As someone that’s been coaching folks for 20+ years and been a physical therapist for nearly 15 years, I commonly get questions around “injuries”. I use the scare quotes because it’s apparently difficult to agree upon what an injury actually is. For the sake of our discussion today, I’m going to define injury as “an incident resulting in a prolonged decrease in performance”. You can already see where things begin to get complicated. What if I have muscle strain but can still perform at my typical level? Do I have an injury. What if an athlete has knee pain but imaging and clinical testing are all negative?
When folks are told they have an injury, they assume they also have a “structural problem”, such as a rotator cuff or hip labral tear. Sometimes this is in fact, true. Other times it is not. When there is a structural problem that has been diagnosed through a combination of imaging and clinical testing, the common response is:
“Do I need surgery?”
It’s a fair question. But the (real) answer is … it depends.
Let’s take a look at what some of the research says about surgical versus conservative treatment for three common orthopedic pathologies. We’re going to specifically look at rotator cuff tears, hip – femoral impingement (FAI), and lastly the dreaded low back pain.
Rotator Cuff Tears
Rotator cuff tears are one of the most common shoulder diagnoses, especially for adults over 40. The term rotator cuff describes several muscles surrounding the glenohumeral (shoulder) joint:
supraspinatus (humeral elevation)
infraspinatus (humeral external rotation)
teres minor (humeral external rotation)
subscapularis (humeral internal rotation)
But here’s the surprising truth: many cuff tears don’t require surgery to regain full strength and function.
In fact, clinical studies have shown that structured physical therapy often leads to the same pain and performance outcomes as surgical repair at the one- and two-years marks. How can this be? One possible scenario is that both (post-surgical and conservative) groups will likely undergo physical therapy. If both groups show improvement (and this is what we would expect), it’s possible the actual mechanism for improvement is simply strengthening the surrounding tissues, improving functional range of motion, and improving coordination and movement.
In other words, the tear might have initiated the pain response or injury, but the structural repair of said tissue isn’t required for recovery. The caveat here would be the extent of the tear. Full thickness tears (fully torn muscle bellies and/or tendinous attachments) would most likely require surgical stabilization and repair whilst partial tears (of varying degree) would more likely respond similarly to surgical / conservative management.
When PT/training works best:
Pain is mild to moderate
You can still lift your arm overhead (consistent with partial tearing)
You’re consistent with rehab or training for 3 to 6 months
If that’s you, you might be a great candidate to get straight to work in the gym restoring shoulder function and strength. In short, a torn RTC doesn’t relegate you to a life of shoulder slings and inactivity.
Hip Impingement (FAI)
FAI — the infamous cam or pincer impingement (read my last article on FAI HERE) is often described as a “bony problem”, and while this is true… bone shape alone doesn’t determine pain or performance.
Surgery and physical therapy produce similar long-term results in “most” FAI cases. These outcomes are seen when the strength training plan improves how the hip moves and how the surrounding muscles stabilize the joint. A good coach (or PT) can work with this knowledge and create a plan that incorporates traditional lifts like squats and pulls (deadlifts) to strength your lower body whilst also recognizing and working with structural and functional limitations. Factors like stance width, foot placement, and lift variation are all useful tools that a qualified coach / PT can absolutely utilize.
A conservative plan focuses on:
Restoring hip internal rotation
Strengthening glutes, adductors, and trunk stability
Adjusting squat/hinge depth to avoid impingement
These changes often reduce pain, protect the cartilage, and even improve low back and knee health, since better hip motion spreads load evenly through the kinetic chain.
Low Back Pain
Here’s what the evidence says loud and clear: most low back pain isn’t a surgical issue.
Barring severe nerve compression, immediate and significant loss of strength, or red-flag symptoms (like bladder/bowel changes), the best outcomes come from movement-based rehab and general strength training. This doesn’t mean the pain the athlete is experiencing isn’t substantial… it typically is. The key message here is that surgery doesn’t necessarily eliminate or reduce that pain. In fact, back surgery is a game of thirds. Here are the stats on back surgery:
1/3 of the time the athlete sees improvement
1/3 of the time the athlete gets worse
1/3 of the time the athlete sees no change
You read that correctly, 66% of the time you can expect no progress or to get worse! You can imagine the amount of pain someone would need to be experiencing to roll the dice on those odds. Strength training can be slow to drive change but here is what we’re aiming to do:
Move confidently under load or stress
Build posterior chain endurance
Stop fearing normal pain signals
Over time, that approach outperforms passive treatments and often matches or exceeds surgical outcomes for chronic cases. Personally, I’ve had very positive results when working with folks that have chronic back pain.
Important factors in the conservative management of low back pain are largely dependent upon the athlete. The athlete must be willing to work through the motions that hurt. For example, if someone with LBP comes to see me, I tell them we MUST deadlift. Probably not right away and perhaps never from the floor but we have to (at some point) negotiate situations where you’re in a forward hinge position and loading your spine. Life demands this ability so we must work through it a little bit at a time.
After their willingness to engage in loading the spine, they must then believe their efforts will have a positive impact on their outcome. I know this sounds a bit subjective, but an athlete’s mindset is a critical component of conservative management (for any injury). We see this time and time again in study after study. Folks that approach conservative treatment with a “get it done” attitude do better. They report less pain and more function than their “woe is me” counterparts. I’m not sure we fully understand why but that’s the reality.
When Surgery Makes Sense
While conservative care is usually first line, there are times when surgery is appropriate:
Complete tendon rupture (e.g., biceps, pectoral, or Achilles)
But even then, post-surgical success depends on strength training, the same process you’d use to avoid surgery in the first place.
The Bottom Line
Every injury produces somewhat unique challenges for the athlete, coaches, and physicians. Many situations can be resolved with smart training and an enthusiastic athlete, but some situations will still require surgery.
Other factors like age and demands (sporting, occupational, and life) are also important considerations. It might make more sense to repair the adolescent soccer player’s partially torn ACL than the 47-year-old post office workers. One has a lifetime of sport ahead of him/her and the other has to be back to work the following Monday. Both will need to train regardless.
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