The evidence: Rotator Cuff Tear Surgery and Regenerative Medicine
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
This article will present the latest research on surgery for complete or full thickness rotator cuff tears. If you have been diagnosed with a partial rotator cuff tear, please see our companion article for discussions of partial rotator cuff tear non-surgical treatments.
How did you get here? You may have had your follow up surgical consultation and you are looking for another answer.
Perhaps you just returned home from your follow up visit with the shoulder surgeon. He/She read the MRI findings report to you. You have a full thickness rotator cuff tear. Your orthopedist may now be recommending a rotator cuff surgery or management with non-surgical methods. Whatever recommendation you received, you are looking up more information online.
So you likely got here because you are confused and concerned by surgical and non-surgical recommendations for your complete or full thickness rotator cuff tear. You may have already visited numerous websites that told you of the traditional symptoms, the traditional conservative care, and the traditional surgical options, but you may still not be getting some of the answers you are looking for.
You may be here because you would probably like to avoid surgery. But is that a realistic option? You may also be asking, “What if I do not have a rotator cuff surgery? What will happen?”
This article will present the for and against surgery for a complete/full thickness tear. In reading this article you may be surprised by the amount of research written by surgeons representing some of the world’s leading medical hospitals and research universities where they themselves expressed concerns about the effectiveness of the rotator cuff surgery and its complications.
You will also read research suggesting that despite what your MRI says, you may not even have a full thickness Rotator Cuff Tear
Do you even have a full thickness tear? Misleading shoulder MRIs lead to unnecessary rotator cuff surgery
We cannot begin to tell you how many times a patient came into one of our clinics with a shoulder MRI depicting a full thickness rotator cuff tear. We cannot begin to tell you how many times after the physical examination, that we advised the patient that we do not believe they have a full thickness tear based on their ability to move their shoulder around. We cannot tell you how many times a patient replied, “well that is not what my MRI says!”
This is from the medical journal The archives of bone and joint surgery, April 2016:
“Magnetic resonance imaging (MRI) has long been considered a perfect imaging study for evaluation of shoulder pathologies despite occasional discrepancies between MRI reports and arthroscopic findings.” Did the same thought enter your mind? If it is perfect how can there be discrepancies?
Later in the same study when comparing MRI to arthroscopic evaluation, the same researchers noted:
“…an orthopedic surgeon has the advantage of freely changing the patient’s shoulder posture during arthroscopy to detect a lesion (tear) in contrast to the single static position of the shoulder in the MRI that is reported by radiologists. This may be another source of disagreement.”(1)
In other words, the complaint about the MRI reading is that it is taking a snapshot and not providing the whole picture. How then is it perfect?
You are more likely to undergo surgery if you had an MRI?
MRI is the pathway to surgery. You get sent for an MRI, surgery is not far behind.
In a 2017 study, Doctors at Brigham and Women’s Hospital and the University of Ottawa studied the prevalence of MRI ordering in cases of a shoulder injury. A total of 475 patients who underwent shoulder MRI were included in the study.
The doctors found that:
- patients who had a prior x-ray were more likely to get an MRI.
- patients who got the MRI were more likely to get the surgery
- Orthopedic specialists ordering MRIs had the highest percentage of patients undergo subsequent surgery (33.3%) compared with the second-most, primary care (18.4%).(2)
In this research a path was followed, a path that you may be following:
- If you had an x-ray you were more likely to get an MRI
- If you had an MRI you were more likely to get a surgery
- If your regular doctor sent you to an MRI you were less likely to get a surgery than if the orthopedist sent you to the MRI.
MRIs performed on patients with NO PAIN, show a high prevalence of tears of the rotator cuff.
Questioning what a shoulder MRI says as the basis for rotator cuff surgery is not a new concept, concern reaches the mainstream in 2011.
In October 2011, the NY Times reported a fascinating article featuring an interview with well-known sports surgeon James Andrews, MD. Seeing that most injured athletes and active people receive MRIs when faced with a sports injury, Dr. Andrews set out to see what MRIs showed on people with no pain or symptoms at all.
- He performed an MRI on 31 perfectly healthy professional baseball players. The results? 90% showed abnormal shoulder cartilage and 87% showed abnormal rotator cuff tendon (tears) despite a 0% incidence of pain.
The article goes on to cite a few other well-known orthopedists who explain that MRIs are sensitive but not specific and that abnormalities are usually inconsequential. In fact, there are almost never “normal” MRIs. Unfortunately, the use of MRIs has become so common that people believe good and accurate care must involve ordering a fancy test. Many of these doctors cited agree that a proper diagnosis can be made by taking a thorough physical and historical evaluation.
The physical examination is the failsafe to errant MRI observation
We do not rely much on MRI for these reasons. MRI may not offer an accurate picture. Physical examination continues to be our “gold” standard.
Please note that this study next to be quoted was published in the Journal of magnetic resonance imaging, a medical journal of radiologists and surgeons.
“Although MRI findings may be diagnostic in some cases, we find that clinical correlation with history and physical examination is critical to differentiate between anatomic variants, incidental findings, and true pathology. We conclude that good communication between the orthopedic surgeon and the radiologist is necessary to optimize diagnostic yield.”(3)
So what does this say?
- Although MRI findings may be diagnostic in some cases, (Provides an accurate picture of what is happening in the patient’s shoulder)
- We find that clinical correlation with history and physical examination is critical to differentiate between anatomic variants, incidental findings, and true pathology. (A physical examination is critical to get to the true cause of the patient’s problems.)
Back to the above, again, we cannot begin to tell you how many times a patient came into one of our clinics with a shoulder MRI report depicting a full thickness rotator cuff tear. We cannot begin to tell you how many times after the physical examination, that we advised the patient that we do not believe they have a full thickness tear based on their ability to move their shoulder around. We cannot tell you how many times a patient replied, “well that is not what my MRI says!”
We cannot tell you how many times we say to them, “you are right, what is wrong in your shoulder, is NOT what your MRI says. You may be going to surgery based on an inaccurate MRI.”
At this point we are confident that we can provide a non-surgical alternative as we will describe below.
In the following studies, you will hear what concerns rotator cuff surgeons: Among their concerns? Surgery can cause more harm than good.
Surgery involves the permanent alteration of the body and when it comes to the rotator cuff, the major stabilizer of the shoulder. Surgery can cause more harm than good. Recovery time is often long and presents its own complications as indicated above where physical therapy is thought to cause re-tears.
It’s estimated that 10-70% of rotator cuff repairs cause repeated problems following surgery.
- In a study out of the Cleveland Clinic, published in the American Journal of Sports Medicine, researchers studied 14 patients who underwent arthroscopic rotator cuff repair. Results showed that within the first year all 14 repairs retracted away from the initial fixation position. While not all repairs resulted in chronic tendon tears, the early retractions correlated with tendon damage and weakness. Researchers noted that this “failure with continuity” or simply continuous failure is common after rotator cuff repair.(4)
The problem with high re-tear rates may lie with physical therapy after the surgery
As noted in the above study, continuous tendon injury and tear is common after rotator cuff repair. In the journal Clinical biomechanics, a team of Canadian researchers suggested that a problem could be physical therapy after the surgery
- Despite improvements in rotator cuff surgery techniques, re-tear rate remains above 20% and increases with tear severity. (The worse the tear the greater the odds it will re-tear).
- Passive early rehabilitation exercises could contribute to re-tear due to excessive stresses. Recommendations arising from this study, for instance, to keep the arm externally rotated during elevation in case of supraspinatus or supraspinatus plus infraspinatus tear, could help prevent re-tear.(5)
The problem of post-surgical shoulder stiffness presents another problem challenging to physical therapy: Research from the Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome publishing in the British Medical Bulletin says doctors have not been able to come up with a plan to help patients with post-surgical stiffness:
“The post-operative rehabilitation protocol remains controversial. We are still far from definitive guidelines for the management of pre- and post-operative stiffness”(6)
The problem with physical therapy and the surgery itself is that the tendons are not healing
In a study from Germany published in Operative Orthopedics and Traumatology, doctors found the problem of re-tear and tears are affected by many factors, but, predominantly, recurrent tears are due to non-healing of the rotator cuff tendons. For many people reading this article who had many shoulder operations, the following may sound very familiar. Tear, re-tear, surgery, re-tear, surgery, re-tear, surgery, until a stage of “permanent” shoulder instability is reached.
Back to the research paper we are citing. How many “successful” rotator cuff surgeries can your rotator cuff tendons take?
- “Different modes of failure are responsible for recurrent defects of the rotator cuff. The management of recurrent defects depends on the clinical symptoms of the patient, the objective function of the shoulder and the pathomorphological (the abnormal function of the shoulder after surgery) changes of the rotator cuff and the shoulder joint itself.
- Besides letting the shoulder heal on its own and/or conservative management, arthroscopic revision of failed cuff repairs appears to be a promising procedure.
- Irreparable tears can be managed using tendon transfer or shoulder replacement procedures (reverse prosthesis) depending on the functional symptoms of the patient.
- The results after re-reconstruction or open revision using tendon transfers are inferior compared to primary intervention (shoulder replacement).”(7)
Does this sound like your case?
- Rotator Cuff Tear Surgery?
- Arthroscopic Revision recommendation?
- Reverse Total Shoulder Replacement recommendation?
This is the standard course of treating difficult to treat rotator cuff repairs.
Research: The use of biological materials, stem cells and blood platelet during surgery may not enhance recovery
Many times a person suffering from rotator cuff pain will suggest that their surgeon says they can use “bio-materials” stem cells or blood platelet solutions during the procedure and this will enhance healing. When we ask a patient how did this come up in conversation, they say they asked the surgeon about PRP and stem cells and were advised that they could get these treatments and the surgery too.
Doctors at the Department of Orthopaedics and Traumatology, University Hospital Bern wrote this in the journal Orthopaedics & Traumatology: Surgery & Research: (Explanatory notes and comments in the parenthesis). The doctors do summarize much of what we covered above.
- Despite advances in surgical reconstruction of chronic rotator cuff tears leading to improved clinical outcomes, failure rates of 13-94% have been reported.
- Reasons for this rather high failure rate include compromised healing at the bone-tendon interface (enthesitis). It is important to note that instead of a physiological enthesis, an abundance of scar tissue is formed, as well as the musculo-tendinous changes that occur after rotator cuff tears, namely retraction and muscle atrophy, as well as fatty infiltration. (Comment: Unyielding scar tissue forms where elastic tendon tissue should be. This will obviously lead to chronic, painful, limiting range of motion. s muscle movement in hampered, muscle atrophy occurs. Muscle is breaking down and fat is replacing atrophied muscle. Not what an athlete or someone who has a physically demanding line of work needs).
- Biological augmentation to improve surgical outcomes, including the application of different growth factors, platelet concentrates such as found in platelet-rich plasma), cells (various types of stem and stroma cells), scaffolds (patches) and various drugs, or a combination of the above have been studied.
- There is only minimal evidence that platelet concentrates may lead to improvement in radiographic, but not clinical outcome. Using stem cells to biologically augment the reconstruction of the tears might have a great potential since these cells can differentiate into various cell types that are integral for healing.(8)
Rotator cuff surgery is a dramatic surgery that involves a lot of cutting of tissue in a joint that by nature is hypermobile in all directions. Healing after surgery, no matter what healing enhancements are added during the surgery, will continue to be a great challenge.
Newly and most recently popularized is the introduction of dehydrated amniotic tissue membrane or “amniotic stem cells,” into a rotator cuff surgery. Learn more about amniotic stem cells and why we do not recommend them.
Why do some surgeons want to introduce stem cells into rotator cuff surgery? To fix the post rotator cuff surgery “hostile healing environment”
Here is what doctors from the United Kingdom and the United States writing in the Orthopaedic Journal of Sports Medicine had to say:
- “Tears within the tendon substance or at its insertion into the humeral head represent a considerable clinical challenge because of the hostile local environment that precludes healing.
- Tears often progress without intervention, and current surgical treatments are inadequate.
- Although surgical implants, instrumentation, and techniques have improved, healing rates have not improved, and a high failure rate remains for large and massive rotator cuff tears. The use of biologic adjuvants that contribute to a regenerative microenvironment have great potential for improving healing rates and function after surgery.”(9)
It is difficult to get stem cells to fix the extensive damage of surgery at the time of the surgery
University and medical researchers in Mexico published a comprehensive review of the use of stem cells in the healing of various degenerative and injuries of the joints and spine. When they got to rotator cuff tears this is what they said in the journal Stem Cell International:
- “Between 30% and 94% of rotator cuff repairs result in failure, perhaps because the highly specialized fibrocartilaginous transition area connecting the rotator cuff and the bone fails to regenerate following repair. The tissue that is formed after the surgery is a fibrovascular scar tissue, and its mechanical properties are relatively poor.”
- Simply the surgery caused the formation of scar tissue where elastic and flexible tissue that allows the shoulder its vast range of motion should be.
- To answer to the high rate of surgical failure? “new materials and surgical techniques have been refined in an effort to augment the strength of the regenerated tissue and replicate the anatomical footprint of the rotator cuff.” Stem cells.
In their research, the Mexican team found promising results but limit results in that stem cells could affect significant change in the formation of scar tissue during the surgery. In fact they cite the work of Dr. João L. Ellera Gomes in Brazil who published that dipping surgical suture in stem cells obtained from a bone marrow aspirate from the iliac crest and going through the bone to hold everything together (the transosseous approach), was effective for 12 out of 12 months at 12 months follow up.(10)
- Comment: It is difficult to get stem cells to fix the extensive damage of surgery at the time of the surgery. This is why your orthopedic surgeons tell you stem cells don’t work. For him/her, they have seen the research on the application of stem cells during surgery, it is not enough.
Bone Marrow Stem Cell Therapy and Platelet Rich Plasma Injections instead of surgery and after surgery
In Stem Cell Prolotherapy we use a person’s own healing cells from bone marrow, fat, and blood (alone or in various combinations) and inject them straight to the area which has a cellular deficiency.
At Caring Medical we utilize Prolotherapy as the first option. It is the among the oldest and most tried of the regenerative medicine injection techniques. A small amount of simple sugar or dextrose is injected at various tender or trigger points in the shoulder to stimulate tissue repair.
Why do we use this treatment as a first option?
- It is inexpensive compared to PRP or stem cell injections.
- It produces good results
In the video below Prolotherapy and Platelet Rich Plasma injections are explained. In combination, we call this PRP Prolotherapy. In Platelet Rich Plasma injections your blood is used, by way of its platelets, to create concentrated platelet solutions rich is healing and regenerative factors.
Stem cell therapy is reserved, in our clinics for very advanced degenerative changes in the shoulder. Treatment utilizing stem cells for rotator cuff as a first line treatment is something that we usually do not offer because of expense and the ability of Prolotherapy and PRP to do a good job of healing. We do discuss this with all patients prior to treatment.
Our ultimate goal with all forms of Prolotherapy is to get the patients back to doing the things that they want to do without pain and without surgery.
Listen to this research from doctors at Washington University published in the Arthritis research & therapy
Problems with rotator cuff recovery and healing time following rotator cuff surgery has long been the concern of doctors and of course patients, because doctors face the challenge of poor tendon healing and irreversible changes associated with rotator cuff degenerative diseases, future treatments should involve non-surgical biologics and tissue engineering (Platelet Rich Plasma Therapy and Mesenchymal stem cell therapy). These treatments should be explored because they hold a promise to improve outcomes for patients suffering from shoulder problems.(11)
- In research from doctors at the Sungkyunkwan University School of Medicine, Seoul, Korea suggests that stem cells applications after surgery can be effective for tendinopathy and rotator cuff tendon tear.(12) The same research team added in a 2018 study in the Journal of Orthopaedic Surgery and Research that bone marrow aspirate and PRP improved pain and shoulder function in patients with a partial tear of the rotator cuff tendon.(13)
- This follows on earlier research from Korean doctors publishing in the American Journal of Sports Medicine who found stimulating bone marrow to release stem cells combined with a biomaterial scaffold patch on the site of huge rotator cuff significantly reduced retear and high surgical failure rates in the arthroscopic repair of massive rotator cuff tears.(14)
- Doctors at the Hospital for Special Surgery in New York also suggested in their animal studies published in the journal Arthroscopy that bone marrow stem cells accelerated healing after arthroscopic surgery at the bone/tendon interface.(15)
Which again begs the question, in certain tears why not try the PRP and stem cells as injections without the surgery?
The goal of the surgery is to repair and restore function but for many patients, this is NOT achieved. Doctors are looking at Platelet Rich Plasma and stem cell injections to regrow the damaged tissue in the shoulder.
German researchers in Munich wrote in Der Orthopäde: “Due to the increasing demand for functionality in an aging yet physically active society, the treatment of rotator cuff tears is of ever-growing importance. Despite intensive research efforts, the treatment of degenerative rotator cuff tears, in particular, their long-term outcome is still a challenge.”
An explanation – what they are saying is that patients, especially aging athletes and people who work at jobs that require strength, demand a functioning shoulder – surgery is not the answer.
“While in recent years the focus was on biomechanics and the technical aspects of rotator cuff reconstruction (surgery), attention has now turned to the biological considerations of tendon regeneration. (healing)”(16)
Goal of treatment: Patients want improved function of their shoulders
Doctors at the Hospital of Special Surgery in New York acknowledged that surgery did not offer what the patients wanted both pain relief and function.
In the journal Current reviews in musculoskeletal medicine, they wrote: “There is some controversy over the role of arthroscopy in the management of irreparable rotator cuff tears. Arthroscopic debridement, partial repair with margin convergence, biceps tenotomy or tenodesis, and more recently suprascapular nerve release have all been described as potential treatments. The literature would suggest that they are effective at alleviating pain, but have little effect on strength.”(17)
So slowly the wheels of medicine are changing – fortunately, biological considerations – non-surgical injection therapy designed to regenerate your shoulder can be offered at Caring Medical today.
Let’s review the research – here are highlights:
- Recent research suggests Prolotherapy is an effective treatment for rotator cuff injuries, pain, and function in patients who failed to respond to conservative treatment.
- Studies show that arthroscopic surgical repair for partial rotator cuff tears and related injuries results in outcomes no better than treatment with exercise or physical therapy alone.
- Athletes favor rotator cuff surgery under the belief that that is their best way back to being active sooner – however research says that being active sooner may cause surgical failure.
- Arthroscopic rotator cuff tear repairs have a high percentage of re-tear risk and frequently result in side effects such as continued pain, stiffness and decreased range of motion.
- Surgical intervention for rotator cuff pain based on MRI’s are often misleading, as studies show the presence of MRI confirmed rotator cuff tears in individuals with absolutely no symptoms. Further compounding problems of the glenoid labrum.
Comprehensive Prolotherapy treatment for torn rotator cuff without surgery
The recurrent theme in the research throughout this article is: Despite surgical improvements – surgical failures continue. This is echoed further in the research below:
“Despite improved surgical techniques, the tendon-to-bone healing rate is unsatisfactory due to difficulties in restoring the delicate transitional tissue between bone and tendon.”(18) This same research from doctors in Spain also says Mesenchymal stem cell therapy is a potentially effective therapy to enhance rotator cuff healing and prevent complications.
These researchers base this opinion on the fact that stem cell therapy increases the amount of fibrocartilage formation. This is the tissue that helps make up ligaments, tendons, and cartilage and are specifically marked for studies on tissue engineering.
But treating the tendon interface and the shoulder ligaments is something that Prolotherapy does as well.
In new research in the medical journal Orthopaedics & Traumatology, Surgery & Research, doctors tested the effectiveness of Prolotherapy in difficult chronic refractory rotator cuff tears. They were hoping to find that dextrose prolotherapy would reduce pain and improve shoulder function and patient satisfaction.
- 120 patients with chronic rotator cuff lesions and symptoms that persisted for longer than 6 months were divided into two groups: one treated with exercise and the other treated with prolotherapy injection
- In the Prolotherapy group, ultrasound-guided prolotherapy injections were applied
- In the exercise group, patients received a physiotherapy protocol three sessions weekly for 12 weeks.
- Both groups were instructed to carry out a home exercise program.
- Both the exercise group and the Prolotherapy group achieved significant improvements.
- Prolotherapy group had significantly better pain relief scores at weeks 3, 6, and 12, and last follow-up.
- Prolotherapy group had significantly better shoulder abduction and flexion at week 12 and last follow-up, and in internal rotation at last follow-up.
- No significant difference was found in external rotation at any follow-up period.
- In the prolotherapy group, 53 patients (92.9%) reported excellent or good outcomes; in the control group, 25 patients (56.8%) reported excellent or good outcomes.(16)
Can we help you get back to work, sport or simply a better quality of life? Even though you have been told you have a full thickness tear?
Caring Medical Regenerative Medicine Clinics have over 25 years experience is 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 some one comes into our office with a rotator cuff injury significant enough that reality says 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.
Do you want to talk about your rotator cuff issues? Get help and information from Caring Medical
References for Rotator Cuff Tear Surgery | Why the high failure rate?
1. Sefidbakht S, Momenzadeh OR, Dehghani S, Gerami H. MRI-Arthroscopic Correlation in Rotator Cuff Tendon Pathologies; A Comparison between Various Centers. Archives of Bone and Joint Surgery. 2016;4(2):141-144. [Google Scholar]
2. Small KM, Rybicki FJ, Miller LR, Daniels SD, Higgins LD. MRI Before Radiography for Patients With New Shoulder Conditions. J Am Coll Radiol. 2017 Apr 20. pii: S1546-1440(17)30214-4. doi: 10.1016/j.jacr.2017.02.031. [Google Scholar]
3. Bencardino JT, Beltran LS. Pain related to rotator cuff abnormalities: MRI findings without clinical significance. J Magn Reson Imaging. 2010 Jun;31(6):1286-99. [Google Scholar]
4. McCarron JA, Derwin KA, Bey MJ, Polster JM, Schils JP, Ricchetti ET, Iannotti JP. Failure with continuity in rotator cuff repair “healing”. The American journal of sports medicine. 2013 Jan;41(1):134-41. [Google Scholar]
5 Haering D, Blache Y, Raison M, Begon M. Mechanical risk of rotator cuff repair failure during passive movements: A simulation-based study. Clin Biomech (Bristol, Avon). 2015 Dec;30(10):1181-8. [Google Scholar]
6 Papalia R, Franceschi F, Vasta S, Gallo A, Maffulli N, Denaro V. Shoulder stiffness and rotator cuff repair. Br Med Bull. 2012 Feb 14. [Google Scholar]
7 Scheibel M. Recurrent defects of the rotary cuff : Causes and therapeutic strategies Oper Orthop Traumatol. 2012 Nov;24(6):458-67. doi: 10.1007/s00064-012-0179-2. [Google Scholar]
8 Zumstein MA, Lädermann A, Raniga S, Schär MO. The biology of rotator cuff healing. Orthop Traumatol Surg Res. 2016 Dec 30. pii: S1877-0568(16)30191-8. doi: 10.1016/j.otsr.2016.11.003. [Google Scholar]
9 Murray IR, LaPrade RF, Musahl V, Geeslin AG, Zlotnicki JP, Mann BJ, Petrigliano FA. Concepts, Future Research, and Barriers to Advancement, Part 2: Orthop J Sports Med. 2016 Mar 31;4(3):2325967116636586. [Google Scholar]
10 Berebichez-Fridman R, Gómez-García R, Granados-Montiel J, Berebichez-Fastlicht E, Olivos-Meza A, Granados J, Velasquillo C, Ibarra C. The Holy Grail of Orthopedic Surgery: Mesenchymal Stem Cells—Their Current Uses and Potential Applications. Stem cells international. 2017;2017. [Google Scholar]
11 Killian ML, Cavinatto L, Galatz LM, Thomopoulos S. Recent advances in shoulder research. Arthritis research & therapy. 2012 Jun 15;14(3):214. [Google Scholar]
12 Kim SJ, Song DH, Park JW, Park S, Kim SJ. Effect of Bone Marrow Aspirate Concentrate Platelet-Rich Plasma on Tendon Derived Stem Cells and Rotator Cuff Tendon Tear. Cell Transplant. 2017 Jan 20. [Google Scholar]
13 Kim SJ, Kim EK, Kim SJ. Effects of bone marrow aspirate concentrate and platelet-rich plasma on patients with partial tear of the rotator cuff tendon. Journal of orthopaedic surgery and research. 2018 Dec;13(1):1. [Google Scholar]
14 Yoon JP, Chung SW, Kim JY, Lee BJ, Kim HS, Kim JE, Cho JH. Outcomes of Combined Bone Marrow Stimulation and Patch Augmentation for Massive Rotator Cuff Tears. Am J Sports Med. 2016 Apr;44(4):963-71. doi: 10.1177/0363546515625044. Epub 2016 Feb 5. [Google Scholar]
15 Degen RM, Carbone A, Carballo C, Zong J, Chen T, Lebaschi A, Ying L, Deng XH, Rodeo SA. The Effect of Purified Human Bone Marrow-Derived Mesenchymal Stem Cells on Rotator Cuff Tendon Healing in an Athymic Rat. Arthroscopy. 2016 Dec;32(12):2435-2443. [Google Scholar]
16 Ficklscherer A, Pietschmann MF, Bendiks M, Roßbach BP, Müller PE. [Clinical management of rotator cuff tears: Current concepts in cell-based therapy strategies].Orthopade. 2016 Feb;45(2):143-8. doi: 10.1007/s00132-015-3213-x. German. [Google Scholar]
17 Khair MM, Gulotta LV. Treatment of irreparable rotator cuff tears. Current reviews in musculoskeletal medicine. 2011 Dec 1;4(4):208. [Google Scholar]
18 Mora MV, Ibán MA, Heredia JD, Laakso RB, Cuéllar R, Arranz MG. Stem cell therapy in the management of shoulder rotator cuff disorders. World J Stem Cells. 2015 May 26;7(4):691-9. doi: 10.4252/wjsc.v7.i4.691. [Google Scholar]
19 Seven MM, Ersen O, Akpancar S, Ozkan H, Turkkan S, Yıldız Y, Koca K. Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthop Traumatol Surg Res. 2017 [Google Scholar]