Before you get Rotator Cuff Tear Surgery

This article will present the latest research for and against surgical, platelet, and stem cell injections in the treatment of complete rotator cuff tears. Please see my companion article on for discussion of partial rotator cuff tear non surgical treatments.

Before you read on, if you have questions about Rotator Cuff Tear Surgery alternatives, get help and information from Caring Medical

Doctors at the Department of Orthopaedics and Traumatology, University Hospital Bern wrote this in the journal Orthopaedics & Traumatology: Surgery & Research: (Explanatory notes and comments in the parenthesis).

THE PROBLEM WITH HIGH RE-TEAR RATES MAY LIE WITH THE REHABILITATION

In the journal Clinical biomechanics, doctors wrote:

Despite improvements in rotator cuff surgery techniques, re-tear rate remains above 20% and increases with tear severity. (The worse the tear the greater the odds it will re-tear).
Passive early rehabilitation exercises could contribute to re-tear due to excessive stresses. Recommendations arising from this study, for instance to keep the arm externally rotated during elevation in case of supraspinatus or supraspinatus plus infraspinatus tear, could help prevent re-tear.2
In a study from Germany, doctors found the problem of re-tear and tears are affected by many factors, but, predominantly, recurrent tears are due to non-healing of the rotator cuff tendons. This means the more tears the less likely that the rotator cuff tendons will completely heal. This is the theme of the German research, how much “successful surgery,” can your tendons take?

For many people reading this article who had many shoulder operations, the following may sound very familiar. Tear, re-tear, surgery, re-tear, surgery, re-tear, surgery, until a stage of shoulder instability is reached.

Back to the research paper we are citing.

HOW MANY "SUCCESSFUL" SURGERIES CAN YOU GET?
“Different modes of failure are responsible for recurrent defects of the rotator cuff. The management of recurrent defects depends on the clinical symptoms of the patient, the objective function of the shoulder and the pathomorphological (the abnormal function of the shoulder after surgery) changes of the rotator cuff and the shoulder joint itself.

Besides letting the shoulder heal on its own and/or conservative management, arthroscopic revision of failed cuff repairs appears to be a promising procedure.

Irreparable tears can be managed using tendon transfer or shoulder replacement procedures (reverse prosthesis) depending on the functional symptoms of the patient.

The results after re-reconstruction or open revision using tendon transfers are inferior compared to primary intervention (shoulder replacement).”3

Does this sound like your case? 

This is the standard course of treating difficult to treat rotator cuff repairs.

EFFECTIVENESS AND SAFETY OF SURGERY AND GROWING CONCERN OVER ROTATOR CUFF SURGERY FAILURES

The research above should point out the obvious – There is a growing concern over Rotator Cuff Surgery Failures.

Surgery involves the permanent alteration of the body and when it comes to the rotator cuff, the major stabilizer of the shoulder. Surgery can cause more harm than good. Recovery time is often long and presents its own complications as indicated above where physical therapy is thought to cause re-tears.

The rotator cuff is a group of four muscles whose main function is to stabilize and provide support for the shoulder. It’s estimated that 10-70% of rotator cuff repairs form a recurrent defect following surgery.

WHEN ROTATOR CUFF TEAR OCCURS - THE SHOULDER TURNS INTO A HOSTILE NON-HEALING ENVIRONMENT - WHEN SURGERY IS PERFORMED IT GETS WORSE

As mentioned, The rotator cuff is a group of four muscles whose main function is to stabilize and provide support for the shoulder. The rotator cuff tendons attach the shoulder muscles to the bone. The four tendons are the supraspinatus, the subscapularis, the infraspinatus and the teres minor.

Partial of full thickness tear in the rotator cuff tendons can result from an impact injury and weakening of the tendon from wear and tear, immobility, and cortisone injections.

In a full thickness tear the entire tendon has pulled off the bone. In a partial tear only part of the tendon has pulled away from the bone. The tears can also be described as distal (further away from bone) or proximal (closer to the bone).

A hostile environment are the words used to describe the shoulder capsule following a rotator cuff tear and “repair surgery,” in a new study doctors expressed concern about the post rotator cuff surgery healing environment.

Here is what doctors writing in the Orthopaedic Journal of Sports Medicine had to say:

Listen to this research from doctors at Washington University:

Problems with rotator cuff recovery and healing time following rotator cuff surgery has long been the concern of doctors and of course patients, because doctors face the challenge of poor tendon healing and irreversible changes associated with rotator cuff degenerative diseases, future treatments should involve non-surgical biologics and tissue engineering (Platelet Rich Plasma Therapy and Mesenchymal stem cell therapy). These treatments should be explored because they hold a promise to improve outcomes for patients suffering from shoulder problems.8

Which again begs the question, in certain tears why not try the PRP and stem cells as injections without the surgery as opposed to a surgical past?

The goal of the surgery is to repair and restore function – to many patients this is NOT achieved. Doctors are looking at Platelet Rich Plasma and stem cell injections to regrow the damaged tissue in the shoulder.

German researchers had this to say: “Due to the increasing demand for functionality in an aging yet physically active society, the treatment of rotator cuff tears is of ever-growing importance. Despite intensive research efforts, the treatment of degenerative rotator cuff tears, in particular their long-term outcome, is still a challenge.”

An explanation – what they are saying is that patients, especially aging athletes and people who work at jobs that require strength, demand a functioning shoulder – surgery is not the answer. 

“While in recent years the focus was on biomechanics and the technical aspects of rotator cuffreconstruction (surgery), attention has now turned to the biological considerations of tendon regeneration. (healing)”12

GOAL OF TREATMENT: PATIENTS WANT FUNCTION IN THEIR SHOULDERS

Doctors at the Hospital of Special Surgery in New York acknowledged that surgery did not offer what the patients wanted both pain relief and function.

“There is some controversy over the role of arthroscopy in the management of irreparable rotator cuff tears. Arthroscopic debridement, partial repair with margin convergence, biceps tenotomy or tenodesis, and more recently suprascapular nerve release have all been described as potential treatments. The literature would suggest that they are effective at alleviating pain, but have little effect on strength.”13

So slowly the wheels of medicine are changing – fortunately biological considerations – non-surgical injection therapy designed to regenerate your shoulder can be offered at Caring Medical today.

Let’s review the research – here are highlights:

COMPREHENSIVE PROLOTHERAPY TREATMENT FOR TORN ROTATOR CUFF WITHOUT SURGERY

The recurrent theme in the research throughout this article is: Despite surgical improvements – surgical failures and changing the healing environment of the shoulder. This is echoed further in the research below:

“Despite improved surgical techniques, the tendon-to-bone healing rate is unsatisfactory due to difficulties in restoring the delicate transitional tissue between bone and tendon.”14 This same research from doctors in Spainalso says Mesenchymal stem cell therapy is a potentially effective therapy to enhance rotator cuff healing and prevent complications.

These researchers base this opinion on the fact that stem cell therapyincreases the amount of fibrocartilage formation. This is the tissue that helps make up ligaments, tendons, and cartilage and are specifically marked for studies on tissue engineering.

But treating the tendon interface and the shoulder ligaments is something that Prolotherapy does as well.

In new research in the medical journal Orthopaedics & traumatology, surgery & research, doctors tested the effectiveness of Prolotherapy in difficult chronic refractory rotator cuff tears. They were hoping to find that dextrose prolotherapy would reduce pain and improve shoulder function and patient satisfaction.

RESULTS:

Are you a candidate for our non-surgical treatments? Ask our specialists

1 Zumstein MA, Lädermann A, Raniga S, Schär MO. The biology of rotator cuff healing. Orthop Traumatol Surg Res. 2016 Dec 30. pii: S1877-0568(16)30191-8. doi: 10.1016/j.otsr.2016.11.003. [Pubmed] [Google Scholar]
2 Haering D, Blache Y, Raison M, Begon M. Mechanical risk of rotator cuff repair failure during passive movements: A simulation-based study. Clin Biomech (Bristol, Avon). 2015 Dec;30(10):1181-8. [Pubmed] [Google Scholar]
3 Scheibel M. Recurrent defects of the rotary cuff : Causes and therapeutic strategies Oper Orthop Traumatol. 2012 Nov;24(6):458-67. doi: 10.1007/s00064-012-0179-2. [Pubmed] [Google Scholar]
4. McCarron JA, Derwin KA, Bey MJ, Polster JM, Schils JP, Ricchetti ET, Iannotti JP. Failure with continuity in rotator cuff repair “healing”. The American journal of sports medicine. 2013 Jan;41(1):134-41. [Pubmed] [Google Scholar]
5. Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.:DOI:10.1002/14651858.CD005619.pub2. [Pubmed] [Google Scholar] [Publisher’s site]
6. Papalia R, Franceschi F, Vasta S, Gallo A, Maffulli N, Denaro V. Shoulder stiffness and rotator cuff repair. Br Med Bull. 2012 Feb 14. [Pubmed] [Google Scholar]
7. Murray IR, LaPrade RF, Musahl V, Geeslin AG, Zlotnicki JP, Mann BJ, Petrigliano FA. Concepts, Future Research, and Barriers to Advancement, Part 2: Orthop J Sports Med. 2016 Mar 31;4(3):2325967116636586. [Pubmed] [Google Scholar]
8. Killian ML, Cavinatto L, Galatz LM, Thomopoulos S. Recent advances in shoulder research. Arthritis research & therapy. 2012 Jun 15;14(3):214. [Pubmed] [Google Scholar]
9. Kim SJ, Song DH, Park JW, Park S, Kim SJ. Effect of Bone Marrow Aspirate Concentrate Platelet-Rich Plasma on Tendon Derived Stem Cells and Rotator Cuff Tendon Tear. Cell Transplant. 2017 Jan 20. doi: 10.3727/096368917X694705. [Pubmed] [Google Scholar]
10. Yoon JP, Chung SW, Kim JY, Lee BJ, Kim HS, Kim JE, Cho JH. Outcomes of Combined Bone Marrow Stimulation and Patch Augmentation for Massive Rotator Cuff Tears. Am J Sports Med. 2016 Apr;44(4):963-71. doi: 10.1177/0363546515625044. Epub 2016 Feb 5. [Pubmed] [Google Scholar]
11. Degen RM, Carbone A, Carballo C, Zong J, Chen T, Lebaschi A, Ying L, Deng XH, Rodeo SA. The Effect of Purified Human Bone Marrow-Derived Mesenchymal Stem Cells on Rotator Cuff Tendon Healing in an Athymic Rat. Arthroscopy. 2016 Dec;32(12):2435-2443. doi: 10.1016/j.arthro.2016.04.019. [Pubmed] [Google Scholar]
12. Ficklscherer A, Pietschmann MF, Bendiks M, Roßbach BP, Müller PE. [Clinical management of rotator cuff tears : Current concepts in cell-based therapy strategies].Orthopade. 2016 Feb;45(2):143-8. doi: 10.1007/s00132-015-3213-x. German. [Pubmed] [Google Scholar]
13. Khair MM, Gulotta LV. Treatment of irreparable rotator cuff tears. Current reviews in musculoskeletal medicine. 2011 Dec 1;4(4):208. [Pubmed] [Google Scholar]
14. Mora MV, Ibán MA, Heredia JD, Laakso RB, Cuéllar R, Arranz MG. Stem cell therapy in the management of shoulder rotator cuff disorders. World J Stem Cells. 2015 May 26;7(4):691-9. doi: 10.4252/wjsc.v7.i4.691. [Pubmed] [Google Scholar]
15. Seven MM, Ersen O, Akpancar S, Ozkan H, Turkkan S, Yıldız Y, Koca K. Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthop Traumatol Surg Res. 2017 [Pubmed]  [Google Scholar]

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