Shoulder replacement options

Ross A. Hauser, MD., Danielle R. Steilen-Matias, PA-C.

Many times a patient will come into our office with advancing osteoarthritis of the shoulder. When they describe their shoulder pain they say things like:

When we manipulate their shoulder to test for range of motion and we all hear the audible pops, clicking, and grinding, sometimes the patient tells us “My shoulder is talking.” Intuitively these people know that their shoulder is talking to them. Do they understand what their shoulder is saying? Do you?

In this article, we will explore options and alternatives to Shoulder Joint Replacement. We will also discuss the various non-surgical regenerative medicine injection techniques. Many people do very well with shoulder replacement surgery. These are not the people that we see in our practice. We see the people who are looking for answers who are not good surgical candidates, have been told that there is a good chance the surgery will not work for them or have already had the surgery with less than happy results. We also see the patient who is exploring their options, maybe the waiting list to get the surgery is long and the only treatments that can be offered at this time are cortisone and increased medications.

What will we be discussing in this article?

You wake up in the morning, your shoulder is killing you

You wake up in the morning, your shoulder is killing you. No matter which way you turn, your shoulder hurts. You hardly slept because of your shoulder. You get up, you stand at the foot of your bed and you begin your morning trying to figure out how far you can lift your arms up. Then you start “loosening up,” and hoping you can get by today without a lot of help from medications. Hopefully going to the toilet, washing, and getting dressed will not be a big chore and you will not have to bother your spouse or other loved ones to help you do these simple tasks.

“I am leaning towards the shoulder replacement because I do not know what else to do.”

We see shoulder pain patients, and no matter how unique their story is, most have the same common problems and the same common medical history. They tell stories like this:

The last treatment available – shoulder replacement

I have had shoulder pain for a long time, my line of work is physically demanding. I have been to my doctors and specialists many times. I have been given varying doses of different pain medications, muscle relaxants, and anti-inflammatories. I have had cortisone twice. I have been sent to physical therapy, tried chiropractic and various electro-stimulation products. I am at the point now that my visits to the orthopedics are long discussions about surgical options.

I am here to explore other options. I do have a good range of motion in my shoulder though I cannot lift my arm over my head because of weakness. I can pick up objects and carry them, I just can’t leave them on a table or platform above my waist.

Doctors aren’t helping you despite the medications and cortisone

During the initial medical history review we have with our patients, they will tell us about the long list of treatment options that were recommended for their degenerative shoulder disease. These treatments do help some people. For some, perhaps like yourself, symptom relief was temporary. For others, the pain relief lasted hours or days if at all.

If you are reading this article it is more than likely you are in that group of patients who are still seeking answers despite years of these treatments and even a past history of “shoulder preserving arthroscopic surgery,” which at this point, does not appear to be successful in preserving your shoulder.

At your last follow-up visit with your orthopedic surgeon, a long discussion may have taken place over whether to continue with your conservative care options or pursue the shoulder replacement. Your concern with these “conservative care” treatments is that you will continue to have more pain, more grinding, more popping, and more clicking. You recognize that you are only being symptom managed and you need to fix it once and for all.

The road to shoulder replacement Conservative Care followed by arthroscopic shoulder surgery

Conservative Care

Arthroscopic shoulder surgery

Here is a case history of a patient who came to Caring Medical.

The patient had extensive shoulder surgery. Seemingly, the surgeon tried to “fix” everything he thought was damaged enough to cause pain. The surgery went as planned, with no complications, and the surgeon accomplished everything he set out to do. Two years following the surgery the patient came to our office, still in pain. How could this be? Let’s look at exactly what was done.

The patient had an arthroscopic procedure for:

The labrum is a lip of cartilage that helps keep the end of the humerus in the shallow socket (glenoid). Chondromalacia is the degeneration of the cartilage inside the joint. Bursitis refers to the bursa, one of the fluid-filled sacks that provide cushioning in joints.

During the procedure, the surgeon debrided the labral tear and the rotator cuff tear. Then, where the chondromalacia was most severe, he performed a chondroplasty.  This consists of scraping the damaged cartilage which covers the surface of the bone in hopes of having healthy cartilage grow back. He scraped both the humeral head and the glenoid. He then performed a bursectomy, removing the inflamed bursa. This is fairly typical of what we see in an arthroscopy report of the shoulder.

The patient expressed a desire to return to tennis as a key to surgery outcome, and surgery did not help him with this, and he was left with chronic pain.

Your rapidly degenerating shoulder is trying to function and survive. It swells up so it can function as best it can. Swelling holds the shoulder together. Your shoulder is trying to hold itself together.

When your shoulder swells up. It is talking to you. It is saying “I am not stable, I have instability. I am going to swell up to hold myself together.”  If you are reading this article, this may be happening to you all the time. Here is the science of what your shoulder is doing. When you understand what your shoulder is doing, you can understand what may be the best treatment for you.

This is research published in the Journal of Shoulder and Elbow Surgery. (1)

Here are the highlights:

A heightened sense of shoulder pain is caused by runaway inflammation. Your shoulder hurts worse than it should because your shoulder is trying to get your attention.

What all this means is that your shoulder hurts worse than it should because your shoulder is trying to get your attention. What is your shoulder trying to get you to do? It wants you to stop doing what you are doing to make it hurt.

Your shoulder is under stress physical and emotional. Yes, your shoulder gets stressed out.

For someone in chronic pain, if you told them that shoulder is stressed out, burnt out, ready to give up. They will probably not argue with you. Because that is the way they feel some days. Stressed, tired, ready to talk about shoulder replacement. Let’s recap what we discussed to this point:

  1. Your shoulder is unstable. The ball and shoulder socket are banging against each other because your rotator cuff tendons, muscles, labrum, and shoulder ligaments are damaged and not holding your shoulder together.
  2. Your shoulder is asking your immune/repair system for more inflammation to bring swelling to act as a “cast,” to hold the ball and shoulder socket in proper alignment.
  3. But the shoulder knows it cannot stay in a constant state of swelling. Chronic inflammation is toxic. It burns out and erodes the joint. Your shoulder is hurting more because it is trying to send you more pain signals that this situation is on the verge of joint “death,” – your shoulder will not survive prolonged chronic inflammation and will need to be replaced.

The shoulder becomes highly inflamed

Back to the research, we cited above (1):

Now let’s talk shoulder replacement – Some doctors suggest shoulder replacement surgery is the only answer

Anatomical shoulder replacement ball and socket

You may be wrestling with the idea of shoulder replacement because you are a worker who needs to work. Shoulder replacement brings with it possible hope, but it also brings with it, the risk of surgery, possibility of complications,  surgical recovery, and rehab time. For some, the problem with the surgery is not the surgery itself, it is the rehabilitation and the downtime away from exercise, physical activity, and sports involvement. For others, it is time away from work. For these workers, some consider shoulder replacement as a means of “forced retirement,” or “disability.” At what price do you have the surgery? At the cost of your job? At the cost of maintaining a fitness lifestyle? Is replacement surgery the only way?

Here is a sample email from someone asking about shoulder replacement options:

My MRI report says I have advanced narrowing of the glenohumeral joint space. Bone spurs. Subchondral cystic change (Bone cysts). Mild Acromioclavicular Joint degeneration. I already had a shoulder replacement in my left shoulder and I do not want to go through another surgery. I have a great deal of pain from my shoulder that radiates into my arm. I am getting physical therapy and while this is helping my range of motion, it is not helping with the pain. Is surgery the only way for me?

Often we will see a patient who says, “I went to two reputable orthopedists, both said surgery was the only way.” Below we are going to show you research that surgery is not the only way for many people. Surgery is usually the only way when the shoulder bones are fractured or there is a gross anatomical failure, bone spurs, complete or near loss of range of motion, no cartilage at all.

The research: When the shoulder is “too far gone.”

Some doctors suggest shoulder replacement surgery is the only answer:  This is from the journal Arthritis Research and Therapy(3)“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.”

Why? Because of poor tendon healing and irreversible changes associated with rotator cuff inflammation.

Return to work after shoulder replacement

A September 2022 paper in the World journal of orthopedics (4) assessed the outcomes of patients being able to return to work following a shoulder replacement. The researchers here made similar observations to patients we see. The patients looking into getting a shoulder replacement are younger and are prioritizing the need for the surgery as a means to get themselves back to work. Outcomes for return to work were measured in patients who had total shoulder replacement, reverse total shoulder replacement, and shoulder hemiarthroplasty.

Results: The majority of patients undergoing total shoulder replacement, reverse total shoulder replacement, or shoulder hemiarthroplasty were able to return to work between one to four months, depending on work (the extent of the physical demand of the job).

While sedentary or light demand jobs generally have higher rates of return to work, moderate or heavy demand jobs tend to have poorer rates of return. The rates of return to work  following total shoulder replacement (71%-93%) were consistently higher than those reported for shoulder hemiarthroplasty (69%-82%) and reverse total shoulder replacement (56%-65%).

Treatments in patients over 80 years old: “Surgical treatment of Glenohumeral osteoarthritis is reserved for patients who do not respond to conservative management or who suffer from debilitating symptoms that severely impair their quality of life”

A February 2022 study in the journal Druga and Aging (5) examined treatment options for patients over 80 years old. The researchers here cite the “prevalence (of shoulder osteoarthritis) is estimated to be between 85 and 94% in men and women over the age of 80 years.”

Looking at the shoulder joint, the ball and socket that forms the Glenohumeral joint the researchers wrote: “Glenohumeral osteoarthritis is a common cause of shoulder pain and is characterized by articular cartilage thinning, glenoid bone loss and deformity, osteophytosis (bone spurs) , and other associated changes.” These are the treatments options typically presented to patients:

“Non-pharmacological treatment options may serve as adjuvants to other therapies and should be incorporated for a more holistic approach to management. Pharmacological treatments include oral agents such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids and antidepressants. . . . (United Kingdom guidelines, this paper comes from Canada) recommend NSAIDS as the first-line drugs for osteoarthritis; topical forms of some of these agents can also be used.

Intra-articular injections such as platelet-rich plasma, cortisone, and hyaluronic acid are usually used to control symptoms in moderate to advanced arthritis or in non-surgical candidates. Other non-surgical treatment options include suprascapular nerve block and radiofrequency ablation, and these options have been studied on different levels of evidence. Furthermore, all these treatments have their own indications, contraindications, and adverse effects profiles. Surgical treatment of Glenohumeral osteoarthritis is reserved for patients who do not respond to conservative management or who suffer from debilitating symptoms that severely impair their quality of life.”

No clear consensus on returning to activity or sport after reverse shoulder replacement

A July 2019 study published in the journal Shoulder & Elbow (6) states clearly that “Reverse total shoulder arthroplasty is now the most frequently performed form of shoulder replacement. There is currently no consensus on recommended levels of activity and sport following Reverse total shoulder arthroplasty.”

However, these researchers do suggest that “Return to sport is tolerated following Reverse total shoulder arthroplasty; however, studies are short to medium term only and although the reported complication rate is low, the studies did not include a radiographic evaluation. Longer-term studies with subgroup analysis evaluating common recreational activities after reverse total shoulder arthroplasty are required, particularly in the younger population, in order to establish clear post-operative guidelines.”

70% return to sports – overhead sports remain problematic

A June 2021 study in the Orthopaedic journal of sports medicine (7) led by the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota offers this opinion: “Patients who had undergone primary uni (one-sided)- or bilateral (both-sided) reverse shoulder replacement reported a 70.1% rate of return to sports with the maintenance of the same level of intensity, duration, and frequency of preoperative sport participation. Rates of return to high-demand sports were lower than low- and medium-demand sports. Patients also had difficulty returning to overhead sports.”

In this report, none of the patients returned to these “high-demand sports”:

In this section, we will discuss the realistic treatment options to shoulder replacement surgery. We will focus on Prolotherapy and PRP injections.

Caring Medical Research:

In the same manner, we present research on shoulder replacement surgery, we would like to present information on regenerative medicine injections. Our focus is on simple dextrose Prolotherapy as the first course of action. In more problematic cases, we may rely on Platelet-rich Plasma injections or bone marrow concentrate commonly referred to as stem cell therapy.

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. The article in its entirety can be downloaded as a PDF

What are we seeing in this image?

A shoulder x-ray showed a large bone spur. This is an x-ray of a patient who was only in their ’30s. The patient suffered from significant shoulder pain and limited range of motion. In this image, the shoulder cartilage is fairly well preserved but the large osteophyte or bone spur is present. This is a situation where Prolotherapy can be helpful with the elimination of the patient’s pain, the bone spur causing restricted movement may require surgery.

A shoulder x-ray showing a large bone spur. This is an x-ray of a patient who was only in the 30's. The patient suffered with significant shoulder pain and limited range of motion. In this image the shoulder cartilage is fairly well preserved but the large osteophyte or bone spur is present. This is a situation where Prolotherapy can be helpful with the elimination of the patient's pain, the bone spur causing restricted movement may require surgery.

94 Patients treated with Prolotherapy with the hopes of avoiding surgery

Here is a summary of our research:

  • 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), 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.

In our research, published in Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders, (8) Ross Hauser, MD and Danielle R. Steilen-Matias, MMS, PA-C  contributed to findings suggesting Dextrose Prolotherapy has been able to reduce pain and disability of traumatic and nontraumatic rotator cuff conditions.

  • The research revealed that treatment of moderate to severe rotator cuff tendinopathy due to injury with injections of hypertonic dextrose on painful entheses (the ligament and tendon attachments to the bone) resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline.

Other research

  • A study published in the journal Archives of Physical Medicine and Rehabilitation found that treatment of moderate to severe rotator cuff tendinopathy with injections of hypertonic dextrose (Prolotherapy) on painful entheses (the tendon attachments to the bone) resulted in superior long-term pain improvement and patient satisfaction. (9)
  • Another study also published in the journal Archives of Physical Medicine and Rehabilitation, demonstrated dextrose Prolotherapy improved in pain, disability, isometric strength, and shoulder active range of motion in patients with refractory chronic non-traumatic rotator cuff disease. (10)
  • In the journal, Alternative Therapies in Health and Medicine, (11) doctors presented a case study at the Medical Center at Southwest College of Naturopathic Medicine in Tempe. Here a  middle-aged male with a long-term history of untreated shoulder pain received injections into the glenohumeral joint space, the acromioclavicular joint, the subacromial space, and the insertion of the supraspinatus.
    • Results: Following 3 sessions of Prolotherapy, the patient reported a 90% reduction in pain and full restoration of normal activity. The findings suggest that dextrose Prolotherapy may be an effective treatment for chronic shoulder pain and may be an alternative to surgery or other more costly and invasive interventions.
  • A March 2019 study in the Journal of Ultrasound in Medicine (12) found that ultrasound-guided Prolotherapy with a 15% dextrose solution is an effective and safe therapeutic option for moderate-to-severe acromial enthesopathy and acromioclavicular joint arthropathy.

A November 2020 study in the Journal of Back and Musculoskeletal Rehabilitation (13) accessed the effectiveness of Prolotherapy in shoulder disorders. To do this the researchers evaluated existing studies to see if they could form a consensus on how effective, or not effective Prolotherapy can be.

Here are the summary learning points:

  • “Wide variation exists regarding usage patterns of prolotherapy.”
    • Explanatory note: These variations included the number of injections given within a treatment (some of the studies these researchers assessed were a single injection treatment. Similar to the way cortisone is given. In our 28 years of experience, we never offer a single shot of Prolotherapy as “the treatment.” It is not effective. Read more you will see these researchers came to this conclusion as well.)
  • “Interestingly, amongst the Prolotherapy studies evaluated in this review, the two in which significant pain relief was sustained long-term both utilized multiple injections and the three with either non-significant or non-sustained pain relief used a single injection.”
    • Explanatory note: Multiple injections at treatment is superior to a single injection at treatment. This is what we have been saying for three decades.

The researchers suggested: “Prolotherapy (appears) to be a safe treatment option with perhaps greater efficacy for shoulder pathology when provided through a series of injections using higher concentrations of dextrose.”

Poor candidate for Prolotherapy

This x-ray shows an image of a patient that we would consider a poor candidate for Prolotherapy treatment. There is the loss of cartilage in the glenohumeral joint and the patient has developed multiple bone spurs. These bone spurs significantly restricted his range of motion.

This x-ray shows an image tof a patient that we would consider a poor candidate for Prolotherapy treatment. There is loss of cartilage in the glenohumeral joint and the patients has developed multiple bone spurs. These bones spurs significantly restricted his range of motion.

A patient who would be considered a fair candidate for Prolotherapy

In this x-ray, we see a patient with shoulder impingement and a moderately limited range of motion with abduction and external rotation. The x-ray image reveals a significant decrease in cartilage which limited the patient’s shoulder and arm range of motion. This patient was considered a fair candidate for treatment and realistic expectations of treatment outcomes should be expected.

In this x-ray we see a patient with shoulder impingement and moderately limited range of motion with abduction and external rotation. The x-ray image reveals a significant decrease in cartilage which limited the patients shoulder and arm range of motion. This patient was considered a fair candidate for treatment and realistic expectation of treatment outcomes should be expected.

A patient who would be considered a good candidate for Prolotherapy

In this x-ray image, we see a patient who would be considered a good candidate for Prolotherapy. The overall architecture and integrity of the shoulder have been maintained in the joint. There is some loss of joint space. Because the overall shoulder structure has been maintained and the patient exhibited a full range of motion in his shoulder, this patient was considered a good candidate for Prolotherapy.

In this x-ray image we see a patient who would be considered a good candidate for Prolotherapy. The overall architecture and integrity of the shoulder has been maintained in the joint. There is some loss of joint space. Because the overall shoulder structure has been maintained and the patient exhibited a full range of motion in his shoulder, this patient was considered a good candidate for Prolotherapy.


Research outcomes on PRP injections and quality of life in shoulder pain patients.

At our center, we typically do not offer PRP injections as a stand-alone treatment. We combine PRP with Prolotherapy treatments to offer what we believe to be an optimal repair of the soft tissue of the shoulder and to provide shoulder stability to help this soft tissue damage from reoccurring once repaired. This treatment approach has helped many people we have seen.

A research study on PRP injections alone was published in November 2021 in the journal Clinics in Shoulder and Elbow (14) which asked the question: “Can platelet-rich plasma injections provide better pain relief and functional outcomes in persons with common shoulder diseases?”

Here is the answer suggested by the study research team:

  • PRP injections were associated with better pain relief and functional outcomes than control interventions.
  • PRP injections were also associated with greater Quality of life.
  • Compared with placebo and corticosteroid injections, PRP injections provided better pain relief and functional improvement.

In this video, a general demonstration of Prolotherapy and PRP treatment is given for a patient with repeated shoulder dislocations

Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:

  • PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
  • In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
  • The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
  • This patient, in particular, came to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
  • The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
  • With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
  • PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrated cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
  • PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments, in this case, it was in his anterior shoulder attachments to address the chronic dislocations.

Will these injection treatments help you avoid a shoulder replacement?

Caring Medical has over 27 years of experience in helping patients avoid surgery. Once we do an examination on the patient we give a clear picture of what he or she can expect from our treatment. Sometimes we are very optimistic that we can offer a lot of help. Sometimes someone comes into our office with shoulder osteoarthritis and rotator cuff damage significant enough that the reality of the situation says surgery and we recommend the surgery. How would you know who you are? An examination usually does a great job determining that. Even if you have been told surgery is the only answer, which we addressed in the research above, we have done countless second opinions where we were able to provide the patient non-surgical options for their shoulder damage.

Treatment after you had shoulder replacement

In this section, we will address how we may be able to help a patient after they had the shoulder replacement surgery. 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.

In this video, Danielle R. Steilen-Matias, MMS, PA-C discusses treating nerve pain following shoulder surgery.

It is not uncommon for us to see patients after shoulder surgery who continue to have shoulder instability issues. Other times we will see patients after shoulder surgery who have continued pain. It may be the same pain that they had before surgery or it may be a different type of pain. What we find in many of these people is that even though healing is occurring and the shoulder looks well, the pain they are having is related to the nerves that may have been impacted during the surgery. We treat these patients with Nerve release injection therapy or more commonly hydrodissection.

Nerve Release & Regeneration Injection Therapy

NRRIT is a nerve hydrodissection technique that is highly successful in releasing peripheral nerve entrapments. It is a quick, straightforward process injection procedure often providing instant relief results for the patient! In the procedure, the practitioner uses ultrasound guidance to identify the nerves being entrapped. Next, simple dextrose is injected around the nerve to nourish the nerve and mechanically release it from the surrounding tissue, fascia, or adjacent structures.

What are we seeing in this image?

Nerve Release Injection Therapy (hydrodissection) of an entrapped nerve. In this image, a 5% dextrose solution is injected around the nerve which releases or separates it from the surrounding tissue. The nerve, which is the central circular object has a dark ring forming around it, as seen strongly in the B image. That is the dextrose solution from the needle, the straight image from the right of the screen. The nerve as seen in B is now surrounded by the nerve-release fluid and therefore “released.”

 

Nerve Release Injection Therapy (hydrodissection) of an entrapped nerve. In this image dextrose solution is injected around the nerve which releases or separates it from the surrounding tissue. The nerve, which is the central circular object has a dark ring forming around it, as seen strongly in the B image. That is the dextrose solution from the needle, the straight image from the right of the screen. The nerve as seen in B is now surrounded by the nerve release fluid and therefore "released."

Caring Medical Research

Ross Hauser, MD discusses the Prolotherapy treatment results that were published a few years ago on part of our article series on the use of Hackett-Hemwall dextrose Prolotherapy, as well as shows a treatment demonstration from a Prolotherapy symposium he taught in 2021

Questions about our treatments?

If you have questions about shoulder replacement alternatives and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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References

1 Noh KC, Park SH, Yang CJ, Lee GW, Kim MK, Kang YH. Involvement of synovial matrix degradation and angiogenesis in oxidative stress–exposed degenerative rotator cuff tears with osteoarthritis. Journal of Shoulder and Elbow Surgery. 2017 Sep 28. [Google Scholar]
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8 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2016 Jan;9:CMAMD-S39160. [Google Scholar]
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14 Barman A, Mishra A, Maiti R, Sahoo J, Thakur KB, Sasidharan SK. Can platelet-rich plasma injections provide better pain relief and functional outcomes in persons with common shoulder diseases: a meta-analysis of randomized controlled trials. Journal of the Korean Shoulder and Elbow Society. 2021 Nov 19. [Google Scholar]


23 Hao KA, Wright TW, Dean EW, Struk AM, King JJ. Preoperative shoulder strength is associated with postoperative primary anatomic total shoulder arthroplasty outcomes and improvement. Journal of Shoulder and Elbow Surgery. 2022 Jan 1;31(1):90-9. [Google Scholar]
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