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 has been 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 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, and 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 treatment options for partial rotator cuff tear.
- Do you even have a partial rotator cuff tear?
- Thinking that an MRI that has a good probability of actually showing a partial rotator cuff tear surgery is flawed medical thinking.
- The reliable diagnosis of partial-thickness tears of the rotator cuff is still elusive in clinical practice.
- The comparative assessment of one hundred patients who underwent ultrasound and MRI for suspected supraspinatus tendinopathy.
- The findings of MRI have calculated odds, you could have a partial rotator tear and be told you don’t, you may not have a partial tear and be told you do.
- Ultrasound outperformed MRI in diagnosing partial-thickness subscapularis tear.
- Does an arthroscopic repair of the rotator cuff cause more pain?
- Patients who were younger had partial-thickness tears and had occupational injuries and experienced more pain postoperatively.
- In other words, something was not right after the arthroscopic surgery. In how many people?
- The JOB and the SPORT were not making the shoulder worse.
- “A partial-thickness rotator cuff tear does not have a significant influence on the athletic performance of professional baseball pitchers in the short term.”
- Risk factors for tear progression in painful rotator cuff tears.
- The rotator cuff surgical options.
- In patients over 50, non-surgical management of partial rotator cuff tear is just as good as arthroscopic rotator cuff repair.
- Cortisone injections into the shoulder prior to arthroscopic rotator cuff repair put patients at greater risk for post-surgical complications.
- 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.”
- 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.
- 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?
- The surgical consult for partial lesions of the supraspinatus tendon: which treatment?
- Our treatment guidelines
- Platelet Rich Plasma Prolotherapy as an alternative to partial torn rotator cuff and shoulder pain surgery
- Stem cell and PRP injection treatment option
- What is the outcome of a partially torn rotator cuff tendon treated one time with PRP and bone marrow aspirate concentrate?
Exploring the many different treatment options 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 firsthand, 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.”
What are we seeing in this image?
The tears of the rotator cuff illustrated: Tear in the supraspinatus tendon, long head of the biceps tendon, and 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:
- “Partial-thickness rotator cuff tears remain difficult to diagnose with single imaging (An MRI or CT) modality. . . “
- “In the primary care office, the initial evaluation of shoulder pain should include a thorough musculoskeletal evaluation in order to identify the source of the pain (e.g., shoulder, cervical spine, chest wall), as well as the development of an initial treatment plan.” (Please see our article Is neck instability causing your shoulder pain?)
- “Information regarding the risks of oral medications for the management of (partial rotator cuff tears) and the associated pain keeps mounting.”
Does this research’s learning points sound familiar to you?
- You had an imaging study, MRI, or CT scan
- You may have or have not had a physical examination. Some patients report that their examination is a simple reading back of the MRI evaluation report.
- You were given stronger prescriptions for pain killers until your doctors could figure out what to do.
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 – to 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 a 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 of 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 on 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:
- The purpose of the study was to determine the diagnostic accuracy of MRI and clinical tests for detecting partial-thickness tears of the rotator cuff as well as the combination of these tests.
There is a problem, partial rotator cuff tears are difficult to diagnose. Your MRI may be wrong. Your diagnosis may be in question.
- Here is a statement from the research and then we will explain what it means in regard to how accurate an MRI is for a partial rotator cuff tear.
- Sensitivity for MR imaging to identify partial-thickness tears was 51.6%, specificity 77.2%, positive predictive value 41.3%, and negative predictive value 83.7%.
What you may notice in those numbers immediately is that there is no “100%.”
- So first thing, the MRI reading of an image is not accurate every single time.
- The sensitivity for MR imaging to identify something that MAY be a partial-thickness tear was 51.6%.
- What does this mean? This means that the MRI chances of accurately detecting the possibility of a partial rotator cuff tear are actually there is about 52%. Basically the same accuracy odds as a coin flip.
- Once this 52% is separated into probable and non-probable, then the probable partial rotator cuff tears are confirmed as partial tears with a specificity of 77.2%. What this means is that there is a 78% chance you do have a rotator cuff tear. You may then have been told the MRI shows a partial rotator cuff tear. Yet, there is, in reality, a 1 in 5 chance that is actually no tear. Are you being sent to surgery on this recommendation of a 78% probability? This answer is probably yes because the surgery, it will be suggested to you, will go in there and see if you really do have a tear and if you do, clean up your shoulder. See below for the research questioning this type of thinking.
- The sensitivity for MR imaging to identify something that MAY be a partial-thickness tear was 51.6%.
The comparative assessment of one hundred patients who underwent ultrasound and MRI for suspected supraspinatus tendinopathy.
In our office, we use ultrasound as a primary means of assessing possible rotator cuff tears.
A September 2020 paper in The Ultrasound Journal (24) reported on the comparative assessment of one hundred patients who underwent ultrasound and MRI for suspected supraspinatus tendinopathy. The supraspinatus tendon was observed in these patients as being intact, suffering from a partial tear, or full-thickness tear. The researchers then looked for agreement between the ultrasound image and the MRI image in the patient’s diagnosis.
- There was an agreement between the ultrasound image and the MRI image in 48/100 patients
- The consistency of agreement varied with the type of pathology:
- intact tendons by ultrasound had 55.8% agreement with MRI,
- partial sided bursal tears 50%,
- partial sided articular tears 25%,
- and full-thickness focal tears 33.3%.
- Full-thickness complete-width tears had a much better agreement with MRI at 90.9%.
- Age was also significant, with increased disagreement between ultrasound and MRI in patients over 50 years old.
The outcome of this paper was a suggestion to primary care physicians that they use ultrasound as the initial test in younger patients and in patients with suspected full supraspinatus tears, based on clinical exam, with MRI as an option for further evaluation to quantify supraspinatus muscle atrophy.
The findings of MRI have calculated odds, you could have a partial rotator 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:
- Sensitivity was 46.9%, which means that an MRI and physical examination’s combined chances of accurately detecting the possibility of a partial rotator cuff tear are actually there and is about 47%.
- Once this 47% is separated into probable and non-probable, then the probable partial rotator cuff tears are confirmed as partial tears with a specificity of 85.4%. So following the physical examination and an MRI in the best, most absolute scenario, you can still only be told it is only likely you have a partial rotator cuff tear. There is no 100% in MRIs.
Ultrasound outperformed MRI in diagnosing partial-thickness subscapularis tear
A February 2022 study in the journal Arthroscopy (25) found ultrasound outperformed MRI in diagnosing partial-thickness subscapularis tear. In this study, a comparison between ultrasound diagnosis and MRI diagnosis was made by confirming these imaging readings against what doctors found during an arthroscopic procedure. The significance of this study is that of 437 patients who were scheduled to undergo arthroscopic rotator cuff repair, preoperative ultrasound and MRI of the shoulder were performed, and ultrasound correctly diagnosed 122 of 157 patients with subscapularis (SSC) tears, with an overall sensitivity of 77.7% which was significantly greater than that of MRI.
- Conclusions: Ultrasound is a reliable and accurate diagnostic method for subscapularis (SSC) tears, especially in easily missed partial-thickness tears.
Does an arthroscopic repair of the 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 rotator cuff 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, (3) they suggest that:
- Rotator cuff repair often results in significant pain postoperatively, the cause of which is undetermined.
- 1624 patients who underwent arthroscopic rotator cuff repair were included in this study.
- Rotator cuff tears were subdivided into groups based on the tear size and re-tear rate found for each group.
- A smaller tear area was associated with:
- more frequent and severe pain with overhead activities, at rest, and during sleep as well as a poorer perceived overall shoulder condition at 6 weeks, 3 months, and 6 months after repair
- Patients who were younger had partial-thickness tears and had occupational injuries experienced more pain postoperatively
- Larger tears did not have more pain 1 week after surgery. The re-tear rate was 7%.
- There were fewer re-tears with smaller tears, but they were more painful than large tears postoperatively from 6 weeks to 6 months after surgery. Patients with smaller tears experienced more pain after rotator cuff repair compared with patients with larger tears. These findings are contrary to previous ideas about tear size and postoperative pain.
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.
What are we seeing in this image?
In this illustration, we see the rotator 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:
- Of 191 professional pitchers who were examined between January 2009 and October 2018, 52 individuals had partial-thickness tears with at least 2 years of follow-up magnetic resonance imaging (MRI) scans
- All initial MRI examinations were performed when a season was finished or during the off-season for regular medical check-up purposes. Hence, any abnormal finding on MRI, which suggests damage to the rotator cuff tendon, was assumed to have occurred during the previous season.
- The study evaluated the changes in 5 statistical performance indicators: earned run average (ERA), fielding independent pitching (FIP), walks plus hits divided by innings pitched (WHIP), winning percentage (WPCT), and innings pitched (IP).
- The partial-thickness tears progressed in 39 of 52 (75%) patients.
- Of these 39 patients, 34 (87%) were grade 1 in severity and 5 (12.8%) were grade 2 or higher.
- A partial-thickness rotator cuff tear does not have a significant influence on the athletic performance of professional baseball pitchers in the short term based on conventional performance indicators. Our findings suggest that WHIP and IP decline significantly 2 years after damage is noticed.
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, and low active, in determining an accurate assessment.
- The theory is that tears in younger patients, high-activity patients, or heavy laborers would progress in size more than those in older patients, low-activity patients, or light laborers. This theory was shown to be INCORRECT.
- 225 consecutive patients with symptomatic rotator cuff tears visited the researcher’s institute between 2009 and 2015.
- Of these, 174 shoulders of 171 patients (average age 67 years old) who underwent at least 2 magnetic resonance imaging (MRI) examinations were prospectively enrolled in the study.
- At an average of 19 months follow-up, tear progression was defined as positive when the tear size increased by more than 7/100ths of an inch.
- Of the 174 shoulders, 82 shoulders (47%) showed tear progression.
- On average, the tear progression is 3.8 mm/year in length (about a 1/6th inch) and 2.0 mm/y (a little more than a 1/12th inch in width.
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.
- YET, sports participation and job type did not show any correlation with tear progression. The JOB and the SPORT were not making the shoulder worse.
The surgical options
At our center, we offer non-surgical treatment options that include regenerative medicine injections which are described below. Not every person will benefit from these injections and not every person will benefit from surgery. When discussing surgical success and failures, since we do not offer surgery, we rely on the most current published medical research for an opinion on the surgery option.
An April 2021 paper in the Journal of Clinical Orthopaedics and Trauma (7) comes from orthopedist surgeons in the United Kingdom. Here are their observations on the surgical recommendation: “There are still many unanswered questions in rotator cuff surgery, but this may be because the success of certain treatment options is highly dependent on patient selection. Despite growing numbers of articles being published on rotator cuff repairs, the level of evidence remains low. Larger, collaborative projects may help in answering the common dilemmas that still face shoulder surgeons.”
To be fair, patient selection is a very important process in all medical treatments. As mentioned above, surgery will not work for everyone, and non-surgical treatments will not work for everyone. Exploring your options by talking to both surgeons and non-surgical providers may help you with your decision-making process.
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, (8) doctors 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.
- Both groups showed an improved range of motion and lessened pain.
The conservative care group did just as well as the surgical repair group.
- Re-tear of the rotator cuff was observed in 9.6% of patients who had an arthroscopic repair and tear progression was found in 6.7% of those who underwent conservative treatment.
Here is an important point:
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 (9) 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 (10), this research team published these findings:
“A single shoulder injection within a year prior to arthroscopic RCR 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”
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. (11)
Here are the learning points:
- Partial-thickness rotator cuff tears are common shoulder injuries in baseball players. For some tears, the symptoms can be relieved through physical therapy or debridement without rotator cuff repair.
- This study assesses whether partial-thickness rotator cuff tear by itself causes shoulder pain and muscle weakness in baseball players.
The researchers studied 87 university baseball players (about 19 years old, been playing for about 11 years)
- Rotator cuff tendons were examined ultrasonographically and allocated to 4 groups:
- (1) no tear,
- (2) supraspinatus tendon tear,
- (3) infraspinatus tendon tear, and
- (4) both the supraspinatus and infraspinatus tendon tears.
Current shoulder pain and shoulder muscle strength (dominant/nondominant) in abduction, external rotation, and internal rotation were compared with standard testing. All players could play baseball with or without shoulder pain in this study.
- Of the 87 players, 41 (47%) had articular (not all the way through)-sided partial-thickness rotator cuff tears diagnosed on ultrasonography;
- the remaining 46 athletes were tear-free.
- Of the 41 affected patients
- 19 had tears in the supraspinatus,
- 13 in the infraspinatus,
- and 9 in both the supraspinatus and infraspinatus tendons.
- Tear depth (AVERAGE) was 4.6 mm in the supraspinatus and 6.2 mm in the infraspinatus.
- Neither the rate of shoulder pain nor muscle strength differed significantly among the 4 groups. (Tear or no tear).
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 suit 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 the Open Access Journal of Sports Medicine (12). Here is what the findings suggested.
- Seventy-six patients (48 males, 28 females) with an average age of 52 were included in the study.
- Patients were evaluated using a standardized format including clinical, imaging, and shoulder-specific quality-of-life outcomes.
- Patients were assessed and treated either successfully nonoperatively or consented to undergo surgical intervention of their partial rotator cuff tear.
- Patients treated nonoperatively underwent follow-up by an MRI arthrogram.
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.”
- Thirty-seven patients (49%) underwent nonoperative treatment.
- In patients with atraumatic partial rotator cuff tear involving less than 50% of the tendon thickness of the nondominant arm, nonoperative treatment was more likely to be successful. These are patients suffering from more age-related degeneration than a recent injury.
- In patients with traumatic lesions involving more than 50% of the tendon thickness of the dominant arm, nonoperative treatment was more likely to fail. Although the reasons for this are unclear
Let’s point out again that the treatment these people had were:
- Rest or activity modification,
- pain medications,
- subacromial steroid injections,
- and a physiotherapist instituted and supervised a home-based rehabilitation program.
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.
The surgical consult for partial lesions of the supraspinatus tendon: which treatment?
Partial lesions of the supraspinatus tendon: which treatment? is the title of an April 2021 paper (13) on recommended treatment options for a partial tear of the supraspinatus tendon. Here is what the paper authors and orthopedists recommended:
“At present, there is no consensus on the management of these (supraspinatus tendon) lesions, and surgery remains a second-line treatment for patients who do not respond to conservative treatment. If done properly, conservative treatment is effective for most patients.
For lesions less than 50% of the tendon thickness (grades 1 and 2) we recommend physiotherapy and possibly (cortisone) infiltration of the subacromial bursa. For all lesions above 50% (grade 3), if conservative treatment failed, we propose arthroscopic suture of the lesion.”
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.
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.
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 5 – 7 days of 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:
- PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
- In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
- This patient in particular comes to us with 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.
- Treatment continues to the 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.
Platelet Rich Plasma Prolotherapy as an alternative to partial torn rotator cuff and shoulder pain surgery
Prolotherapy can be 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.
- Prolotherapy solutions are injected into your painful areas to repair damaged tissue.
- The injections create a localized inflammation triggering the immune system to create the building blocks of ligaments, tendons, cartilage, and bone.
- Prolotherapy, through a series of injections, REBUILDS the rotator cuff soft tissue.
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. (14) This research appeared in the Journal of Prolotherapy.
- In this study, Prolotherapy caused a significant improvement in pain and stiffness.
- Ninety-one percent of patients felt Prolotherapy gave them 50% or greater pain relief, and 71% felt the pain relief was greater than 75%.
- The patients’ quality of life was improved as depression, anxiety, and medication usage decreased while their range of motion, sleep, and exercise ability improved.
- Prolotherapy was able to eliminate the need for surgery realistically in 31 out of 34 patients.
- The recent research from Korean doctors written in the Archives of Physical Medicine and Rehabilitation (15) suggests Prolotherapy showed improvement in pain, disability, isometric strength, and range of motion in patients with refractory chronic rotator cuff disease.
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 this study, 120 patients with chronic rotator cuff lesions and symptoms that persisted for longer than 6 months were divided into two groups: one treated with exercise as the control group, and the other treated with Prolotherapy injection. In the Prolotherapy group, ultrasound-guided Prolotherapy injections were applied.
- In the exercise group, patients received a physiotherapy protocol three sessions weekly for 12 weeks.
- Both groups were instructed to carry out a home exercise program.
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. (16)
In the January 2016 edition of the Archives of Physical Medicine and Rehabilitation (17) 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).
- Group one received dextrose Prolotherapy
- Group two injections into the entheses with saline (control/placebo group)
- Group three, injections above the entheses with saline (control/placebo group)
- All participants received concurrent programmed physical therapy.
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.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
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 improving 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 (18) wrote 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 (19) described 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 (20) 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.”
Corticosteroids provide a fast pain-relieving effect and improvement in function in partial-thickness rotator cuff tears, but these effects diminish over time, whereas Prolotherapy provides a long-lasting effect.
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 (21) in which they suggest that “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 (22) 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 by 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.
An April 2022 paper in the Journal of Sport Rehabilitation (26) assessed the effectiveness of Ultrasound-Guided corticosteroid injections, Prolotherapy, and exercise therapy on partial-thickness supraspinatus tears.
- A total of 64 patients with clinically and radiologically diagnosed partial-thickness supraspinatus tear who received either a cortisone injection, dextrose Prolotherapy, or physical therapy combined with home-based exercise therapy were included. The main outcome measures were patients’ visual analog (PAIN) scale scores, Western Ontario Rotator Cuff (WORC – Disability, pain, and function) Index scores, and the Shoulder Pain and Disability Index scores at the baseline, three weeks, and three months.
“The effect of group, time, and group-time interaction on the visual analog scale, WORC, and Shoulder Pain and Disability Index scores were statistically significant (all the treatments demonstrated benefits). . . Corticosteroids provide a fast pain-relieving effect and improvement in function in partial-thickness rotator cuff tears, but these effects diminish over time, whereas Prolotherapy provides a long-lasting effect. ”
What are we seeing in this image?
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 (23) 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?
- The study showed that BMAC-PRP injection was associated with improved function and pain by standardized scoring systems at 3 months after injection as compared to the control group, while the change in the tear size and MMT (manual muscle test) did not differ between groups. There were no side effects or complications of BMAC-PRP injection.
- The researchers pointed out that the BMAC-PRP injection did not decrease tear size within three months, but instigated other repairs. This is something we see often too and why we advise patients that stem cell treatments and PRP treatments, even when combined, require more than one treatment session.
- They also point out that the best results were seen at the 12-week mark, where a significant improvement in shoulder function was noted. At the 8-week mark of tendinopathy, symptoms showed improvement.
- Also noted was an improvement in tendon function that might be explained by the enhancement of tendon-bone junction healing by PRP.
Do you have a question about your rotator cuff tear?
We hope you found this article informative and that it helped answer many of the questions you may have surrounding your shoulder problems. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
1 Mathiasen R, Hogrefe C. Evaluation and management of rotator cuff tears: a primary care perspective. Current reviews in musculoskeletal medicine. 2018 Mar 1;11(1):72-6. [Google Scholar]
2 Brockmeyer M, Schmitt C, Haupert A, Kohn D, Lorbach O. Limited diagnostic accuracy of magnetic resonance imaging and clinical tests for detecting partial-thickness tears of the rotator cuff. Archives of orthopaedic and trauma surgery. 2017 Dec 1;137(12):1719-24. [Google Scholar]
3 Yeo DY, Walton JR, Lam P, Murrell GA. The Relationship Between Intraoperative Tear Dimensions and Postoperative Pain in 1624 Consecutive Arthroscopic Rotator Cuff Repairs. Am J Sports Med. 2017 Mar;45(4):788-793. [Google Scholar]
4 Rizvi SM, Lam P, Murrell GA. Repair Integrity in Patients Returning for an Unscheduled Visit After Arthroscopic Rotator Cuff Repair: Retorn or Not?. Orthopaedic journal of sports medicine. 2018 May 29;6(6):2325967118775061. [Google Scholar]
5 Park JY, Kim J, Lee JH, Oh KS, Chung SW, Park H. Does a Partial Rotator Cuff Tear Affect Pitching Ability? Results From an MRI Study. Orthopaedic Journal of Sports Medicine. 2019 Nov 26;7(11):2325967119879698. [Google Scholar]
6 Yamamoto N, Mineta M, Kawakami J, Sano H, Itoi E. Risk Factors for Tear Progression in Symptomatic Rotator Cuff Tears: A Prospective Study of 174 Shoulders. The American Journal of Sports Medicine. 2017 Jun 13:0363546517709780. [Google Scholar]
7 Viswanath A, Monga P. Trends in rotator cuff surgery: Research through the decades. Journal of Clinical Orthopaedics and Trauma. 2021 Apr 19. [Google Scholar]
8 Lee WH, Do HK, Lee JH, Kim BR, Noh JH, Choi SH, Chung SG, Lee SU, Choi JE, Kim S, Kim MJ, Lim JY. Clinical Outcomes of Conservative Treatment and Arthroscopic Repair of Rotator Cuff Tears: A Retrospective Observational Study. Ann Rehabil Med. 2016 Apr;40(2):252-62. [Google Scholar]
9 Puzzitiello RN, Patel BH, Nwachukwu BU, Allen AA, Forsythe B, Salzler MJ. Adverse impact of corticosteroid injection on rotator cuff tendon health and repair: A systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019 Dec 17. [Google Scholar]
10 Desai VS, Camp CL, Boddapati V, Dines JS, Brockmeier SF, Werner BC. Increasing numbers of shoulder corticosteroid injections within a year preoperatively may be associated with a higher rate of subsequent revision rotator cuff surgery. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019 Jan 1;35(1):45-50. [Google Scholar]
11 Mihata T, Morikura R, Fukunishi K, Fujisawa Y, Kawakami T, Hasegawa A, Neo M. Partial-thickness Rotator Cuff Tear Itself Did Not Cause Shoulder Pain Or Muscle Weakness In Baseball Players. Orthopaedic Journal of Sports Medicine. 2019 Jul 29;7(7_suppl5):2325967119S00430.
12 Lo IK, Denkers MR, More KD, Nelson AA, Thornton GM, Boorman RS. Partial-thickness rotator cuff tears: clinical and imaging outcomes and prognostic factors of successful nonoperative treatment. Open access journal of sports medicine. 2018;9:191. [Google Scholar]
13 Fugazzotto A, Vallotton J, Brenn S. Partial lesions of the supraspinatus tendon: which treatment?. Revue Medicale Suisse. 2021 Apr 1;17(735):794-7. [Google Scholar]
14 Hauser, RA, et al. Prolotherapy as an Alternative to Surgery: A Prospective Pilot Study of 34 Patients from a Private Medical Practice. Journal of Prolotherapy. 2010;(2)1:272-281.
15 Lee DH, Kwack KS, Rah UW, Yoon SH. Prolotherapy for refractory rotator cuff disease: retrospective case-control study of one year follow-up. Arch Phys Med Rehabil. 2015 Aug 5. pii: S0003-9993(15)00594-8. doi: 10.1016/j.apmr.2015.07.011. [Google Scholar]
16 Seven MM, Ersen O, Akpancar S, Ozkan H, Turkkan S, Yıldız Y, Koca K. Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthop Traumatol Surg Res. 2017 May;103(3):427-433. [Google Scholar]
17 Bertrand H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose prolotherapy versus control injections in painful rotator cuff tendinopathy. Archives of physical medicine and rehabilitation. 2016 Jan 1;97(1):17-25. [Google Scholar]
18 Mei-Dan O, Carmont MR. The role of platelet-rich plasma in rotator cuff repair. Sports Med Arthrosc. 2011 Sep;19(3):244-50. [Google Scholar]
19 Jo CH, Kim JE, Yoon KS, Shin S. Platelet-rich plasma stimulates cell proliferation and enhances matrix gene expression and synthesis in tenocytes from human rotator cuff tendons with degenerative tears. The American journal of sports medicine. 2012 May;40(5):1035-45. [Google Scholar]
20 Pauly S, Klatte-Schulz F, Stahnke K, Scheibel M, Wildemann B. The effect of autologous platelet rich plasma on tenocytes of the human rotator cuff. BMC musculoskeletal disorders. 2018 Dec;19(1):422. [Google Scholar]
21 Lin MT, Chiang CF, Wu CH, Huang YT, Tu YK, Wang TG. Comparative effectiveness of injection therapies in rotator cuff tendinopathy: A systematic review, pairwise and network meta-analysis of randomized controlled trials. Archives of physical medicine and rehabilitation. 2018 Aug 2. [Google Scholar]
22 Giovannetti de Sanctis E, Franceschetti E, De Dona F, Palumbo A, Paciotti M, Franceschi F. The Efficacy of Injections for Partial Rotator Cuff Tears: A Systematic Review. Journal of Clinical Medicine. 2020 Dec 25;10(1):51. [Google Scholar]
23 Kim SJ, Kim EK, Kim SJ. Effects of bone marrow aspirate concentrate and platelet-rich plasma on patients with partial tear of the rotator cuff tendon. Journal of orthopaedic surgery and research. 2018 Dec;13(1):1. [Google Scholar]
24 Dalai A, Langford L, Beavis C, Obaid H. Development of supraspinatus imaging guidance for primary care physicians with a focus on patient selection. The Ultrasound Journal. 2020 Dec;12(1):1-6. [Google Scholar]
25 Zhu S, Pu D, Li J, Wu D, Huang W, Hu N, Chen H. Ultrasonography outperforms magnetic resonance imaging in diagnosing partial-thickness subscapularis tear. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2022 Feb 1;38(2):278-84. [Google Scholar]
26 Eroglu A, Yargic MP. Effectiveness of Ultrasound-Guided Corticosteroid Injections, Prolotherapy, and Exercise Therapy on Partial-Thickness Supraspinatus Tears. Journal of Sport Rehabilitation. 2022 Apr 21;1(aop):1-7. [Google Scholar]