the tear look like on the MRI?
Why ask it
Surgeons look for muscle that has thinned or been replaced by fat, and many give it a grade. Write the grade down and ask what it means for your shoulder, because a reattached tendon still depends on the muscle that pulls on it.
Can this tear still be fully repaired, or is it past that point?
Why ask it
A plain 'yes' is good news, so follow it with how confident the surgeon is. If you hear 'partly' or 'we will see', get the name of each fallback, such as a partial repair, a graft, a tendon transfer or a reverse shoulder replacement, so you read about the right operation tonight.
Did this tear come from an injury or from years of wear, and does that change your plan?
Why ask it
Tell the surgeon about the fall, the lift or the dislocation if there was one, and the day the weakness began. Then find out whether a sudden tear in a shoulder that worked fine last month is handled on a different clock from one that crept up.
Is there arthritis or anything else in this shoulder besides the tear?
Why ask it
Reports often list more than the tear: wear in the joint, a spur, fluid, a frayed biceps tendon. Go down the report line by line and have each item marked as a cause of your pain, something to deal with during the repair, or something to leave alone.
How much of my pain and weakness do you think the tear explains?
Why ask it
Mention anything that does not fit a shoulder: pain running below the elbow, tingling in the fingers, a stiff neck. A careful answer ties the weak movements found on the exam to the torn tendon and says whether the neck has been ruled out.
Repair or wait
What is likely to happen to this tear if I wait six months or a year?
Why ask it
Three things to listen for: whether it tends to grow, whether the tendon pulls back further, and whether the muscle could change enough to take repair off the table. 'Tears like yours often sit still for years' is a fair answer too, so find out what puts yours in that group.
Could physical therapy alone get me to where I want to be?
Why ask it
Start with what you have already done: how many weeks, with whom, and whether you kept up the home exercises. Therapy works on the muscles that are left, so the real question is whether those can cover for the torn one in the things you need the arm for.
Would a cortisone injection buy me time, or could it get in the way of a repair later?
Why ask it
Surgeons hold different views on injections near a repair. Get this one's limit on how many, the gap they want between the last shot and an operation, and what a few good weeks afterward would or would not prove.
If I hold off, how will we keep an eye on the tear?
Why ask it
Leave with a date for the next exam or scan and a short list of changes that bring you back sooner, such as new weakness or an arm you suddenly cannot raise. Waiting with a check date is a plan; waiting until it gets bad is not.
If we do operate, is there a deadline, or can I pick the month that suits my work and family?
Why ask it
Recovery from a cuff repair runs across several months, so the date is worth choosing. Say what you are trying to fit it around, a school term, tax season, a wedding, and push for an answer about your own tear, not the general advice to avoid delay.
If it goes well, what should I expect to get back: less pain, more strength, or both?
Why ask it
Surgeons often speak about the two separately, and with more confidence about pain. Name the one thing you most want back, be it sleeping on that side, the top shelf or your serve, and hear how likely that one is with a tear like yours.
Does my age, or anything about my health or habits, change the odds that the tendon heals?
Why ask it
Smoking and diabetes are the two that surgeons most often bring up, alongside age. If you use nicotine in any form, find out whether the surgeon will operate before you stop and how long ahead they want you off it. Sort the rest of the answer into what you can change before the date and what you cannot.
If I took this MRI to another shoulder surgeon, where might they disagree with you?
Why ask it
It is an easy way into a second opinion, and it tends to draw out the judgment calls: repair now or watch, repairable or not, which operation. Request the images on a disc or a portal link along with the report, since a second surgeon will want the pictures and not only the write-up.
The operation
Will the repair be arthroscopic, mini-open or open, and why that one for my tear?
Why ask it
Arthroscopic means a camera and instruments through a few small cuts; the other two use a longer incision. See whether the reason given comes from your tear or from what the surgeon does most often, and whether the sling and therapy schedule is any different.
How many rotator cuff repairs do you do in a year, and how many are tears like mine?
Why ask it
Say it plainly; surgeons hear it often. The second half matters most with a large tear or one that has been repaired before, where a surgeon who does many small repairs may see only a few of yours. At a teaching hospital, add who would be placing the anchors: this surgeon, or a resident or fellow working under them.
What will hold the tendon to the bone, and does it stay in my shoulder for good?
Why ask it
The usual answer is suture anchors: small implants set into the bone with stitches attached, placed in one row or two. You are not there to judge the technique. What you can use is what the anchors are made of, whether they are ever taken out, and what they mean for a later MRI of that shoulder.
What else do you expect to do while you are in there, such as shaving a bone spur or treating the biceps tendon?
Why ask it
Collect the name of each extra step, because they show up on the consent form and the bill. If the biceps is involved, find out whether it would be cut or re-anchored, whether the arm will look different, and whether it adds a restriction on bending the elbow against weight.
If the tendon will not reach the bone once you can see it, what will you do instead?
Why ask it
You will be asleep when this choice is made, so the visit is the time to hear 'partial repair' or 'graft' for the first time. Get the surgeon's order of preference, and check that the sling time and therapy plan you were quoted would still hold.
Will I have a nerve block along with general anesthesia, and when will it wear off?
Why ask it
The anesthesiologist has the final word, but the surgeon knows the usual routine. Find out roughly what hour the numbness fades so it does not catch you asleep with nothing taken, and whether a hand that is still numb or weak the next day is expected or a reason to call.
Where will the operation be done, and do I go home that afternoon?
Why ask it
You will leave with one arm strapped to your side and possibly still numb, so settle who drives and whether someone has to stay the night. Get the length of the operation and of the recovery room stay as well, so your driver knows when to be back. Which facility it is can decide who sends the bills, and how that works depends on your insurer or health system, so put that part to the office.
Should I be doing therapy or stretches between now and the operation, or resting the arm?
Why ask it
Some surgeons want a shoulder moving freely before they repair it and send people for a few sessions first; others say to leave it alone. Either way, have someone teach you the exercises planned for the first weeks afterward while the arm still does what you tell it.
Which of my medicines and supplements do I stop before surgery, and on what day?
Why ask it
Blood thinners and anti-inflammatories are the ones surgeons usually rule on, and diabetes or weight-loss injections can matter to the anesthesia team. Give the office the whole list, herbal products included, and leave with a stop day and a restart day marked on it. When the doctor who prescribes one of them says something different, the two offices should sort it out between them.
Who can tell me what the surgeon, the facility, the anesthesia, the sling and months of therapy will cost me?
Why ask it
The surgeon seldom knows, so get the name of the person in the office who does and the procedure codes to give your insurer. Therapy is the line people forget: it runs for months, and what each visit costs you depends on your plan or health system. Check the sling and any cold-therapy machine too, which are sometimes charged apart from the operation.
Retears and risks
How often does a repair of a tear this size fail to heal or tear again?
Why ask it
Push for a figure for your size of tear and your age, not for all repairs lumped together. Then find out where it comes from: a count based on scanning every patient afterward and one based on who came back complaining are very different numbers.
If the repair does not heal, will I necessarily know?
Why ask it
Some surgeons will tell you that people with a repair that did not hold can still end up with less pain than they started with. Hear what an unhealed repair usually feels like in this surgeon's patients, and how it would be picked up.
What would a second operation look like if this one fails?
Why ask it
Surgeons often quote lower odds for a second repair than for a first, so do not assume a retear can simply be done again. Hear what this surgeon would offer you at your age with the tendon you have left, and whether they would operate at all on a failed repair that was not hurting.
How likely is a stiff or frozen shoulder afterward, and what do you do about it?
Why ask it
Stiffness is worth raising by name, because early movement, the usual guard against it, pulls against protecting the repair. Hear how this surgeon balances the two and how long they wait before treating a shoulder that will not loosen. If you have diabetes or have had a frozen shoulder before, say so and ask what it changes.
What are my risks of infection, nerve injury and blood clots with this operation?
Why ask it
All three are printed on the consent form, so spend the time on what is particular to you: a past clot, diabetes, a skin problem near the shoulder, an infection after an earlier operation. Then get the surgeon to name the complication they have had to treat most often after cuff repairs, and how it first showed itself.
What tends to cause a retear in the first three months, and which of those are in my hands?
Why ask it
Expect a list along the lines of a fall, catching yourself with that arm, lifting it under its own power too soon, or leaving the sling off. Whichever one the surgeon sees most is the one to arrange your house and habits around.
What should I do if I fall, or grab something with that arm by reflex, during those weeks?
Why ask it
It happens: a missed stair, a dog on a leash, a door swinging shut. Find out whom to call, whether a sudden pop or a new loss of movement matters more than soreness, and whether they would examine you or scan again. Having the answer ahead of time keeps one bad second from becoming a month of worry.
After I am home, what should make me phone you, and what should send me to an emergency room?
Why ask it
If you are going home the same day, the first bad night is yours to manage. Go through a fever, a wound that leaks, a hand that turns cold or stays numb long after the block should have faded, a swollen calf and trouble breathing, and have each one put under 'phone' or 'emergency room'. Tape the sheet and the after-hours number to the refrigerator for whoever is staying with you.
In the sling
How many weeks will I be in the sling, and does it stay on at night?
Why ask it
The number often follows the size of the tear and how secure the repair felt, so check whether it could change once the operation is over. Then go through when it may come off: in the shower, for exercises, sitting at a table.
What kind of sling will it be, and can I try it on before the operation?
Why ask it
Many cuff repairs go into a sling with a pillow that holds the arm away from the body, and it is bulkier than people picture. Learning the straps and finding shirts that fit over it is far easier while both arms still work.
How should I sleep, and how long before I can lie flat or on that side?
Why ask it
Plenty of people spend the first weeks in a recliner or propped on a wedge of pillows. Have the surgeon describe the position they want and try it for a night before the date, so the first night home is not the experiment.
How painful are the first two weeks, and what will I take for it?
Why ask it
This operation has a reputation for hard nights early on, so get the plan as a timetable: what goes by the clock, what is only for when you need it, and the day the strongest medicine is meant to stop. Raise ice or a cold-therapy machine, and this surgeon's rule on anti-inflammatories while the tendon heals, because rules differ.
When can I shower, and how do I wash and dress with the sling off?
Why ask it
Two answers are needed: when the dressings may get wet, and how to hold the arm in the minutes it is out of the sling. Have a nurse or therapist show you the movement for getting a shirt on, and do it once in front of them.
What am I allowed to do with that hand, wrist and elbow while the shoulder is in the sling?
Why ask it
Go through real tasks one by one: typing, holding a phone, using a fork, lifting a full mug. Surgeons draw the line in different places, and a biceps procedure can bring its own limit on the elbow.
When is it safe for me to drive, and what decides it?
Why ask it
Most answers turn on being out of the sling and off the strong pain medicine, not on a date. Whether you are allowed or insured to drive before then depends on where you live and on your policy, so get the surgeon's rule and check the rest yourself. Line up rides to therapy in the meantime.
What will I need another person for in the first weeks, and what can I manage alone?
Why ask it
Say who lives with you and whether this is your writing hand. Walk through the first night, cooking, jars and bottles, the dog, a small child, shoelaces. If you live alone, find out what other patients in that position arranged.
Therapy and return
When does physical therapy start, and what are the stages?
Why ask it
Plans usually move from the therapist moving the arm for you, to you moving it with help, to moving it yourself, to strengthening. Get the week each stage begins for your repair, and a printed protocol to hand to your therapist at the first visit.
Can I choose my own therapist, and how will they know what you repaired?
Why ask it
A therapist who has the protocol and the operative note can match the pace to the repair. Find out whether the surgeon favors particular clinics and how the two of them talk, then book the first visits before surgery. How many visits are covered is one for your insurer or health system.
When will I be allowed to lift the arm under its own power?
Why ask it
This is the line between passive and active motion, and it is the restriction people break without noticing. Get the week, and have someone show you what counts, because reaching for a cup on the table does.
What should therapy feel like in the early months, and what kind of pain is a warning?
Why ask it
Have the surgeon describe the difference in their own words, for instance a stretching ache against something sharp or catching, and repeat that description to your therapist. Check whether to take something for pain before a session.
How long before I can do my job: desk work, light duty and full duty?
Why ask it
Describe the job in motions and weights: hours at a keyboard, the heaviest thing you lift, work above shoulder height, ladders, driving. Get a separate date for each and a letter listing the restrictions. What your employer has to offer and what leave pays vary by workplace and location, so take that to HR.
When can I reach overhead, and when can I lift something heavy up there?
Why ask it
These are two milestones, often months apart: getting the arm up to put a plate on a shelf, and loading it to lift a suitcase into a rack. Collect both in months, along with what has to be true of the shoulder before each.
When can I go back to my sport or the gym, and is anything off the list for good?
Why ask it
Name the activity exactly: golf, swimming, a tennis serve, bench press, throwing. See whether it comes back in steps, such as putting before a full swing, and whether this surgeon tells people to give up heavy overhead lifting altogether.
How long until the shoulder is as good as it is going to get?
Why ask it
Have the surgeon say where most of their patients are at three months, six months and a year, so there is something to measure your own progress against. With those markers in hand, a slow month in the middle is easier to read.
How will we know the tendon has healed: by exam, by a follow-up scan, or by how it feels?
Why ask it
Not every surgeon scans again as a matter of routine. Get the schedule of follow-up visits, what is checked at each one, and what would lead to an ultrasound or MRI.
Getting ready for the rotator cuff consultation
Practical guidance for the conversation itself
Matching the list to your tear
A small or partial tear
Here the open question is often whether to operate at all. Give most of the visit to the second group: what waiting risks, how the tear would be watched, and what a proper course of therapy could do. The sling and therapy questions can keep until a date is set.
A large tear, or one that has pulled back
Put retraction, the state of the muscle and whether a full repair is still possible at the top, followed by the retear figure for a tear this size. Do not leave without the names of the fallback operations, and plan on showing the scan to a second shoulder surgeon.
A sudden tear after a fall or a dislocation
Give the date of the injury and what the arm could do the week before it. Then go straight to timing: some surgeons prefer to repair a fresh tear sooner, and you want this surgeon's clock for yours in weeks.
A repair that has torn again
Bring the operative note from the first repair if you can get it, because the surgeon will want to know what is already in the bone and where. Ask how many repeat repairs they do in a year and what odds they would quote for one, which may not match the figure for a first repair.
A date already on the calendar
Skip to the operation, the sling and therapy. Those answers arrive as numbers of weeks, and quickly, so hand the list to whoever comes with you and have them write a number beside each question. Going alone, ask at the start if you may record the explanation.
Words you will hear in the consultation
Partial and full thickness
These describe how deep the tear goes through the tendon, not how wide it is. A full-thickness tear can be small. So after you hear the depth, get the width in centimeters as well.
Retraction and atrophy
Retraction is how far the torn end has pulled away from the bone. Atrophy and fatty change describe the muscle behind it. Together they are much of what a surgeon weighs when judging whether a tear can still be repaired, so have both pointed out on your own scan.
Anchors, single row and double row
Anchors hold the stitches in the bone, and the rows describe how they are arranged. Surgeons choose between them for reasons of tear shape and habit. The useful thing to take away is the reason for the choice in your shoulder.
Passive and active motion
Passive means someone or something else moves the arm while the shoulder muscles stay quiet. Active means the shoulder lifts the arm itself. Most of the early restrictions are written in these two words, so have the difference shown to you, not only explained.
Turning the answers into a calendar
One column of milestones
Before the appointment, write a column: sling off, lifting the arm unaided, driving, desk work, light lifting, overhead reach, full duty, sport. Fill in the surgeon's number of weeks beside each. Whatever is still blank when you stand up is your next question.
Count forward from each possible date
Take a candidate surgery date and mark where the sling weeks fall. Icy sidewalks, a house move, a harvest, a trip with luggage and the weeks a partner is away are all worth steering around. If the surgeon said the tear can wait a little, use that room.
Book therapy before the operation
Good clinics fill up, and the first visits are tied to the surgery date. Make the bookings once the date is set, and pick a clinic you can reach without driving yourself.
Give your employer ranges
Pass on what the surgeon said as ranges and conditions, such as 'desk work once the strong medicine stops, no lifting until cleared'. Get the paperwork your workplace needs from the surgeon's office early. Which forms those are differs by employer, so find out from yours.
Setting up the house for one arm
Decide where you will sleep
If the surgeon expects you to sleep propped up, borrow or position the recliner now, or build the stack of pillows and spend a night on it. Put a lamp, water, your phone charger and the medicine chart within reach of the good hand.
Clothes that go on with one hand
Set aside loose shirts that button or zip down the front, pants with an elastic waist and shoes that slip on. Practice dressing with the arm held still at your side, and move anything fiddly to the back of the closet.
Move things to waist height
Bring down the plates, pans, coffee and shampoo you use every day so nothing needs a reach or two hands. Loosen jar lids, decant heavy bottles into small ones and cook a few meals for the freezer.
Line up the first night and the rides
Agree who brings you home, who stays that night and who drives you to the first follow-up and therapy visits. Write the surgeon's after-hours number where that person can find it.