Most patients spend more time researching a car purchase than they do the surgeon who will repair their shoulder. That's understandable - you were referred to someone, they seem competent, and the anatomy is unfamiliar territory. But rotator cuff repair is one of the most commonly performed orthopedic procedures in the country, and outcomes vary considerably depending on who does it and how.
You don't need a medical degree to ask good questions. Here are seven that will tell you a great deal.
1. Do I actually need surgery?
Start here. Not every rotator cuff tear needs to be repaired. Many degenerative, partial-thickness tears in older patients do well with physical therapy, activity modification, and time. An acute traumatic tear in an active 52-year-old is a different conversation entirely.
A surgeon who can clearly explain why your particular tear warrants repair - tear size, tendon quality, muscle atrophy, your age, your demands, how long it's been torn - is a surgeon who is thinking about you rather than about the schedule. If the answer to "what happens if I wait?" is vague, keep asking.
2. What's your training, and how many of these do you do?
Rotator cuff repair is performed by general orthopedic surgeons, sports medicine surgeons, and shoulder and elbow specialists. All are legitimate. But the literature does show a relationship between focused training and outcomes.
A nationwide analysis of nearly 95,000 arthroscopic rotator cuff repairs found that surgeons with sports medicine or shoulder and elbow fellowship training had lower two-year reoperation rates and fewer 90-day emergency department visits than surgeons without that training.1 A separate systematic review of shoulder surgeon volume identified fewer than 12 rotator cuff repairs per year as a low-volume threshold, associated with longer operative times and higher reoperation rates.2
Fair questions: Are you fellowship trained in sports medicine or shoulder and elbow surgery? Roughly how many cuff repairs do you perform in a year? What percentage of your practice is shoulder?
3. How do you perform the repair - arthroscopic or open?
Arthroscopic repair - done through several small incisions with a camera - has become the dominant approach in the United States, and for good reason. It avoids splitting the deltoid, allows a complete look inside the joint (biceps pathology, labral tears, and articular-sided findings that an open approach can miss), and generally means less early postoperative pain.
To be clear about what the evidence does and doesn't show: prospective comparative studies have found broadly similar clinical outcomes and retear rates between arthroscopic and open repair when both are performed well. Open and mini-open repair remain reasonable techniques, and there are specific situations - a severely retracted, immobile massive tear, certain revisions, tendon transfers - where an open approach is genuinely the right call.
The question isn't really "open or scope." It's why. A surgeon who chooses an approach deliberately, for reasons specific to your tear, is doing it right. A surgeon who does every case the same way regardless of what the MRI shows is worth a second opinion.
4. Do you use biologic augmentation, and why or why not?
This is where the field is moving, and most patients have never heard of it.
The uncomfortable truth about rotator cuff repair is that a meaningful percentage of repairs don't fully heal. A meta-analysis of 31 studies put the 12-to-24-month retear rate at about 21% overall, and reported failure rates in the literature range from under 10% for small tears to as high as 94% in large and massive tears. The repair looks perfect on the day of surgery; the biology is what determines whether the tendon actually knits back to the bone.
Disclosure, up front: the product I describe below is made by Atreon Orthopedics. I receive royalties from Atreon, consult for the company, and hold a minority ownership stake in it. You should weigh what follows with that in mind, and you should ask any surgeon - including me - about their industry relationships.
Augmentation strategies try to address that biology directly. In my practice I use an interpositional nanofiber scaffold (Rotium, Atreon Orthopedics) - a fully synthetic, bioresorbable scaffold placed at the bone-tendon interface, where healing actually has to happen, rather than laid on top of the tendon. It resorbs over three to four months. In a sheep model it produced stronger repairs with more natural Sharpey-like fiber formation.6 My colleagues and I published a randomized comparison in 2023: among 30 patients over 55 with full-thickness tears, cumulative repair failure was 7% with the scaffold versus 50% without (p=0.017).8 I also co-authored the paper describing the surgical technique itself.7
Two honest qualifications to my own data. First, that study was small, and Atreon paid for the scaffolds and the postoperative MRIs. Second - and this matters - patients in both groups reported essentially the same pain and function scores at two years. The difference we measured was in how the tendon healed on imaging, not in how patients said they felt. Whether better healing translates into better long-term outcomes is exactly what larger trials still need to answer.
I'll be straightforward about the state of the evidence: the clinical data on interpositional scaffolds is early. The studies are small, follow-up is short, and larger trials are underway. Bone marrow stimulation and other augmentation techniques have their own supporting data. What matters is that your surgeon has thought about healing biology at all - and can tell you what they use, what the evidence behind it is, and what it costs you.
5. How long does the surgery usually take?
This one surprises people, but it's a legitimate proxy for experience.
Operative time is an independent risk factor for complications. One large database study found that every additional 15 minutes of operative duration was associated with increased 30-day complication risk after arthroscopic cuff repair,3 and a review of over 3,000 arthroscopic repairs identified operative time as an independent risk factor for postoperative infection.4 Longer time under anesthesia also means more fluid extravasation and more swelling.
Published operative times for arthroscopic cuff repair commonly fall in the range of roughly 70 to 115 minutes,5 and experienced surgeons working efficiently are often well below that. In our randomized study, mean procedure time was 53 to 59 minutes.8 A straightforward repair taking several hours is worth asking about.
The important caveat: faster is not automatically better, and slower is not automatically worse. A massive three-tendon tear, a revision, or a case requiring a tendon transfer should take longer. What you're listening for is whether the surgeon can explain their time - not whether the number is small.
6. What's your plan if the tear can't be repaired?
Sometimes what's on the MRI and what's in the shoulder aren't the same thing. Tendon can be more retracted, more atrophied, or of poorer quality than imaging suggested.
Ask what happens then. Superior capsular reconstruction, subacromial balloon spacer, lower trapezius or latissimus transfer, partial repair, or a staged conversation about reverse shoulder replacement are all part of the modern toolkit. A surgeon who has a clear Plan B - and who will have discussed it with you before you're asleep - is a surgeon who has been in that room before.
This matters for a second reason. Research on reverse shoulder replacement suggests that patients who come to it after a failed prior cuff repair tend to have somewhat worse functional scores than those without prior surgery, though in most studies these differences are small and fall below the threshold patients actually notice.10,11 Getting the first repair right still matters.
7. What does recovery actually look like?
Ask about the sling and for how long. Ask when passive motion starts, when active motion starts, and when strengthening starts. Ask how many months until you can lift overhead, sleep normally, or return to your sport or your job. Ask who is directing your therapy and whether they'll be communicating with your surgeon.
Rotator cuff recovery is measured in months, not weeks, and the rehab protocol is as much a part of the outcome as the repair itself. If nobody has walked you through it before surgery, that's information too.
The bottom line
A good surgeon will welcome these questions. It's a relief to operate on a patient who understands what's happening and why. If asking makes the room uncomfortable, that discomfort is your answer.
Brian Badman, MD, is a fellowship-trained orthopedic shoulder surgeon with Central Indiana Orthopedics, practicing as IndyShoulder in Indianapolis, Indiana. To schedule a consultation or a second opinion, call 317-785-1890 or 317-773-4301, or visit indyshoulder.com.
Disclosure: Dr. Badman receives royalties from Atreon Orthopedics, serves as a paid consultant to the company, and holds a minority equity interest in it. Atreon manufactures the Rotium nanofiber scaffold discussed in this article, and Dr. Badman is a co-author of references 7, 8, and 9. He also receives personal fees from Enovis, Anika, Embody, CTM Biomedical, and Paragen Biomedical, outside the subject of this article.
This article is educational and is not medical advice. It does not create a physician-patient relationship. Consult a qualified physician about your own condition.