The evidence for alternatives to shoulder replacement

Danielle.Steilen.ProlotherapistDanielle R. Steilen-Matias, MMS, PA-C
In this article, we will explore options and alternatives to Shoulder Joint Replacement and Reverse Total Shoulder Replacement

We frequently see patients who have had surgery for shoulder pain, but are subsequently left with chronic pain after surgery. The surgery, such as arthroscopic surgery for glenoid labrum tearsSlap lesions of the shoulder, and of course for various degrees of rotator cuff tears and damage will sometimes lead to rapid shoulder deterioration and subsequent arthritis. At some time then in the future shoulder replacement will be recommended.

According to the American Academy of Orthopaedic Surgeons website, total shoulder replacements are successfully performed in many patients with shoulder arthritis, however, the procedure is not as beneficial for patients with large rotator cuff tears who have developed  “cuff tear arthropathy,” a degenerative condition causing excessive shoulder joint instability.

Understanding the reverse total shoulder replacement and conventional shoulder replacement surgery.

For these patients, conventional total shoulder replacement may result in pain and limited motion. Therefore a reverse total shoulder replacement may be suggested as an option.

The procedure sounds exactly as it is named. In a traditional shoulder replacement,  a plastic “cup” is fitted into the shoulder socket (glenoid), and a metal “ball” is attached to the top of the upper arm bone (humerus). In a reverse total shoulder replacement, the socket and metal ball are switched.

The benefits of the reverse procedure are studied in a paper published in the medical journal Orthopedics.

The paper suggests that a reverse total shoulder arthroplasty is better suited for older patients with glenohumeral arthritis and a deficient rotator cuff.

However, as a semiconstrained prosthesis, (that is implants which create an artificial stability by limiting the prosthesis range of motion) conventional reverse total shoulder replacement in a young patient could fail over time because of the polyethylene wear and subsequent osteolysis – the joint replacement causes accelerated bone loss. Please see Dr. Hauser’s article on Stem cell therapy for bone repair in osteoarthritis on our site.

Postoperative outcomes are disappointing, and the complication rate is high

The researchers in the current study suggest at first that a metal-on-metal prosthesis may avoid this type of failure. However, they concluded: “Although metal-on-metal total shoulder replacement may appear to be an attractive choice in the treatment of young patients with limited reconstructive options, postoperative outcomes are disappointing, and the complication rate is high.”(1)

Another study from Dr. Pascal Boileau of the Department of Orthopedic and Sports Surgery Pasteur 2 Hospital, University Institute of Locomotion and Sports in France examined outcomes and complications in young patients undergoing revision reverse total shoulder arthroplasty (RTSA) for failed prior total shoulder arthroplasty or ball replacement and compared them with those of older patients undergoing the same procedure. While reverse total shoulder arthroplasty is effective in reducing pain and improving function after failed arthroplasty in young patients, complication rates are high and expectations should be managed appropriately. Subjective outcome scores are worse for older patients.(2)

Shoulder Replacement Works Better For Older Patients – But Complications, painkiller use, and complications are still a concern to surgeons

Here are the bullet points to recent medical studies:

Ironically – shoulder replacement surgery is seen as a main contributor to problems of rotator cuff inflammation. In other words, the surgery to correct the problem is the main cause of the problem.

This is supported by researchers from Texas Orthopedic Hospital, the University of Houston, University of Texas, who released their findings and documented that the number of shoulder replacements being performed has increased exponentially in recent years, with a corresponding increase in the number of second surgeries to fix the first one.

CONCLUSION: Shoulder implant replacement improved function in the present series, but with a high rate of complications and reoperations.(5)

This of course will throw a big concern at patients – shoulder replacement recovery time – complications are often lengthy and sometimes never go away.

In other research some doctors suggest shoulder replacement surgery is the only answer

Yet in other research some doctors suggest shoulder replacement surgery is the only answer:   “While research in cartilage regeneration has not yet been translated clinically, the field of shoulder arthroplasty has advanced to the point that joint replacement is an excellent and viable option.” (6)

Why? Because of poor tendon healing and irreversible changes associated with rotator cuff inflammation. In other words the shoulder is “too far gone.” But the same researchers also say: “Future treatment types involving biologics and tissue engineering (stem cells) hold further promise to improve outcomes for patients suffering from shoulder pathologies.”

Complications leading to reoperation are often multiple and underestimated

Doctors writing in the Muscles, ligaments and tendons journal, suggest that if you had a surgery that failed to fix your shoulder pain –  it is not recommended that you get a second surgery to fix the first one because 36% of those surgeries fail too.(7)

The most common causes of revision surgery after reverse total shoulder arthroplasty (RTSA) are:

Doctors at the University of Washington sum up shoulder failure surgery as: “…surgery has failed when it does not achieve the expectations of the patient and the surgeon. Failure can result from stiffness, weakness, instability, pain or failure to heal as well as from complications such as infection or nerve injury

Every surgery has a risk of failure whether it is an operation for dislocation, rotator cuff tear, arthritis or fracture. Because fracture fixation, Bankart repairs, rotator cuff repairs, shoulder joint replacements and reverse total shoulders are performed commonly, a substantial number of patients have experienced these failures.”

Obesity is a problem

Doctors from the Mayo Clinic writing in the Journal of bone and joint surgery discuss the problems of obesity causes in patients after shoulder replacement surgery.

Here is what they said:


Alternatives to shoulder replacement surgery

In regenerative injection techniques like Prolotherapy, Platelet Rich Plasma Therapy or Stem Cell Prolotherapy, the goal is always to preserve and regenerate these cushions and connective tissues rather than remove them. (See cartilage repair). It makes our job here at Caring Medical a little more difficult when treating a patient who has had an extensive procedure, but it is still possible to achieve healing after surgery.

Caring Medical Research:

The article in its entirety can be downloaded as a PDF

A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois

Hauser RA, Hauser MA. A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;1(4):205-216.


  • We studied a sample of 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy.
  • An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment.
  • The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation), to the p<.0000001 level with Prolotherapy, including the 39% of patients who were told by their medical doctors that there were no other treatment options for their pain and the twenty-one percent who were told that surgery was their only option.
  • Over 82% of all patients experienced improvements in sleep, exercise ability, anxiety, depression, and overall disability with Prolotherapy. Ninety-seven percent of patients received pain relief with Prolotherapy.

Conclusion: In this study, patients with chronic shoulder pain reported significant improvements in many clinically relevant parameters and overall quality of life after receiving Hackett-Hemwall dextrose Prolotherapy.

If you have questions and would like to discuss your shoulder pain issues with our staff you can get help and information from our Caring Medical staff.

Prolotherapy Specialists

1. Riley C, Idoine J, Shishani Y, Gobezie R, Edwards B. Early Outcomes Following Metal-on-Metal Reverse Total Shoulder Arthroplasty in Patients Younger Than 50 Years. Orthopedics. 2016 Jun 23:1-5. [Google Scholar]
2. Boileau P. Complications and revision of reverse total shoulder arthroplasty. Orthop Traumatol Surg Res. 2016 Feb 12. pii: S1877-0568(15)00349-7.  [Google Scholar]
3. Malhas A, Rashid A, Copas D, Bale S, Trail I. Glenoid bone loss in primary and revision shoulder arthroplasty. Shoulder Elbow. 2016 Oct;8(4):229-40. [Google Scholar]
4. Young AA, Walch G, Pape G, Gohlke F, Favard L. Secondary rotator cuff dysfunction following total shoulder arthroplasty for primary glenohumeral osteoarthritis: results of a multicenter study with more than five years of follow-up. J Bone Joint Surg Am. 2012 Apr 18;94(8):685-93.[Google Scholar]
5. Morris BJ, O’Connor DP, Torres D. Risk factors for periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2014 Aug 26. pii: S1058-2746(14)00281-X. [Google Scholar]
6. Killian ML, Cavinatto L, Galatz LM, Thomopoulos S. Recent advances in shoulder research. Arthritis Res Ther. 2012 Jun 15;14(3):214. [Google Scholar]
7. De Giorgi S, Garofalo R, Tafuri S, Cesari E, Rose GD, Castagna A. Can arthroscopic revision surgery for shoulder instability be a fair option? Muscles Ligaments Tendons J. 2014 Jul 14;4(2):226-31. eCollection 2014. [Google Scholar]
8. Wagner ER, Houdek MT, Schleck C, Harmsen WS, Sanchez-Sotelo J, Cofield R, Sperling JW, Elhassan BT. Increasing Body Mass Index Is Associated with Worse Outcomes After Shoulder Arthroplasty. J Bone Joint Surg Am. 2017 Jun 7;99(11):929-937. [Google Scholar]
9. Murphy AB, Menendez ME, Watson SL, Ponce BA. Metabolic syndrome and shoulder arthroplasty: epidemiology and peri-operative outcomes. Int Orthop. 2016 Sep;40(9):1927-33.  [Google Scholar]


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