Rotator cuff tear.

Rotator cuff tendons tear are among one of the most frequently seen tendon tears. One common modality of treatment is surgical repair but the failure rate is extremely high. Achieving sustained healing fails in about 20 to 90% of patients! 

         A)   CAUSES AND RISK FACTORS OF ROTATOR CUFF TEARS. 

The two causes of tears are injury or degeneration. Because most rotator cuff tears are largely caused by the normal wear and tear and degeneration that goes along with aging, people over 40 are at greater risk.

People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.

Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.

         B)   WHY SUCH A HIGH RATE OF RE-TEAR AFTER SURGERY?

 Surgical repair is a common modality used to treat these types of injuries but the failure rate of achieving sustained healing ranges between 20 to 90%. Re-tears are very, very, common.

 The reason for the high failure rate and re-tears has to do with compromised healing at the junction of the tendon to the bone, at the so called enthesis. This is mainly due to poor vascularity, fatty infiltration etc. that occurs after the tear. The more re-tears the worse it gets.  Additionally early rehabilitation exercises could contribute to re-tear due to excessive stresses. Recommendations arising from one study, suggest for instance to keep the arm externally rotated during elevation in cases of supraspinatus or supraspinatus plus infraspinatus tear, since this could help prevent re-tear. Remember the more tears the less likely that the rotator cuff tendons will completely heal and it eventually leads to shoulder instability and possible shoulder replacement surgery!

         C) EFFECTIVENESS AND SAFETY OF SURGERY AND GROWING CONCERNS OVER ROTATOR CUFF SURGERY FAILURES.

When rotator cuff tear occurs the shoulder turns into a hostile non-healing environment and when surgery is performed this hostile non-healing environment gets worse. This hostile environment precludes healing.

A hostile environment are the words used by some surgeons 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:

• “Tears within the tendon substance or at its insertion into the humeral head represent a considerable clinical challenge because of the hostile local environment that precludes healing.

• Tears often progress without intervention, and current surgical treatments are inadequate.

• Although surgical implants, instrumentation, and techniques have improved, healing rates have not improved, and a high failure rate remains for large and massive rotator cuff tears.

The use of biologic adjuvants that contribute to a regenerative microenvironment have great potential for improving healing rates and function even after surgery. Other articles describe that the goal of our treatment should be to turn a hostile non-healing joint environment into a healing environment through the use of regenerative comprehensive Prolotherapy that includes healing factors from blood platelets and stem cells.

         D) WHAT SHOULD THE GOAL OF TREATMENT BE? FUNCTION! THAT IS WHAT PATIENTS WANT! WE SHOULD AIM TO PROVIDE THAT.  

Arthroscopic debridement, partial repair with margin convergence, biceps tenotomy or tenodesis, and more recently suprascapular nerve release have all been described as potential treatments which are effective at alleviating pain, but have little effect on strength and funtion. 

Comprehensive Prolotherapy treatment for torn rotator cuff without surgery produces great results. By stimulating stem cell growth, it increases the amount of fibrocartilage formation. This is the tissue that helps make up ligaments, tendons, and cartilage and stabilize the joint improving the hostile environment and promoting healing of the tear.

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

• 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 and the other treated with prolotherapy injections.

• In the Proliferative therapy 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.)

RESULTS:

• Both the exercise group and the Prolotherapy group achieved significant improvements.

- Prolotherapy group had significantly better pain relief scores at weeks 3, 6, and 12, and last follow-up.

-Prolotherapy group had significantly better shoulder abduction and flexion at week 12 and last follow-up, and in internal rotation at last follow-up.

In the prolotherapy group, 53 patients (92.9%) reported excellent or good outcomes;(No significant difference was found in external rotation at any follow-up period).

-  in the control group, 25 patients (56.8%) reported excellent or good outcomes.

As shown by the research rotator cuff tears can be treated with stem cells, platelet rich plasma, and Prolotherapy with great success.