Alternatives to Rotator Cuff Tear Surgery – The evidence for non-surgical options
Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C
Alternatives to Rotator Cuff Tear Surgery
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. Do you want to talk about your rotator cuff issues? Get help and information from Caring Medical
A December 2021 review study (1) from orthopedic surgeons at the University of Lausanne in Switzerland gives us a summary of the challenges patients with rotator cuff disorders face in deciding on treatments.
“Shoulder pain in the context of rotator cuff disorders is a frequent source of medical consultation. A wide range of therapeutic options is reported in the literature. Non- or minimally invasive treatments include physiotherapy, anti-inflammatory medication, and infiltration of corticosteroids or platelet-rich plasma. Surgical treatments include subacromial debridement, long head of the biceps tenotomy/tenodesis, rotator cuff repair, superior capsular reconstruction, and tendon transfers. Reverse shoulder arthroplasty completes the therapeutic arsenal. Guiding and advising the patient in the face of all these options can therefore be challenging.”
Those are some of the many treatments to choose from. Ultimately, however, when those treatments fail, surgery is often recommended. Then people begin their quest for information on the pros and cons of surgery.
- The evidence for and against Rotator Cuff Tear Surgery and Non-surgical regenerative medicine injections.
- You may be here because you would probably like to avoid shoulder surgery. But is that a realistic option for you?
- You may also be asking, “What if I do not have rotator cuff surgery? What will happen?” According to one study, “patients can do very well” without surgery.
- “Patients with rotator cuff tears tended to improve regardless of whether they received operative or nonoperative treatment.”
- Choosing between Rotator Cuff Surgery or no surgery? The debate for all age groups.
- The size of the tear does not seem to be a factor in determining who should be recommended for surgery. Is the size of the tear not as important as many think?
- But if you had previous cortisone injections into your shoulder, this may be a problem for those considering surgery. Surgeons express concern.
The evidence for and against Rotator Cuff Tear Surgery and Non-surgical regenerative medicine injections
Here is a typical email we receive at our office:
“I was just diagnosed by MRI and physical exam by two shoulder specialists that I have a tear in my supraspinatus tendon. How realistic is it for me to expect to avoid surgery for this? Is avoiding a surgery a typical outcome for these treatments?”
When this type of email comes in we have to explore with the person sending it, the many factors of their situation before we can give a confident recommendation. We always look for range of motion, daily ability to function and do everyday activities, pain levels, and what type of treatments has the person had in the past. A history of cortisone use would be especially revealing. Once we have this information we can make recommendations.
So perhaps you are like the above emailer. You recently 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 until such time that you can be scheduled for surgery. Whatever recommendation you received, you are looking up more information online and that is how you wound up here at our article.
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.
In January 2022, doctors writing in the Journal of patient experience (32) sought to help other doctors understand what was going through the rotator cuff tendinopathy patient’s mind when it comes to treatments and their medical experience. According to the doctors of this study, they sought to answer three questions:
- What is it like to live with rotator cuff tendinopathy?
- What are the barriers and facilitators of a healthy lifestyle with an aging shoulder?
- And, what are the outcomes that matter most to people seeking care for rotator cuff tendinopathy?
- Surgeons suggest who would be better candidates for rotator cuff surgery.
- Who would be a lesser candidate for surgery?
- What if I do get the surgery? When can I go back to work? “A vast majority of patients undergoing rotator cuff repair can expect to return to work within 8 months of surgery.”
The patients in this study expressed these concerns:
- Problems with less restful sleep
- Difficulty with work and life transitions
- Loss of baseline (basic function) abilities,
- and limitation in social roles in the capability realm; physical pain, despair, and loneliness in the comfort realm; and lack of direction or progress and feeling uncared for in the calm realm.
- Barriers identified included: the sense that rotator cuff tendinopathy is something correctable rather than age-associated and the sense that painful activities will make the tendinopathy worse (common misconceptions); tenuous (not good or weak) relationships and limited trust with clinicians; loss of hope; and a sense that care is directionless.
- Among what matter most? The feeling that they are getting effective care and not being dismissed.
You may be here because you would probably like to avoid shoulder surgery. But is that a realistic option for you?
This article will present some arguments 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 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.
You may also be asking, “What if I do not have rotator cuff surgery? What will happen?” According to one study, “patients can do very well” without surgery.
There have been numerous studies published in recent years outlining options to rotator cuff surgery and what happens if you do not get one. Let’s start with this 2018 study from the University of Calgary, which was published in the Journal of Shoulder and Elbow Surgery. (2) It tells the story of a group of patients who decided against rotator cuff surgery and the doctors who followed what happened to them over a five-year period.
Here are the study’s summary points:
- Patients with chronic (more than three months), full-thickness rotator cuff tears (demonstrated on imaging) who were referred to 1 of 2 senior shoulder surgeons were enrolled in the study between October 2008 and September 2010.
- The patients participated in a comprehensive, nonoperative, home-based treatment program. After 3 months, the outcome in these patients was defined as “successful” or “failed.”
- Patients in the successful group were essentially asymptomatic and did not require surgery.
- Patients in the failed group were symptomatic and consented to undergo surgical repair.
- All patients were followed up at 1 year, 2 years, and 5 or more years.
- At 5 or more years approximately 75% of patients remained successfully treated with nonoperative treatment at 5 years and reported a mean rotator cuff quality-of-life index score of 83 of 100.
- Furthermore, between 2 and 5 years, only 3 patients who had previously been defined as having a successful outcome became more symptomatic and underwent surgical rotator cuff repair.
- Those in whom nonoperative treatment had failed and who underwent surgical repair had a mean rotator cuff quality-of-life index score of 89.
- The operative and nonoperative groups at 5-year follow-up were not significantly different.
CONCLUSION: “Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. While some clinicians may argue that nonoperative treatment delays inevitable surgical repair, our study shows that patients can do very well over time.”
“Patients with rotator cuff tears tended to improve regardless of whether they received operative or nonoperative treatment”
In September 2021 doctors at the University of Michigan and Indiana University published a paper in the Orthopaedic Journal of Sports Medicine (3) citing this 2018 study above. What they found was: “Patients with rotator cuff tears tended to improve regardless of whether they received operative or nonoperative treatment, but patients who underwent operative treatment improved faster. There appear to be several predictors of improved and worsened outcomes for patients with rotator cuff tears undergoing operative or nonoperative treatment.”
To explore this further here are some more details from this study:
- Patients with rotator cuff disease who presented for treatment were on average 58.8 years of age and had more than five years of self-reported shoulder symptoms.
- Patients who had surgery did better than did patients who chose not to have surgery across all follow-up points on all outcome measures, although the magnitude of this superior effect was modest in most cases.
- Just over 50% of the patients underwent surgery, and these patients were more likely to be younger and to be current or recent smokers. Upon visual inspection of trends in scores on all outcome measures, the operative group tended to improve faster, with little additional improvement after 1 year of follow-up, and the nonoperative group appeared to continue to improve out to years 3 and 4, at which point their improvement approximated that of the operative group on average.
Basically, 3 to 4 years out the surgery group and the non-surgery group had similar outcomes in patients in their late 50s and early 60s.
Choosing between Rotator Cuff Surgery or no surgery? The debate for all age groups
The debate between surgery or no surgery goes beyond doctor vs. doctor, it goes on in your mind, it is a family decision, and it is a decision that has many factors. Some people do very well with surgery, some people can get by without surgery. In a July 2020 study in The Journal of Bone and Joint Surgery American Volume, (4) research led by the Vanderbilt University Medical Center found that patients undergoing nonoperative treatment had significantly better outcomes in the initial follow-up period compared with patients undergoing a surgical procedure, but this trend reversed in the longer term. The researchers recommended that this information be used to inform patients of realistic expectations for nonoperative and operative treatments for rotator cuff tears.
So this may be in agreement that initially people do well without surgery but eventually, the shoulder will continue to break down.
But the question is in the comparison of treatments. What is the surgery being compared against? What are the non-operative treatments? Physical therapy? Cortisone injections? Anti-inflammatory protocols. We know these treatments do not work in the long run. How? Because people move on to the surgery. Below we will discuss other treatments.
In June 2022, doctors at the University of Utah wrote in the journal Arthroscopy, sports medicine, and rehabilitation (33) of the likelihood and risk factors for, progression of rotator cuff tendinopathy to tear in patients treated with traditional conservative care treatments for at least one year.
In this study the doctors reviewed the cases of 135 patients in the Veterans Health Administration who had an initial MRI demonstrating rotator cuff tendinopathy. On subsequent MRI at an average 3.4 year follow-up, 39% of patients had progressed to a tear.
- When grouped on the basis of time between scans as 1 to 2 years 32% progressed to a tear
- Between 2 to 5 years 37% progressed to a tear
- Over 5 years 54% progressed to a tear.
Surgeons suggest who would be better candidates for rotator cuff surgery
Here is a paper published in March 2020 (5) that gives general recommendations for who should consider surgery and who should consider other options. It was published in The Journal of the American Academy of Orthopaedic Surgeons.
People should consider NON-surgical options first and then get surgery if life-alternating pain or neurological or functional problems develop.
- Partial-thickness tears
- Large tears with advanced muscle changes (A lot of damage has already been done to the shoulder making surgery more challenging).
- People over 65 years old
- Atraumatic (Degenerative) full-thickness tears less than 15 mm in size with an intact anterior cable. (The anterior cable is a bundle of ligament and soft connective tissue that helps hold the shoulder together.)
People who MAY consider NON-surgical options and surgical options because of the medium risk of progression of shoulder disease.
- Degenerative full-thickness tears greater than 15 mm
- Anterior cable disruption (Ligaments weakness and damage creating shoulder instability).
- Acute injury but preserved function in the shoulder and arm.
In this group, the surgeons recommend: “Informed discussion of surgical and nonsurgical options and surveillance exams with successful conservative treatment, (keeping an eye on it.)
People SHOULD consider surgical options because of a high risk of progression of shoulder disease.
- Acute chronic tears with new pseudoparalysis (loss of muscle strength) or profound external rotation weakness
- Minimal muscle degenerative changes
- Age compatible with healing (You are younger).
Who would be a lesser candidate for surgery?
In July 2021, doctors at the University of Rome wrote in the journal Quality of Life Research (6) about recent studies that “major levels of psychological distress correlate with higher pain and reduced function in patients with shoulder and rotator cuff pathology. . . In patients undergoing repair of the rotator cuff tear, there was a correlation between poor psychological function before surgery and worsening post-surgical outcomes, such as persistence of postoperative pain intensity and worse levels of function/disability.”
What if I do get the surgery? When can I go back to work? “A vast majority of patients undergoing rotator cuff repair can expect to return to work within 8 months of surgery.”
Here is a study from October 2019, it comes from researchers at Wake Forest University, The Ohio State University, Loma Linda University, the Hospital for Special Surgery, the University of South Florida Health, and Rush University Medical Center. It was published in the Orthopaedic Journal of Sports Medicine. (7) The research suggests the dominating factors in getting someone back to work after rotator cuff surgery. Type of work they did, dominant vs. non-dominant arm, good attitude, or positive mental health helped a lot.
Here are the summary points of this research:
- 89 patients with a job underwent surgery. Seven months later:
- If the patient had a sedentary workload – they had a 100% return to work.
- If the patient had a light workload they had an 84% return to work.
- If the patient had a moderate workload they had a 77.4% return to work.
- If the patient had a heavy workload they had a 63.3%, return to work.
- Injury to a patient’s dominant side had reduced odds for return to work at full duty.
Conclusion: “A vast majority of patients undergoing rotator cuff repair can expect to return to work within 8 months of surgery. Preoperative mental health scores can predict a future return to work, which supports the concept that mental health status plays an important role in the outcomes after rotator cuff repair surgery.”
The size of the tear does not seem to be a factor in determining who should be recommended for surgery. Is the size of the tear not as important as many think?
We get many emails from people with shoulder problems, and these emails begin with a description of the size of their tears. “I have a (pick a number) centimeter tear of my rotator cuff. . . ” is how so many of these emails begin. The reason so many people begin their emails with the tear size is that the perceived importance the patient has of the tear size is influenced by what their doctors are telling them. Is tear size important or not?
Here is a recently published study from the Department of Orthopaedic Surgery, Washington University in St. Louis. It is from October 2019 and appeared in the Journal of Shoulder and Elbow Surgery. (8)
Factors that are associated with surgical intervention: SIZE OF TEAR
The researchers examined “patient-related factors for the perceived need for surgery for degenerative rotator cuff tears,” something they write that, “is not known,” and wrote: “Asymptomatic, degenerative rotator cuff tears were followed prospectively to identify the onset of pain and tear enlargement. Newly painful tears were continually monitored with a focus on identifying patient-specific (age, occupation, activity level) and tear-specific (tear type and size, tear progression, American Shoulder and Elbow Surgeons score, muscle degeneration) factors that are associated with surgical intervention.”
- Forty-eight of 169 newly painful shoulders were eventually managed surgically.
- Factors associated with surgical treatment included:
- younger age
- pain development earlier in surveillance (greater and more accelerated pain early in the study)
- a decline in American Shoulder and Elbow Surgeons score (a functional score to determine the patient’s arm function),
- and history of contralateral shoulder surgery (If you had the other shoulder operated on, you were more likely to have both shoulders operated on.)
Neither tear type, tear enlargement, nor tear size was associated with surgery.
- Eighty-five of the 169 tears (50%) enlarged either before or within 2 years of pain development.
- Neither tear type, tear enlargement, nor tear size was associated with surgery.
- “For newly painful rotator cuff tears, patient-specific factors such as younger age and prior surgery on the contralateral shoulder are more predictive of future surgery than tear-specific factors or changes in tear size over time.”
But if you had previous cortisone injections into your shoulder, this may be a problem for those considering surgery. Surgeons express concern.
In the emails we get into our office, after a description of the size of the tear, we will in many cases, get the cortisone injection history this person has had.
“I have a 5 cm tear in my rotator cuff. I just had a cortisone injection and it helped for a while, but now the pain is back and my doctor wants to perform the surgery.”
Surgeons suggest “Caution should be taken when deciding to inject a patient (with cortisone).”
In December 2019, researchers at Tufts Medical Center, Rush University Medical Center, and the Hospital For Special Surgery published these research findings in the medical journal Arthroscopy. (9) In it, they examined if cortisone injections before surgery cause complication problems after surgery and if this caused a higher risk for the need for a second surgery.
What they discovered was:
- Single cortisone injection for rotator cuff tendinosis was associated with an increased risk of revision rotator cuff repair when administered up to a year prior to surgery.
- A single cortisone injection increased the risks of postoperative infections when administered within a month prior to rotator cuff tendinosis.
- The risk of adverse outcomes after arthroscopic rotator cuff repair is greatest if a cortisone injection is administered within 6 months of surgery or if more than two cortisone injections are given within a year of surgery.
Several recent clinical trials have demonstrated that cortisone injections are correlated with an increased risk of revision surgery after arthroscopic rotator cuff repair. “Caution should be taken when deciding to inject a patient, and this treatment should be withheld if an arthroscopic rotator cuff repair is to be performed within the following six months.”
- Female golfer, 55 years old.
- Developed shoulder pain, diagnosed with a rotator cuff tear.
- Shoulder pain limited her golf game and ability to play golf.
- Recommended to Cortisone. Cortisone had limited success.
- The ultimate failure of cortisone allowed the surgeon to recommend rotator cuff surgery
- The patient decided on Prolotherapy and Platelet-rich Plasma Injections (treatments are shown and described in videos below).
“Caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears”
A January 2019 study (10) in the journal Arthroscopy examined the effects of one or multiple corticosteroid injections a patient received for shoulder pain prior to having rotator cuff surgery. Here were these findings:
- “A single shoulder injection within a year prior to arthroscopic rotator cuff repair was not associated with an increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery . . . caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears.
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 our clinic with a shoulder MRI depicting a full-thickness rotator cuff tear, however, after a physical examination and ultrasound, along with their ability to move their shoulder around, we advised that it was not likely the rotator cuff was fully torn. Of course, most patients reply, “well that is not what my MRI says!”
This is from the medical journal The Archives of Bone and Joint Surgery, April 2016:(11)
“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.”
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 (12) 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 undergoing subsequent surgery (33.3%) compared with the second-most, primary care (18.4%).
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 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. The 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.”(13)
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.)
At this point, we are confident that we can provide a non-surgical alternative as we will describe below. Or, that patient will end up getting surgery based on an inaccurate MRI.
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. (14)
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 are 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, the 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 stress. 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. (15)
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 published 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”(16)
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.
Kinesio tape and rotator cuff disease
An August 2021 study in The Cochrane database of systematic reviews (17) sought to determine the benefits of Kinesio Taping in adults with rotator cuff disease. Here is what they found:
“Kinesio Taping is one of the conservative treatments proposed for rotator cuff disease. Kinesio Taping is an elastic, adhesive, latex-free taping made from cotton, without active pharmacological agents. Clinicians have adopted it in the rehabilitation treatment of painful conditions, however, there is no firm evidence on its benefits. . . Kinesio taping for rotator cuff disease has uncertain effects in terms of self-reported pain, function, pain on motion and active range of motion when compared to sham taping or other conservative treatments as the certainty of evidence was very low. Low-certainty evidence shows that kinesio taping may improve quality of life when compared to conservative treatment. We downgraded the evidence for indirectness due to differences among co-interventions, imprecision due to small number of participants across trials as well as selection bias, performance and detection bias. Evidence on adverse events was scarce and uncertain. Based upon the data in this review, the evidence for the efficacy of Kinesio Taping seems to demonstrate little or no benefit.”
The ligaments of the rotator cuff stabilize the shoulder and help prevent a tear of the rotator cuff tendons
The complexity of shoulder movement. When the rotator cuff is compromised by tears and structural problems, the whole shoulder becomes unstable. This is why surgeries can often fix one or two problems but other problems remain that send the shoulder into degenerative disease and ultimately the need for more surgeries. Here we see how rotator cuff tears can be only one aspect of shoulder damage. The pulley complex can be compromised by way of damage to the superior glenohumeral ligament, the coracohumeral ligament, and the distal attachment of the subscapularis tendon.
Back to the research paper, 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).”(18)
Does this sound like your case?
- Rotator Cuff Tear Surgery?
- Arthroscopic Revision recommendation?
- Reverse Total Shoulder Replacement recommendation?
Research: The use of biological materials, stem cells and blood platelets, 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 with your surgeon? 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 musculotendinous 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 is 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 an improvement in radiographic, but not the clinical outcome. Using stem cells to biologically augment the reconstruction of the tears might have great potential since these cells can differentiate into various cell types that are integral for healing. (19)
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 has great potential for improving healing rates and function after surgery.”(20)
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 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 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 limited results in that stem cells could affect significant changes 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. (21)
- 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 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. Prolotherapy is an injection technique utilizing simple sugar or dextrose. It is among the oldest and most tried 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 in healing and regenerative factors.
Rotator Cuff Tears- Prolotherapist FAQs: When are Prolotherapy & PRP used? Can surgery be avoided?
Danielle Matias, PA-C gives a general overview of when Comprehensive Prolotherapy with PRP is used for rotator cuff or other shoulder tears and shoulder instability cases and compares this to when a patient is typically referred for surgery.
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, comes 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.
Stem cell therapy is reserved, in our clinic, 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 have 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. (22)
- In research from doctors at the Sungkyunkwan University School of Medicine, Seoul, Korea suggests that stem cell applications after surgery can be effective for tendinopathy and rotator cuff tendon tear. (23) 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. (24)
- This follows on earlier research from Korean doctors published 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. (25)
- 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. (26)
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 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)”(27)
The goal of treatment: Patients want the 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.”(28)
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 MRIs is 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 first injection is intra-articular, directly into the shoulder joint.
- Next to the acromioclavicular joint. Shoulder osteoarthritis, rotator cuff tendon issues including tears as well as tendinosis, responds well to Prolotherapy.
- Next are the posterior shoulder structures including the posterior joint capsule as well as the various ligament attachments in the back of the shoulder.
- Next, the interior structures in the front of the shoulder are done including the ligaments as well as the various rotator cuff tendon attachments including the Supraspinatus tendon.
- Prolotherapy is effective for rotator cuff tears, labral tears and biceps tendonitis, various tendonitis as well as shoulder instability.
- Finally treating the acromioclavicular joint, or AC joint as the biceps tendon attachments.
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.”(29) 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 based this opinion on the fact that stem cell therapy increases the amount of fibrocartilage formation. This is the tissue that helps makeup ligaments, tendons, and cartilage and is specifically marked for studies on tissue engineering.
But treating the tendon interface and the shoulder ligaments is something that Prolotherapy does as well.
In research in the medical journal Orthopaedics & Traumatology, Surgery & Research, (30) 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.
- The Prolotherapy group had significantly better pain relief scores at weeks 3, 6, and 12, and last follow-up.
- The 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.
Can we help you get back to work, sport, or simply a better quality of life?
A patient came into our clinic. She had been recommended for rotator cuff surgery. Her story goes something like this:
She woke up one morning with significant shoulder pain. The pain started as a small, nagging “twinge” but worsened over the following months. When the pain became chronic, she decided to consult with an orthopedic physician. According to x-ray and MRI results, she was dealing with an impingement as well as a rotator cuff tear. The orthopedic performed a cortisone injection which temporarily relieves her shoulder pain.
The patient was a golfer and she could still play golf on a regular basis, despite a painful swing. The patient also kept in shape by lifting weights. An activity she was frightened to continue for fear of worsening her injury. Eventually, the shoulder pain caused significant decreases in her quality of life. She could not perform basic tasks such as getting dressed without pain and the pain would eventually interrupt her sleep.
Should I get the surgery anyway?
The orthopedic recommended surgery to repair the tear, but the patient told us she would prefer an alternative to shoulder surgery. She received four rounds of H3 Prolotherapy with Platelet Rich Plasma over a period of three months. Each treatment comprehensively treated her whole shoulder. Our goal was to treat the rotator cuff tear as well as the underlying joint instability which had eventually led to the impingement. Targeting injections at the rotator cuff tear alone is not enough. The patient was also provided with a tailored exercise program to help her reach her goals. She understood the importance of the treatment plan recommended and remained compliant between treatments.
After her first two treatments, the patient began physical therapy at the recommendation of the Prolotherapist and continued to improve with each H3 Prolotherapy treatment. Physical therapy can be a helpful adjunctive therapy for shoulder Prolotherapy. We often work with our physical therapists to give individualized recommendations to achieve optimal results.
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 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 with non-surgical options.
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.
Research: Prolotherapy effective in helping patients after failed rotator cuff surgery
Many people do well with rotator cuff surgery, these are typically not the people we see. We see the people who did not do well after the rotator cuff surgery. In many instances, we have been able to help these patients with pain and function. Doctors in Turkey have also seen the positive results of Prolotherapy treatments in patients following a failed rotator cuff surgery. In a study from February 2019, (31) surgeons, sports specialists, and military doctors combined their research efforts to suggest the effectiveness of Prolotherapy injections in the treatment of failed rotator cuff repair surgery. The researchers concluded in their research:
“Our study results show that prolotherapy is effective in the treatment of patients with failed rotator cuff repair surgery with significant improvements in shoulder function and pain relief.”
Do you want to talk about your rotator cuff issues? Get help and information from Caring Medical
1 Goetti P, Vauclair F, Becce F, Farron A. Prise en charge des lésions de la coiffe des rotateurs : choisir la meilleure option pour le patient [Management of rotator cuff disorders. How to choose the most appropriate treatment option for my patient ?]. Rev Med Suisse. 2021 Dec 15;17(763):2166-2172. French. PMID: 34910402.
2 Boorman RS, More KD, Hollinshead RM, Wiley JP, Mohtadi NG, Lo IK, Brett KR. What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. Journal of shoulder and elbow surgery. 2018 Mar 1;27(3):444-8. [Google Scholar]
3 Gagnier J, Bedi A, Carpenter J, Robbins C, Miller B. A 5-Year Follow-up of Patients Treated for Full-Thickness Rotator Cuff Tears: A Prospective Cohort Study. Orthopaedic Journal of Sports Medicine. 2021 Sep 6;9(9):23259671211021589. [Google Scholar]
4 Song A, DeClercq J, Ayers GD, Higgins LD, Kuhn JE, Baumgarten KM, Matzkin E, Jain NB. Comparative Time to Improvement in Nonoperative and Operative Treatment of Rotator Cuff Tears. JBJS. 2020 Jul 1;102(13):1142-50. [Google Scholar]
5 Keener JD, Patterson BM, Orvets N, Chamberlain AM. Degenerative rotator cuff tears: refining surgical indications based on natural history data. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019 Mar 1;27(5):156-65. [Google Scholar]
6 Panattoni N, Longo UG, De Salvatore S, Castaneda NS, Risi Ambrogioni L, Piredda M, De Marinis MG, Denaro V. The influence of psychosocial factors on patient-reported outcome measures in rotator cuff tears pre-and post-surgery: A systematic review. Quality of Life Research. 2021 Jul 3:1-26. [Google Scholar]
7 Gowd AK, Cvetanovich GL, Liu JN, Nwachukwu BU, Cabarcas BC, Cole BJ, Forsythe B, Romeo AA, Verma NN. Preoperative Mental Health Scores and Achieving Patient Acceptable Symptom State Are Predictive of Return to Work After Arthroscopic Rotator Cuff Repair. Orthopaedic journal of sports medicine. 2019 Oct 25;7(10):2325967119878415. [Google Scholar]
8 Keener JD, Aleem AW, Chamberlain AM, Sefko J, Steger-May K. Factors associated with choice for surgery in newly symptomatic degenerative rotator cuff tears: a prospective cohort evaluation. Journal of shoulder and elbow surgery. 2020 Jan 1;29(1):12-9. [Google Scholar]
9 Puzzitiello RN, Patel BH, Nwachukwu BU, Allen AA, Forsythe B, Salzler MJ. Adverse impact of corticosteroid injection on rotator cuff tendon health and repair: A systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019 Dec 17. [Google Scholar]
10 Desai VS, Camp CL, Boddapati V, Dines JS, Brockmeier SF, Werner BC. Increasing numbers of shoulder corticosteroid injections within a year preoperatively may be associated with a higher rate of subsequent revision rotator cuff surgery. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019 Jan 1;35(1):45-50. [Google Scholar]
11 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]
12 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]
13 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]
14 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]
15 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]
16 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]
17 Gianola S, Iannicelli V, Fascio E, Andreano A, Li LC, Valsecchi MG, Moja L, Castellini G. Kinesio taping for rotator cuff disease. Cochrane Database of Systematic Reviews. 2021(8). [Google Scholar]
18 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]
19 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]
20 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]
21 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]
22 Killian ML, Cavinatto L, Galatz LM, Thomopoulos S. Recent advances in shoulder research. Arthritis research & therapy. 2012 Jun 15;14(3):214. [Google Scholar]
23 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]
24 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]
25 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]
26 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]
27 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]
28 Khair MM, Gulotta LV. Treatment of irreparable rotator cuff tears. Current reviews in musculoskeletal medicine. 2011 Dec 1;4(4):208. [Google Scholar]
29 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]
30 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]
31 Akpancar S, Örsçelik A, Seven MM, Koca K. The effectiveness of prolotherapy on failed rotator cuff repair surgery. Turkish Journal of Physical Medicine and Rehabilitation. 2019 Jun;65(4):394. [Google Scholar]
32 Ulack C, Suarez J, Brown L, Ring D, Wallace S, Teisberg E. What are People That Seek Care for Rotator Cuff Tendinopathy Experiencing in Their Daily Life?. Journal of Patient Experience. 2022 Jan;9:23743735211069811. [Google Scholar]
33 Quinlan NJ, Frandsen JJ, Smith KM, Lu CC, Chalmers PN, Tashjian RZ. Conservatively Treated Symptomatic Rotator Cuff Tendinopathy May Progress to a Tear. Arthroscopy, sports medicine, and rehabilitation. 2022 Aug 1;4(4):e1449-55. [Google Scholar]
This page was updated January 15, 2022