In this article we will present the latest research for and against surgical procedures and the use of biomaterials including platelet rich plasma and stem cell injections in the treatment of complete rotator cuff tears.
The introduction to this article comes from a Chinese study appearing in the scientific publication: Colloids and surfaces. B, Biointerfaces.
“Tearing of the rotator cuff commonly occurs as among one of the most frequently experienced tendon disorders. While treatment typically involves surgical repair, failure rates to achieve or sustain healing range from 20 to 90%.
The insufficient capacity to recover damaged tendon to heal to the bone, especially at the enthesis (the tendon-bone attachment), is primarily responsible for the failure rates reported.
Various types of biomaterials with special structures have been developed to improve tendon-bone healing and tendon regeneration, and have received considerable attention for replacement, reconstruction, or reinforcement of tendon defects.”1
While many studies explore the future of rotator cuff repair without surgery, we will explore what can be done for the patients today.
Doctors at the Department of Orthopaedics and Traumatology, University Hospital Bern also wrote in the journal Orthopaedics & Traumatology: Surgery & Research of the challenges with rotator cuff surgery: (Explanatory notes and comments in the parenthesis).
- (As mentioned in the above study), despite advances in surgical reconstruction of chronic rotator cuff tears leading to improved clinical outcomes, failure rates of 13-94% have been reported.
- Reasons for this rather high failure rate include compromised healing at the bone-tendon interface (this is the enthesitis). It is important to note that instead of a physiological enthesis, an abundance of scar tissue is formed, as well as the musculo-tendinous changes that occur after rotator cuff tears, namely retraction and muscle atrophy, as well as fatty infiltration. (Simply scar tissue forms limiting range of motion. Muscle is breaking down and fat is replacing atrophied muscle. Not what an athlete or someone who has a physically demanding line of work needs).
- Biological augmentation, including the application of different growth factors, platelet concentrates such as found in platelet rich plasma), cells (various types of stem and stroma cells), scaffolds (patches) and various drugs, or a combination of the above have been studied.
- There is only minimal evidence that platelet concentrates may lead to improvement in radiographic, but not clinical outcome. Using stem cells to biologically augment the reconstruction of the tears might have a great potential since these cells can differentiate into various cell types that are integral for healing.2 (That is pretty even reporting.)
The problem with high re-tear rates may lie with the rehabilitation
- Despite improvements in rotator cuff surgery techniques, re-tear rate remains above 20% and increases with tear severity. (The worse the tear the greater the odds it will re-tear).
- Passive early rehabilitation exercises could contribute to re-tear due to excessive stresses. Recommendations arising from this study, for instance to keep the arm externally rotated during elevation in case of supraspinatus or supraspinatus plus infraspinatus tear, could help prevent re-tear.3
In a study from Germany, doctors found the problem of re-tear and tears are affected by many factors, but, predominantly, recurrent tears are due to non-healing of the rotator cuff tendons. This means the more tears the less likely that the rotator cuff tendons will completely heal. This is the theme of the German research, how much “successful surgery,” can your tendons take?
For many people reading this article who had many shoulder operations, the following may sound very familiar. Tear, re-tear, surgery, re-tear, surgery, re-tear, surgery, until a stage of shoulder instability is reached.
How many “successful” surgeries can you get?
Quoting now from the German study: “Different modes of failure are responsible for recurrent defects of the rotator cuff. The management of recurrent defects depends on the clinical symptoms of the patient, the objective function of the shoulder and the pathomorphological (the abnormal function of the shoulder after surgery) changes of the rotator cuff and the shoulder joint itself.
Besides letting the shoulder heal on its own and/or conservative management, arthroscopic revision of failed cuff repairs appears to be a promising procedure.
Irreparable tears can be managed using tendon transfer or shoulder replacement procedures (reverse prosthesis) depending on the functional symptoms of the patient.
The results after re-reconstruction or open revision using tendon transfers are inferior compared to primary intervention (shoulder replacement).”4
Does this sound like your case?
- Rotator Cuff Tear Surgery?
- Arthroscopic Revision recommendation?
- Reverse Total Shoulder Replacement recommendation?
This is the standard course of treating difficult to treat rotator cuff repairs.
Effectiveness and safety of surgery and growing concern over Rotator Cuff Surgery Failures
The research above should point out the obvious – There is a growing concern over Rotator Cuff Surgery Failures.
Surgery involves the permanent alteration of the body and when it comes to the rotator cuff, the major stabilizer of the shoulder. Surgery can cause more harm than good. Recovery time is often long and presents its own complications as indicated above where physical therapy is thought to cause re-tears.
The rotator cuff is a group of four muscles whose main function is to stabilize and provide support for the shoulder. It’s estimated that 10-70% of rotator cuff repairs form a recurrent defect following surgery.
- In a study out of the Cleveland Clinic, researchers studied 14 patients who underwent arthroscopic rotator cuff repair. Results showed that within the first year all 14 repairs retracted away from the initial fixation position. While not all repairs resulted in recurrent tendon defects, the early retractions correlated with tendon defects. Researchers noted that this “failure with continuity” is common after rotator cuff repair and suggest repairs be protected in the early post-operative period.5
- A Cochrane systematic review of various studies of interventions for shoulder disorders set out to determine the effectiveness and safety of surgery for rotator cuff injuries. The results were not in favor of surgery.
- In the plain language summary presented by the publishers, researchers found: “There was not enough information in the included studies to tell whether surgery would make a difference in the ability to use your shoulder normally, your quality of life, your shoulder’s range of motion, your strength, the chance that your symptoms might come back, the time it takes to return to work or sports and whether people are satisfied with surgery.
- Side effects that occurred in the studies included pain, infection, difficulty moving the shoulder after the operation, wasting of the shoulder muscle (as indicated above), and the need to have another surgical procedure. There were no differences in side effects in the people who had arthroscopic surgery compared with those who had open surgery. “6
- Research from the Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome published in the British Medical Bulletin says doctors have not been able to come up with a plan to help patients with post-surgical stiffness: “The post-operative rehabilitation protocol remains controversial. We are still far from definitive guidelines for the management of pre- and post-operative stiffness, and prospective double-blinded randomized clinical trials are needed to obtain evidence allowing to establish a reliable and effective management plan for shoulder stiffness.”7
When Rotator Cuff Tear Occurs – the shoulder turns into a hostile Non-Healing Environment – When surgery is performed it gets worse
As mentioned, The rotator cuff is a group of four muscles whose main function is to stabilize and provide support for the shoulder. The rotator cuff tendons attach the shoulder muscles to the bone. The four tendons are the supraspinatus, the subscapularis, the infraspinatus and the teres minor.
Partial of full thickness tear in the rotator cuff tendons can result from an impact injury and weakening of the tendon from wear and tear, immobility, and cortisone injections.
In a full thickness tear the entire tendon has pulled off the bone. In a partial tear only part of the tendon has pulled away from the bone. The tears can also be described as distal (further away from bone) or proximal (closer to the bone).
A hostile environment are the words used to describe the shoulder capsule following a rotator cuff tear and “repair surgery,” in a new study doctors expressed concern about the post rotator cuff surgery healing environment.
- “Tears within the tendon substance or at its insertion into the humeral head represent a considerable clinical challenge because of the hostile local environment that precludes healing.
- Tears often progress without intervention, and current surgical treatments are inadequate.
- Although surgical implants, instrumentation, and techniques have improved, healing rates have not improved, and a high failure rate remains for large and massive rotator cuff tears. The use of biologic adjuvants that contribute to a regenerative microenvironment have great potential for improving healing rates and function after surgery.”8
As I have discussed in other articles, the goal of our treatment is to turn a hostile non-healing joint environment into a healing environment through the use of regenerative comprehensive Prolotherapy that includes healing factors from blood platelets and stem cells.
Problems with rotator cuff recovery and healing time following rotator cuff surgery has long been the concern of doctors and of course patients, because doctors face the challenge of poor tendon healing and irreversible changes associated with rotator cuff degenerative diseases, future treatments should involve non-surgical biologics and tissue engineering (Platelet Rich Plasma Therapy and Mesenchymal stem cell therapy). These treatments should be explored because they hold a promise to improve outcomes for patients suffering from shoulder problems.9
- In the latest research, doctors at the Sungkyunkwan University School of Medicine, Seoul, Korea suggest that PRP and stem cells applications at the time of the surgery can be effective for tendinopathy and rotator cuff tendon tear.10
- This follows on earlier research from Korean doctors publishing in the American Journal of Sports Medicine who found stimulating bone marrow to release stem cells combined with a biomateral scaffold patch on the site of huge surgical incisions significantly reduced retear and high surgical failure rates in the arthroscopic repair of massive rotator cuff tears.11
- Doctors at the Hospital for Special Surgery in New York say in their animal studies bone marrow stem cells accelerated healing after arthroscopic surgery at the bone/tendon interface.12
Which again begs the question, in certain tears why not try the PRP and stem cells as injections without the surgery as opposed to a surgical past?
The goal of the surgery is to repair and restore function – to many patients this is NOT achieved. Doctors are looking at Platelet Rich Plasma and stem cell injections to regrow the damaged tissue in the shoulder.
German researchers had this to say: “Due to the increasing demand for functionality in an aging yet physically active society, the treatment of rotator cuff tears is of ever-growing importance. Despite intensive research efforts, the treatment of degenerative rotator cuff tears, in particular their long-term outcome, is still a challenge.”
An explanation – what they are saying is that patients, especially aging athletes and people who work at jobs that require strength, demand a functioning shoulder – surgery is not the answer.
“While in recent years the focus was on biomechanics and the technical aspects of rotator cuff reconstruction (surgery), attention has now turned to the biological considerations of tendon regeneration. (healing)”13
Goal of treatment: Patients want function in their shoulders
“There is some controversy over the role of arthroscopy in the management of irreparable rotator cuff tears. Arthroscopic debridement, partial repair with margin convergence, biceps tenotomy or tenodesis, and more recently suprascapular nerve release have all been described as potential treatments. The literature would suggest that they are effective at alleviating pain, but have little effect on strength.”14
So slowly the wheels of medicine are changing – fortunately biological considerations – non-surgical injection therapy designed to regenerate your shoulder can be offered at Caring Medical today.
Let’s review the research – here are highlights:
- New research suggests Prolotherapy is an effective treatment for rotator cuff injuries, pain and function in patients who failed to respond to conservative treatment.
- Studies show that arthroscopic surgical repair for partial rotator cuff tears and related injuries results in outcomes no better than treatment with exercise or physical therapy alone.
- Athletes favor rotator cuff surgery under the belief that that is their best way back to being active sooner – however research says that being active sooner may cause surgical failure.
- Arthroscopic rotator cuff tear repairs have a high percentage of re-tear risk and frequently result in side effects such as continued pain, stiffness and decreased range of motion.
- Surgical intervention for rotator cuff pain based on MRI’s are often misleading, as studies show the presence of MRI confirmed rotator cuff tears in individuals with absolutely no symptoms. Further compounding problems of the glenoid labrum.
Comprehensive Prolotherapy treatment for torn rotator cuff without surgery
The recurrent theme in the research throughout this article is: Despite surgical improvements – surgical failures and changing the healing environment of the shoulder. This is echoed further in the research below:
“Despite improved surgical techniques, the tendon-to-bone healing rate is unsatisfactory due to difficulties in restoring the delicate transitional tissue between bone and tendon.”15 This same research from doctors in Spain also says Mesenchymal stem cell therapy is a potentially effective therapy to enhance rotator cuff healing and prevent complications.
These researchers base this opinion on the fact that stem cell therapy increases the amount of fibrocartilage formation. This is the tissue that helps make up ligaments, tendons, and cartilage and are specifically marked for studies on tissue engineering.
But treating the tendon interface and the shoulder ligaments is something that Prolotherapy does as well.
In new research in the medical journal Orthopaedics & traumatology, surgery & research, doctors tested the effectiveness of Prolotherapy in difficult chronic refractory rotator cuff tears. They were hoping to find that dextrose prolotherapy would reduce pain and improve shoulder function and patient satisfaction.
- 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 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.
- Both the exercise group and the Prolotherapy group achieved significant improvements.
- Prolotherapy group had significantly better pain relief scores at weeks 3, 6, and 12, and last follow-up.
- Prolotherapy group had significantly better shoulder abduction and flexion at week 12 and last follow-up, and in internal rotation at last follow-up.
- No significant difference was found in external rotation at any follow-up period.
- 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.16
As shown by the research about rotator cuff tears can be treated with stem cells, platelet rich plasma, and Prolotherapy.
1. Zhao S, Su W, Shah V, Hobson D, Yildirimer L, Yeung KW, Zhao J, Cui W, Zhao X. Biomaterials based strategies for rotator cuff repair. Colloids and Surfaces B: Biointerfaces. 2017 Jun 6.
2. Zumstein MA, Lädermann A, Raniga S, Schär MO. The biology of rotator cuff healing. Orthop Traumatol Surg Res. 2016 Dec 30. pii: S1877-0568(16)30191-8. doi: 10.1016/j.otsr.2016.11.003.
3 Haering D, Blache Y, Raison M, Begon M. Mechanical risk of rotator cuff repair failure during passive movements: A simulation-based study. Clin Biomech (Bristol, Avon). 2015 Dec;30(10):1181-8.
4 Scheibel M. Recurrent defects of the rotary cuff : Causes and therapeutic strategies Oper Orthop Traumatol. 2012 Nov;24(6):458-67. doi: 10.1007/s00064-012-0179-2.
5. McCarron JA, Derwin KA, Bey MJ, Polster JM, Schils JP, Ricchetti ET, Iannotti JP. Failure with continuity in rotator cuff repair “healing”. The American journal of sports medicine. 2013 Jan;41(1):134-41.
6. Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.:DOI:10.1002/14651858.CD005619.pub2.
7. Papalia R, Franceschi F, Vasta S, Gallo A, Maffulli N, Denaro V. Shoulder stiffness and rotator cuff repair. Br Med Bull. 2012 Feb 14.
8. Murray IR, LaPrade RF, Musahl V, Geeslin AG, Zlotnicki JP, Mann BJ, Petrigliano FA. Concepts, Future Research, and Barriers to Advancement, Part 2: Orthop J Sports Med. 2016 Mar 31;4(3):2325967116636586.
9. Killian ML, Cavinatto L, Galatz LM, Thomopoulos S. Recent advances in shoulder research. Arthritis research & therapy. 2012 Jun 15;14(3):214.
10. Kim SJ, Song DH, Park JW, Park S, Kim SJ. Effect of Bone Marrow Aspirate Concentrate Platelet-Rich Plasma on Tendon Derived Stem Cells and Rotator Cuff Tendon Tear. Cell Transplant. 2017 Jan 20. doi: 10.3727/096368917X694705.
11. Yoon JP, Chung SW, Kim JY, Lee BJ, Kim HS, Kim JE, Cho JH. Outcomes of Combined Bone Marrow Stimulation and Patch Augmentation for Massive Rotator Cuff Tears. Am J Sports Med. 2016 Apr;44(4):963-71. doi: 10.1177/0363546515625044. Epub 2016 Feb 5.
12. Degen RM, Carbone A, Carballo C, Zong J, Chen T, Lebaschi A, Ying L, Deng XH, Rodeo SA. The Effect of Purified Human Bone Marrow-Derived Mesenchymal Stem Cells on Rotator Cuff Tendon Healing in an Athymic Rat. Arthroscopy. 2016 Dec;32(12):2435-2443. doi: 10.1016/j.arthro.2016.04.019.
13. Ficklscherer A, Pietschmann MF, Bendiks M, Roßbach BP, Müller PE. [Clinical management of rotator cuff tears : Current concepts in cell-based therapy strategies].Orthopade. 2016 Feb;45(2):143-8. doi: 10.1007/s00132-015-3213-x. German.
14. Khair MM, Gulotta LV. Treatment of irreparable rotator cuff tears. Current reviews in musculoskeletal medicine. 2011 Dec 1;4(4):208.
15. Mora MV, Ibán MA, Heredia JD, Laakso RB, Cuéllar R, Arranz MG. Stem cell therapy in the management of shoulder rotator cuff disorders. World J Stem Cells. 2015 May 26;7(4):691-9. doi: 10.4252/wjsc.v7.i4.691.
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