Marc Darrow, MD, JD.
The shoulder is a common source of disability resulting from traumatic and degenerate tears of the rotator cuff and biceps tendon, tendinitis, bursitis, subacromial impingement, labral tears, chronic dislocations, and osteoarthritis. Nonoperative management has too often focused on narcotics, other analgesics, anti-inflammatory medications, and steroid injections such as cortisone.
The Leading Causes of Shoulder Pain
- Repetitive overhead sports motions such as pitching, swimming, or the tennis serve.
- Heavy lifting.
- Excessive force or impact on the shoulder such as a fall.
- Degeneration due to aging or overuse.
- Narrowing or laxity of the space (acromioclavicular joint) between the collarbone (clavicle) and the top portion (acromion) of the shoulder bone (scapula).
- Abrasion of the rotator cuff surface by the top portion of the shoulder bone (the acromium).
- Non-operative management has focused treatment on painkillers, analgesics, and anti-inflammatory medications. Often—but not recommended by us—corticosteroids are offered in injectable or oral form.
The shoulder is really a combination of the glenohumeral and A/C joints, combined in an intricate arrangement of muscles and tendons that provides the arm a wide range of motion, flexibility and stability. The rotator cuff is a group of four shoulder muscles that surround the top of the upper arm bone, the humerus, and holds it firmly in the shoulder joint. These muscles are responsible for moving the arm in various directions, and unlike the relatively large deltoid muscle of the upper arm, are smaller and generally more vulnerable to injury.
The four muscles and their tendons of the rotator cuff are the supraspinatus, infraspinatus, teres minor and subscapularis. It is the supraspinatus that is most commonly inflamed, worn down, or torn. Keep in mind that tendons connect muscles to bone, and ligaments connect bones to bones. Both tissue types are made of collagen.
Because the supraspinatus and the rest of the shoulder muscles are designed to allow a remarkable array of motion they are frequently subjected to the injuries listed above. Such injuries cause problems of instability or impingement, leading to soft tissue and arthritic pain. The pain may be constant, or may occur only when the shoulder is moved. In any case, shoulder pain that
persists more than a few days should be diagnosed and treated as necessary.
The proper diagnosis of shoulder pain is essential in order to determine the root cause of the problem and the proper method of treatment. Because many shoulder conditions are caused by specific activities, a detailed medical history is an invaluable tool. A physical examination should also include screening for physical abnormalities, including swelling, deformity, muscle weakness, and tender areas, along with the range of shoulder motion.
A patient should receive a detailed physical examination. The examination should include screening for physical abnormalities—swelling, deformity, muscle weakness, and tender areas—and observing the range of shoulder motion—how far and in which directions the arm can be moved. In the diagnosis of shoulder pain, a doctor who is assessing non-surgical treatment methods needs to be able to reproduce pain by touching the shoulder and arm. If the doctor can put his/her finger on the exact spot that is causing the pain, then it is likely that the injury involves the soft tissue—
muscles, ligaments, and tendons—rather than the bones. These soft tissue injuries are precisely the kinds of injury that respond to regenerative medicine injections.
This article is an overview of the many shoulder problems we see and it is divided into sections.
- Section one is conservative care options for most shoulder pain.
- Section two – failures of arthroscopic and shoulder replacement surgery.
Conservative care options for shoulder pain
Many patients come into our office after a long history of conservative care options. Cortisone injections being one of them. In the article below there are many research studies comparing cortisone to other treatments. In this section I will explore other options.
A top treatment for shoulder pain is also one of the most unpopular treatments. The treatment is called Activity Modification. Activity Modification simply means that you have stopped working or altered the way you work to stop aggravating your shoulder injury, or, you have given up the sport or activity that you love to play in, golf, tennis, rock climbing, surfing, weight training, etc, or you are playing less frequently. Many people do try resting the shoulder. For many people this works very well and they are able to resume playing or working at their physically demanding job. For other however, rest was “only a waste of time.” As soon as these people felt that they have rested their shoulder long enough they tried to resume activities and immediately the shoulder hurt. Is shoulder surgery the only answer for this athlete or laborer who wants a quick return to their sport or work? Many athletes believe that the answer is yes because the common alternative recommendation from their orthopedic specialist of ice, rest, physical therapy, and to wait six months is not the option they want.
Non-steroidal Anti-inflammatory Medications (NSAIDs)
For many people NSAIDS can make their shoulders feel better in the short-term. However, higher doses maybe needed in the long-term to achieve similar results. In a September 2019 study (33) doctors compared ibuprofen and acetaminophen in patients with shoulder pain, specifically pain in the rotator cuff. There were two groups of patients (an ibuprofen group and an acetaminophen group), and there was significant variability in response to these medications. Even if the average pain score was improved, several patients exhibited worsening of their condition.
In most cases, before someone can get a recommendation to surgery, they have to complete a course of physical therapy. People who are frequently diagnosed with rotator cuff tendinopathy. I frequently see patients with an MRI of a shoulder tendon tear or an MRI of a problem of chronic tendinopathy. Tendinopathy is a more recent term to describe a chronic pathology of a tendon that causes shoulder pain. The problem of Tendinopathy can be divided into two broad categories:
- Tendinitis means inflammation of the shoulder tendons. This is the characteristic swelling that comes with a worsening wear and tear or acute injury.
- Tendinosis is the “old, nagging injury.” The tendon is injured but the body has given up trying to heal it. It is an injury without inflammation. Why did the body give up? In some of the people we see, it comes as the result of a long and extensive anti-inflammatory or cortisone treatment history.
Many people have had successful physical therapy for treating rotator cuff tendinitis, tendinosis, and shoulder impingement syndrome. The idea of course being the avoidance of movement that causes pain and postural adjustments in the workplace setting to help avoid having the shoulders roll in or sloop. Physical therapy may be less effective or not work at all in situations where the shoulder tendons are stretched or damaged enough that they cannot provide the resistance needed to strengthen the muscles.
Cortisone and Physical therapy
The “go to” injection choice is corticosteroid or more commonly a cortisone shot. Many people will not get the cortisone injection alone, it will be coupled with a physical therapy program. The reasoning being that research shows cortisone and physical therapy work better than physical therapy alone. An August 2021 study (34) suggested “(a) combination of corticosteroid injection and physiotherapy is more effective than the physiotherapy alone in resolving the shoulder pain and disability of shoulder.”
An August 2021 paper (32) examined the effectiveness of Kinesio or KT in people suffering from rotator cuff disease. Kinesio Taping (KT) is one of the conservative treatments proposed for rotator cuff disease. As the study authors describe it: “KT is an elastic, adhesive, latex-free taping made from cotton, without active pharmacological agents. Clinicians have adopted it in the rehabilitation treatment of painful conditions, however, there is no firm evidence on its benefits.” Their findings suggest that “Kinesio taping for rotator cuff disease has uncertain effects in terms of self-reported pain, function, pain on motion and active range of motion when compared to sham taping or other conservative treatments as the certainty of evidence was very low. Low-certainty evidence shows that kinesio taping may improve quality of life when compared to conservative treatment. We downgraded the evidence for indirectness due to differences among co-interventions, imprecision due to small number of participants across trials as well as selection bias, performance and detection bias. Evidence on adverse events was scarce and uncertain. Based upon the data in this review, the evidence for the efficacy of KT seems to demonstrate little or no benefit.”
Why consider shoulder surgery options? Shoulder Surgery Failures
Despite research showing surgical failures, more patients are having shoulder replacement surgery. The most common indications for shoulder arthroplasty (replacement) are osteoarthritis, inflammatory arthritis, proximal humerus fracture, irreparable rotator cuff tear, rotator cuff arthropathy, and avascular necrosis of the humeral head. In one study, radiologists looked for key imaging features of these indications.
These features facilitate a correlative understanding between the initial diagnosis and the choice of type of arthroplasty used. These include total shoulder arthroplasty,(1) which is acceptable if surgery is the only option. For many patients, however, surgery can be avoided.
Shoulder Arthritis and Shoulder Replacement
There are many types of arthritis, but most often in the shoulder it is triggered by an initial trauma. It can also involve “wear and tear” of the tissues of the joint, causing inflammation, swelling, and pain. This is called osteoarthritis. Other forms of arthritis may be rheumatoid arthritis, or crystalline arthritis such as gout or calcium pyrophosphate disease. Often people will react by instinctively limiting their shoulder movements in order to lessen the pain. This can lead to a tightening or stiffening of the soft tissue parts of the joint, resulting in yet further pain and restriction
of motion. In the worst cases, adhesive capsulitis occurs and the arm can not be moved.
Doctors discuss shoulder replacement hardware failures known to plague shoulder patients
In a recent study, doctors discuss hardware failures known to plague patients: “The longevity of total shoulder replacement is primarily limited by the performance of the ultra high-molecular-weight polyethylene glenoid component. [This study] demonstrates that glenoid component fracture associated with oxidation has not been eliminated with the advent of modern materials (HXL) in the shoulder domain.” In other words, a hardware problem not fixed.(2)
Another problem with shoulder replacement is bone disintegration—an issue that bone marrow aspirate concentrate injection has been shown to heal. From one research study: “Subchondral bone changes associated with osteoarthritis may be important factors to consider when choosing a replacement component. For surgical treatment, many implant options exist, and survivability is often dependent on patient age, activity level, and progression of osteoarthritis.”(3)
If bone must be repaired in preparation for surgery, why not repair the bone to avoid surgery? The shoulder is a difficult joint to replace, and a failed shoulder replacement is even more difficult to replace.
Does comprehensive arthroscopic management for glenohumeral osteoarthritis adversely affect outcomes after subsequent total shoulder replacement?
A June 2021 paper (27) examined if people who had a failed arthroscopic shoulder surgery would be at risk for a failed total shoulder replacement. Patients younger than 70 years who underwent primary total shoulder replacement or arthroscopic surgery first then total shoulder replacement were examined at least two years after their last surgery. There were 56 patients in total at the end of the study. Of which 19 patients had the arthroscopic surgery first then total shoulder replacement and 37 patients had the total shoulder replacement without prior arthroscopic shoulder surgery.
- There were 4 patients (7.1%) who had failure, and failure rates did not differ significantly between the arthroscopic surgery first then total shoulder replacement (5.3%) and primary total shoulder replacement only group.
- Additionally, 2 patients underwent revision arthroplasty because of trauma.
- A total of 50 patients who did not experience failure (17 arthroscopic surgery first then total shoulder replacement and 33 primary primary total shoulder replacement) completed patient surveys at almost five years after their last surgery measures with no significant difference between the arthroscopic surgery first then total shoulder replacement and primary primary primary total shoulder replacement.
- Both groups improved significantly from preoperatively to postoperatively in all survery scores.
The conclusion of this research: “Patients with severe glenohumeral osteoarthritis who failed previous arthroscopic surgery benefited similarly from total shoulder replacement compared with patients who opted directly for total shoulder replacement.”
How many shoulder surgeries?
Above we see a paper that describes the benefits of the second surgery compared to the failure of the first shoulder surgery. Why, however, subject someone to the possibility of a failed surgery?
The following research from the Journal of Shoulder and Elbow Surgery explains why patients must be given information on treatment options outside of surgery: “The management of a failed shoulder represents a complex and difficult problem for the treating surgeon, with potential difficulties and complications that are related to the need to remove a well-fixed stem.” (4) If the prosthesis is removed due to failure, the bone becomes compromised, and it is even more difficult to place another prosthesis.
Shoulder replacement complications
An August 2021 study (28) assessed the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this connection between complication and revision shoulder replacement, according to the study authors, have not been well quantified.
Patients were recommended to a revision shoulder replacement surgery because of:
- component loosening 20% (601 patients of 3,041 patients)
- shoulder instability 19% (577 patients of 3,041 patients),
- rotator cuff failure 17% (528 patients of 3,041 patients),
- and infection 16% (490 patients of 3,041 patients).
- Intraoperative complication (complication during the revision surgery) was 8% (230 of 2,915 patients)
- Postoperative complication was 22% (825 of 3,843 patients), and
- Reoperation rates were 13% (584 of 3,843 patients).
For various reasons some chose not to have the secondary surgery. The authors concluded: “Satisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse shoulder replacement.”
Despite research showing more shoulder replacement failures, more patients are having shoulder replacement surgery.
In a study published in the journal Radiographics, radiologists (23) looked for key imaging features in patient shoulders to help them distinguish between the shoulder problems listed above. If they could find MRI evidence for the source of pain, radiologists could guide surgeons in choosing the type of replacement surgery the patients should get. This they suggested would help limit surgical failures and get the shoulder to as normal a range of motion as possible.
Sounds good, but as we have seen in patients here in our clinic that had an MRI, had the source of their pain pinpointed, had preoperative planning, had the best prosthetic device for them, had the best intention of the health providers to get that shoulder to as good as new as possible. The surgery still failed catastrophically.
A study (24) in the The open orthopaedics journal from 2017 wrote: “The application of different growth factors and mesenchymal stem cells appears as promising approaches for enhancing biologic repair. However, data from clinical studies are still limited, and future studies need to improve understanding of the repair process in cellular and molecular level and evaluate the effectiveness of biologic factors in the management of shoulder disorders.”
The Darrow Stem Cell Institute has published research on the treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow derived stem cells. The research appears in the peer-reviewed journal Cogent Medicine. The study can be found here in its entirety: Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections with a June 20, 2019 publication date.
Doctors are looking for shoulder replacement alternatives.
Doctors are looking for shoulder replacement alternatives. One study found that surgical repairs of degenerate and torn tissue are often prone to failure, and that some biological (biomedical) therapies (such as Platelet-Rich Plasma Therapy or Bone Marrow Aspirate Concentrate sometimes referred to as bone marrow stem cell therapy which are explained below) might improve outcomes.
In fact, injections of platelet-rich plasma have led to reduced pain and improved recovery in other degenerated areas, together with the restoration of function.(5)
Doctors in Germany looked at repairing cartilage defects and soft tissue injury in the shoulder before it leads to advanced osteoarthritis. They concluded that a treatment of stem cells for cartilage regeneration was a minimally invasive approach for shoulder joint preservation and an alternative to shoulder replacement.(6)
A proper diagnosis of the shoulder pain is essential to determine the root cause of the problem and the best method of treatment, research suggests: “Clinical decision-making is made more difficult because of the variable presentations observed in patients with a documented full-thickness rotator cuff tear: some have good function and no pain, some have good function and pain, some have poor function and no pain, and some have both poor function and pain.”(7)
Because it is difficult to determine what the pain generator is, my approach to PRP and bone marrow aspirate of stem cell therapy is to regenerate the entire shoulder, including, but not limited to the rotator cuff tendons, the glenoid and acromioclavicular joints, the labrum, ligaments, and the subdeltoid bursa. In the worst case of shoulder replacement I have seen, an elderly man presented with right shoulder pain. When I asked him to lift his arms, he lifted his right arm, but had no motion at all in his left shoulder. I was perplexed and asked if his left shoulder also hurt. His response was alarming. He told me that he had a left shoulder replacement, and the arm prosthesis had dislocated out of the shoulder, and he had absolutely no use of his left arm since the dislocation that could not be relocated into the false joint. He obviously wanted to avoid surgery to his right shoulder.
Rotator Cuff Tear Treatments
Researchers say that despite increasing medical knowledge, treating shoulder pain—whether in workers, the aging, athletes, or others—remains one of the most challenging tasks in medicine. The problem? Continued shoulder tearing and degeneration after treatment.
Researchers looked at the long-term risks of rotator cuff tear enlargement and symptom progression associated with degenerative asymptomatic tears. (8) They collected patients who had tears but no symptoms in one shoulder, and pain due to rotator cuff disease in the other shoulder. Among the 224 patients in the study, who were followed for an average of five years, there were:
- 118 initial full-thickness tears
- 56 initial partial-thickness tears
- 50 undiagnosed controls
- Tear enlargement was seen in 49% of the shoulders within an average of 2.8 years.
- Of the 244 subjects, 100 (46%) developed new pain.
According to a study on athletes, “The results of treatment are not as predictable as the patient, family, trainer, coach, and doctor would like to think.”(9)
Patients at greater risk for rotator cuff revision surgery if they have had a history of cortisone injections
An December 2019 (10) study in the journal Radiology described four main adverse findings that have been structurally observed in patients after cortisone injections.
- Cortisone injections accelerates the progression of degenerative arthritis.
- Cortisone injections cause bone fractures by weakening bone strength.
- Cortisone injections causes bone death and complications of osteonecrosis.
- Cortisone injections cause rapid joint destruction.
Another December 2019 study (11) in the journal Arthroscopy suggests that a steroid injection in the shoulder prior to rotator cuff surgery, puts you at a greater risk for post-surgical shoulder complications and possiboly the need for a secondary or revision shoulder surgery. Here is what the study says: “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 steroid), and this treatment should be withheld if an arthroscopic rotator cuff repair is to be performed within the following six months.”
Most recently, doctors in Switzerland compared PRP injections to cortisone injections in the shoulder. The doctors found good results for the PRP and were able to conclude that PRP injections are a good alternative to cortisone injections, especially in patients with contraindication to cortisone. (12)
Like all injections side effects of cortisone can include infection at the injection site. However, cortisone does have its own history of documented concerns and side-effects.
A December 2019 study (29) suggests that a steroid injection in the shoulder prior to rotator cuff surgery, puts you at a greater risk for post-surgical shoulder complications and possibly the need for a secondary or revision shoulder surgery.
A January 2019 study (30) examined the effects of one or multiple corticosteroid injections a patient received for shoulder pain prior to having rotator cuff surgery. The research team found administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery.”
An October 2020 study (31) compared one PRP injection to one corticosteroid injection for pain relief and improved function in patients with rotator cuff tendinopathy and partial thickness rotator cuff tears. After the one injection, patients were followed and results recorded at six weeks, three and twelve months post-injection. The researchers observed that patients with partial rotator cuff tears or tendinopathy experienced improvement in pain after both ultrasound-guided corticosteroid and PRP injections. However the patients who received PRP had superior improvement in pain and function at short-term follow up (3 months). One injection of PRP is not the way we offer the treatment.
Effectiveness of Rotator Cuff Tear Surgery
There has long been a debate over the effectiveness of rotator cuff tear surgery. Numerous medical studies have shown that the re-tear rate of a surgically repaired shoulder can be anywhere from 20% to 90%, depending on the patient’s particular circumstances. Australian researchers presenting at the American Academy of Orthopaedic Surgeons (AAOS) 2012 Annual Meeting said that the failure rate they measured among 500 patients was 57%.
I see many patients in my office who have had a shoulder surgery with less than expected results. Worsening complications may include infection, increased stiffness, weakness, instability, decreased range of motion, and, of course, increased pain.
Now doctors are trying to answer surgical concerns postoperatively with growth factors of regenerative medicine, namely Platelet-Rich Plasma Therapy (PRP) and bone marrow aspirate concentrate injections. Recent research notes that the goal of rotator cuff surgery is return of strength, mechanical stability, and healing of the tendon-to-bone interface. Advances in the understanding of rotator cuff biology and biomechanics, as well as improvements in surgical techniques, have led to the development of new strategies that may allow a tendon-to-bone interface healing process rather than the formation of fibrovascular scar tissue. Such strategies involve the use of PRP, stem cells, and other growth factors.
If you are under 30 years of age, shoulder surgery is typically recommended because younger patients / athletes are much more prone to repeated dislocations than older patients. Until recently it was common in cases of dislocation to immobilize the shoulder for long periods of time. But studies showed that while immobilization helped alleviate the pain of such injuries, it also contributed
to a general weakening of the ligaments and predominance of adhesive capsulitis, or frozen shoulder. Additionally, if a second surgery is needed the patient must be made aware of a high rate of recurrent instability, low rates of return to play, and low clinical outcome scores, or successful treatment. This is why choosing the correct treatment should be given great care.
Bone marrow aspirate concentration (stem cell), Platelet-Rich Plasma Therapy, and Prolotherapy for Rotator Cuff Injury
For many patients, not all, stem cell therapy or bone marrow aspirate concentrate may be effective. In our research which appears in the peer-reviewed journal Cogent Medicine found here in its entirety: Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections with a June 20, 2019 publication date, we were able to demonstrate:
- Selected patients with rotator cuff tendinopathy and degenerative shoulder disease would benefit from either one and two stem cell treatments. Patients reported significant improvements in resting pain, active pain, and functionality score when compared to baseline.
This is the summary of that research and it explains the bone marrow aspirate concentrate stem cell therapy treatment:
“Human bone marrow offers a promising new therapy for the treatment of chronic shoulder pain. This includes Whole Bone Marrow (WBM) therapy, where the bone marrow is aspirated and reinjected without manipulation, or as Bone Marrow Concentrate (BMC) therapy, where the bone marrow is centrifuged and cleared of red blood cells. Human bone marrow contains many growth factors and important cytokines as well as platelets and mesenchymal stem cells (MSCs). . .
Our study demonstrated that a single injection of Bone Marrow Concentrate or Whole Bone Marrow in the treatment of shoulder osteoarthritis and rotator cuff tears significantly improved resting pain, active pain and functionality score. Patients that received two injections of Bone Marrow Concentrate or Whole Bone Marrow reported greater mean improvement that were also statistically significant when compared to baseline. When injection groups were compared, the two treatment group demonstrated statistically significant improvements in active pain when compared to the one injection group. In addition, there were significant findings across all measure variables when analyzing based on osteoarthritis and rotator cuff tear pathologies. The results of our study show that Bone Marrow Concentrate and Whole Bone Marrow are efficacious in the treatment of rotator cuff tear as well as osteoarthritis with clinically significant benefits to patients after one treatment.”
Similarly, other research has suggested that bone marrow aspirate concentration stem cells showed encouraging results in pain and motion relief for patients with rotator cuff and shoulder
The video below demonstrates the treatment
Shoulder Tendinitis / Tendinosis / Bursitis
Tendinitis in the shoulder occurs from inflammation of the tendons as a result of the wearing process that takes place over a period of time, or from an unusual load on the joint, or awkward movement, or fall. Although doctors and patients tend to identify any pain originating from the tendons as tendinitis, research recently has found that tendinitis is the microtearing of the tendon with inflammation. On the other hand, tendinosis is the wearing of the tendon’s collagen without inflammation and usually occurs after the inflammatory process ends. Either way, healing can occur with regeneration of the tendon’s collagen.
Sometimes excessive use or injury of the shoulder leads to inflammation and swelling of the subdeltoid bursa, a condition known as bursitis. Bursae are fluid filled sacs located around the
body and joints. They cushion tendons, ligaments, and muscles from bones. Bursitis often occurs when the sac is inflamed and may be in association with rotator cuff tendinitis. Symptoms of shoulder bursitis include mild to severe pain, limiting the use and range of motion of the shoulder. In extreme cases the joint capsule stiffens and range of motion is lost. This condition is known as “frozen shoulder,” also referred to by doctors as adhesive capsulitis which I discuss below.
In a July 2021 study (35), study researchers wrote: “Rotator cuff tendinitis has been treated using various methods including physiotherapy, steroid injections and recently platelet rich plasma (PRP). Most of these methods aim at giving symptomatic relief rather than addressing the pathology (the cause of the problem). There is no clear consensus over the benefit of using PRP for tendinitis. (The authors) decided to do a prospective clinical study to demonstrate the efficacy of PRP and study the functional outcome in the treatment of rotator cuff tendinopathy.
- Patients with shoulder pain for more than three months not responding to NSAIDs or physiotherapy with a diagnosis of rotator cuff tendinitis, confirmed by MRI, were included in the study.
- Thirty patients received an ultrasound guided PRP injection in the subacromial space followed by a six-week exercise program.
- Patients were followed-up at three, six and 12 weeks and were assessed clinically using the Pain and functional scoring systems.
The ten point Visual Analogue System score 0 being no pain and 10 being unbearable pain improved from a pre injection score of 7.4 (significant pain) to a score of 1.9 (little pain) in the 12th week. The mean SPADI (Shoulder Pain and Disability Index) score and Constant (pain and shoulder rotation score the lower the number the better) score improved significantly.
Conclusion: “Platelet Rich Plasma injections showed good to excellent early results, in patients with rotator cuff tendinopathy with improvement in VAS, SPADI and Constant scores.”
SLAP Lesions (Superior Labral Anterior Posterior)
The surgical treatment of labral (tissue around shoulder joint) SLAP tears continues to be challenging for both physicians and patients. Of course, it becomes much more challenging to the patient if the surgery does not work to the patient’s expectations. A 2016 paper stated that tears of the superior labrum involving the biceps anchor are a common occurrence, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature, particularly for young athletes.
However, the results for athletes whose sport involves throwing are less successful, with a significant proportion of patients who will not regain their pre-injury level of performance. The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates compared to younger patients. In this population, tenotomy (surgical division of a tendon) or tenodesis (suturing of the end of the biceps tendon to the bone) are viable alternatives to SLAP repairs in order to improve clinical outcomes.(14) In tenodesis, the surgeon moves the
bicep tendon attachment to a different place on the bone (usually as part of a more complex surgery).
SLAP (Labral) Lesions May Actually be Rare Injuries
Recently, Dr. Stephen C. Weber presented the findings of his study showing that American Board of Orthopaedic Surgery (ABOS) Part II candidates (young surgeons) may be performing superior labral tear anterior to posterior (SLAP) repairs at greater rates than they should.
He noted that the increase in surgeries was leading to poor outcomes and increased complication rates. One of the reasons too many surgeries were being performed was because MRI suggested a SLAP tear when SLAP tears were not there. Dr. Weber noted that magnetic resonance imaging (MRI) scans often produce false positives and that SLAP lesions are difficult to diagnose clinically.
Numerous studies suggest that even experts disagree on how to define a type II SLAP tear.
“Furthermore, repairing SLAPs is not a benign process, and caring for failed SLAPs can be very difficult,” said Dr. Weber. “Complications include stiffness, persistent rotator cuff tears next to the portals, and damage to the articular cartilage.” He expressed particular concern about the number of older patients receiving SLAP tear repairs because of the potential for a significant number of complications and poor outcomes.
Dr. Weber suggested that educating young orthopaedists to distinguish between pathologic SLAP lesions and incidental degeneration of the labrum might help to reduce the rates of SLAP repair and improve outcomes. “I think we need to do a better job of defining labral pathology for the patients who truly have symptomatic SLAP lesions,” he said. (15)
Too many times I see patients complaining of continued pain after a failed labral repair. Was the “torn” labrum the pain generator? Probably not, or perhaps the surgery may have caused more damage. Consider what happens when a knife cuts into the body and tools are used to “repair” the area. And why is it that I often see patients with pain and loss of range of motion that show no pathology on MRI. I am pressing you to understand that as doctors we really don’t always know exactly what is going on, even after the history, physical, and diagnostic films. That’s why my first law of medicine is to be conservative, and do no harm. And with this in mind in light of too many surgeries being done, why not regenerate the tissue instead of cutting it out?
Is shoulder surgery the answer for the athlete who wants a quick return to their sport? For many athletes and non-athletes, the answer is yes, because the alternative recommendations from their orthopedic specialist of ice, rest, physical therapy and waiting six months is not the option they want. And honestly, even today, most surgeons—even those who do PRP and Stem Cells—do not believe alternative therapies work, using them simply as a way to bring patients into the office. When the pain persists after an incomplete course of treatment, surgery is then recommended.
Unfortunately, the process of tissue regrowth often takes several treatments over several weeks. I always suggest nonsurgical options, since, as noted at the start of this book, I personally had a failed shoulder surgery that made my shoulder much worse. After surgery, my arm filled with fluid, I had a fever, and large blisters developed on my arm and shoulder. I liked my surgeon, who was my professor while I was doing orthopedic surgery in my training—but at that point I realized that surgery was a mistake in many instances, and I questioned whether I still wanted to make it my lifetime work. When I learned about regenerative medicine, I injected my own shoulder and the pain was gone when I awakened the next morning. My shoulder remained pain-free for twelve years until I reinjured it, at which point I repeated the injections, and again healed my own shoulder. It has been pain free since then.
It takes nine months to recover from surgery to return to sport – unless you are a throwing athlete or pitcher
A December 2019 paper (16) offered these timetables for a return to sport in evaluating individuals undergoing arthroscopic SLAP repair. This research encompasses 22 previously published articles involving a total of 944 patients undergoing arthroscopic SLAP repair.
- Of the total included patients, 270 were identified as overhead athletes, with 146 pitchers.
- Across all patients, 69.6% (657/944 patients) of individuals undergoing arthroscopic SLAP repair returned to sport.
- There was a 69.0% (562/815 patients) return to previous level of play, with a mean time to return to sport of about nine months.
- The return-to-sport rate for pitchers compared with the return-to-activity rate for nonpitchers, encompassing return to work and return to sport, was 57.5% (84/146 patients) and 87.1% (572/657 patients), respectively, after arthroscopic SLAP repair.
Conclusion: “Arthroscopic SLAP repair is associated with a fair return to sport, with 69.6% of individuals undergoing arthroscopic SLAP repair returning to sport. SLAP repair in pitchers has significantly decreased return to sport in comparison with nonpitching athletes. Athletes on average return to sport within 9 months postoperatively.”
Shoulder Impingement: Surgery Not Often the Answer
Researchers state that surgical interventions for subacromial impingement syndrome do not reveal one surgical technique to be better than another, nor do they show that surgery is superior in any way to conservative interventions.(17)
Further data shows, when young athletes have arthroscopic stabilization surgery, it must be emphasized to the patients and their families that the recurrence rate following arthroscopic procedures is higher in young people than in the adult population.(18)
Shoulder impingement surgery may not be the fastest way back to health. A patient with problems of the rotator cuff or shoulder impingement may think that surgery will be a quick fix. However,
surgery is an invasive procedure that often requires lengthy recovery and physical therapy even if it is successful. Further, even “successful” surgery may not relieve the pain, and shoulder weakness can remain.
Complications can also include nerve damage and increased weakness. One study noted that “[m]ost patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms post-operatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge.”(19)
The traditional treatment options include another surgery to repair the first one, or surgery to transfer a tendon into the area, and arthroplasty.
Shoulder Impingement Surgery Alternatives
Although “impingement” refers specifically to pressure on the tendons and bursa in the shoulder, it is a generalized term often used to refer to shoulder pain of unknown origin. Other terms used are tendinitis, tendinosis, and bursitis, when none of these are actually proven as pain generators.
Bone Marrow Aspirate Stem Cell Therapy, Platelet-Rich Plasma (PRP) Therapy, and Prolotherapy are injection techniques that can accelerate the body’s own regenerative actions to repair the worn or injured tissue. By isolating the areas that are damaged and injecting these spots with various “proliferants”—which may range from hypoertonic dextrose (Prolotherapy) to your own blood platelets or stem cells—the practitioner is summoning the natural injury-repair mechanism of the body to the area that needs healing. Part of the cure is the manufactured, controlled inflammation caused by these proliferants.
This stimulates a new collagen matrix, which makes the tissue stronger and thicker and can restore it to its pain-free state. In a recent study, doctors found that following Prolotherapy treatments,
patients with refractory chronic rotator cuff disease showed improvement in the areas of pain, disability, isometric strength, and range of motion.(20)
Most recently, doctors in Switzerland compared PRP injections to cortisone in the shoulder. The doctors found good results for the PRP and were able to conclude that PRP injections are a good alternative to cortisone injections, especially in patients with contraindication to cortisone. (21)
There are many injuries that result in 100% tearing of the rotator cuff tendons in previously healthy shoulders. These often occur in sports, car accidents, or situations where the shoulder is exposed to sudden extreme force.
Even with complete tendon tear, Bone Marrow Stem Cell Therapy, PRP, and Prolotherapy, may be the preferred treatment. Occasionally, surgery to repair torn tissue might be the only option. Even so, Stem Cell Therapy and PRP can accelerate healing after surgery.
The shoulder comprises a complex matrix of bone and soft tissue that enables an extreme range of motion. But the price the shoulder pays for that range of motion is a greater risk of chronic injury. The shoulder is held together by soft tissue stabilizers, the ligaments that connect bone to bone. Over the course of time, especially in sports that involve heavy shoulder-to-shoulder contact (such as hockey, lacrosse, football, wrestling, and basketball), the ligaments may stretch out and become “lax.” When the ligaments become lax, the risk of dislocation and separation becomes greater.
In a study published in the British Journal of Sports Medicine, researchers took a look at rugby players with measurable shoulder laxity to gauge the risk of shoulder dislocation. What they found was that 50% of the athletes tested were at significant risk.
It is estimated that 95% of shoulder dislocations occur when athletes suffer a blow to the shoulder that forces the shoulder joint “back” or downward, or occur when they fall to the ground with their arms stretched over their heads.
Chronic Shoulder Dislocation Treatment
Traumatic shoulder dislocation is a frequent injury in the sports population. An acute shoulder dislocation often means a one-time traumatic episode, whereas chronic shoulder instability indicates multiple recurrent dislocations.
Following an initial shoulder dislocation, doctors debate whether or not to perform surgery to prevent recurrence. If there is an accompanying labral or tendon tear, that can be addressed along with tightening of the capsule around the joint. This can lead to a loss of range of motion. I have used Stem Cell Therapy with platelets (both are in the bone marrow) or just PRP from the blood, both with good results, to tighten the shoulder after a failed surgery for chronic dislocations.
If the patient is under 30 years of age, shoulder surgery is typically recommended by surgeons because younger athletes are much more prone to repeated dislocations than older athletes.
Until recently, it was common in cases of dislocation to immobilize the shoulder for long periods of time. But studies showed that while immobilization helped alleviate the pain of such injuries, it also contributed to a general weakening of the ligaments and predominance of “adhesive capsulitis,” where the arm is frozen (frozen shoulder) and can no longer be lifted.
Surgery for shoulder dislocation can be effective for some but, as always, surgery should be considered a last option because of issues of complications, downtime (immobilization), and—for both the “weekend warrior” and the professional athlete—a weakening of the shoulder through the removal of or damage to other connective tissue in the surgical process.
Some athletes may opt for immediate surgery because of the typical six-month healing time (if healing occurs at all) required in the case of a Bankart lesion (an injury of the anterior [inferior] glenoid labrum) without Stem Cell Therapy or PRP. Researchers have pointed out that “[r]epairs of degenerate and torn tissue are often prone to failure due to many intrinsic and extrinsic factors” and that Platelet-Rich Plasma Therapy has been shown to reduce pain and improve recovery in shoulder tears.(22)
The key to avoiding shoulder surgery or shoulder separation requiring surgery is to strengthen the shoulder girdle. This can be accomplished by working the strong shoulder muscle group and by
treating the weakened shoulder ligaments with injections of regenerative medicine.
To understand the importance of having strong ligaments to hold the shoulder together, the patient needs to understand that the severity of the shoulder dislocation is measured by the degree of injury to the ligaments and the amount of instability of the joint.
The acromioclavicular (AC) and the coracoclavicular (CC) ligaments hold the shoulder together at the point where the collarbone (clavicle) and the top (acromion) of the shoulder meet. This joint can also be traumatically separated. I see this most commonly in bicycling accidents in which the patient has flown over the handlebars and landed on the shoulder.
This is a very small joint that heals well with regenerative medicine.
- In type I level separation, the AC is partially torn; the CC is not.
- In type II separation, the AC is completely torn; the CC is partially or not torn.
- In type III separation, both ligaments are completely torn.
With this injury one can often see the collarbone sticking up above the top of the shoulder. Obviously, the more significant the tearing, the longer the athlete is out of their sport. Untreated shoulder instability can lead to an alteration of an athlete’s game to protect the sore shoulder, or, worse, chronic shoulder separation that can keep athletes away from their sport for significant
amounts of time. Bone Marrow Stem Cell Therapy and PRP use the patient’s own cells to repair and rebuild ligaments and the joint itself.
Research on Platelet Rich Plasma injections – PRP may help frozen shoulders
There are many treatments that can work for to get the shoulder “unstuck” or “unfrozen” as described in the above research. Platelet Rich Plasma is seen as a treatment that can help frozen shoulder by addressing the problems of shoulder instability which can cause a thickening of the shoulder capsule. A January 2021 (25) study suggested PRP injections could help frozen shoulder.
This was triple blind study, the doctors did not know what they were injecting, the patients didn’t know what they were being inject with and the researcher analysis did not know what treatment offered the results they were examining. The researchers found PRP injections were found to be effective in both pain and disability, and showed improvements in a restricted shoulder due to adhesive capsulitis. These findings might point out PRP as a therapeutic option in the management of adhesive capsulitis.
Ultrasound guided platelet rich plasma injection treatments
An August 2017 (26) study published in the Journal of clinical imaging science found: Ultrasound guided platelet rich plasma injection for partial rotator cuff tears is an effective procedure that leads to significant decrease in pain, improvement in shoulder functions, much cost-effective and less problematic compared to a surgical treatment. “There is conclusive benefit for reducing pain and improving shoulder function in partial rotator cuff tears with ultrasound-guided PRP. . . This study succeeded in demonstrating that those patients receiving PRP injections have decreased pain, healing properties, and superior functional outcomes.”
A patient with problems of the rotator cuff or shoulder impingement may believe surgery is still the best answer for them, and maybe it is. However, surgery is a still an invasive procedure that requires lengthy recovery and physical therapy even if successful. Further, even successful surgery has been shown to not always relieve all preexisting pain and shoulder weakness can remain. Complications may also include nerve damage.
Shoulder injuries can be divided into two groups —the more common and the first to be discussed is the wear and tear injury to the tendons. The shoulder tendons are main players in rotator cuff problems, shoulder impingement, osteoarthritis, and disorders of pain and weakness that get worse over time.
The symptoms of tendon weakness and injury are many and include inflammation of the tendons (tendinitis), and/or bursitis– inflammation of the bursa, the protective sac that sits between the bones of the shoulders and allows the tendons the space they need to move.
All medical professionals would agree that treating the tendons and allowing the tendons to function normally would be the optimal treatment in shoulder pain, but that is where the agreement ends. Surgeons will insist that surgery after failed conservative treatments is the way to go while other doctors have pioneered quicker and less intrusive methods.
Bone Marrow stem cell therapy and Platelet Rich Plasma Therapy are injection techniques that can accelerate the body’s own inflammatory response to repair the tendons. In the case of Stem Cell Injection Therapy, the stem cells can morph into, and rejuvenate the tissue that is damaged.
By isolating the areas of the tendons that are damaged and injecting these spots, the doctor is focusing the natural injury repair mechanism of the body to the spot of deterioration. The treatment is the new, controlled inflammation and tissue regrowth. This will stimulate a new collagen matrix, making the tendons stronger, thicker, and restoring them to their normal pain-free state. To any
athlete stronger is always the best option.
Side-effects are also limited and are typical of any injection side effect including infection or swelling or discomfort at the injection site. and in many cases the athlete can continue their activities during treatments.
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