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.

Article summary

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:

The patients in this study expressed these concerns:

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:


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:

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.

In this image we see the many types of tears that can occur in the rotator cuff. In many patients we see they have many tears or lesions simultaneously. Here we see a tear in the supraspinitus tendon; in the long head of the biceps tendon; a tear in the subscapularis tendon; and concurrent SLAP tear of the labrum.

In this image, we see the many types of tears that can occur in the rotator cuff. In many patients, we see they have many tears or lesions simultaneously. Here we see a tear in the supraspinatus tendon; in the long head of the biceps tendon; a tear in the subscapularis tendon; and a concurrent SLAP tear of the labrum.

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.

People who MAY consider NON-surgical options and surgical options because of the medium risk of progression of shoulder disease.

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.

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:

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.”

Neither tear type, tear enlargement, nor tear size was associated with surgery.

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:

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.”

Case study

In this case study we have a patient who is diagnosed with a rotator cuff tear. She is a 55 year old patient who developed shoulder pain which inhibited her ability to play golf as well as other activities she enjoyed. Her treatments included cortisone injections which provided minimal relief. The patient was referred to surgery and opted out to peruse regenerative medicine injections including Prolotherapy and platelet rich plasma. She she reported 100% Improvement. 100% improvement is not a typical result but some level of improvement in good candidates for treatment are routinely seen.

In this case study, we have a patient who is diagnosed with a rotator cuff tear. She is a 55-year-old patient who developed shoulder pain which inhibited her ability to play golf as well as other activities she enjoyed. Her treatments included cortisone injections which provided minimal relief. The patient was referred to surgery and opted out to peruse regenerative medicine injections including Prolotherapy and platelet-rich plasma. She reported 100% Improvement. 100% improvement is not a typical result but some level of improvement in good candidates for treatment is routinely seen.

“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:

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:

In this research a path was followed, a path that you may be following:

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.

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?

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.

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

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.

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?

Does this sound like your case?

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.

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:

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:

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)

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?

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:

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)

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:

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.”(29This 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.


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


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This page was updated January 15, 2022


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