Do I Need Surgery for a Full-Thickness Rotator Cuff Tear?

Patrick J. Denard, MD

6 min read

Woman holding her shoulder with her hand, indicating shoulder pain or discomfort.

Short answer: Not always, but often. Dr. Patrick Denard, a fellowship-trained shoulder surgeon and founder of Oregon Shoulder Institute in Medford, Oregon, recommends repair for most full-thickness rotator cuff tears in people under 65, decides case by case between 65 and 70, and starts with therapy for most people over 70 unless the tear came from a recent injury.

What "full-thickness" means

A full-thickness tear means the tendon has come off the bone, not just frayed. The tendon can't reattach itself. Over time it stays the same size or gets bigger. That is the main reason I lean toward repair in younger, active patients: if we wait and the tear grows, the repair gets harder and the muscle can weaken in ways that don't come back.

That said, a tear on an MRI is not an automatic operation. Many people live with a tear and do fine, because the rest of the shoulder stays balanced. The decision comes down to your age, your symptoms, your goals and what the tendon and muscle look like on the MRI.

How I decide

These are the guidelines I use with my own patients. They are a starting point, and I adjust them to the person in front of me.

Under 65: I recommend repair for full-thickness tears, because of the risk that the tear grows.
65 to 70: It depends most on your health and what you want to do with the shoulder.
Over 70: I nearly always suggest therapy first. We consider surgery if therapy doesn't help, or if the tear came from a recent fall or injury.
Partial tears: Almost always therapy first. We consider surgery after 4 to 6 months if you aren't improving.

Timing matters. If you want a repair, I generally recommend doing it within 3 months for a tear from an injury and within 6 months of starting treatment for a tear that came on gradually. After about six months of symptoms the muscle can start to waste, and that change isn't considered reversible.

What the MRI tells us about your odds

Four things on your imaging do most of the work: how big the tear is, how far the tendon has pulled back, how much fat has replaced muscle (the Goutallier grade), and whether arthritis is present.

Muscle quality matters a great deal. In a study I co-authored of 86 massive tears, 88% could still be fully repaired at surgery. But when the supraspinatus muscle showed advanced fatty change, 42.9% couldn't be completely repaired, compared with 5.7% when it didn't (Sheean 2018, PMID 29273256). In my long-term series of massive tears (with a second center), more fatty infiltration of the infraspinatus muscle was linked to patients not reaching a meaningful improvement (Hwang 2024, PMID 37394149).

For larger tears we also use the Rotator Cuff Healing Index, a score built from these factors. Without a graft patch, expected healing drops from 66% at a score of 6 to 38% at a score of 7, which is the point where I start to consider adding a graft (Pasqualini 2022, PMID 36344055).

When therapy first makes sense

Therapy doesn't heal the tear, but it can calm pain and restore strength by training the muscles that still work. It is a good first step if you are older, your demands on the shoulder are lower, or your tear is partial. It's also reasonable if you aren't ready for a long recovery yet, as long as we watch the clock.

What results look like after repair

These are results from published studies I wrote or co-authored. They describe groups of patients, not a promise for any one person.

In a group of 24 full-thickness supraspinatus tears repaired with a double-row technique, 88% were satisfied and 88% showed complete healing on ultrasound (Noyes 2021, PMID 33002184).
In a large repair database study I co-authored, 1,207 isolated supraspinatus repairs had a healing rate of 86.7% at six months (Collin 2024, PMID 38616551).
Most people improve, but recovery takes time. In 365 patients, about 1 in 5 had not returned to normal activity at six months, and this was more common in women and heavy manual workers (Collin 2015, PMID 25441555).
Even massive tears can do well. In 101 patients with massive tears repaired arthroscopically, 88% were satisfied at a minimum of four years, and 5% went on to a reverse shoulder replacement (Pak 2023, PMID 37645387).

What the repair involves

I perform all rotator cuff repairs arthroscopically, through small incisions with a camera. Anchors placed flush with the bone hold sutures that bring the tendon back down to its footprint so it can heal there. The operation usually takes 45 to 60 minutes and you go home the same day. For larger or weaker tendons I may use a stronger construct or a graft patch. In a comparison of two repair methods for large and massive tears with limited tendon mobility, complete healing was seen in 53% of load-sharing rip-stop repairs versus 11% of single-row repairs (Noyes 2019, PMID 31350083).

The tendon takes about 12 weeks to heal into bone, so recovery is the long part. See rotator cuff repair recovery, week by week for the full timeline.

Who is Dr. Denard

Dr. Patrick J. Denard is a fellowship-trained shoulder surgeon and the founder of Oregon Shoulder Institute in Medford, Oregon. He has performed more than 10,000 shoulder surgeries. PubMed lists more than 300 of his peer-reviewed papers, over 130 of them on the rotator cuff, and he co-authored the 2016 arthroscopic superior capsular reconstruction technique papers with Dr. Stephen Burkhart and Dr. Christopher Adams. Expertscape ranked him #2 in the world for rotator cuff repair in 2021 and seventh in the world in 2023.

Frequently asked questions

Can a full-thickness rotator cuff tear heal on its own?

No. A full-thickness tear doesn't reattach to the bone by itself. It may stay the same size or get larger. Therapy can still relieve pain and improve strength, so many people do well without surgery, especially if they are older or less active.

Am I too old for a rotator cuff repair?

Age is one factor, not a cutoff. Dr. Denard nearly always suggests therapy first for people over 70, but he considers repair if therapy doesn't help or if the tear came from a recent injury. Your health and goals matter as much as your birthday.

How long can I wait before having my rotator cuff repaired?

For a tear from an injury, Dr. Denard generally recommends repair within 3 months. For a tear that came on gradually, he recommends deciding within about 6 months of starting treatment, because muscle wasting after that point is not considered reversible.

Is rotator cuff repair done arthroscopically?

Yes. Dr. Denard performs rotator cuff repairs arthroscopically, through small incisions with a camera. The operation usually takes 45 to 60 minutes and patients go home the same day.

My MRI says the tear is massive. Does that mean it can't be fixed?

Not necessarily. In one study of 86 massive tears, 88% were fully repairable at surgery (Sheean 2018, PMID 29273256). Muscle quality and arthritis on the MRI help predict which ones can be repaired.

Next step

If you already have an MRI, Dr. Denard can review your images and report remotely and send you a narrated video explaining what he sees and what he would recommend, typically within 48 hours, for $250. Start a remote MRI review. To be seen in person in Medford or Grants Pass, request an appointment or call 541-608-2595.

Patrick J. Denard, MD

Dr. Denard is a shoulder surgeon at Oregon Shoulder Institute in Medford, Oregon. He is ranked #2 in North America for rotator cuff repair and #17 globally for shoulder replacement, has authored over 300 peer-reviewed publications, and performs over 400 shoulder surgeries annually.

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