Partial rotator cuff tear non surgical repair
The shoulder is a complex joint, easily susceptible to instability and loss of pain free motion. When one part of the shoulder is injured, it usually causes disruption throughout the shoulder complex. This includes problems caused by a partial-thickness rotator cuff tear.
- Before reading on, do you have a question about your rotator cuff tear? You can get help and information for our Caring Medical Staff
A January 2018 study from South Korean doctors published in the Journal of orthopaedic surgery and research found positive benefit of a combined bone marrow aspirate concentrate (stem cell) and platelet-rich plasma BMAC-PRP injection in patients with partial tear of the rotator cuff tendon.
The study had a very short follow up time to measure results, where success of arthroscopic surgery is measure 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.
So what happens to 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 repair. 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 best results were seen at the 12 week mark, where significant improvement in shoulder function was noted. At the eight week mark tendinopathy symptoms showed improvement.
- Also noted was improvement in tendon function that might be explained by the enhancement of tendon-bone junction healing by PRP.(1)
We will discuss more about PRP and stem cells and Comprehensive Prolotherapy below, but first let’s look at some of the research surrounding the surgical options.
Research in the Journal of Elbow and Shoulder injury wrote of problems of partial-thickness (greater than 50%) rotator cuff tears and glenohumeral kinematics and translation (Simply the natural movement of the shoulder and what caused that natural movement to change).(2) For more on this read: Doctors question effectiveness of glenoid labrum surgery.
Below we will look at two studies. One in athletes and one in patients over 50 years and look at the situation where a partial rotator cuff tear is causing problems of shoulder motion and strength, even post surgery. Further we will explore how to repair these problems. But first – how much tearing can a partial tear do?
Rotator Cuff tear progression
Doctors at Tohoku University School of Medicine writing in the American Journal of Sports Medicine were looking for the risk factors for tear progression in painful rotator cuff tears which doctors have not yet clarified in research. The doctors also wanted to let it be known that it is important for orthopaedic surgeons to know the natural course of tear progression when nonoperative management is to be chosen.
- 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.
- 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 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 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.
The size of medium tears significantly increased compared with that of other tears.
Higher risk groups were
- Rotator cuff injury on the same side as hand dominance
- Trauma were correlated with tear progression.(3)
Does arthroscopic repair of rotator cuff cause more pain?
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, 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 retear 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 at 1 week after surgery. The retear rate was 7%.
- There were fewer retears 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.(4)
In a very recent study in the Annals of Rehabilitation Medicine, 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 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.(5)
Here is an important point:
Platelet Rich Plasma Prolotherapy as alternative to partial torn rotator cuff and shoulder pain surgery
- In a heavily cited study, doctors in Israel writing in the medical journal Sports medicine and arthroscopy review wrote that injections of platelet-rich plasma have led to reduced pain and improved recovery in rotator cuff with the restoration of function.(6)
- Doctors at the Seoul National University College of Medicine publishing in the American journal of sports medicine wrote: “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.”(7)
In another study PRP was added during an arthroscopic rotator cuff repair. The results showed a decrease in the incidence of MRI-observed re-tears and supports the use of PRP to “augment and enhance the healing of arthroscopic rotator cuff tears.”(8)
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.
Prolotherapy is an excellent option for rotator cuff injuries because it involves the regeneration of 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 Hackett-Hemwall dextrose Prolotherapy in lieu of surgery. Twenty of these patients were faced with joint replacements and nine with arthroscopic procedures.(9) This research appeared in the Journal of Prolotherapy.
- In this study, Prolotherapy caused 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 range of motion, sleep and exercise ability increased.
- Also from the Journal of Prolotherapy: Prolotherapy was able to eliminate the need for surgery realistically in 31 out of 34 patients.(10)
- In the recent research from Korean doctors writing in the Archives of physical medicine and rehabilitation suggest Prolotherapy showed improvement in pain, disability, isometric strength, and range of motion in patients with refractory chronic rotator cuff disease.(11)
Prolotherapy is a simple injection therapy with a short recovery time and allows use of the shoulder during recovery. Prolotherapy is a first-line alternative to a costly and invasive surgery, which addresses the root cause of the problem (often missed by surgery), and leads to a better recovery.
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 rotatory cuff lesions.(12)
*Note- Knowing whether the rotator cuff tendon is completely torn is imperative in order to determine the best course of action.
A complete rotator cuff tear needs immediate surgical repair. This is usually manifested by an inability to lift the arm overhead and is almost always the result of severe trauma.
Those with complete rotator cuff tears will only be able to move their shoulders about 30 degrees on their own, and will have good range of motion away from the body only if someone else moves the arm. Any other type of rotator cuff injury can be treated successfully with Prolotherapy and surgery can be avoided.
Avoiding surgery should be a goal for anyone with a rotator cuff injury. In the event of failed rotator cuff surgery, Prolotherapy can address and cure the residual pain and stiffness.
Do you have a question about your rotator cuff tear? You can get help and information for our Caring Medical Staff
1 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.
2 Pinkowsky GJ, ElAttrache NS, Peterson AB, Akeda M, McGarry MH, Lee TQ. Partial-thickness tears involving the rotator cable lead to abnormal glenohumeral kinematics. J Shoulder Elbow Surg. 2017 Mar 27. [Pubmed]
3 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.
4 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.
5 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.
6 Mei-Dan O, Carmont MR. The role of platelet-rich plasma in rotator cuff repair. Sports Med Arthrosc. 2011 Sep;19(3):244-50.
7 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.
8. Barber FA, Hmack SA, Snyder SJ, Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation. Arthroscopy: The Journal of Arthroscopy and Related Surgery.2011; 27(8):1029-1035.
9 Hauser RA, Hauser, MA. A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;4:205-216.
10 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.
11. 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. [Pubmed]
12. 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.