'Physio's not going to repair a torn tendon': patient decision-making related to surgery for rotator cuff related shoulder pain

Key points

1. 01Severe pain and long symptom duration (50% had pain for a year or more) were the most common reasons patients felt surgery was their only option.
2. 02Most participants (10/15) believed a torn tendon could only be fixed mechanically by surgery, a belief often reinforced by clinicians citing imaging findings.
3. 03All 15 participants had tried exercise before surgery; 10/15 also tried steroid injections, yet most felt non-surgical treatment had failed or made them worse.
4. 04Trust in surgeons was very high - some patients described surrendering decision-making entirely to the surgeon's authority.
5. 05About half the participants (7/15) felt informed about surgical risks; 3/15 were actively dissatisfied with the information they received, and several were unaware of non-surgical alternatives.

How it was conducted

Design

Qualitative study using in-depth semi-structured interviews with inductive thematic analysis

Participants

15 adults who had elective surgery for rotator cuff related shoulder pain within the previous 12 months, recruited from a large Melbourne imaging facility

Sampling

Purposive sampling by age, gender, and surgeon (6 surgeons in total); drawn from 30 surgical patients in a larger observational survey of 120

Interview duration

30 to 45 minutes per interview; audio-recorded and transcribed verbatim

Analysis

Inductive thematic analysis using NVivo; themes refined by two researchers with member checking (3/15 participants responded)

Primary outcome

Key themes describing patient decision-making processes related to choosing surgery

What they found

• Six themes were identified: (1) needing to get it done; (2) non-surgical treatment experience; (3) mechanical problem belief; (4) trust in medical professionals; (5) varied information sources; (6) organisational barriers.
• 10 of 15 participants (two thirds) expressed pain narratives describing profoundly negative impact on quality of life as a primary driver for surgery.
• 50% of the cohort had had pain for a year or longer at the time of surgery.
• All 15 participants had trialled exercise before surgery; 10/15 had tried steroid injections; 7/15 had tried massage, dry needling, or acupuncture.
• 10 of 15 participants felt they had exhausted all non-surgical options before choosing surgery.
• 10 of 15 participants believed their RCRSP was a mechanical problem requiring surgical repair; this belief was often reinforced by clinicians discussing imaging findings.
• 10 of 15 participants expressed trust in their surgeon as a key factor in the decision; some described surrendering decision-making to the surgeon entirely.
• 7 of 15 participants felt informed about potential surgical risks; 3/15 were dissatisfied with the level of information received; 5/15 had no strong opinion; several participants reported receiving no information about harms or non-surgical alternatives.
• 10 of 15 participants searched for information online as part of their decision-making process.
• Data saturation was reached at 15 interviews with no new themes emerging.

Limitations

• Single-site recruitment from one Melbourne imaging facility limits generalisability to other settings or healthcare systems.
• Recall bias is possible as participants were interviewed up to one year after surgery and may not accurately remember information they received beforehand.
• Responses may be influenced by the outcome of surgery (positive or negative), since only post-surgical patients were interviewed.
• Clinicians' perspectives (surgeons, GPs, physiotherapists) were not explored, leaving one side of the shared decision-making interaction unexamined.

Why it matters

For patients

Patients considering shoulder surgery should ask their surgeon directly about non-surgical alternatives and the actual evidence for surgical benefit, particularly since beliefs that a torn tendon can only be fixed by surgery are common but not always supported by evidence.

For clinicians

Clinicians, especially surgeons, should actively provide balanced information about the uncertain evidence for rotator cuff surgery, the prevalence of asymptomatic tendon tears, and the potential risks of surgery to support genuine shared decision-making.

For readers

This study highlights a gap between clinical guidelines recommending shared decision-making and what patients actually experience, suggesting that improving pre-surgical information provision could reduce rates of potentially unnecessary shoulder surgery.