Q: Do you think there's any risk in delaying rotator cuff surgery indefinitely? I'd like to take a wait-and-see approach but I'm afraid that could jeopardize surgery if it turns out that's what I'll need.

A: The four tendons of the rotator cuff attach to the deep rotator cuff muscles. This group of muscles lies just outside the shoulder joint. These muscles help raise the arm from the side and rotate the shoulder in the many directions. They are involved in many day-to-day activities. The rotator cuff muscles and tendons also help keep the shoulder joint stable by holding the humeral head in the glenoid socket.

Degenerative changes due to the aging process are the most common cause of rotator cuff tears in older adults. Studies show that once the rotator cuff starts to tear, the tear will continue to get worse and increase in size over time. These tears are divided into two basic groups based on severity: partial-thickness and full-thickness tears. As the names suggest, how far down the tear goes through the tissues determines the category.

The tendon tries to heal itself but often ends up just filling in the gap caused by the tear. Fat cells form the filler, but these are not structurally strong. This in-fill process is called fatty infiltration. Fatty infiltration does not improve shoulder motion, strength, or function.

Surgery may be needed but before subjecting patients to this type of invasive procedure, conservative (nonoperative) care is usually recommended first. Temporarily delaying surgical repair in favor of physical therapy does not seem to put the patient back in any way.

The therapist assists each patient by creating an individualized treatment program that addresses postural component and alignment factors first. Then restoring motion and strength are next. The therapist always keeps the patient's goal, activity and lifestyle, and general health in mind. For those individuals who are still out in the work force, specific work requirements are determined as well.

For those patients who either have failed to improve with conservative care or who have massive tears unlikely to respond to a nonoperative approach, surgery may be necessary. The decision to have surgery and the timing of the procedure depend on several factors. For example, your general health must be taken into consideration. Any specific medical problems you may have that could compromise recovery are important, too.

Whether or not delaying surgical repair indefinitely will impact your potential recovery is difficult to predict. Your surgeon is the best one to asnwer this question. He or she will gauge your symptoms, assess the clinical presentation (range of motion, function), and review imaging studies (X-rays, MRIs) to determine severity of the situation.

Sometimes the final decision is best made during the arthroscopic examination. At that time, the surgeon can see the true extent of the damage and make the best treatment decision based on actual tissue pathology.

Reference: Claudius D. Jarrett, MD, and Christopher C. Schmidt, MD. In The Journal of Hand Surgery. September 2011. Vol. 36A. No. 9. Pp. 1541-1552.