Rotator Cuff Tendinopathy: Comparing physical therapy, injections, and surgical options
Ross A. Hauser, MD.
Rotator Cuff Tendinopathy – Supraspinatus tendinopathy
You are most likely on this page because you are an athlete or someone with a physically demanding line of work who has continued weakness and pain in your shoulder and this is greatly impacting your ability to train/workout or perform at work. Maybe you have shoulder pain after sleeping. Sleeping on the shoulder causes a pinching of the rotator cuff muscles and can lead to rotator cuff weakness. There are cases where the cause of the rotator cuff tendon laxity was due to years of sleeping on the shoulder.
You may be wondering “is Rotator Cuff Tendinopathy,” the same thing as a rotator cuff tear?
You are also likely to be someone who is confused by the diagnosis you received for your shoulder pain. Simply, and generally speaking, Rotator Cuff Tendinopathy is a problem with the tendons that attach the rotator cuff muscles to the bones of the shoulder. The tendons can be worn, injured, stretched, and/or torn. A rotator cuff tear is a tear in the muscles or the tendons of the rotator cuff structure.
You may also be on this page because you went to your health care provider and received the typical recommendations of:
- Anti-inflammatory medications, which have stopped helping (See our article When NSAIDs make the pain worse)
- REST, which is not something someone who is working can do most of the time
- Physical therapy
So here you are looking for answers. We are probably the tenth or 20th page you visited online. What we hope to share with you here is that you have continued issues in your shoulder because you cannot isolate one problem in the shoulder and treat it and realistically expect great or long-term results. The shoulder needs to be treated as a unit.
Article summary and outline:
- Rotator Cuff Tendinopathy, Tendinitis and Tendinosis treatments.
- Rotator cuff tendonitis occurs with muscle weakness or injury.
- The swelling went away but the rotator cuff pain remains? Why?
- The medical community is in debate as to what is “true tendinitis,” and what is “true tendinosis.”
- Research: Ibuprofen does not help tendinosis it may make it worse.
- The reason your shoulder is not better? Because everyone is looking at a tendon, they should be looking at your whole shoulder.
- So here you are stuck in degenerative shoulder disease looking for a way out.
- Swelling protects the shoulders, when anti-inflammatories take the swelling away, the shoulder is vulnerable.
- One cortisone injection versus one PRP injection in providing pain relief and improved function in patients with rotator cuff tendinopathy and partial-thickness rotator cuff tears.
- Comparing PRP to Physical Therapy and Steroid injection in the treatment of rotator cuff tendinopathy.
- What is the most effective exercise for rotator cuff-related shoulder pain and lateral elbow tendinopathy? “There is no consensus.”
- Are Platelet Rich Plasma Injections effective treatments?
- How about Arthroscopic rotator cuff surgery?
- If there is no added benefit to the surgery, why take the risk of complications and/or a failed procedure?
- Rotator Cuff Tendinopathy – Tendinitis – Tendinosis treatment – The research.
- Rotator cuff tendinosis degeneration in response to chronic overuse.
- Focus on the supraspinatus tendon and progression to rotator cuff tears.
- Rotator Cuff Tendinosis Treatment.
- Research on Prolotherapy and supraspinatus tendinopathy .
Rotator Cuff Tendinopathy, Tendinitis and Tendinosis treatments
You had a follow-up visit with your orthopedist. You were told that your tendinopathy or “tendon problems” have not responded to the treatments that you were prescribed above. This came as no surprise to you. You know something is wrong with your shoulder. You have pain and sometimes you can barely move your arm. But, one thing you did notice, is that the swelling and inflammation in your shoulder has pretty much gone away. This may have made you curious as to why your joint swelling went away but the pain remains. You initially thought the swelling and inflammation reduction was a good thing and that your tendon was healing. Now you are finding out pain without swelling is not such a good thing and you have progressed to “rotator cuff tendinosis.” You are anxious to get something positive done but this is now turning into a long-term, “I have to live with this problem.”
In the image below we see the rotator cuff muscles viewed from behind.
Rotator cuff tendonitis occurs with muscle weakness or injury
Rotator cuff tendonitis occurs when the small muscles of the rotator cuff, the supraspinatus, infraspinatus, teres minor, and subscapularis, become strained causing weakness of these structures and subsequent tendonitis. While the deltoid muscle is the big and strong muscle of the shoulder, as seen on many well-built athletes, the small and relatively weak rotator cuff muscles perform key functions. The supraspinatus helps seat the humeral head (ball) into the glenoid cavity (socket) when the arm is raised from the side (abducted). The infraspinatus and teres minor rotate the forearm away from the body or in the hand-waving position (external rotation), and the subscapularis rotates the forearm towards the body (internal rotation). Once the balance between motion and joint stability is altered through weakness in the static structures (ligaments) or the dynamic structures (rotator cuff muscles), pain and impaired function will invariably ensue. Baseball pitchers, quarterbacks, tennis players (serving), and swimmers are prone to rotator cuff tendonitis and impingement syndrome. This is because these athletes perform a lot of overhead movements. The rotator cuff is most vulnerable in this position.
The swelling went away but the rotator cuff pain remains? Why?
This is a problem we see in many patients. They thought they were healing because the conservative care methods of inflammation reduction were working to reduce their inflammation, BUT, the pain remained. Clearly, then, it was not the inflammation causing the pain, nor was the inflammation fixing or healing the problem.
What are we seeing in this image?
Shoulder joint instability causes accelerated and stressful forces on the rotator cuff tendons. This stress and force put great strain on the rotator cuff tendons which move the shoulder joint through a normal range of motion. The strain on the tendons causes weakness, fraying, tearing, and whole joint capsule instability. Rotator cuff tear caused by chronic wear and tear is a symptom of shoulder instability.
When a patient comes to Caring Medical with joint problems related to sports, an active lifestyle, or a physically demanding job and a diagnosis of one of the various tendinopathy issues described in this article, many of them will have an advanced case. It will either be advanced tendinitis or advanced tendinosis. Briefly, these are:
Rotator Cuff Tendinitis – The initial wear and tear and overuse injuries to tendons usually involve a degree of inflammation. This is the Tendinitis stage. This is where your health care provider will attack your problems with anti-inflammatory medications and possibly cortisone injections.
Rotator Cuff Tendinosis – You continue to have pain but not inflammation. In essence, your body has given up trying to repair the tendon because your body believes, it is “too far gone.”
The medical community is in debate as to what is “true tendinitis,” and what is “true tendinosis.” This affects your treatment, you have to pay attention and talk to your doctor
The differences between Rotator Cuff tendinitis and Rotator Cuff tendinosis are important as it helps guide treatments. Clearly, a path of anti-inflammatory treatments would have to be carefully evaluated for effectiveness in tendinosis.
Research: Ibuprofen does not help tendinosis it may make it worse
You do not have to be a scientist to understand this research. Ibuprofen does not help tendinosis.
This research came from the University of Copenhagen and was published in the Journal of Applied Physiology in November 2017 (1).
Highlights of research
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat tendinopathy, but evidence for this treatment is lacking, and little is known regarding the effects of NSAIDs on the human tendinopathic tendon.
- This study investigated the effects of NSAID treatment (ibuprofen) on the human tendinopathic tendon, with changes in gene expression (generally: Gene expression is your cells talking to each other or signaling each other that they need to heal something) as the primary outcome, and tendon pain, function, and blood flow as secondary outcomes.
- Noteworthy of this research: “Nonsteroidal anti-inflammatory drugs are widely used in the treatment of tendinopathy, but little is known of the effects of these drugs on tendon tissue. We find that one week of ibuprofen treatment has no effect on gene expression of collagen and related growth factors in an adult human tendinopathic tendon in vivo . . . suggesting that tendinopathic cells are not responsive to ibuprofen.”
Ibuprofen does not stimulate healing in tendinosis – Ibuprofen may make your tendinopathy worse
In a May 2018 study published in the Journal of Musculoskeletal Disorders and Treatment, (2) researchers at Rush University Medical Center offered these observations on an Achilles injury in laboratory rats:
- Post-tendon injury analgesia (pain relief) is often achieved with NSAIDs such as Ibuprofen, however, there is increasing evidence that NSAID usage may interfere with the healing process.
- We have examined the effect of oral Ibuprofen, on Achilles tendon healing in rat tendinopathy.
- The rats received ibuprofen 3 days after the initial injury (acute cellular response phase – this is during the time of inflammation in response to injury) and continued for 22 days
- or started at 9 days after injury (transition to matrix regeneration phase – this is the time of repair after the initial inflammatory phase) and given for 16 days.
- Ibuprofen prevented key processes of the inflammatory response to healing. Including the processes of removing dead injured tissue and the process of rebuilding the damaged tendon. The researchers concluded that the use of ibuprofen for pain relief during inflammatory phases of tendinopathy might interfere with the normal processes of healing.
What are we seeing in this image?
In this illustration we see tendinopathy leading to tendon tears of the supraspinatus tendon, the tendon of the long head of biceps, and the subscapularis tendon. Tendinopathy is caused by and contributes to shoulder instability which will eventually lead to shoulder surgery.
The reason your shoulder is not better? Because everyone is looking at a tendon, they should be looking at your whole shoulder.
When someone comes into one of our clinics, and they come in with swimmer’s shoulder, or supraspinatus tendinopathy, or a rotator cuff tendinopathy diagnosis, they come in knowing that their shoulder hurts, there is a problem with tendons, and they are thinking that somewhere along the line someone, if they have not already, is going to eventually recommend a surgery.
Surgery means extended time away from sport or work. Surgery for many, therefore, is not a realistic option.
But perhaps the biggest problem is that everywhere this person has been, all the talk is about a single tendon or the rotator cuff as a single unit. It is most probable that no one sat down with this person and said to them, “to heal this tendon problem, we have to heal your whole shoulder because:
- Rotator Cuff Tendinopathy is the cause of your shoulder instability and weakening.
- Your Rotator Cuff Tendinopathy is the result of your shoulder is loosening and weakening because of wear and tear and damage to the shoulder ligaments, or
- Your shoulder labrum is wearing away and progressively making your shoulder lose and wobbly.
The very strong message here is, your shoulder tendons do not live on an island, they are part of the shoulder joint complex that includes ligaments and labrum. You cannot just address the tendons and expect long-term healing and return to pre-injury shoulder strength.
So here you are stuck in degenerative shoulder disease looking for a way out.
Your shoulder has a plan to treat itself. Here it is:
When the problems of shoulder instability occur and manifest pain, loss of strength, and reduced performance the body has three protective mechanisms:
- Engage or spasm the muscles to hold the shoulder together,
- Swell the joint,
- and eventually, grow more bone. This is why bone spurs and arthritis are the long-term results of joint instability which was treated only for the symptoms it produced: inflammation and muscle spasms.
Let’s go back to the beginning of this article. “You initially thought this was a good thing and that your tendon was healing. Now you are finding out pain without swelling is not such a good thing and you have progressed to “rotator cuff tendinosis.” Corticosteroid shots and anti-inflammatories address the shoulder swelling and inflammation, so the symptoms appear better and people keep taking them, but rotator cuff degenerative problems caused by shoulder instability continues.
Swelling protects the shoulders, when anti-inflammatories take the swelling away, the shoulder is vulnerable.
Understanding the role of chronic swelling in the shoulder is to understand the good news/bad news scenario. The good news is that your shoulder is swelling up. That means it is trying to heal and protect itself. The bad news is, your shoulder is CHRONICALLY swelling up. This means that the shoulder cannot attain a level of permanent “heal.” Chronic inflammation is a toxic soup that your shoulder is swimming in. This inflammation slowly and unceasingly dissolves the soft tissue and bone which leads to degenerative shoulder disease.
The chronic inflammation continues because it is still trying to offer the “protection” of joint swelling and diffuse further destructive motion exerted on the rotator cuff tendons. The body now swells the tendons through inflammation to help them handle the heavier workload. But the inflammation is not a long-term answer, it is a short-term response to help get the shoulder through a tough time. To save the shoulder, that inflammation and swelling need to be shut down.
Does Cortisone make the shoulder more vulnerable?
Cortisone is of course the last best anti-inflammatory weapon that your shoulder specialist may have. While some people will get a short-term benefit from cortisone, doctors are concerned with the long-term and how this would impact a future rotator cuff repair surgery.
Researchers from Tufts Medical Center, Rush University Medical Center, and the Hospital For Special Surgery published a December 2019 study in the medical journal Arthroscopy (3) in which they highlighted that cortisone injections into the shoulder prior to arthroscopic rotator cuff repair, puts patients at greater risk for post-surgical complications and eventually, the need for a secondary or revision shoulder surgery.
From this research:
“Several recent clinical trials have demonstrated that corticosteroid injections are correlated with increased risk of revision surgery after arthroscopic rotator cuff repair.”
“Caution should be taken when deciding to inject a patient (with cortisone), and this treatment should be withheld if an arthroscopic rotator cuff repair is to be performed within the following six months.”
Earlier in 2019, researchers from the Mayo Clinic, Hospital for Special Surgery, and the University of Virginia, examined the association between the use of subacromial corticosteroid injections within a year before rotator cuff repair and subsequent need for revision rotator cuff surgery. Also published in the medical journal Arthroscopy (4), this research team published 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”
The caption of the image reads: Supraspinatus ultrasound. Injection of the supraspinatus tendon (rotator cuff) using ultrasound guidance.
One cortisone injection versus one PRP injection in providing pain relief and improved function in patients with rotator cuff tendinopathy and partial-thickness rotator cuff tears.
We are going to explain more about PRP or platelet-rich plasma injections below. For the purpose of our discussion on cortisone, we are going to make a comparison. In the research above we found that one cortisone injection did not present as much a risk for degenerating the rotator cuff as two cortisone injections would. So this next study examined how good one cortisone injection would be in helping the patient as compared to one Platelet Rich Plasma or PRP injection would.
Researchers from the University of Calgary’s section of orthopedic surgery published findings in the February 2021 issue of the medical journal Arthroscopy (5) in which they compared the benefits or non-benefits of cortisone against PRP.
The researchers of this study performed a randomized controlled trial comparing one injection of platelet-rich plasma (PRP) with one standard corticosteroid injection in providing pain relief and improved function in patients with rotator cuff tendinopathy and partial-thickness rotator cuff tears.
To measure the outcomes:
- Patients completed patient-reported outcome assessments at baseline and at 6 weeks, 3 months, and 12 months after injection.
- The primary outcome was improvement in the visual analog scale (VAS) score for pain. Secondary outcomes included changes in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Rotator Cuff Index (WORC) scores (Scores to assess pain and function).
- Treatment failure was defined as (the need for) subsequent injection, consent to undergo surgery (patients agreed to have surgery), or operative intervention (patients had surgery after injection).
Results: (The researchers) followed up on 99 patients (47 in the PRP group and 52 in the corticosteroid group) until 12 months after injection.
- At 3 months after injection, the PRP group had superior improvement in pain and function scores.
- There were no differences in patient-reported outcomes at 6 weeks or 12 months.
- There was no difference in the rate of failure or conversion to surgery between groups.
Conclusions: Patients with partial rotator cuff tears or tendinopathy experienced a clinical improvement in pain and patient-reported outcome scores after both ultrasound-guided corticosteroid and PRP injections.
- Patients who received PRP obtained superior improvement in pain and function at short-term follow-up (3 months).
- There was no sustained benefit of PRP over steroid injection at longer-term follow-up (12 months).
This study suggests what many studies suggest, PRP injections did better in one-shot comparisons. However as we have stressed, PRP will likely not be effective if it is administered as a single one-time injection. That is not the way we offer PRP.
Comparing PRP to Physical Therapy and Steroid injection in the treatment of rotator cuff tendinopathy.
A July 2021 study in the Malaysian Orthopaedic Journal (6) noted what many have before that the treatments of physiotherapy and corticosteroids, while possibly helpful for some, are not long-term fixes and simply address the problems of symptoms rather than the cause or pathology of the shoulder problem. They also noted that there is no clear consensus over the benefit of using PRP for tendinitis over these other treatments. What the researchers did then was to conduct a clinical study to demonstrate the effectiveness (if there was any) of PRP and study the functional outcome in the treatment of rotator cuff tendinopathy.
Here are the learning summary points:
- “Patients with shoulder pain for more than three months not responding to NSAIDs or physiotherapy with a diagnosis of rotator cuff tendinitis, confirmed by MRI, were included in the study.”
- 30 patients who received 5ml of (ultrasound) guided PRP injection in the subacromial space followed by a six-week exercise program.
- Patients were followed-up at three, six, and 12 weeks and were assessed using standard pain, function, and disability scoring systems.
- Conclusion: “Platelet Rich Plasma injections showed good to excellent early results, in patients with rotator cuff tendinopathy with improvement in (standard pain, function, and disability scoring systems).
What is the most effective exercise for rotator cuff-related shoulder pain and lateral elbow tendinopathy? “There is no consensus.”
Please see our article: Physical therapy and exercise for shoulder pain. When it works, when it does not work.
An August 2022 paper from physical therapist specialists at the University of Malaga in Spain and published in the journal Musculoskeletal science & practice (20) examined the effectiveness of therapeutic exercise in the management of upper limb tendinopathies. The research team notes: “Among upper limb tendinopathies, rotator cuff-related shoulder pain and lateral elbow tendinopathy are the most representative disorders. Therapeutic exercise arises as an effective approach, but there is no consensus about the optimal progression criteria.”
In other words, what is the most effective exercise for rotator cuff-related shoulder pain and lateral elbow tendinopathy? “There is no consensus.” In an effort to offer suggestions on exercise programs to their fellow physical therapists, the researchers here compared progression criteria (more demanding exercises as the therapy progressed) and resulting impact on pain and function.
What prevented the patient from having a more successful physical therapy? “Pain was the most frequent benchmark when modulating and progressing the exercises, although other criteria were found such as fatigue or self-perceived ability. Progressive exercise seems effective to manage upper limb tendinopathies, but the superiority of a progression criterion against others remains unclear.”
These finding suggest that pain, fatigue, and the patient’s perception about the difficulty and worth of doing the exercise played a key role in less than successful physical therapy.
Are Platelet Rich Plasma Injections effective treatments?
A September 2021 editorial in the medical journal Arthroscopy (7) gives us a brief explanation of why PRP or Platelet Rich Plasma injections could be beneficial for patients.
“Platelet-rich plasma (PRP) injections continue to be used at increasing rates to treat common musculoskeletal conditions. PRP has a low-risk profile and emerging in vitro evidence to support its positive effects on soft-tissue healing. PRP has been shown to be of benefit for knee osteoarthritis, but less has been published regarding the shoulder. PRP delivers a high concentration of growth factors, cytokines, and other important inflammatory modulators. Its use is appealing for treating partial-thickness rotator cuff tears, subacromial bursitis, and rotator cuff tendinopathy since rotator cuff tendons often have poor healing capacity due to intrinsic degeneration.”
Many people reading this article may have been told about Platelet Rich Plasma therapy (PRP). They may have heard very good things, they may have heard some not good things. The not-good things usually are confined to the “it will not work for you,” suggestion they are given. This is typically supported by research that suggests over the long haul if you get one PRP injection you will likely need surgery anyway.
We are going to challenge that statement with some independent research and the 28+ years of experience we have in offering patients treatments for their chronic hip and sports-related injury problems.
First, what is PRP therapy, can I see a treatment?
- Platelet Rich Plasma Therapy draws out your own blood into a vial. Your blood is then “spun,” in a centrifuge to isolate out the components that heal injuries. These would be the anti-inflammatory and growth factors found in the blood platelets. This “Platelet Rich,” solution is then reintroduced, via injection, into the areas causing pain and weakness.
How about Arthroscopic rotator cuff surgery?
There are people who do very well with surgical repair of the rotator cuff tendons. These are typically people we do not see in our office. We see the people who had the surgery or had concerns that the surgery would not address the problems they were having. In some, the surgery created more problems for them. Many people do seek out surgery when there is an issue with bone spurs.
Arthroscopic rotator cuff surgery can remove bone spurs and inflamed tissue around the shoulder. While small tears can be treated with arthroscopic surgery, larger tears would require open surgery through a larger incision to repair the torn tendon. Please see our article Rotator Cuff Tear Surgery
Unfortunately, surgery may make the problem worse because they are concentrating solely on the tear or an MRI or X-ray finding that, again, the overall joint weakness is not addressed. Let alone, decisions to remove cartilage or other tissue will most commonly fast-track the onset of arthritis.
- Doctors from Finland writing in the Bone and Joint Journal, (15) suggest that arthroscopic decompression not be recommended for patients with rotator cuff tendinopathy.
In their study patients were randomized into two treatment groups:
- arthroscopic acromioplasty (shaving down bone to relieve pressure), and a supervised exercise treatment
- and a similar supervised exercise treatment alone.
Self-reported pain on a visual analog scale (VAS) questionnaire was the primary means of determining the study’s results.
The researchers also looked for problems of disability, working ability, pain at night.
- A total of 90 patients (64%) returned questionnaires at an average of 12 years after research began.
- Both treatment groups reached statistically significant improvement compared with the baseline for pain, but there was no significant difference between groups.
The same was true in the secondary outcome measures. Due to group changes, the results were also analyzed per protocol: operated or not. No significant differences between the groups were found.
The researchers were forced to conclude that surgery was of no added benefit. The summarized the research findings as such:
- Even though the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results.
- In the future, an optimum exercise regime should be searched for, as the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy.
If there is no added benefit to the surgery, why take the risk of complications and/or a failed procedure?
In the Journal of Hand Therapy, (16) doctors at the University of Queensland suggest that patients receiving surgery for upper extremity disorders including Carpal tunnel syndrome, Lateral epicondylalgia, and Rotator cuff tendinopathy from workplace overuse injury needed to be better categorized after surgery failure. We have written extensively about rotator cuff surgery failure rates.
Here we have a situation of a large group of people with surgical failure, yet doctors are in a disagreement about what level of failure these patients are in. It should seem that failure is a failure. In this study the Australian doctors recognized this disagreement and found in their surveys the experts say:
- Forty-two experts defined a delayed return to work as either a worker not returning to pre-injury (or similar) work within the expected time frame (45%);
- not returning to any type of work (36%);
- or recovering slower than expected (12%).
Two-thirds of the experts believed that universal time points to delineate delayed Return To Work should be avoided. In other words, there is no accurate way to determine how long recovery from Rotator cuff tendinopathy will take or how successful a worker will be in returning to work in full or less than full capacity.
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.
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:
- PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
- In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
- This patient, in particular, came to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
- The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
- With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
- PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrated cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
- PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments, in this case, it was in his anterior shoulder attachments to address the chronic dislocations.
As you see from the video above, we do not offer PRP injections without Prolotherapy injections.
As you see from the video above, we do not offer PRP injections without Prolotherapy injections. PRP is different than Prolotherapy as it utilizes the patient’s blood platelets as a healing injectable in the shoulder.
More research on PRP
Interest in PRP treatments for shoulder tendinopathy has been going on for decades. In 2011, in a heavily cited study (research used by other researchers), doctors in Israel writing in the medical journal Sports Medicine and Arthroscopy Review (8) wrote that injections of platelet-rich plasma have led to reduced pain and improved recovery in the rotator cuff with the restoration of function.
A December 2020 study in the Journal of Clinical Medicine (9) compared the effectiveness of cortisone and other conservative care treatments for a partial rotator cuff tear partial-thickness tears. Specifically the comparison between cortisone and Platelet-Rich Plasma. How effective these treatments were was measured in how much any treatment reduced pain and shoulder functionality. The findings: “The most important finding of this study was that the treatment of partial rotator cuff tears with PRP injections seems to lead to significantly better outcomes in terms of pain and shoulder function in long-term follow-up, whereas, in short- and medium-term follow up, PRP injections seem to be superior only in terms of shoulder function.”
This research also mentions the use of Prolotherapy. Here are those mentions:
“The use of corticosteroids should be carefully evaluated given the high risk of muscle weakness, tendon rupture, and collagen collapse. PRP is a method recently developed due to the discovery of growth factors released by platelets, which have been shown to be effective in tissue repair. Prolotherapy injection is a technique that has been previously used treating other orthopedic diseases; the ease of application, the reduced cost, and the reduction of the rehabilitation process make it advantageous. . . (several examined papers) agree with the concept that repeated corticosteroids injections at short intervals are dangerous with regard to tendon atrophy and reduction of connective tissue quality. Despite the efficacy of Prolotherapy on rotator cuff lesions (reported in different papers), only two studies included in this review analyzed (Prolotherapy); therefore more comparative trials need to be carried out to better evaluate this treatment.
Compared to the success we have seen with Prolotherapy and PRP in treating rotator cuff injuries, we believe it would be beneficial to try PRP injections first instead of surgery.
Rotator Cuff Tendinopathy – Tendinitis – Tendinosis treatment – The research
Again, let’s explore the differences in Tendinopathy, Tendinitis, and Tendinosis, of the rotator cuff. In her article published in the International Journal of Therapeutic Massage and Bodywork, Evelyn Bass, LMT wrote that:(10)
- Tendinitis is the inflammation of the tendon and results from micro-tears in an acute injury
- Tendinosis (literally diseased tendon) is degeneration in response to chronic overuse; when overuse is continued without giving the tendon time to heal and rest, such as with repetitive strain injury, tendinosis results. Even tiny movements, such as clicking a mouse, can cause tendinosis when done repeatedly. The confusion about the difference between tendinitis (inflammation of the tendon) and tendinosis (diseased tendon without inflammation) is widespread.
- Tendinopathy refers generally to damaged and injured tendons.
Many injuries commonly presumed to be tendinitis are actually tendinosis.
The suggestion that tendinitis (inflammation) comes before tendinosis (chronic degenerative disease) is at odds with the fact that a healthy tendon is up to twice as strong as the muscle, making the body of the tendon unlikely to tear before the muscle unless the tendon has already been weakened by degenerative changes.
- In other words, you do not need an inflamed joint to have a diseased tendon. However, that does not mean that inflammation will not lead to tendinosis.
Rotator cuff tendinosis degeneration in response to chronic overuse
The shoulder is made up of two joints, the glenohumeral joint, and the acromioclavicular joint. The glenohumeral joint is a ball and socket joint formed by the top of the humerus and the socket of the scapula. A rotator cuff is a group of four muscles and tendons that surround the glenohumeral joint and hold the head of the humerus into the scapula. The glenohumeral ligaments, however, are the main stabilizers.
The rotator cuff functions to stabilize the shoulder and allow the arms to move through a full range of motion. The rotator cuff works together with the deltoid muscle to provide motion and strength to the shoulder for activities that require motion above the waist and shoulders.
Rotator cuff tendinosis (the disease and degeneration process) occurs when the small muscles of the rotator cuff, the supraspinatus, infraspinatus, teres minor, and subscapularis, become strained, causing weakness of these structures and subsequent tendonitis (tendon inflammation). As we mentioned above, the muscles go first before the tendon in most cases. This is especially true in the small and relatively weak rotator cuff muscles which are asked to perform key functions.
- The supraspinatus helps seat the humeral head (ball) into the glenoid cavity (socket) when the arm is raised from the side (abducted).
- The infraspinatus and teres minor rotate the forearm away from the body or in the hand-waving position (external rotation),
- and the subscapularis rotates the forearm towards the body (internal rotation).
Once the balance between motion and joint stability is altered through a weakness in the static structures (ligaments) or the dynamic structures (rotator cuff muscles), pain and impaired function will invariably ensue. Baseball pitchers, quarterbacks, tennis players (serving), and swimmers are prone to rotator cuff tendonitis and rotator cuff impingement syndrome. This is because these athletes perform a lot of overhead movements. The rotator cuff is most vulnerable in this position.
Other causes of rotator cuff tendinosis include:
- occupational overuse (working with the arms overhead for many hours or days);
- an existing weakness of the rotator cuff muscles, ligaments, or tendons;
- use of improper technique during a sport or occupational activity;
- poor posture;
- sleeping on the same arm each night; Sleeping on the shoulder causes a pinching of the rotator cuff muscles and can lead to rotator cuff weakness. There are cases where the cause of the rotator cuff tendon laxity was due to years of sleeping on the shoulder.
- cervical spine nerve pinching;
- an improper training schedule, such as too much too soon;
- a direct trauma, such as a fall directly onto the shoulder or onto an outstretched arm;
- poor muscle control or coordination; poor posture over the years; or a loose or unstable shoulder joint following a previous dislocation.
- If the rotator cuff continues to be injured or inflamed it will eventually tear, resulting in a more serious problem.
Focus on the supraspinatus tendon and progression to rotator cuff tears
A supraspinatus tendon problem is manifested by pain with abduction and external rotation of the shoulder, especially when reaching for things above shoulder level, or pain in the shoulder after sleeping due to compression of the supraspinatus tendon. The supraspinatus tendon often refers pain to in the back of the shoulder.
Those who have supraspinatus tendon laxity causing pain will stop moving their arms into the painful position. Although they may not realize it, they are slowly but surely losing shoulder movement.
The progression from tendinitis to rotator cuff tear was documented in new research from doctors at the Seoul National University College of Medicine in South Korea who published their findings in the journal Knee Surgery, Sports Traumatology, Arthroscopy. (11)
This study showed that the degeneration of the supraspinatus tendon increases as the stage of rotator cuff disease progresses from tendinopathy to partial rotator cuff tear, and then to full rotator cuff tear. Significant tendon degeneration began from the stage of a partial rotator cuff tear. The clinical relevance of the study is that strategies and goals of the treatment for rotator cuff disease should be specific to its stage, in order to prevent disease progression for tendinopathy and partial rotator cuff tear, as well as to restore the structural integrity for full rotator cuff tear. In other words, treat it early!
Rotator Cuff Tendinosis Treatment
As mentioned above, and to review, the initial treatment for rotator cuff tendinosis is frequently to limit above shoulder level activity, application of ice to the shoulder, anti-inflammatory medications for pain, and physical therapy to maintain flexibility.
Although common in the treatment of rotator cuff tendonitis, the use of anti-inflammatories and steroids may actually hinder the healing of soft tissues, such as tendons and ligaments, and do not address the root of the problem. Likewise, physical therapy does not help heal the affected ligaments and tendons. Although these treatments may help temporarily, they do not address the original cause of the problem, thus, it eventually returns. In addition, degenerative fraying and tearing of the tendon may occur with constant irritation of the tendon.
When symptoms persist, patients who experience rotator cuff tendonitis are commonly referred to a surgeon for arthroscopic surgery.
Research on Prolotherapy and supraspinatus tendinopathy
- Prolotherapy is the simple injection of dextrose (sugar) into the shoulder joint. Many studies have documented Prolotherapy treatments’ effectiveness in treating the problems of chronic pain. We are going to look at two studies here, then discuss surgical options. Then return to more research on Prolotherapy.
Doctors at Taipei Medical University published a February 2022 study in the Archives of Physical Medicine and Rehabilitation (19) on the effects of Prolotherapy on pain and shoulder disability in patients with chronic supraspinatus tendinosis.
This was a randomized double-blind placebo-controlled trial.
In this study, 57 patients with symptomatic chronic supraspinatus tendinosis were examined. The patients were randomly divided with 29 getting 20% hypertonic dextrose (Prolotherapy) or 5% normal saline (28 patients getting a placebo).
The Prolotherapy group exhibited significant improvements in the visual analog scale (pain measured 0 – 10) and Shoulder Pain and Disability Index scores compared with baseline scores at week two. However, the effect was not sustained to week six.
Flexion ROM (range of motion) increased at weeks 2 and 6 weeks compared with baseline. The thickness of the supraspinatus tendon improved at weeks 6 and 12 compared with the baseline.
Conclusion: Hypertonic dextrose Prolotherapy injection could provide short-term pain and disability relief in patients with chronic supraspinatus tendinosis. Ultrasound imaging at week 6 revealed changed tendon morphology.
The review of this study revealed familiar findings. Prolotherapy treatment can help BUT prolotherapy treatment will not be as successful if it is one shot one time, the initial success of pain relief and better range of motion and function can be sustained if further treatments are initiated.
In October 2019, doctors at the University of Toronto, McMaster University, and UPMC Center for Sports Medicine in Pittsburg wrote in PM & R: the Journal of Injury, Function, and Rehabilitation (12) of the “Effectiveness of Dextrose Prolotherapy for Rotator Cuff Tendinopathy.”
Here is the learning point of this research:
- A comprehensive (research study) search was completed to identify randomized controlled trials addressing prolotherapy using hyperosmolar (higher dextrose amounts injected into the shoulder) dextrose solution for rotator cuff tendinopathy.
- Included studies in this review analyzed a total of 272 participants with a final follow-up ranging 6-weeks to 12-months.
- Prolotherapy (application) differed greatly among studies. (The number of injections given varied. One study used cortisone concurrently. In our office, we do not utilize cortisone with Prolotherapy.
- There was a statistically significant improvement in pain intensity with multi-site injection protocols compared to physical therapy and medical management in both studies.
- The complication rate was low with only 6/272 participants experiencing adverse events consisting of the transient increase in pain for 1-2 days post-intervention.
The study concludes:
“Prolotherapy with hyperosmolar dextrose solution is a potentially effective adjuvant intervention to physical therapy for patients with rotator cuff tendinopathy ranging from tendinosis to partial-thickness and small full-thickness tears. Further studies are necessary to determine effects in subpopulations as well as optimal technique including dextrose concentration, volume, and location.”
In December 2018, research published in the European Journal of Physical and Rehabilitation Medicine (13) also explored the effectiveness of Prolotherapy treatments in supraspinatus tendinopathy.
These are the learning points of the study:
- Although patients with symptoms caused by chronic rotator cuff tendinopathy can be treated using conservative treatments, some of them may still experience refractory or difficult to resolve symptoms. Hypertonic dextrose Prolotherapy may be another treatment choice for these difficult to resolve symptoms.
- The study group was 31 patients with chronic supraspinatus tendinopathy and shoulder pain for more than 6 months.
The study was conducted with a single injection of Prolotherapy vs Placebo
- The study patients were treated with one dose of an ultrasound-guided hypertonic dextrose injection at the supraspinatus enthesis site, whereas control patients received one dose of 5% normal saline through the same method.
- Pain and disability improvement scores were noted at 2 and 6 weeks after intervention.
The study group indicated a significant improvement in pain and disability scores including improved range of motion compared with the control group at 2 weeks after the injection. However, the effect did not sustain until 6 weeks after the injection.
This is our treatment, with multiple injections at each visit. The reality of treatment is that months or years of degenerative tendinopathy in the shoulder cannot realistically be expected to be reversed with a single injection of anything.
One Prolotherapy treatment vs One Cortisone Injection
A March 2021 study in the journal Advanced Biomedical Research (14) compared the effectiveness of Prolotherapy injections with corticosteroid injection in patients with rotator cuff dysfunction.
In this study:
- Thirty to sixty-five-year-old patients with chronic rotator cuff disease were divided into two groups. Ultrasound-guided dextrose Prolotherapy of supraspinatus tendon was done for one group and ultrasound-guided corticosteroid injection in the subacromial bursa was done for the other groups.
- Visual analog scale (VAS) and Shoulder Pain and Disability Index (SPADI) were evaluated for both groups at baseline, 3 and 12 weeks after injections.
- Thirty-three patients were included in the result.
- Both the groups showed significant improvement in visual analog scale and Shoulder Pain and Disability Index scores in 3 and 12 weeks after injections compared with pre-injection times with no difference between the two groups neither in 3 weeks nor in 12 weeks after injections.
Conclusion: Both ultrasound-guided dextrose Prolotherapy and cortisone injections are effective in the management of rotator cuff-related shoulder pain in both short-term and long-term with neither being superior to the other. Therefore, Prolotherapy may be a safe alternative therapy instead of corticosteroid injection due to the lack of its side effects.
One item to note is that we typically do not find Prolotherapy to be a one-time treatment. We see its maximum benefit in three to six treatments.
Prolotherapy Rotator Cuff tendinopathy treatments
To review, Comprehensive Prolotherapy, as practiced in our practice for rotator cuff tendonitis involves multiple injections of a dextrose-based solution to the various ligament and tendon attachments around the shoulder, as well as inside the joint. Prolotherapy to all of the adjacent structures stimulates a natural inflammatory response in the weakened rotator cuff tissues. This mild, localized inflammatory reaction draws immune cells to the area to regenerate the injured tissues. The increase in blood flow and regenerative cells are the body’s natural healing response. The body also responds by depositing collagen at the site of injury, strengthening the rotator cuff tendons that once were weak.
- Prolotherapy injections strengthen the ligaments and the tendinous insertions of the rotator cuff and deltoid. This combined with the gradual re-strengthening of the rotator cuff muscles promises an excellent chance for a full recovery and full performance in many patients.
There is a lot of research to support the use of Comprehensive Prolotherapy injections for Rotator Cuff Tendinopathy beyond the two studies we cited above.
In January 2016, doctors at the University of British Columbia and the University of Kansas (Dean Reeves MD) published in the Archives of Physical Medicine and Rehabilitation (17) a comparison of the effects of dextrose Prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy against 2 saline control injection procedures.
- 73 patients with chronic shoulder pain, examination findings of rotator cuff tendinopathy, and ultrasound-confirmed supraspinatus tendinosis/tear.
- Three monthly injections either:
- (1) onto painful entheses (tendon attachment to the bone) with dextrose (Enthesis-Dextrose),
- (2) onto entheses with saline (Enthesis-Saline), or
- (3) above entheses with saline (Superficial-Saline). All solutions included 0.1% lidocaine as a pain agent. All participants received concurrent programmed physical therapy.
Conclusion of the research: “In participants with painful rotator cuff tendinopathy who receive physical therapy, injection of hypertonic dextrose on painful entheses resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect. Dextrose Prolotherapy may improve on the standard care of painful rotator cuff tendinopathy for certain patients.”
Periarticular Neurofascial Dextrose Prolotherapy
A 2019 study in the Journal of Clinical Rheumatology (18) compared periarticular (neurofascial) dextrose Prolotherapy versus physiotherapy for treatment of chronic rotator cuff tendinopathy in the short term.
Lyftogt Perineural Injection Treatment™ (also called Neurofascial Prolotherapy, as well as Neural Prolotherapy and Subcutaneous Prolotherapy) is a sometimes used side-by-side treatment with traditional dextrose based Prolotherapy. As these techniques work by different mechanisms they can diminish the pain of similar conditions, so they can be given together or separately. In Dextrose base Prolotherapy the ligament and tendon attachments are being treated, in Perineural Injection, the nerves are being treated.
In this study, doctors carried out a randomized clinical trial. In total, 66 patients with chronic rotator cuff tendinopathy were randomly allocated to 2 groups. The outcomes changed in shoulder pain intensity (primary) and disability (secondary) index. For physiotherapy, participants received superficial heat, transcutaneous electrical nerve stimulation, and pulsed ultrasound. Also, they carried out an exercise program, 10 sessions of 30 minutes for 3 weeks. For Prolotherapy, injections of 8 mL of 12.5% dextrose and 40 mg of 2% lidocaine were injected 2 times with 1-week interval superficially around the shoulder joint and to tender points along the suprascapular nerve.
The results: Neurofascial dextrose was more effective than physiotherapy for alleviating pain in 2 weeks and they were similar 3 months after the interventions. For disability, dextrose was more effective than physiotherapy 2 weeks and 3 months after the interventions. However, the changes in the physiotherapy group seemed to be more sustained.
Conclusions: Both interventions are effective for the short-term management of rotator cuff tendinopathy. However, Prolotherapy is more successful as the initial treatment. Besides, the treatment time is much shorter for dextrose Prolotherapy compared with physiotherapy.
Caring Medical Research
Ross Hauser, MD discusses the Prolotherapy treatment results that were published a few years ago on part of our article series on the use of Hackett-Hemwall dextrose Prolotherapy, as well as shows a treatment demonstration from a Prolotherapy symposium he taught in 2021
Summary, recap, and contact us. Can we help you?
Common treatment for rotator cuff tendonitis and impingement syndrome by traditional medical doctors includes rest, non-steroidal anti-inflammatory drugs (NSAIDS), physical therapy, and cortisone injections into the subacromial space. Because a cortisone injection has very strong anti-inflammatory properties, it may reduce the swelling in the tendon and bursa, relieving the symptoms. These treatments may temporarily help, but since the underlying cause has not been addressed the problem invariably returns. Degenerative fraying and tearing of the tendon may occur if constant irritation of the tendon occurs from the impingement process over time.
A supraspinatus tendon problem is manifested by pain with abduction and external rotation of the shoulder, especially when reaching for things above shoulder level, or pain in the shoulder after sleeping due to compression of the supraspinatus tendon. The supraspinatus tendon often refers pain to the back of the shoulder. The supraspinatus tendon is the main abductor and external rotator of the shoulder.
The key muscle group of the shoulder is the rotator cuff, made up of (from anterior to posterior) the subscapularis, supraspinatus, infraspinatus, and teres minor. The primary role of the rotator cuff is to function as the dynamic and functional stabilizer of the glenohumeral joint. Specifically, the supraspinatus muscle helps seat the humeral head (ball) into the glenoid cavity (socket) when the arm is raised from the side. For the serious athlete or those performing a lot of overhead work, this happens thousands of times, so it is no wonder the supraspinatus tendon becomes injured.
Sleeping on the shoulder causes a pinching of the rotator cuff muscles and can lead to rotator cuff weakness. There are cases where the cause of the rotator cuff tendon laxity was due to years of sleeping on the shoulder.
In most cases, traditional therapies such as exercise and physical therapy will resolve rotator cuff tendonitis. It is not uncommon, however, for rotator cuff injuries to linger because the blood supply to the rotator cuff tendons is poor. Poor blood supply is a reason the rotator cuff is so commonly injured. In chronic cases of shoulder pain due to rotator cuff weakness, Prolotherapy can be an effective treatment.
As previously stated, the supraspinatus muscle causes shoulder abduction and external rotation. When this muscle weakens, movement becomes painful. Those who have supraspinatus tendon laxity causing pain will stop moving their arms into the painful position. Although they may not realize it, they are slowly but surely losing shoulder movement. What begins as a simple rotator cuff muscle weakness has the potential to become a frozen shoulder because of scar tissue formation inside the shoulder that was left untreated. The scar tissue formation, which causes a decrease in the ability to move the shoulder, is called adhesive capsulitis. Pain means something is wrong.
A misunderstanding of the supraspinatus tendon’s referral pattern keeps clinicians from diagnosing the rotator cuff problem. This tendon refers to pain to the back and side of the shoulder, leading clinicians to believe their patients have a muscle problem, when in fact they have a tendon problem. A complaint of shoulder pain is almost always a rotator cuff weakness problem. Prolotherapy can be extremely effective at strengthening the rotator cuff tendons.
We hope you found this article informative and it helped answer many of the questions you may have surrounding your shoulder issues. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
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This article was updated August 16, 2022