Not Every Shoulder Problem Needs Surgery — A Surgeon's Perspective

EXPERT PERSPECTIVE

By Dr. Ghazwan Maki

Consultant Orthopedic Surgeon · Board certified in Denmark, Sweden and Norway

A question I am asked almost every week

"Do I need surgery?"

It is usually the first question, and often the one the patient has been worrying about since the pain started.

My answer is frequently: not yet, and possibly not at all.

That may seem an unusual position for a surgeon. But it reflects how I was trained, and what I have observed across more than thirty years of practice in Europe and the UAE.

I trained and worked within three Nordic health systems — Denmark, Sweden and Norway — and completed advanced training in sports injury management at Copenhagen University Hospital in Hvidovre.

Those systems share a way of thinking that shaped my practice: you begin with the least intervention that can reasonably achieve the goal, and you escalate only when there is a clear reason to.

Surgery is a tool. A valuable one, and one I use regularly. But it is not the automatic answer to shoulder pain.

Why the shoulder is particularly misunderstood

The shoulder is the most mobile joint in the body. That mobility is what allows us to reach, throw, lift and work above our heads — and it is also why the shoulder depends heavily on the muscles and tendons around it for stability.

This has an important consequence.

Many shoulder problems are problems of function rather than structure. How the shoulder blade moves, how the surrounding muscles coordinate, how much load the tendons can tolerate, and how the neck and upper back contribute — all of these affect shoulder pain, and none of them are fixed by an operation.

When a shoulder is painful, the structure and the function are often both involved. The clinical question is which one is actually driving the problem.

That is a question an operation cannot answer. Only assessment can.

What scans do and do not tell us

Patients often arrive with an MRI report and considerable anxiety about what it says.

I want to be clear about something that is well established but not widely known: imaging findings in the shoulder are common in people who have no pain at all.

Rotator cuff changes, degenerative findings and other structural changes become more frequent with age. They are often present in shoulders that function perfectly well and cause no symptoms whatsoever.

This means a finding on a scan is not automatically the cause of your pain.

If I treated every scan report rather than every patient, I would operate far more often — and help people considerably less.

A scan is one piece of information. It becomes meaningful when it is read alongside your symptoms, your examination, how your shoulder actually moves, what you need it to do, and how it has responded to treatment so far.

When I recommend against surgery

There are situations where I will advise a patient not to proceed to surgery, at least not yet:

When the problem is primarily one of function. If the shoulder blade is not moving well, if certain muscles are not contributing effectively, or if the shoulder simply lacks the capacity for what is being asked of it, structured rehabilitation often addresses this far better than an operation.

When rehabilitation has not genuinely been tried. "I did some exercises" and "I completed a properly structured, progressive rehabilitation programme" are very different things. I want to know which one has actually happened before considering surgery.

When the expectation does not match what surgery can deliver. Surgery can address specific structural problems. It cannot restore a shoulder to the condition it was in twenty years ago, and it cannot compensate for a shoulder that lacks strength and control.

When the timing is wrong. A shoulder that is stiff and irritable will often do better with a period of appropriate treatment before any surgical decision is made.

When surgery is the right recommendation

I do not want to overstate the case for conservative treatment either. There are clear situations where surgery is the appropriate recommendation, and delaying it does not serve the patient:

• Significant traumatic injuries, particularly in younger and active patients
• Certain full-thickness tears where the clinical picture supports repair
• Recurrent instability and dislocation that continues despite rehabilitation
• Advanced joint degeneration causing significant pain and functional loss, where joint replacement is appropriate
• Problems that have not responded to a genuine, well-conducted course of non-surgical treatment

I perform shoulder surgery regularly, including shoulder replacement. When it is indicated, it can be genuinely life-changing.

The point is not that surgery is bad. The point is that it should be a decision, not a default.

What the Nordic approach actually means in practice

"Nordic-inspired healthcare" can sound like branding. In practice, it means something quite specific in how I assess a patient.

Start with the person, not the image. What can you not do that you want to do? That question shapes the whole plan.

Establish what has genuinely been tried. Not what was suggested — what was actually done, and for how long.

Use the least intervention that can reasonably achieve the goal. If rehabilitation can achieve it, that is the right starting point.

Escalate deliberately, not reflexively. If conservative treatment is not working, that is important information — and it strengthens rather than weakens the case for intervention.

Be honest about uncertainty. Not every shoulder problem has a clean answer. Saying "I am not certain, here is how we find out" is better medicine than false confidence.

What I would suggest if your shoulder hurts

Get it assessed properly rather than guessing. Shoulder pain has many possible causes and they are managed differently.

Do not panic about a scan report. Bring it, absolutely — but let it be interpreted alongside everything else.

Give rehabilitation a genuine attempt where it is indicated, with proper structure and progression rather than a printed sheet of exercises.

Ask what happens if you do nothing. For some shoulder problems the honest answer is "it may well settle". For others it is "this is likely to get harder to treat". Both are useful to know.

Ask why an operation is being recommended, and what it will and will not achieve. Any surgeon should be able to answer that clearly.

The short version

• Many shoulder problems are problems of function, not structure — and those respond better to rehabilitation than to surgery.
• Scan findings are common in shoulders that do not hurt. A finding is not automatically the cause.
• Surgery is genuinely valuable when it is indicated — and I recommend it when it is.
• The right question is not "do I need surgery?" but "what is actually causing this, and what is the least intervention that will address it?"

Dr. Ghazwan Maki is a Consultant Orthopedic Surgeon at IDUNN by Orthoflex in Dubai Healthcare City. He is board certified in orthopedic surgery in Denmark, Sweden and Norway, registered with the UK General Medical Council, and completed advanced training in sports injury management at Copenhagen University Hospital, Hvidovre. His areas of expertise include shoulder surgery, elbow surgery, hand and wrist surgery, sports injuries and trauma.

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