Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: a systematic review and meta-analysis

Key points

1. 01Large to massive rotator cuff tears (over 5 cm, two or more tendons) heal poorly and have high retear rates, so the best management is genuinely uncertain.
2. 02At 12 months, pain significantly favored the non-exercise or surgical group (SMD 0.47), but the roughly 0.5-point VAS difference was smaller than the clinically important threshold of 1.4, so it is statistically but not clinically meaningful.
3. 03Exercise produced a clinically meaningful 9 degree gain in shoulder external rotation at 6 months versus controls.
4. 04Function and quality of life showed no significant difference between exercise and comparators at any time point.
5. 05Only 2 of the 5 trials actually compared exercise to surgery, and just 4 to 32% of participants had true large to massive tears, so the findings are heavily indirect.

How it was conducted

Design

Systematic review and meta-analysis of RCTs (PROSPERO 244502), Cochrane RoB 2 and GRADE certainty

Search

Five databases, updated to October 2021; 5 RCTs included (297 participants, mean age 66.7 years, 55% male)

Intervention

Shoulder exercise (stretching, strengthening, range of motion, proprioceptive) versus another non-surgical intervention (3 trials) or surgical repair (2 trials)

Outcomes

Primary: quality of life, disability, pain; secondary: range of motion; exercise reporting quality scored with the 19-item CERT

Analysis

Mean or standardised mean differences (RevMan 5), fixed effect if I2 50% or less and random effects above, compared against minimal clinically important differences

What they found

• Pain at 12 months (3 trials, 219 participants): SMD 0.47 (95% CI 0.07 to 0.88), p = 0.02, favoring the non-exercise or surgical group, but below the VAS MCID of 1.4; very low certainty.
• Pain at 3 months (SMD -0.14, 95% CI -0.53 to 0.25) and 6 months (SMD -0.09, 95% CI -1.23 to 1.05): no significant difference.
• External rotation ROM at 6 months (2 trials, 100 participants): MD 9.19 degrees (95% CI 2.16 to 16.22) favoring exercise, low certainty; flexion and abduction showed no significant difference.
• Function and quality of life: no significant difference at 3, 6, or 12 months (for example function at 12 months SMD -0.18, 95% CI -0.72 to 0.35).
• Exercise reporting was poor (median CERT 7 of 19, range 4 to 12); certainty of evidence low or very low across all outcomes.

Limitations

• Only 4 to 32% of participants across trials met the large to massive tear definition, creating very serious indirectness for this population.
• Certainty of evidence was low or very low for every outcome, with high heterogeneity and no possible subgroup analysis.
• Just five small trials (297 participants) with varied comparators and a wide age range were pooled.
• Exercise interventions were poorly and inconsistently reported (low CERT scores), so the active programs cannot be reliably replicated.

Why it matters

For patients

For a large rotator cuff tear, exercise may match surgery for day-to-day function and quality of life, though surgery showed a small extra pain benefit at one year that may not be noticeable in practice.

For clinicians

Exercise is a reasonable option for large to massive tears, but the title's equivalence claim is not firmly supported, and poor trial reporting limits how confidently a specific program can be prescribed.

For readers

Despite the optimistic title, the evidence comparing exercise and surgery for large rotator cuff tears is sparse and low certainty, with mixed signals across pain, motion, function, and quality of life.