Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, IllinoisDavid Woznica, MD
The shoulder is a complex joint, easily susceptible to instability and loss of pain-free motion. When one part of the shoulder is injured, it usually causes disruption throughout the shoulder complex. This includes problems caused by a partial-thickness rotator cuff tear.
Many times a patient will tell us that they have a surgery planned. But they do not want one. If you are in this similar situation, you like them, are looking at recovery times that a partial rotator cuff surgery may require as part or maybe your whole reason to avoid the surgery. But something does need to be done to prevent the partial from becoming a full tear and you suffering from a worsening condition. But is it surgery? Next question, do you even have a partial rotator cuff tear? One thing for sure is you do have shoulder pain so something is wrong.
Do you even have a partial rotator cuff tear?
That an MRI that has a good probability of actually showing a partial rotator cuff surgery is flawed medical thinking
The concern about surgery for partial rotator cuff tears is that you may be operating on something that is not even there. This is not solely our opinion, there are many studies confirming that an MRI may send you to an unnecessary shoulder surgery.
Many patients come into our office with an MRI of their shoulder. These patients have bounced from doctor to doctor, from specialist to specialist looking for a treatment option. The one thing that has remained constant with many of them is that the picture of their MRI is an accurate reflection of what is going on in their shoulder. This is not always the case. The MRI may be leading this patient down a path of treatment that is not accurate to their situation.
This is probably why you are still searching for treatment, you are chasing a partial rotator cuff tear as the sole problem. We are going to present evidence that you may be chasing the wrong target. What you should be chasing is total shoulder treatment.
An MRI that has a good probability of actually showing a partial rotator cuff surgery is still flawed.
We are going to help take you on a journey of MRI understanding that will reinforce our suggestions that the MRI may be leading you astray. We are going to use the help of some new research.
This study comes from the Department of Orthopaedics and Orthopaedic Surgery at Saarland University Medical Center in Germany. It was published in the Archives of orthopaedic and trauma surgery. (1) Here are the learning points:
- The reliable diagnosis of partial-thickness tears of the rotator cuff is still elusive in clinical practice.
- The purpose of the study was to determine the diagnostic accuracy of MRI and clinical tests for detecting partial-thickness tears of the rotator cuff as well as the combination of these tests.
There is a problem, partial rotator cuff tears are difficult to diagnose. Your MRI may be wrong. Your diagnosis maybe in question.
- Here is a statement from the research and then we will explain what it means in regard to how accurate an MRI is for a partial rotator cuff tear.
- Sensitivity for MR imaging to identify partial-thickness tears was 51.6%, specificity 77.2%, positive predictive value 41.3% and negative predictive value 83.7%.
What you may notice in those numbers immediately is that there is no “100%.”
- So first thing, the MRI reading and image is not accurate every single time.
- Sensitivity for MR imaging to identify something that MAYBE a partial-thickness tears was 51.6%.
- What does this mean? This means that the MRIs chances of accurately detecting the possibility of a partial rotator cuff tear is actually there is about 52%. Basically the same accuracy odds as a coin flip.
- Once this 52% is separated into probable and non-probable, then the probable partial rotator cuff tears are confirmed as partial tears with a specificity of 77.2%. What this means is that there is a 78% chance you do have a rotator cuff tear. You may then have been told the MRI shows a partial rotator cuff tear. Yet, there is in reality a 1 in 5 chance that is actually no tear. Are you being sent to surgery on this recommendation of 78% probability? This answer is probably yes because the surgery, it will be suggested to you, will go in there and see if you really do have a tear and if you do, clean up your shoulder. See below on the research questioning this type of thinking.
- Sensitivity for MR imaging to identify something that MAYBE a partial-thickness tears was 51.6%.
The findings are all calculated odds, you could have a partial tear and be told you don’t, you may not have a partial tear and be told you do.
So, if you had 100 patients who were sent to an MRI with suspect partial rotator cuff tear. If the negative predictive value was 83.7% it means that the MRI’s ability to successfully predict that a partial rotator cuff tear is NOT THERE is almost 84% of the time. So there is a 16% chance that you do have a rotator cuff there and you will be told you do not. Equally, there is a 78% chance that you do have a tear, be told you have a tear, and there is a 1 in 5 chance that you do not. This is why there is no 100% in MRIs. This is why you may be chasing the wrong problem.
The researchers of this study took this one step further. They combined the MRI findings with a physical examination to see if the physical examination correlated with the MRI findings and if it helped to accurately diagnose the partial tear. The physical examinations were standard Jobe-Test and Sensitivity for the Impingement-sign which try to predict the possibility of a muscle tear in the rotator cuff.
For the combination of MR imaging, Jobe-test and Impingement-sign, the results were as follows:
- Sensitivity was 46.9%, this means that an MRIs and physical examination’s combined chances of accurately detecting the possibility of a partial rotator cuff tear is actually there is about 47%.
- Once this 47% is separated into probable and non-probable, then the probable partial rotator cuff tears are confirmed as partial tears with a specificity of 85.4%. So following the physical examination and an MRI in the best, most absolute scenario, you can still only be told it is only likely you have a partial rotator cuff tear. There is no 100% in MRIs.
Does an arthroscopic repair of rotator cuff cause more pain?
Patients who were younger, had partial-thickness tears, and had occupational injuries experienced more pain postoperatively
Back to you. You are exploring alternatives to surgery because you may need to get back to work or a sport and the post-surgical recovery time is more than you want to manage at this point. In the above scenario of MRI probabilities in assessing whether you actually have a partial rotator cuff tear, doctors may recommend an arthroscopic or exploratory surgery to see what is “really going on.” While they are in your shoulder, they will clean up what they find.
Doctors at the University of New South Wales are suggesting something totally contradictory to our understanding of rotator cuff arthroscopy. Writing in the American Journal of Sports Medicine, March 2017, (2) they suggest that:
- Rotator cuff repair often results in significant pain postoperatively, the cause of which is undetermined.
- 1624 patients who underwent arthroscopic rotator cuff repair were included in this study.
- Rotator cuff tears were subdivided into groups based on the tear size and re-tear rate found for each group.
- A smaller tear area was associated with:
- more frequent and severe pain with overhead activities, at rest, and during sleep as well as a poorer perceived overall shoulder condition at 6 weeks, 3 months, and 6 months after repair
- Patients who were younger, had partial-thickness tears, and had occupational injuries experienced more pain postoperatively
- Larger tears did not have more pain at 1 week after surgery. The re-tear rate was 7%.
- There were fewer re-tears with smaller tears, but they were more painful than large tears postoperatively from 6 weeks to 6 months after surgery. Patients with smaller tears experienced more pain after rotator cuff repair compared with patients with larger tears. These findings are contrary to previous ideas about tear size and postoperative pain.
A June 2018 study in the Orthopaedic journal of sports medicine (3) found that “After rotator cuff repair, some patients have ongoing problems significant enough to warrant presentation to a clinic for reassessment.” In other words something was not right after the surgery. In how many people? Measured by how many patients had to make an unscheduled postoperative visit to the surgeons office? About 1 in 6. Some people knew right away that things were not right, about 1/3rd of patients with problems after surgery were in the surgeons office within 2 weeks after the surgery for an unscheduled follow up.
The JOB and the SPORT was not making the shoulder worse.
People do have success with shoulder arthroscopic surgery. In our offices we do not see those successful stories, we see the non-successful stories, we see the problems the inappropriate treatments and the failed surgery have caused and are pretty blessed that patients have sought us out to handle these significant challenges with them. The tone of this article reflects our experience. We want to reiterate people do have successful surgeries.
What if you do not have a surgery?
Doctors at Tohoku University School of Medicine writing in the American Journal of Sports Medicine (4) were looking for the risk factors for tear progression in painful rotator cuff tears when a patient decides not to have the surgery. These researchers also looked at the type of patient, high active, low active, in determining an accurate assessment.
- The theory is that tears in younger patients, high-activity patients, or heavy laborers would progress in size more than those in older patients, low-activity patients, or light laborers. This theory was shown to be INCORRECT.
- 225 consecutive patients with symptomatic rotator cuff tears visited the researcher’s institute between 2009 and 2015.
- Of these, 174 shoulders of 171 patients (average age 67 years old) who underwent at least 2 magnetic resonance imaging (MRI) examinations were prospectively enrolled in the study.
- At an average 19 months follow up, tear progression was defined as positive when the tear size increased by more than 7/100ths of an inch.
- Of the 174 shoulders, 82 shoulders (47%) showed tear progression.
- On average, the tear progression 3.8 mm/year in length (about a 1/6th inch) and 2.0 mm/y (a little more than a 1/12th inch in width.
The size of full-thickness tears significantly increased compared with that of articular-sided (closest to shoulder as cared to bursa side) partial-thickness tears.
- YET, sports participation, and job type did not show any correlation with tear progression. The JOB and the SPORT was not making the shoulder worse.
In patients over 50, non-surgical management of partial rotator cuff tear is just as good as arthroscopic rotator cuff repair
Many people over 50 are very active in sports and maintain physically demanding jobs. Some are living a more relaxed lifestyle. One of the reasons for the more relaxed lifestyle maybe their shoulder injury preventing them from doing the activities they love. They too are afraid of making the shoulder worse and them facing the need for surgery.
Non-surgery treatment options just as good as surgery
In a very recent study in the Annals of Rehabilitation Medicine, (5) doctors in South Korea say that in patients over 50, non-surgical management of partial rotator cuff tear is just as good as arthroscopic rotator cuff repair.
Patients with either a high-grade partial-thickness or small-to-medium-sized full-thickness tear were included in this study. The primary outcome measurements to see which patients did well or did not do well were a pain assessment score and range of motion score one year after treatment.
Another thing the researchers looked for was how many patients had tear progression or re-tear and pain after the treatments.
A total of 357 patients were enrolled, including 183 patients that received conservative treatment and 174 patients who received an arthroscopic repair.
- Both groups showed an improved range of motion and lessened pain.
The conservative care group did just as well as the surgical repair group.
- Re-tear of the rotator cuff was observed in 9.6% of patients who had an arthroscopic repair and tear progression was found in 6.7% of those who underwent conservative treatment.
Here is an important point:
You have a partial rotator cuff tear, you don’t want surgery. What’s next? A look at regenerative medicine at shoulder instability
When someone comes into our clinic with a diagnosis of a partial rotator cuff tear they are here because they are trying to avoid a surgery. So are we. To help you avoid a surgery we will do a physical examination and take a medical history to assess what type of treatments we can offer that best suits the demands you place on your shoulder, whether through sports or physically demanding jobs. We then go about repairing your shoulder and the problems that lead to your degenerative rotator cuff tear or the dmage sustained in an impact injury forceful enough to cause the rotator cuff tear.
A quick note on shoulder instability
Shoulder instability increases the force on rotator cuff tendons. The rotator cuff is designed to move the shoulder joint, not stabilize it. This causes the tendons to weaken and degenerate, increasing susceptibility to tearing. Rotator cuff tears are indicative of joint instability. Traditional treatment for shoulder instability is rotator cuff strengthening exercises, specifically of the supraspinatus muscle, the primary muscle responsible for the external rotation of the shoulder. The rotator cuff is a group of four muscles: the supraspinatus, infraspinatus, subscapularis, and teres minor. The rotator cuff muscles help stabilize the shoulder and assist with movement. Rotator cuff strengthening exercises help strengthen shoulder muscles but often do not cure the underlying problem of shoulder instability. To fix shoulder joint instability, the shoulder ligaments and shoulder capsular structures must be strengthened.
Platelet Rich Plasma Prolotherapy as alternative to partial torn rotator cuff and shoulder pain surgery
Prolotherapy is an excellent option for rotator cuff injuries because it involves the regeneration of soft tissue. Prolotherapy is a simple injection therapy with a short recovery time and allows the use of the shoulder during recovery. Prolotherapy is a first-line alternative to a costly and invasive surgery, which addresses the root cause of the problem (often missed by surgery), and leads to a better recovery.
- Prolotherapy solutions are injected into your painful areas to repair damaged tissue.
- The injections create a localized inflammation triggering the immune system to create the building blocks of ligaments, tendons, cartilage, and bone.
- H3 Prolotherapy, through a series of injections, REBUILDS the rotator cuff soft tissue.
In a published study conducted with our own patients – we showed the benefits of Prolotherapy as an alternative to shoulder surgery. Thirty-four chronic pain patients who were told by their medical doctor/surgeon that surgery was needed were treated with dextrose Prolotherapy in lieu of surgery. Twenty of these patients were faced with joint replacements and nine with arthroscopic procedures.(9) This research appeared in the Journal of Prolotherapy.
- In this study, Prolotherapy caused significant improvement in pain and stiffness.
- Ninety-one percent of patients felt Prolotherapy gave them 50% or greater pain relief, and 71% felt the pain relief was greater than 75%.
- The patients’ quality of life was improved as depression, anxiety, and medication usage decreased while range of motion, sleep and exercise ability increased.
- Also from the Journal of Prolotherapy: Prolotherapy was able to eliminate the need for surgery realistically in 31 out of 34 patients.(6)
- In the recent research from Korean doctors writing in the Archives of physical medicine and rehabilitation suggest Prolotherapy showed improvement in pain, disability, isometric strength, and range of motion in patients with refractory chronic rotator cuff disease.(7)
In May 2017, Turkish doctors wrote in the journal Orthopaedics & Traumatology, Surgery & Research, that Dextrose Prolotherapy will reduce pain and improve shoulder function and patient satisfaction.
- In this study, 120 patients with chronic rotator cuff lesions and symptoms that persisted for longer than 6 months were divided into two groups: one treated with exercise as the control group, and the other treated with Prolotherapy injection. In the Prolotherapy group, ultrasound-guided prolotherapy injections were applied.
- In the exercise group, patients received a physiotherapy protocol three sessions weekly for 12 weeks.
- Both groups were instructed to carry out a home exercise program.
In the Prolotherapy group, 53 patients (92.9%) reported excellent or good outcomes; in the control group, 25 patients (56.8%) reported excellent or good outcomes. Prolotherapy is an easily applicable and satisfying auxiliary method in the treatment of chronic rotatory cuff lesions.(8)
In the January 2016 edition of the Archives of physical medicine and rehabilitation (9) doctors including our friend and colleague K. Dean Reeves of the Department of Physical Medicine and Rehabilitation, University of Kansas, assessed the effects of dextrose prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy.
The participants in this study received three monthly injections into the entheses (the tissue that attaches the tendon to the bone).
- Group one received dextrose prolotherapy
- Group two injections into the entheses with saline (control / placebo group)
- Group three, injections above the entheses with saline (control / placebo group)
- All participants received concurrent programmed physical therapy.
The primamry conclusion of this research was: “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. Dextrose prolotherapy may improve on the standard care of painful rotator cuff tendinopathy for certain patients.”
What does the PRP injections do?
As you see from the video above, we do not offer PRP injections without Prolotherapy injections. PRP is different than Prolotherapy as it utilizes the patient’s blood platelets as a healing injectable in the shoulder.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
Above we discussed treating the whole shoulder as opposed to focusing on the partial rotator cuff tear. PRP and Prolotherapy injections achieve this goal. The PRP helps focus on the tendon and muscle damage, Prolotherapy focuses on strengthening the ligaments and the shoulder instability. If you repair the rotator cuff, without addressing the shoulder ligaments, you are limiting your chance for long-term healing.
The research on PRP
In a heavily cited study, doctors in Israel writing in the medical journal Sports medicine and arthroscopy review (10) wrote that injections of platelet-rich plasma have led to reduced pain and improved recovery in rotator cuff with the restoration of function.
Doctors at the Seoul National University College of Medicine publishing in the American journal of sports medicine (11) described how PRP heals tendons on the cellular level: “Platelet-rich plasma promoted cell proliferation and enhanced gene expression and the synthesis of tendon matrix in tenocytes from human rotator cuff tendons with degenerative tears. . . These findings suggest that PRP might be used as a useful biological tool for regenerative healing of rotator cuff tears.”
This research was supported by findings published in the journal BioMed Central musculoskeletal disorders (12) by German medical university researchers who wrote: “PRP is a source of growth factors such involved with tendon-bone healing. PRP had an anabolic effect the ability to construct connective tissue) on the human rotator cuff tenocytes.”
Comparison to cortisone
Doctors at the National Taiwan University Hospital, published their findings in the February 2019 edition of the Archives of physical medicine and rehabilitation (13) in which they suggest “patients with rotator cuff tendinopathy, corticosteroid plays a role in the short term (3-6 weeks) but not in long-term (over 24 weeks) pain reduction and functional improvement. By contrast, PRP and prolotherapy may yield better outcomes in the long term (over 24 weeks).
Compared to the success we have seen with Prolotherapy and PRP in treating rotator cuff injuries, we believe it would be beneficial to try PRP injections first instead of surgery.
Stem cell and PRP injection treatment option
Some of the treatments we may use are stem cell treatments where we would use your own stem cells to accelerate your rotator cuff healing or your own blood platelets, better known as Platelet Rich Plasma therapy. We offer a unique method for these treatments in that we couple them with comprehensive H3 Prolotherapy injections.
NOTE: We do not offer stem cell injections to every patient. We have found PRP and Prolotherapy injections can offer the desired results.
Let’s help you with your research:
A January 2018 study from South Korean doctors published in the Journal of orthopaedic surgery and research (14)found a positive benefit of a combined bone marrow aspirate concentrate (stem cell) and platelet-rich plasma BMAC-PRP injection in patients with a partial tear of the rotator cuff tendon.
The study had a very short follow up time to measure results, where success of arthroscopic surgery is measured in terms of follow up at 12 and 24 months, the South Korean team published results at 3 weeks and three months and felt confident that the results at three month follow-up would confidently predict patient success at 24 months.
What is the outcome of a partially torn rotator cuff tendon treated one time with PRP and bone marrow aspirate concentrate?
- The study showed that BMAC-PRP injection was associated with improved function and pain by standardized scoring systems at 3 months after injection as compared to the control group, while the change in the tear size and MMT (manual muscle test) did not differ between groups. There were no side effects or complications of BMAC-PRP injection.
- The researchers pointed out that the BMAC-PRP injection did not decrease tear size within three months, but instigated other repairs. This is something we see often too and why we advise patients that stem cell treatments and PRP treatments, even when combined, require more than one treatment session.
- They also point out that best results were seen at the 12 week mark, where significant improvement in shoulder function was noted. At the eight week mark tendinopathy symptoms showed improvement.
- Also noted was an improvement in tendon function that might be explained by the enhancement of tendon-bone junction healing by PRP.
Do you have a question about your rotator cuff tear?
You can get help and information for our Caring Medical Staff
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