Prolotherapy in the treatment of Rotator Cuff Tendinopathy

Rotator Cuff Tendinopathy – Supraspinatus tendinopathy 

You are on this page most likely because you are an athlete or someone with a physically demanding line of work who has continued weakness and pain in your shoulder and this is greatly impacting your sports performance or your work performance. You may also be someone who is confused by the diagnosis you received. You may be wondering “is Rotator Cuff Tendinopathy,” the same thing as a rotator cuff tear? Simply, and generally speaking, Rotator Cuff Tendinopathy is a problem with the tendons that attach the rotator cuff muscles to the bones of the shoulder. The tendons can be worn, injured, stretched and torn. A rotator cuff tear, is indeed, a tear in the muscles or the tendons of the rotator cuff structure.

You may also be on this page because you went to your health care provider and received the typical recommendations of:

  • Anti-inflammatory medications, which have stopped helping (See our article When NSAIDs make the pain worse)
  • REST, which is not something someone who is working can do most of the time
  • Physical therapy

So here you are looking for answers. We are probably the tenth or 20th page you visited online. What we hope to share with you here is that you have continued issues in your shoulder because you cannot isolate on one problem in the shoulder and treat it and realistically expect great or long-term results. The shoulder needs to be treated as a unit.

Rotator Cuff Tendinopathy, Tendinitis and Tendinosis treatments

You went to your follow up visit with your orthopedist. You were told that your Tendinopathy or “Tendon problems,” have not responded to the treatments that you were prescribed above. This came as no surprise to you. You know something is wrong in your shoulder. You have pain and sometimes you can barely move. But, one thing you did notice, is that the swelling and inflammation in your shoulder has pretty much gone away. This may have made you curious as to why your joint swelling went away. You initially thought this was a good thing and that your tendon was healing. Now you are finding out pain without swelling is not such a good thing and you have progressed to “rotator cuff tendinosis.” You are anxious to get something positive done but this is now turning into a long-term, “I have to live with this problem.”

Rotator Cuff Tendinosis, the long-term consequences of non-treatment or ineffective tendon injury

When a patient comes to Caring Medical with joint problems related to sports or active lifestyle or physically demanding job and a diagnosis of one of the various tendinopathy issues described in this article, many of them will have an advanced case. It will either be advanced tendinitis or advanced tendinosis. Briefly these are:

Rotator Cuff Tendinitis – The initial wear and tear and overuse injuries to tendons usually involve a degree of inflammation. This is the Tendinitis stage. This is where your health care provider will attack your problems with anti-inflammatory medications and possibly cortisone injections.

Rotator Cuff Tendinosis – You continue to have pain but not inflammation. In essence, your body has given up trying to repair the tendon because your body believes, it is “too far gone.”

The medical community is in debate as to what is “true tendinitis,” and what is “true tendinosis.”

This affects your treatment, you have to pay attention and talk to your doctor

The differences between Rotator Cuff tendinitis and Rotator Cuff tendinosis are important as it helps guide treatments. Clearly, a path of anti-inflammatory treatments would have to be carefully evaluated for effectiveness in tendinosis.

Research: Ibuprofen does not help tendinosis it may make it worse

You do not have to be a scientist to understand this research. Ibuprofen does not help tendinosis.

This research came from the University of Copenhagen and was published in the Journal of Applied Physiology in November 2017 (1).

Highlights of research

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat tendinopathy, but evidence for this treatment is lacking, and little is known regarding the effects of NSAIDs on human tendinopathic tendon.
  • This study investigated the effects of NSAID treatment (ibuprofen) on human tendinopathic tendon, with changes in gene expression (generally: Gene expression is your cells talking to each other or signalling each other that they need to heal something) as the primary outcome, and tendon pain, function, and blood flow as secondary outcomes.
  • Noteworthy of this research: “Nonsteroidal anti-inflammatory drugs are widely used in the treatment of tendinopathy, but little is known of the effects of these drugs on tendon tissue. We find that one week of ibuprofen treatment has no effect on gene expression of collagen and related growth factors in adult human tendinopathic tendon in vivo  . . . suggesting that tendinopathic cells are not responsive to ibuprofen.”

Ibuprofen does not stimulate healing in tendinosis – Ibuprofen may make your tendinopathy worse

In a May 2018 study published in the Journal of musculoskeletal disorders and treatment, (2) researchers at Rush University Medical Center offered these observations on an achilles injury in laboratory rats:

  • Post-tendon injury analgesia (pain relief) is often achieved with NSAIDs such as Ibuprofen, however there is increasing evidence that NSAID usage may interfere with the healing process.
  • We have examined the effect of oral Ibuprofen, on Achilles tendon healing in rat tendinopathy.
    • The rats received Ibuprofen 3 days after initial injury (acute cellular response phase – this is during the time of inflammation in response to injury) and continued for 22 days
    • or started at 9 days after injury (transition to matrix regeneration phase – this is the time of repair after the initial inflammatory phase) and given for 16 days.
    • Ibuprofen prevented key processes of the inflammatory response to healing. Including the processes of removing dead injured tissue and the process of rebuilding the damaged tendon. The researchers concluded that the use of Ibuprofen for pain relief during inflammatory phases of tendinopathy, might interfere with the normal processes of healing.

The reason your shoulder is not better? Because everyone is looking at a tendon, they should be looking at your whole shoulder.

When someone comes into one of our clinics, and they come in with Swimmer’s shoulder, or supraspinatus tendinopathy, or a rotator cuff tendinopathy diagnosis, they come in knowing that their shoulder hurts, there is a problem with tendons, and they are thinking that somewhere along the line someone, if they have not already, is going to eventually recommend a surgery.

Surgery means extended time away from sport or work. Surgery for many, therefore, is not a realistic option.

But perhaps the biggest problem is that everywhere this person has been, all the talk is about a single tendon or the rotator cuff as a single unit. It is most probable that no one sat down with this person and said to them, “to heal this tendon problem, we have to heal your whole shoulder because:

  • Rotator Cuff Tendinopathy is the cause of your shoulder instability and weakening.
  • Your Rotator Cuff Tendinopathy is the result of your shoulder is loosening and weakening because of wear and tear and damage to the shoulder ligaments, or
  • Your shoulder labrum is wearing away and progressively making your shoulder loose and wobbly.

The very strong message here is, your shoulder tendons do not live on an island, they are part of the shoulder joint complex that includes ligaments and labrum. You cannot just address the tendons and expect long-term healing and return to pre-injury shoulder strength.

So here you stuck in degenerative shoulder disease looking for a way out.

Your shoulder has a plan to treat itself. Here it is:

When the problems of shoulder instability occur and manifest pain, loss of strength, and reduced performance the body has three protective mechanisms:

  1. Engage or spasm the muscles to hold the shoulder together,
  2. Swell the joint,
  3. and eventually, grow more bone. This is why bone spurs and arthritis are the long-term results of joint instability which was treated only for the symptoms it produced: inflammation and muscle spasms.

Let’s go back to the beginning of this article. “You initially thought this was a good thing and that your tendon was healing. Now you are finding out pain without swelling is not such a good thing and you have progressed to “rotator cuff tendinosis.” Corticosteroid shots and anti-inflammatories address the shoulder swelling and inflammation, so the symptoms appear better and people keep taking them, but rotator cuff degenerative problems caused by shoulder instability continues.

Swelling protects the shoulders when anti-inflammatories take the swelling away, the shoulder is again vulnerable.

Shoulder instability is joint breakdown and joint decay. Without the “protection” of the joint swelling, further pressures continue to be exerted on the rotator cuff tendons. The body now swells the tendons through inflammation to help them handle the heavier workload. But the inflammation is not a long-term answer, it is a short-term response to help get the shoulder through a tough time.

Rotator Cuff  Tendinopathy – Tendinitis – Tendinosis treatment – The research

Again, let’s explore the differences in Tendinopathy, Tendinitis, and Tendinosis, of the rotator cuff. In her article published in the International Journal of Therapeutic Massage and Bodywork, Evelyn Bass, LMT wrote that:(3)

  • Tendinitis is the inflammation of the tendon and results from micro-tears in an acute injury
  • Tendinosis (literally diseased tendon) is degeneration in response to chronic overuse; when overuse is continued without giving the tendon time to heal and rest, such as with repetitive strain injury, tendinosis results. Even tiny movements, such as clicking a mouse, can cause tendinosis, when done repeatedly. The confusion about the difference between tendinitis (inflammation of the tendon) and tendinosis (diseased tendon without inflammation) is widespread.
  • Tendinopathy refers to generally to damaged and injured tendons.

Many injuries commonly presumed to be tendinitis are actually tendinosis.

The suggestion that tendinitis (inflammation) comes before tendinosis (chronic degenerative disease) is at odds with the fact that a healthy tendon is up to twice as strong as the muscle, making the body of the tendon unlikely to tear before the muscle unless the tendon has already been weakened by degenerative changes.

  • In other words, you do not need an inflamed joint to have a diseased tendon. However, that does not mean that inflammation will not lead to tendinosis.

Rotator cuff tendinosis degeneration in response to chronic overuse

The shoulder is made up of two joints, the glenohumeral joint, and the acromioclavicular joint. The glenohumeral joint is a ball and socket joint formed by the top of the humerus and the socket of the scapula. The rotator cuff is a group of four muscles and tendons that surround the glenohumeral joint and hold the head of the humerus into the scapula. The glenohumeral ligaments, however, are the main stabilizers.

The rotator cuff functions to stabilize the shoulder and allow the arms to move through a full range of motion. The rotator cuff works together with the deltoid muscle to provide motion and strength to the shoulder for activities that require motion above the waist and shoulders.

Rotator cuff tendinosis (the disease and degeneration process) occurs when the small muscles of the rotator cuff, the supraspinatus, infraspinatus, teres minor, and subscapularis, become strained, causing weakness of these structures and subsequent tendonitis (tendon inflammation). As we mentioned above, the muscles go first before the tendon in most cases. This is especially true in the small and relatively weak rotator cuff muscles which are asked to perform key functions.

  • The supraspinatus helps seat the humeral head (ball) into the glenoid cavity (socket) when the arm is raised from the side (abducted).
  • The infraspinatus and teres minor rotate the forearm away from the body or in the hand-waving position (external rotation),
  • and the subscapularis rotates the forearm towards the body (internal rotation).

Once the balance between motion and joint stability is altered through a weakness in the static structures (ligaments) or the dynamic structures (rotator cuff muscles), pain and impaired function will invariably ensue. Baseball pitchers, quarterbacks, tennis players (serving), and swimmers are prone to rotator cuff tendonitis and rotator cuff impingement syndrome. This is because these athletes perform a lot of overhead movements. The rotator cuff is most vulnerable in this position.

Other causes of rotator cuff tendinosis include:

  • occupational overuse (working with the arms overhead for many hours or days);
  • an existing weakness of the rotator cuff muscles, ligaments or tendons;
  • use of improper technique during a sport or occupational activity;
  • poor posture;
  • sleeping on the same arm each night; Sleeping on the shoulder causes a pinching of the rotator cuff muscles and can lead to rotator cuff weakness. There are cases where the cause of the rotator cuff tendon laxity was due to years of sleeping on the shoulder.
  • cervical spine nerve pinching;
  • an improper training schedule, such as too much too soon;
  • a direct trauma, such as a fall directly onto the shoulder or onto an outstretched arm;
  • poor muscle control or coordination; poor posture over the years; or a loose or unstable shoulder joint following a previous dislocation.
  • If the rotator cuff continues to be injured or inflamed it will eventually tear, resulting in a more serious problem.

Focus on the supraspinatus tendon and progression to rotator cuff tears

WikiCommons/ Creative Commons

A supraspinatus tendon problem is manifested by pain with abduction and external rotation of the shoulder, especially when reaching for things above shoulder level, or pain in the shoulder after sleeping due to compression of the supraspinatus tendon. The supraspinatus tendon often refers pain to the back of the shoulder.

Those who have supraspinatus tendon laxity causing pain will stop moving their arms into the painful position. Although they may not realize it, they are slowly but surely losing shoulder movement.

The progression from tendinitis to rotator cuff tear was documented in new research from doctors at the Seoul National University College of Medicine in South Korea who published their findings in the journal Knee Surgery, Sports Traumatology, Arthroscopy.(4)

This study showed that the degeneration of supraspinatus tendon increases as the stage of rotator cuff disease progresses from tendinopathy to partial rotator cuff tear, and then to full rotator cuff tear. Significant tendon degeneration began from the stage of a partial rotator cuff tear. The clinical relevance of the study is that strategies and goals of the treatment for rotator cuff disease should be specific to its stage, in order to prevent disease progression for tendinopathy and partial rotator cuff tear, as well to restore the structural integrity for full rotator cuff tear.In other words, treat it early!

Rotator Cuff Tendinosis Treatment

As mentioned above, and to review, the initial treatment for rotator cuff tendinosis is frequently to limit above shoulder level activity, application of ice to the shoulder, anti-inflammatory medications for pain, and physical therapy to maintain flexibility.

Although common in the treatment of rotator cuff tendonitis, the use of anti-inflammatories and steroids may actually hinder the healing of soft tissues, such as tendons and ligaments, and do not address the root of the problem. Likewise, physical therapy does not help heal the affected ligaments and tendons. Although these treatments may help temporarily, they do not address the original cause of the problem, thus, it eventually returns. In addition, degenerative fraying and tearing of the tendon may occur with constant irritation of the tendon.

When symptoms persist, patients who experience rotator cuff tendonitis are commonly referred to a surgeon for arthroscopic surgery.

New research on Prolotherapy and supraspinatus tendinopathy 

  • Prolotherapy is the simple injection of dextrose (sugar) into the shoulder joint. We are going to look at two studies here, then discuss surgical options. Then return to more research on Prolotherapy.

In October 2019, doctors at the University of Toronto, McMaster University, and UPMC Center for Sports Medicine in Pittsburg wrote in PM & R : the journal of injury, function, and rehabilitation (5) of the “Effectiveness of Dextrose Prolotherapy for Rotator Cuff Tendinopathy.”

Here are the learning point of this research:

  • A comprehensive (research study) search was completed to identify randomized controlled trials addressing prolotherapy using hyperosmolar (higher dextrose amounts injected into the shoulder) dextrose solution for rotator cuff tendinopathy.
  • Included studies in this review analyzed a total of 272 participants with a final follow-up ranging 6-weeks to 12-months.
  • Prolotherapy (application) differed greatly among studies.(The amount of injections given varied. One study used cortisone concurrently. In our office we do not utilize cortisone with Prolotherapy.
    • There was statistically significant improvement in pain intensity with multi-site injection protocols compared to physical therapy and medical management in both studies.
    • The complication rate was low with only 6/272 participants experiencing adverse events consisting of transient increase in pain for 1-2 days post-intervention.

The study concludes:

Prolotherapy with hyperosmolar dextrose solution is a potentially effective adjuvant intervention to physical therapy for patients with rotator cuff tendinopathy ranging from tendinosis to partial thickness and small full-thickness tears. Further studies are necessary to determine effects in sub-populations as well as optimal technique including dextrose concentration, volume, and location.”

In December 2018, research published in the European Journal of Physical and Rehabilitation Medicine (6) also explored the effectiveness of Prolotherapy treatments in supraspinatus tendinopathy.

These are the learning points of the study:

  • Although patients with symptoms caused by chronic rotator cuff tendinopathy can be treated using conservative treatments, some of them may still experience refractory or difficult to resolve symptoms. Hypertonic dextrose prolotherapy may be another treatment choice for these difficult to resolve symptoms.
  • Study group was 31 patients with chronic supraspinatus tendinopathy and shoulder pain for more than 6 months.

Study conducted with a single injection of Prolotherapy vs Placebo

  • The study patients were treated with one dose of an ultrasound-guided hypertonic dextrose injection at the supraspinatus enthesis site, whereas control patients received one dose of 5% normal saline through the same method.
  • Pain and disability improvement scores were noted at 2 and 6 weeks after intervention.

The study group indicated a significant improvement in pain and disability scores including improved range of motion compared with the control group at 2 weeks after the injection. However, the effect did not sustain until 6 weeks after the injection.

This is our treatment, multiple injections at each visit. The reality of treatment is that months or years of degenerative tendinopathy in the shoulder cannot realistically be expected to be reversed with a single injection if anything.

How about Arthroscopic rotator cuff surgery?

There are people who do very well with surgical repair of the rotator cuff tendons. These are typically people we do not see in our office. We see the people who had the surgery or had concerns that the surgery would not address the problems they were having. In some the surgery created more problems for them. Many people do seek out the surgery when there is issue with bone spurs.

Arthroscopic rotator cuff surgery can remove bone spurs and inflamed tissue around the shoulder. While small tears can be treated with arthroscopic surgery, larger tears would require open surgery through a larger incision to repair the torn tendon.  Please see our article Rotator Cuff Tear Surgery

Unfortunately, surgery may make the problem worse because they are concentrating solely on the tear or an MRI or X-ray finding that, again, the overall joint weakness is not addressed. Let alone, decisions to remove cartilage or other tissue will most commonly fast-track the onset of arthritis.

  • Doctors from Finland writing in the Bone and Joint Journal, (7suggest that arthroscopic decompression not be recommended for patients with rotator cuff tendinopathy.

In their study patients were randomized into two treatment groups:

  1. arthroscopic acromioplasty (shaving down bone to relieve pressure), and a supervised exercise treatment
  2. and a similar supervised exercise treatment alone.

Self-reported pain on a visual analogue scale (VAS) questionnaires was the primary means of determining the study’s results.

The researchers also looked for problems of disability, working ability, pain at night.

  • A total of 90 patients (64%) returned questionnaires at an average 12 years after research began.
  • Both treatment groups reached statistically significant improvement compared with the baseline for pain, but there was no significant difference between groups.

The same was true in the secondary outcome measures. Due to group changes, the results were also analyzed per protocol: operated or not. No significant differences between the groups were found.

The researchers were forced to conclude that surgery was of no added benefit. The summarized the research findings as such:

  • Even though the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results.
  • In the future, an optimum exercise regime should be searched for, as the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy.

If there is no added benefit to the surgery, why take the risk of complications and failed procedure?

In the Journal of Hand Therapy, (8) doctors at the University of Queensland suggest that patients receiving surgery for upper extremity disorders including Carpal tunnel syndrome, Lateral epicondylalgia and Rotator cuff tendinopathy from workplace overuse injury needed to be better categorized after surgery failure. We have written extensively about rotator cuff surgery failure rates.

Here we have a situation of a large group of people with surgical failure, yet doctors are in a disagreement about what level of failure these patients are in. It should seem that failure is failure. In this study the Australian doctors recognized this disagreement and found in their surveys the experts say:

  • Forty-two experts defined a delayed return to work as either a worker not returning to pre-injury (or similar) work within the expected time frame (45%);
  • not returning to any type of work (36%);
  • or recovering slower than expected (12%).

Two-thirds of the experts believed that universal time points to delineate delayed Return To Work should be avoided. In other words, there is no accurate way to determine how long recovery from Rotator cuff tendinopathy will take or how successful a worker will be in returning to work in full or less than full capacity.

Prolotherapy Rotator Cuff tendinopathy treatments

To review, Comprehensive Prolotherapy, as practiced in our practice for rotator cuff tendonitis involves multiple injections of a dextrose-based solution to the various ligament and tendon attachments around the shoulder, as well as inside the joint. Prolotherapy to all of the adjacent structures stimulates a natural inflammatory response in the weakened rotator cuff tissues. This mild, localized inflammatory reaction draws immune cells to the area to regenerate the injured tissues. The increase in blood flow and regenerative cells is the body’s natural healing response. The body also responds by depositing collagen at the site of injury, strengthening the rotator cuff tendons that once were weak.

  • Prolotherapy injections strengthen the ligaments and the tendinous insertions of the rotator cuff and deltoid. This combined with the gradual re-strengthening of the rotator cuff muscles promises an excellent chance for a full recovery and full performance in many patients.

There is a lot of research to support the use of Comprehensive Prolotherapy injections for Rotator Cuff Tendinopathy beyond the two studies we cited above.

In January 2016, doctors at the University of British Columbia and the University of Kansas (Dean Reeves MD) published in the Archives of physical medicine and rehabilitation (9) a comparison of the effects of  dextrose prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy against 2 saline control injection procedures.

Study points:

  • 73 patients with chronic shoulder pain, examination findings of rotator cuff tendinopathy, and ultrasound-confirmed supraspinatus tendinosis/tear.
  • Three monthly injections either:
    • (1) onto painful entheses (tendon attachment to the bone) with dextrose (Enthesis-Dextrose),
    • (2) onto entheses with saline (Enthesis-Saline), or
    • (3) above entheses with saline (Superficial-Saline). All solutions included 0.1% lidocaine as pain agent. All participants received concurrent programmed physical therapy.

Conclusion of the research: “In participants with painful rotator cuff tendinopathy who receive physical therapy, injection of hypertonic dextrose on painful entheses resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect. Dextrose prolotherapy may improve on the standard care of painful rotator cuff tendinopathy for certain patients.”

1 Heinemeier KM, Øhlenschlæger TF, Mikkelsen UR, Sønder F, Schjerling P, Svensson RB, Kjaer M. Effects of anti-inflammatory (NSAID) treatment on human tendinopathic tissue. Journal of Applied Physiology. 2017 Aug 31;123(5):1397-405. [Google Scholar]
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8 Peters SE, Coppieters MW, Ross M, Johnston V. Experts’ perspective on a definition for delayed return-to-work after surgery for nontraumatic upper extremity disorders: Recommendations and implications. J Hand Ther. 2017 Mar 21. pii: S0894-1130(17)30045-5. doi: 10.1016/j.jht.2017.02.009. [Google Scholar]
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