Partial rotator cuff tear – Do you really need a surgery?

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

Partial rotator cuff tear – Do you really need surgery? Do you even want one?

Many people have very successful shoulder surgeries. In part what made their surgeries successful was they had the time for post-surgical recovery. They also had the time to go through the pre-treatment protocol to clear the way for surgery. This would be conservative care with anti-inflammatory, physical therapy, and ultimately a cortisone injection. If pain continues after these treatments, then the person is declared a good candidate for surgery or that “surgery is the only choice now.” In our practice, we see many people who are exploring options for surgery for a partial rotator cuff tear. Let’s start this article first with some patient concerns we hear in our examination rooms from our new patients. Here are some of the things we typically hear:

I cannot wait three months to train

Doctor, here is my MRI, as you can see I have a small tear in my supraspinatus tendon. The tear is small enough that I do not need surgery now but if I do not rest it the tear will worsen. With rest and conservative care, my doctor told me 3 months for complete recovery. I am in training, I cannot wait three months to swim, get on the bike, or run. I am getting physical therapy so I do not develop a “frozen shoulder.”

I cannot wait a year for a complete healing

I am thinking about surgery. My doctor is confident that if I do not have the surgery my shoulder will heal up fine, BUT, it could take up to a year. I am trying to stay active, I have been prescribed NSAIDs for the inflammation and I ice it a lot.  I am here because I am trying to speed up the healing process and want to resume weight lifting.

I had an MRI no one knows what it says or what to do next

I had an MRI, no one could tell what was really happening in my shoulder. The specialist told me that my MRI really wasn’t revealing anything and that when he goes in there (shoulder surgery), he will be able to see what is wrong and hopefully fix it up. I have a physically demanding job, I work for myself, I am not comfortable not knowing what I am “in for.”

I need to get ready for baseball

I need to pitch this season. My doctor wants me to have the surgery before my arm gets worse. He says there is a good chance I will be ready for the spring. Not 100% 

How realistic is it for me to expect to be able to avoid surgery?

I was just diagnosed by MRI and physical exam by two shoulder specialists that I have a partial tear in my supraspinatus tendon. How realistic is it for me to expect to avoid surgery for this? Is avoiding surgery a typical outcome for these treatments?

Exploring the many different options for what to do for partial rotator cuff tear

Many people have very successful surgeries for partial rotator cuff tears. In our office, we usually do not see these people. We see the people who did not have a good surgical outcome in the past or had a very successful outcome in the past but the patient did not want to go through the extensive rehabilitation.

“I had an MRI no one knows what it says or what to do next.”

Many of the people we see with problems of partial rotator cuff tear are exploring the many different options for what to do for their shoulder problems. As you may know first hand, the choice of many options may lead to confusion as to what treatments may offer you the best chance of shoulder healing success. How can you tell what is the best option for you? While there are no guarantees any treatment will work all the time, there is research guidance that may help your decision-making.

“I had an MRI no one knows what it says or what to do next.”

The tears of the rotator cuff illustrated: Tear in the supraspinatus tendon, longhead of the biceps tendon, subscapularis tendon.

The tears of the rotator cuff illustrated: Tear in the supraspinatus tendon, long head of the biceps tendon, subscapularis tendon.

Above we reported often hearing that the patient had an MRI and then no clear plan as to what to do next. If you are reading this article, you may be in the same situation and clearly, you are not alone.

A study led by the  University of Nebraska Medical Center (1) reported on problems of treatment: Some learning points are:

Does this research’s learning points sound familiar to you?

An email we receive sounds something like this:

“I felt something tear in my shoulder. This is not the first time this has happened, I have had tears in both shoulders before. I am scheduled for MRI but I can tell that I will be on conservative care because the injury will not be considered severe enough for surgery. So I will be in a limbo period either waiting for my shoulder to heal or get worse enough to need the surgery.  I had partial rotator cuff repair surgery before. It was very successful but the rehab was almost a year-long and very demanding. By the time I wait for my shoulder to get worse and get the surgery I could be in this for a year – 18 months. I need to work.”

Do you even have a partial rotator cuff tear?

Many times a patient will tell us that they have surgery planned. But they do not want one. If you are in this similar situation, you like them, are looking at recovery times that a partial rotator cuff tear surgery may require as part or maybe your whole reason to avoid the surgery. But something does need to be done to prevent the partial from becoming a full tear and from you suffering from a worsening condition. But is it surgery? Next question, do you even have a partial rotator cuff tear? One thing for sure is you do have shoulder pain so something is wrong.

Thinking that an MRI that has a good probability of actually showing a partial rotator cuff tear surgery is flawed medical thinking

The concern about surgery for partial rotator cuff tears is that you may be operating on something that is not even there. This is not solely our opinion, there are many studies confirming that an MRI may send you to unnecessary shoulder surgery.

Like the stories we hear from patients, one which we relayed above, you may get an MRI that no one can make heads or tails out of and when that happens you will be recommended to a surgery “to see what is really going on.”

Many patients come into our office with an MRI of their shoulder. These patients have bounced from doctor to doctor, from specialist to specialist looking for a treatment option. The one thing that has remained constant with many of them is that the picture of their MRI is an accurate reflection of what is going on in their shoulder. This is not always the case. The MRI may be leading this patient down a path of treatment that is not accurate to their situation.

This is probably why you are still searching for treatment, you are chasing a partial rotator cuff tear as the sole problem. We are going to present evidence that you may be chasing the wrong target. What you should be chasing is shoulder instability treatment.

The reliable diagnosis of partial-thickness tears of the rotator cuff is still elusive in clinical practice.

We are going to help take you on a journey of MRI understanding that will reinforce our suggestions that the MRI may be leading you astray. We are going to use the help of some new research.

This study comes from the Department of Orthopaedics and Orthopaedic Surgery at Saarland University Medical Center in Germany. It was published in the Archives of Orthopaedic and Trauma Surgery. (2) Here are the learning points:

There is a problem, partial rotator cuff tears are difficult to diagnose. Your MRI may be wrong. Your diagnosis may be in question.

What you may notice in those numbers immediately is that there is no “100%.” 

The findings are all calculated odds, you could have a partial tear and be told you don’t, you may not have a partial tear and be told you do.

So, if you had 100 patients who were sent to an MRI with suspect partial rotator cuff tear. If the negative predictive value was 83.7% it means that the MRI’s ability to successfully predict that a partial rotator cuff tear is NOT THERE is almost 84% of the time. So there is a 16% chance that you do have a rotator cuff there and you will be told you do not. Equally, there is a 78% chance that you do have a tear, be told you have a tear, and there is a 1 in 5 chance that you do not. This is why there is no 100% in MRIs. This is why you may be chasing the wrong problem.

The researchers of this study took this one step further. They combined the MRI findings with a physical examination to see if the physical examination correlated with the MRI findings and if it helped to accurately diagnose the partial tear. The physical examinations were standard Jobe-Test and Sensitivity for the Impingement-sign which try to predict the possibility of a muscle tear in the rotator cuff.

For the combination of MR imaging, Jobe-test, and Impingement-sign, the results were as follows:

Does an arthroscopic repair of rotator cuff cause more pain?


Patients who were younger had partial-thickness tears and had occupational injuries experienced more pain postoperatively

Back to you. You are exploring alternatives to surgery because you may need to get back to work or a sport and the post-surgical recovery time is more than you want to manage at this point. In the above scenario of MRI probabilities in assessing whether you actually have a partial rotator cuff tear, doctors may recommend arthroscopic or exploratory surgery to see what is “really going on.” While they are in your shoulder, they will clean up what they find.

Doctors at the University of New South Wales are suggesting something totally contradictory to our understanding of rotator cuff arthroscopy. Writing in the American Journal of Sports Medicine, March 2017, (3they suggest that:

In other words, something was not right after the surgery. In how many people?

A June 2018 study in the Orthopaedic Journal of Sports Medicine (4) found that “After rotator cuff repair, some patients have ongoing problems significant enough to warrant presentation to a clinic for reassessment.” In other words, something was not right after the surgery. In how many people? Measured by how many patients had to make an unscheduled postoperative visit to the surgeon’s office? About 1 in 6. Some people knew right away that things were not right, about 1/3rd of patients with problems after surgery were in the surgeon’s office within 2 weeks after the surgery for an unscheduled follow-up.

The JOB and the SPORT were not making the shoulder worse.

People do have success with shoulder arthroscopic surgery. In our office, we do not see those successful stories, we see the non-successful stories, we see the problems the inappropriate treatments and the failed surgery have caused, and are pretty blessed that patients have sought us out to handle these significant challenges with them. The tone of this article reflects our experience. We want to reiterate people do have successful surgeries.

In this illustration we see the orator cuff muscles that support and move the shoulder. These include the supraspinatus, infraspinatus, and the teres minor muscle.

In this illustration, we see the orator cuff muscles that support and move the shoulder. These include the supraspinatus, infraspinatus, and the teres minor muscle.

“A partial-thickness rotator cuff tear does not have a significant influence on the athletic performance of professional baseball pitchers in the short term”

A November 2019 study published in the Orthopaedic Journal of Sports Medicine (5) asks the question, can a pitcher still pitch with a partial rotator cuff tear WITHOUT SURGERY?

Here is a summary of this study:

RESULTS:

Risk factors for tear progression in painful rotator cuff tears

Doctors at Tohoku University School of Medicine writing in the American Journal of Sports Medicine (6) were looking for the risk factors for tear progression in painful rotator cuff tears when a patient decides not to have the surgery. These researchers also looked at the type of patient, high active, low active, in determining an accurate assessment.

The size of full-thickness tears significantly increased compared with that of articular-sided (closest to shoulder as cared to bursa side) partial-thickness tears.

In patients over 50, non-surgical management of partial rotator cuff tear is just as good as arthroscopic rotator cuff repair

Many people over 50 are very active in sports and maintain physically demanding jobs. Some are living a more relaxed lifestyle. One of the reasons for the more relaxed lifestyle may be their shoulder injury preventing them from doing the activities they love. They too are afraid of making the shoulder worse and them facing the need for surgery.

Non-surgery treatment options just as good as surgery

In a recent study in the Annals of Rehabilitation Medicine, (7doctors in South Korea say that in patients over 50, non-surgical management of partial rotator cuff tear is just as good as arthroscopic rotator cuff repair.

Patients with either a high-grade partial-thickness or small-to-medium-sized full-thickness tear were included in this study. The primary outcome measurements to see which patients did well or did not do well were a pain assessment score and range of motion score one year after treatment.

Another thing the researchers looked for was how many patients had tear progression or re-tear and pain after the treatments.

A total of 357 patients were enrolled, including 183 patients that received conservative treatment and 174 patients who received an arthroscopic repair.

The conservative care group did just as well as the surgical repair group.

Here is an important point:

The conservative therapies were oral pain medication, steroid injections, and shoulder exercise. Only exercise therapy could be considered a healing treatment.

Cortisone injections into the shoulder prior to arthroscopic rotator cuff repair put patients at greater risk for post-surgical complications

Cortisone is the last best anti-inflammatory 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 journal Arthroscopy (8) in which they suggested 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 (9), this research team published these findings:

“A single shoulder injection within a year prior to arthroscopic RCR was not associated with any 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”

What about me? I pitch.


“Articular-sided partial-thickness rotator cuff tear-by itself-did not cause shoulder pain and muscle weakness in university baseball players.”

Here is an October 2019 study from the Department of Orthopedic Surgery, Osaka Medical College published in the American Journal of Sports Medicine. (10)

Here are the learning points:

The researchers studied 87 university baseball players (about 19 years old, been playing about 11 years)

Current shoulder pain and shoulder muscle strength (dominant/nondominant) in abduction, external rotation, and internal rotation were compared by with standard testing. All players could play baseball with or without shoulder pain in this study.

Articular-sided partial-thickness rotator cuff tear by itself did not cause shoulder pain and muscle weakness in university baseball players. Most so-called articular-sided partial-thickness rotator cuff tears may not be pathologic tendon tears.

Is the problem then one of overall general shoulder instability causing weakness, tearing, and damage?


You have a partial rotator cuff tear, you don’t want surgery. What’s next? A look at regenerative medicine at shoulder instability

When someone comes into our clinic with a diagnosis of a partial rotator cuff tear they are here because they are trying to avoid surgery. So are we. To help you avoid surgery we will do a physical examination and take a medical history to assess what type of treatments we can offer that best suits the demands you place on your shoulder, whether through sports or physically demanding jobs. We then go about repairing your shoulder and the problems that lead to your degenerative rotator cuff tear or the damage sustained in an impact injury forceful enough to cause the rotator cuff tear.

A quick note on shoulder instability

Shoulder instability increases the force on rotator cuff tendons. The rotator cuff is designed to move the shoulder joint, not stabilize it. This causes the tendons to weaken and degenerate, increasing susceptibility to tearing. Rotator cuff tears are indicative of joint instability. Traditional treatment for shoulder instability is rotator cuff strengthening exercises, specifically of the supraspinatus muscle, the primary muscle responsible for the external rotation of the shoulder. A rotator cuff is a group of four muscles: the supraspinatus, infraspinatus, subscapularis, and teres minor. The rotator cuff muscles help stabilize the shoulder and assist with movement. Rotator cuff strengthening exercises help strengthen shoulder muscles but often do not cure the underlying problem of shoulder instability. To fix shoulder joint instability, the shoulder ligaments and shoulder capsular structures must be strengthened.


You had an MRI or ultrasound, there is a clear partial rotator cuff tear
Can imaging studies help predict who can benefit from non-surgical procedures?

You had an MRI or ultrasound, there is a clear partial rotator cuff tear. The imagining evidence in your case is clear. Does this mean you should get surgery? Researchers at the University of Calgary and McMaster University in Canada published their findings in the September 2018 issue of Open access journal of sports medicine (11). Here is what the findings suggested.

Results:

The non-surgery treatment plan included:

“Treatment plans were personalized to each patient and included any combination of rest or activity modification, pain medications, anti-inflammatories, subacromial steroid injections, and a physiotherapist instituted and supervised home-based rehabilitation program. The program included stretching exercises, and strengthening exercises including posterior capsular stretching and rotator cuff and parascapular muscle strengthening.”

Let’s point out again that the treatment these people had were:

Many patients we see have come in following an extensive course of physical therapy. At these sessions, the therapists may concentrate on helping the tear by strengthening the other areas of the rotator cuff. Strengthening the other areas of the rotator cuff can be very beneficial, but, if you complete the prescribed course of physical therapy and you still have shoulder pain, this is typically not considered a successful treatment and an indication that something else is going on in the shoulder beyond rotator cuff.

Some patients come in after a cortisone injection. We do not recommend cortisone injections. The foremost reason is tissue degeneration and breakdown. Surgeons have documented the difficulties of performing rotator cuff surgery on patients who had previous cortisone injections because of the frailty of the tendons. Please see our article Rotator Cuff Tendinopathy Comparing Prolotherapy, PRP, and Cortisone for a greater discussion on this topic.

Our treatment guidelines

We use Prolotherapy injections as the main treatment. Prolotherapy is the injection of simple dextrose into the shoulder which stimulates repair by calling the repair cells of the body to the site of the tear. This treatment is explained further below with a video demonstration of the treatment. Sometimes the patient’s tear is more significant and needs more aggressive treatment. In this case, we want to add healing cells at the site of the injury.

We may utilize Platelet Rich Plasma therapy. Here we take the healing cells found in your blood platelets and concentrate them down into an injectable solution. This treatment is also described and demonstrated below. Rarely do we use stem cell therapy for these types of injuries and the PRP and Prolotherapy injections used in combination can offer the patient equal results without extra costs.

As also demonstrated in the treatment videos below, we do not solely focus on the torn area of the shoulder during treatment, we want to treat the entire shoulder within the treatment. This provides support in stabilizing the shoulder joint capsule.

During treatment, we may suggest to the patient movement or activity restrictions to help facilitate healing. Many patients are recommended to 5 – 7 days rest before continuing with their treatments.


In this video, a general demonstration of Prolotherapy and PRP treatment is given for a patient with MRI findings showing multiple labral tears and rotator cuff problems

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

Prolotherapy is an injection technique utilizing simple sugar or dextrose.

Platelet Rich Plasma Prolotherapy as an alternative to partial torn rotator cuff and shoulder pain surgery

Prolotherapy is an excellent option for rotator cuff injuries because it involves the regeneration of soft tissue. Prolotherapy is a simple injection therapy with a short recovery time and allows the use of the shoulder during recovery. Prolotherapy is a first-line alternative to costly and invasive surgery, which addresses the root cause of the problem (often missed by surgery), and leads to a better recovery.

In a published study conducted with our own patients – we showed the benefits of Prolotherapy as an alternative to shoulder surgery. Thirty-four chronic pain patients who were told by their medical doctor/surgeon that surgery was needed were treated with dextrose Prolotherapy in lieu of surgery. Twenty of these patients were faced with joint replacements and nine with arthroscopic procedures.(12) This research appeared in the Journal of Prolotherapy.

In May 2017, Turkish doctors wrote in the journal Orthopaedics & Traumatology, Surgery & Research, that Dextrose Prolotherapy will reduce pain and improve shoulder function and patient satisfaction.

In the Prolotherapy group, 53 patients (92.9%) reported excellent or good outcomes; in the control group, 25 patients (56.8%) reported excellent or good outcomes. Prolotherapy is an easily applicable and satisfying auxiliary method in the treatment of chronic rotator cuff lesions. (14)

In the January 2016 edition of the Archives of Physical Medicine and Rehabilitation (15) doctors including our friend and colleague K. Dean Reeves of the Department of Physical Medicine and Rehabilitation, University of Kansas, assessed the effects of dextrose prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy.

The participants in this study received three monthly injections into the entheses (the tissue that attaches the tendon to the bone).

The primary conclusion of this research was: “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.  Dextrose prolotherapy may improve on the standard care of painful rotator cuff tendinopathy for certain patients.”

What do the PRP injections do?

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.

Above we discussed treating the whole shoulder as opposed to focusing on the partial rotator cuff tear. PRP and Prolotherapy injections achieve this goal. The PRP helps to focus on the tendon and muscle damage, Prolotherapy focuses on strengthening the ligaments and improve shoulder stability. If you repair the rotator cuff, without addressing the shoulder ligaments, you are limiting your chance for long-term healing.

The research on PRP

In a heavily cited study, doctors in Israel writing in the medical journal Sports Medicine and Arthroscopy Review (16wrote that injections of platelet-rich plasma have led to reduced pain and improved recovery in the rotator cuff with the restoration of function.

Doctors at the Seoul National University College of Medicine publishing in the American Journal of Sports Medicine (17described how PRP heals tendons on the cellular level: “Platelet-rich plasma promoted cell proliferation and enhanced gene expression and the synthesis of tendon matrix in tenocytes from human rotator cuff tendons with degenerative tears. . . These findings suggest that PRP might be used as a useful biological tool for regenerative healing of rotator cuff tears.”

This research was supported by findings published in the journal BioMed Central Musculoskeletal Disorders (18) by German medical university researchers who wrote: “PRP is a source of growth factors such involved with tendon-bone healing. PRP had an anabolic effect (the ability to construct connective tissue) on the human rotator cuff tenocytes.”

Comparison to cortisone

Doctors at the National Taiwan University Hospital published their findings in the February 2019 edition of the Archives of Physical Medicine and Rehabilitation (19) in which they suggest “patients with rotator cuff tendinopathy, corticosteroid plays a role in the short term (3-6 weeks) but not in long-term (over 24 weeks) pain reduction and functional improvement. By contrast, PRP and prolotherapy may yield better outcomes in the long term (over 24 weeks).

A December 2020 study in the Journal of clinical medicine (20) 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 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. ”

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.

Shoulder joint instability causes accelerated and stressful force on the rotator cuff tendons. This stress and force puts great strain on the rotator cuff tendons which move the shoulder joint through 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.

Shoulder joint instability causes an accelerated and stressful force 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.

Stem cell and PRP injection treatment option

Some of the treatments we may use are stem cell treatments where we would use your own stem cells to accelerate your rotator cuff healing or your own blood platelets, better known as Platelet Rich Plasma therapy. We offer a unique method for these treatments in that we couple them with comprehensive H3 Prolotherapy injections.

NOTE: We do not offer stem cell injections to every patient. We have found PRP and Prolotherapy injections can offer the desired results of the treatment without the need for stem cell therapy.

Let’s help you with your research:

A January 2018 study from South Korean doctors published in the Journal of Orthopaedic Surgery and Research (21) found a positive benefit of a combined bone marrow aspirate concentrate (stem cell) and platelet-rich plasma BMAC-PRP injection in patients with a partial tear of the rotator cuff tendon.

The study had a very short follow up time to measure results, where the success of arthroscopic surgery is measured in terms of follow up at 12 and 24 months, the South Korean team published results at 3 weeks and three months and felt confident that the results at three-month follow-up would confidently predict patient success at 24 months.

What is the outcome of a partially torn rotator cuff tendon treated one time with PRP and bone marrow aspirate concentrate?

Do you have a question about your rotator cuff tear?
You can get help and information from our Caring Medical Staff

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Article updated April 8, 2021

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