If you went to an orthopedic surgeon, there is a good chance that he/she will follow the guidelines published in January 2022 in The Orthopedic clinics of North America journal. (1) Those guidelines are quoted here:
“Acute, traumatic rotator cuff tears typically occur in younger patients with a fall on an outstretched hand, grabbing an object to catch oneself when falling, or a glenohumeral dislocation. These tears are best evaluated with MRI. Partial-thickness tears may be managed nonoperatively with physical therapy, NSAIDs, and injections. Full-thickness tears in most patients should be managed with surgical repair as soon as possible, with better outcomes shown when repaired within 4 months of injury.”
Whether you chose to have surgery or not, it is apparent in many people that the rotator cuff tear should be dealt with in a timely fashion to prevent further shoulder deterioration.
A November 2021 study (2) points out that “Rotator cuff tear arthropathy (Rotator cuff tear degenerative disease) describes a pattern of glenohumeral degenerative changes following chronic rotator cuff tears that is characterized by superior humeral head migration (the ball of the shoulder is floating in the joint), erosion of the greater tuberosity (bone) of the humeral head, contouring of the coracoacromial arch to create a socket for the humeral head, and eventual glenohumeral arthritis. Acute and chronic inflammatory changes following rotator cuff tears are thought to contribute to cartilage damage, muscle fibrosis, and fatty infiltration in the glenohumeral joint.”
Many people have very good surgical results and they are satisfied with the outcomes. Many people have good success managing their shoulder pain with anti-inflammatory medications, physical therapy, the occasional cortisone injection and other non-surgical care methods. Nevertheless, we get many emails and phone calls from people wanting to know what their options are in regard to their shoulder problems. Some of these people are athletes or work at physically demanding lines of work and for them, surgery will be a down time that they would prefer to avoid.
We offer non-surgical injection treatments for the person who we have a realistic expectation that these injections can help
We do not offer surgery in our practice. We offer non-surgical injection treatments for the person who we have a realistic expectation that these injections can help. The reason these people come to our office is in part because they have done a lot of their own research into the realities of rotator cuff surgery and they had concern about possible side-effects, recovery times and the rehabilitation process. Some were more than a little concerned. These people figured surgery was the fastest way back to work or sport but the post-surgical recovery times, intensive physical therapy after surgery, and worse, they had concerns over possibility the surgery may fail.
Who do doctors suggest would be a good candidate for treatment
A paper published in March 2020 (3) gives doctors a series of general recommendation of who should be sent to surgery and who should be recommended to non-surgical treatments.
In the try conservative non-surgical options first group are:
- People who have partial-thickness tears
- People who have large tears and the surgery to fix them may do more harm.
- People over the age of 65 years
- Degenerative full thickness tear but the patient’s shoulder is still stable
Is there really a high rotator cuff surgical failure rate?
We see many patients following a failed shoulder surgery. I myself became involved in regenerative medicine injections after a failed shoulder surgery plagued me. We also see many patients, who after getting as much information as they could and then some, came to the realization that for them at least, they should look into non-surgical options.
What are these people researching? For one thing, the complication rate of a rotator cuff repair in people who had cortisone injections in their shoulder. I have written numerous articles that discuss the impact of cortisone injections not only on future surgery, but future healing.
A 2019 paper from the Mayo Clinic (4) examined the impact of one or more corticosteroid injections into a patient’s shoulder up to one year prior to having rotator cuff repair. The Mayo doctors wote: “A single shoulder injection within a year prior to arthroscopic rotator cuff repair was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery.”
This research was noted in an October 2020 study (5) that assessed the use of cortisone in rotator cuff injury: “Multiple database studies have evaluated the relationship of steroid injections and rotator cuff repair outcomes and have found that steroid injections prior to rotator cuff repair have an increased risk of requiring revisions surgery compared with matched controls in a dose- and time-dependent manner.”
Other risks for rotator cuff surgery failure
A December 2022 study (11) looked at patient outcomes following a revision rotator cuff repair. In this study 69 patients with an average age of 55 were followed after the second surgery to measure patient satisfaction. The initial findings showed the rotator cuff tendons did not heal to the tuberosity (where the muscle attaches to the bone) in 36% of the shoulders (25 of 69) following revision cuff surgery. Further, in 13 of the 69 patients, infection developed.Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied.
Also from the Mayo Clinic (6) is a 2017 study that discusses the reasons for surgical failures in younger patients: “Management of failed rotator cuff repair may be difficult, especially in young patients. Various non-modifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing.”
In 2021 this research was used in a new study (7) suggesting: “Re-tear following rotator cuff repair is common and has been reported to range from between 13 and 94% despite satisfactory clinical outcomes following rotator cuff surgery. Various risk factors have been associated with an increased tear rate, including patient factors, tear and shoulder morphology, repair technique, and rehabilitation regimes. Different modes of rotator cuff failure have been described. The management of re-tear in patients following rotator cuff repair is challenging and depends on the age, functional status and requirements of the patient, and re-tear size and residual tendon length.”
Is PRP injections realistic options to surgery and cortisone?
For PRP treatments we take a small amount of your blood and spin it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the shoulder to stimulate healing and regeneration. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Platelets act as wound and injury healers.
The platelets contain healing agents, or “growth factors.” Let’s look at some of the growth factors and what they do:
- Platelet-derived growth factor (PDGF) is a protein that helps control cell growth and division, especially blood vessels. When more blood (and the oxygen it carries) is delivered to the site of a wound, there is more healing.
- Transforming growth factor beta (or TGF-β) is a polypeptide and is important in tissue regeneration.
- Insulin-like growth factors are signaling agents. They help change the environment of the damaged joint from diseased to healing by “signaling” the immune system to start rebuilding tissue.
- Vascular endothelial growth factor (VEGF) is an important protein that brings healing oxygen to damaged tissue where blood circulation might be damaged or inadequate.
- Epidermal growth factor plays a key role in tissue repair mechanisms.
For many people, PRP can be considered a good and realistic treatment option for their rotator cuff injury. Let’s look at some studies and patient outcomes recently published in the medical literature.
A November 2019 study (8) compared three treatments, cortisone injection, PRP injection and Prolotherapy injection. Prolotherapy injections use a simple sugar or dextrose and concentrates itself ligament and tendon repair. It acts very much like PRP in its repair function. The main difference is the strength of the injectable. While Prolotherapy was the main injectable we used in the past, we moved forward to the use of PRP as clinical observation revealed a faster and stronger heal with less treatments. What this study found was that corticosteroid injection provided short-term relief for pain, function, and quality of life, while PRP injection worked more long-term. All three injection treatments showed improvement in pain, function and quality of life.
Comparison study of Cortisone and PRP as first treatments
An October 2020 study (9) compared platelet-rich plasma injection treatment to corticosteroid to determine which provided pain relief and improved function in patients with rotator cuff tendinopathy and partial thickness rotator cuff tears. In this study 99 patients received one PRP injection or one cortisone injection.
The 99 patients were then monitored at six weeks, three months, and 12 months post-injection. The researchers here noted that in their randomized double blind study patients with partial rotator cuff tears or tendinopathy experienced clinical improvement in pain and patient-reported outcome scores after both ultrasound-guided corticosteroid and PRP injections. This study was one injection versus one injection. Typically PRP is much more successful as a multi-injection treatment. This is shown by the 12 month out result. Patients who received the PRP injection obtained superior improvement in pain and function at the three month follow up. However there was no sustained benefit of PRP over corticosteroid at the 12 month follow up.
No consensus regarding treatment of partial thickness tears that fail conservative treatment
More recently a May 2021 study (10) examined the problem of “no consensus regarding treatment of partial thickness tears that fail conservative treatment.” The purpose then of this study was to assess the effectiveness and safety of two injections of PRP into the rotator cuff who have failed other conservative treatments with follow up two years after the PRP treatments. The conclusion of This study was “PRP injection is a safe and effective treatment for rotator cuff injury in patients who have failed conservative treatment of activity modification and physical therapy without deterioration of results two years after treatment. Better results are obtained with greater structural tendon damage than in shoulders with inflammation without structural damage.”
Do you have a question about your rotator cuff issues for Dr. Darrow?
What we see in this research is that PRP injections can be an effective treatment for many people. Over the years we have been able to develop realistic healing programs for patients to get them to a pain-free range of motion in a functioning shoulder. Many times we can get people to this goal, many times we come close to getting people to this goal with significant improvement to their quality of life. There are times when we can only help a little. There are times we cannot help at all. People we cannot help would be significantly advanced tears and cases of degenerative shoulder disease. Perhaps 10 to 20% of patients who seek regenerative medicine will not be good candidates. This is why I invite people to email me to discuss before they make an appointment. You can do so as well by using the form below. Use the form below and tell me about your shoulder problems and I will get back to you and we can explore the realistic healing options that we may be able to offer you.
1 Patel M, Amini MH. Management of Acute Rotator Cuff Tears. The Orthopedic clinics of North America. 2022;53(1):69-76.
2 Nelson GB, McMellen CJ, Kolaczko JG, Millett PJ, Gillespie RJ, Su CA. Immunologic Contributions Following Rotator Cuff Injury and Development of Cuff Tear Arthropathy. JBJS reviews. 2021 Nov 1;9(11):e21.
3 Keener JD, Patterson BM, Orvets N, Chamberlain AM. Degenerative rotator cuff tears: refining surgical indications based on natural history data. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019 Mar 1;27(5):156-65.
4 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.
5 Jensen AR, Taylor AJ, Sanchez-Sotelo J. Factors influencing the reparability and healing rates of rotator cuff tears. Current Reviews in Musculoskeletal Medicine. 2020 Jul 17:1-2.
6 Elhassan BT, Cox RM, Shukla DR, Lee J, Murthi AM, Tashjian RZ, Abboud JA. Management of failed rotator cuff repair in young patients. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2017 Nov 1;25(11):e261-71.
7 Mandaleson A. Re-tears after rotator cuff repair: Current concepts review. Journal of Clinical Orthopaedics and Trauma. 2021 May 21.
8 Sari A, Eroglu A. Comparison of ultrasound-guided platelet rich plasma, prolotherapy, and corticosteroid injections in rotator cuff lesions. Journal of back and musculoskeletal rehabilitation. 2019 Nov 8(Preprint):1-0.
9 Kwong CA, Woodmass JM, Gusnowski EM, Bois AJ, Leblanc J, More KD, Lo IKY. Platelet Rich Plasma in Patients with Partial Thickness Rotator Cuff Tears or Tendinopathy Leads to Significantly Improved Short-Term Pain Relief and Function Compared to Corticosteroid Injection: A Double-blind Randomized Controlled Trial. Arthroscopy. 2020 Oct 27:S0749-8063(20)30893-8. doi: 10.1016/j.arthro.2020.10.037. Epub ahead of print. PMID: 33127554.
10 Prodromos CC, Finkle S, Prodromos A, Chen JL, Schwartz A, Wathen L. Treatment of Rotator Cuff Tears with platelet rich plasma: a prospective study with 2 year follow‐up. BMC Musculoskeletal Disorders. 2021 Dec;22(1):1-3.
11 Azar M, Van der Meijden O, Pireau N, Chelli M, Gonzalez JF, Boileau P. Arthroscopic Revision Cuff Repair: Do Tendons have a Second Chance to Heal?. Journal of Shoulder and Elbow Surgery. 2022 Jun 6.