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When Not to have Rotator Cuff Surgery? Know Your
Options

It happened as you were playing racketball. There was loud pop
followed by immediate pain. Moving your shoulder is almost
impossible.  What is the rotator cuff?  What causes rotator cuff
tears?  What is rotator cuff surgery?  When not to have rotator
cuff surgery?  Let’s dig in.

What Is the Rotator Cuff? (4 Tendons)

The rotator cuff is a group of four muscles and tendons that
stabilize the ball and socket shoulder joint (1).  The four muscles
that compromise the rotator cuff are the:

Supraspinatus

Infraspinatus

Subscapularis

Teres minor

The rotator cuff is also important in shoulder functions such as
reaching outward, reaching overhead, and putting your hand into
your back pocket.  Tendons attach muscles to bones.  Tendons are
susceptible to acute inflammation, degeneration, and tears. 
Rotator cuff tears are common.  The prevalence of rotator cuff
tendon tears in the general population is 22.1% (2).    Who is
at risk for a rotator cuff tear?

Patients who use their shoulders extensively or who have
impingement, diabetes, elevated cholesterol, elevated blood
pressure, and smoke are a risk for rotator cuff tears (3).

What Causes Rotator Cuff Tears? (Aging, Trauma & Overuse)

Aging

As we grow older there is a tendency for the rotator cuff
tendons to become more fragile and susceptible to injury.  Just as
your skin wrinkles and your hair turns gray, the likelihood of
having a rotator cuff tear increases as you grow older.  Why does
this occur?   As we age the number of stem cells in the tendon
declines (4).   The lower the stem cell count the more susceptible
the tendon is to injury including tears.

Trauma

Sports, motor vehicle accidents, and other forms of trauma can
cause rotator cuff tears.

Overuse

Weight lifters and other athletes and workers who used their
shoulders extensively are at risk for tears.

Are There Different Types of Rotator Cuff Tears?

Tears in the rotator cuff are not all the same.  In fact, there
are three principal types of tears that you should know about.


Partial Thickness Tear

This is illustrated in the second image above. 
This is where a portion of the tendon has been
torn
.  It can be located near the top which is called
bursal-sided tear.  It can also be located near the bottom of the
tendon which is called an articular sided tear.  Finally, it may be
directly on the inside of the tendon in which case it is called
interstitial or intrasubstance tear.  the type and location of the
tear is important as is typically described in detail in the MRI
formal report.

Complete Non-retracted Tear

This is illustrated in the third image above.  This is where
tear extends across the entire tendon but the tendon is still held
together by small remaining fibers.

Complete Retracted Tear

This is illustrated in the fourth image and is the worst-case
scenario.  This is where the tear extends across the entire tendon
and rips apart like a rubber band.  It results in two ends of the
tendon that are pulled apart.  It is commonly referred to as a â€
massive rotator cuff tearâ€.

What Is Rotator Cuff Surgery? (Cutting and Re-Attaching)

Rotator cuff surgery most often involves cutting your
injured rotator cuff
and then re-attaching the severed
tendon to the upper arm bone (humerus).  This involves an
anchor that is drilled into the bone.  The anchor
attaches the tendon to the bone.  The procedure can be done through
a large incision (open) or a shoulder arthroscopy which uses a
small camera that allows visualization of the joint and rotator
cuff tendons. Shoulder arthroscopy is the most common surgical
technique.  From 1996 to 2006, the number of shoulder arthroscopies
increased by 600%, including an overall 115% increase in the number
of rotator cuff repairs (5).

During surgery, nothing is done to address the reduced number of
stem cells in the tendon.  The reduced number of repair cells makes
the tendon more fragile and at risk for injury and tearing.

When Not to Have Rotator Cuff Surgery

If you have a partial thickness or complete non retracted
rotator cuff tear surgery is NOT your best option.  Research has
shown that surgery for a partial tear produces no better outcomes
than just physical therapy (6).  Failure after
surgery is common.  Approximately 6 out of 10
patients
who undergo surgical repair of their torn rotator
cuff ends up re-tearing the tendon.

Multiple medical studies exist that demonstrate PRP is effective
in the treatment of partial-thickness tears (7-19).  Stem cell
injections are also effective.  Earlier this year we published the
mid-term analysis of a multi-year shoulder rotator cuff randomized
controlled trial at the Centeno-Schultz Clinic. The paper
demonstrated that the precise injection of high-dose bone marrow
concentrate into the damaged rotator cuff tendon using ultrasound
guidance helped many patients recover without the need for surgery
(10).  Others have published similar results using bone
marrow-derived stem cells to treat partial-thickness tears.

The procedures are challenging and require extensive training
and competency in the use of ultrasound. These are procedures that
your family physician and orthopedic surgeon can not perform.  To
watch one of my shoulder stem cell injections please click on the
video below.

img

 

In Conclusion

The rotator cuff is a group of four muscles and tendons that
stabilize the ball and socket shoulder joint.  Aging, trauma, and
overuse are common causes of rotator cuff tears. A reduced number
of stem cells within the rotator cuff tendon makes it susceptible
to injury. There are three different types of rotator cuff tears: 
partial thickness, full-thickness no-retracted and complete
retracted tears.  Surgery most often involves cutting the rotator
cuff tendon and then reattaching it to the upper arm bone.  If you
have a partial-thickness or full-thickness tear that is not
retracted surgery is not your best option.  PRP and stem cells are
both effective treatment options that allow patients to forgo the
complications and risks associated with surgery.

If you have a rotator cuff tear and are interested in treatment
options that do not include dependence on medication or surgeries
with high failure rates the good news is that you have options.  At
the Centeno-Schultz Clinic, we are national experts on the
treatment of rotator cuff tears.   Both PRP and stem cells are
effective in treating rotator cuff injuries.  Call us to schedule a
telemedicine consult to see if you are a candidate.  Act now before
the tear, pain, and limitation gets worse.

 

1.Huri G, Kaymakoglu M, Garbis N. Rotator cable and rotator
interval: anatomy, biomechanics and clinical importance. EFORT Open
Rev. 2019;4(2):56–62. Published 2019 Feb 20.
doi:10.1302/2058-5241.4.170071.

2.Minagawa H, Yamamoto N, Abe H, et al. Prevalence of
symptomatic and asymptomatic rotator cuff tears in the general
population: From mass-screening in one village. J Orthop.
2013;10(1):8-12. Published 2013 Feb 26.
doi:10.1016/j.jor.2013.01.008

3. Abate M, Di Carlo L, Salini V, Schiavone C. Risk factors
associated to bilateral rotator cuff tears. Orthop Traumatol Surg
Res. 2017 Oct;103(6):841-845. doi: 10.1016/j.otsr.2017.03.027. Epub
2017 May 31. PMID: 28578100.

4. Hernigou P, Merouse G, Duffiet P, Chevalier N, Rouard H.
Reduced levels of mesenchymal stem cells at the tendon-bone
interface tuberosity in patients with symptomatic rotator cuff
tear. Int Orthop. 2015 Jun;39(6):1219-25. doi:
10.1007/s00264-015-2724-8. Epub 2015 Mar 12. PMID: 25757411.

5. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL.
National trends in rotator cuff repair. J Bone Joint Surg Am.
2012;94(3):227–233

6. Nazari G, MacDermid JC, Bryant D, Athwal GS. The
effectiveness of surgical vs conservative interventions on pain and
function in patients with shoulder impingement syndrome. A
systematic review and meta-analysis. PLoS One.
2019;14(5):e0216961. Published 2019 May 29. doi:10.1371/journal.pone.0216961

7. Ilhanli I, Guder N, Gul M. Platelet-Rich Plasma Treatment
With Physical Therapy in Chronic Partial Supraspinatus Tears. Iran
Red Crescent Med J. 2015;17(9):e23732. Published 2015 Sep 28. doi:
10.5812/ircmj.23732.

8. Cai YU, Sun Z, Liao B, Song Z, Xiao T, Zhu P. Sodium
Hyaluronate and Platelet-Rich Plasma for Partial-Thickness Rotator
Cuff Tears. Med Sci Sports Exerc. 2019;51(2):227–233. doi:
10.1249/MSS.0000000000001781.

9. Rha DW, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the
therapeutic effects of ultrasound-guided platelet-rich plasma
injection and dry needling in rotator cuff disease: a randomized
controlled trial. Clin Rehabil. 2013 Feb;27(2):113-22. doi:
10.1177/0269215512448388.

10. Centeno C, Fausel Z, Stemper I, Azuike U, Dodson E. A
Randomized Controlled Trial of the Treatment of Rotator Cuff Tears
with Bone Marrow Concentrate and Platelet Products Compared to
Exercise Therapy: A Midterm Analysis. Stem Cells Int. 2020 Jan
30;2020:5962354. doi: 10.1155/2020/5962354. PMID: 32399045; PMCID:
PMC7204132.

 

 

 

The post
When Not to have Rotator Cuff Surgery? Know Your Options

appeared first on Centeno-Schultz Clinic.

It happened as you were playing racketball. There was loud pop
followed by immediate pain. Moving your shoulder is almost
impossible.  What is the rotator cuff?  What causes rotator cuff
tears?  What is rotator cuff surgery?  When not to have rotator
cuff surgery?  Let’s dig in.

What Is the Rotator Cuff? (4 Tendons)

The rotator cuff is a group of four muscles and tendons that
stabilize the ball and socket shoulder joint (1).  The four muscles
that compromise the rotator cuff are the:

Supraspinatus

Infraspinatus

Subscapularis

Teres minor

The rotator cuff is also important in shoulder functions such as
reaching outward, reaching overhead, and putting your hand into
your back pocket.  Tendons attach muscles to bones.  Tendons are
susceptible to acute inflammation, degeneration, and tears. 
Rotator cuff tears are common.  The prevalence of rotator cuff
tendon tears in the general population is 22.1% (2).    Who is
at risk for a rotator cuff tear?

Patients who use their shoulders extensively or who have
impingement, diabetes, elevated cholesterol, elevated blood
pressure, and smoke are a risk for rotator cuff tears (3).

What Causes Rotator Cuff Tears? (Aging, Trauma & Overuse)

Aging

As we grow older there is a tendency for the rotator cuff
tendons to become more fragile and susceptible to injury.  Just as
your skin wrinkles and your hair turns gray, the likelihood of
having a rotator cuff tear increases as you grow older.  Why does
this occur?   As we age the number of stem cells in the tendon
declines (4).   The lower the stem cell count the more susceptible
the tendon is to injury including tears.

Trauma

Sports, motor vehicle accidents, and other forms of trauma can
cause rotator cuff tears.

Overuse

Weight lifters and other athletes and workers who used their
shoulders extensively are at risk for tears.

Are There Different Types of Rotator Cuff Tears?

Tears in the rotator cuff are not all the same.  In fact, there
are three principal types of tears that you should know about.


Partial Thickness Tear

This is illustrated in the second image above. 
This is where a portion of the tendon has been
torn
.  It can be located near the top which is called
bursal-sided tear.  It can also be located near the bottom of the
tendon which is called an articular sided tear.  Finally, it may be
directly on the inside of the tendon in which case it is called
interstitial or intrasubstance tear.  the type and location of the
tear is important as is typically described in detail in the MRI
formal report.

Complete Non-retracted Tear

This is illustrated in the third image above.  This is where
tear extends across the entire tendon but the tendon is still held
together by small remaining fibers.

Complete Retracted Tear

This is illustrated in the fourth image and is the worst-case
scenario.  This is where the tear extends across the entire tendon
and rips apart like a rubber band.  It results in two ends of the
tendon that are pulled apart.  It is commonly referred to as a â€
massive rotator cuff tearâ€.

What Is Rotator Cuff Surgery? (Cutting and Re-Attaching)

Rotator cuff surgery most often involves cutting your
injured rotator cuff
and then re-attaching the severed
tendon to the upper arm bone (humerus).  This involves an
anchor that is drilled into the bone.  The anchor
attaches the tendon to the bone.  The procedure can be done through
a large incision (open) or a shoulder arthroscopy which uses a
small camera that allows visualization of the joint and rotator
cuff tendons. Shoulder arthroscopy is the most common surgical
technique.  From 1996 to 2006, the number of shoulder arthroscopies
increased by 600%, including an overall 115% increase in the number
of rotator cuff repairs (5).

During surgery, nothing is done to address the reduced number of
stem cells in the tendon.  The reduced number of repair cells makes
the tendon more fragile and at risk for injury and tearing.

When Not to Have Rotator Cuff Surgery

If you have a partial thickness or complete non retracted
rotator cuff tear surgery is NOT your best option.  Research has
shown that surgery for a partial tear produces no better outcomes
than just physical therapy (6).  Failure after
surgery is common.  Approximately 6 out of 10
patients
who undergo surgical repair of their torn rotator
cuff ends up re-tearing the tendon.

Multiple medical studies exist that demonstrate PRP is effective
in the treatment of partial-thickness tears (7-19).  Stem cell
injections are also effective.  Earlier this year we published the
mid-term analysis of a multi-year shoulder rotator cuff randomized
controlled trial at the Centeno-Schultz Clinic. The paper
demonstrated that the precise injection of high-dose bone marrow
concentrate into the damaged rotator cuff tendon using ultrasound
guidance helped many patients recover without the need for surgery
(10).  Others have published similar results using bone
marrow-derived stem cells to treat partial-thickness tears.

The procedures are challenging and require extensive training
and competency in the use of ultrasound. These are procedures that
your family physician and orthopedic surgeon can not perform.  To
watch one of my shoulder stem cell injections please click on the
video below.

img

 

In Conclusion

The rotator cuff is a group of four muscles and tendons that
stabilize the ball and socket shoulder joint.  Aging, trauma, and
overuse are common causes of rotator cuff tears. A reduced number
of stem cells within the rotator cuff tendon makes it susceptible
to injury. There are three different types of rotator cuff tears: 
partial thickness, full-thickness no-retracted and complete
retracted tears.  Surgery most often involves cutting the rotator
cuff tendon and then reattaching it to the upper arm bone.  If you
have a partial-thickness or full-thickness tear that is not
retracted surgery is not your best option.  PRP and stem cells are
both effective treatment options that allow patients to forgo the
complications and risks associated with surgery.

If you have a rotator cuff tear and are interested in treatment
options that do not include dependence on medication or surgeries
with high failure rates the good news is that you have options.  At
the Centeno-Schultz Clinic, we are national experts on the
treatment of rotator cuff tears.   Both PRP and stem cells are
effective in treating rotator cuff injuries.  Call us to schedule a
telemedicine consult to see if you are a candidate.  Act now before
the tear, pain, and limitation gets worse.

 

1.Huri G, Kaymakoglu M, Garbis N. Rotator cable and rotator
interval: anatomy, biomechanics and clinical importance. EFORT Open
Rev. 2019;4(2):56–62. Published 2019 Feb 20.
doi:10.1302/2058-5241.4.170071.

2.Minagawa H, Yamamoto N, Abe H, et al. Prevalence of
symptomatic and asymptomatic rotator cuff tears in the general
population: From mass-screening in one village. J Orthop.
2013;10(1):8-12. Published 2013 Feb 26.
doi:10.1016/j.jor.2013.01.008

3. Abate M, Di Carlo L, Salini V, Schiavone C. Risk factors
associated to bilateral rotator cuff tears. Orthop Traumatol Surg
Res. 2017 Oct;103(6):841-845. doi: 10.1016/j.otsr.2017.03.027. Epub
2017 May 31. PMID: 28578100.

4. Hernigou P, Merouse G, Duffiet P, Chevalier N, Rouard H.
Reduced levels of mesenchymal stem cells at the tendon-bone
interface tuberosity in patients with symptomatic rotator cuff
tear. Int Orthop. 2015 Jun;39(6):1219-25. doi:
10.1007/s00264-015-2724-8. Epub 2015 Mar 12. PMID: 25757411.

5. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL.
National trends in rotator cuff repair. J Bone Joint Surg Am.
2012;94(3):227–233

6. Nazari G, MacDermid JC, Bryant D, Athwal GS. The
effectiveness of surgical vs conservative interventions on pain and
function in patients with shoulder impingement syndrome. A
systematic review and meta-analysis. PLoS One.
2019;14(5):e0216961. Published 2019 May 29. doi:10.1371/journal.pone.0216961

7. Ilhanli I, Guder N, Gul M. Platelet-Rich Plasma Treatment
With Physical Therapy in Chronic Partial Supraspinatus Tears. Iran
Red Crescent Med J. 2015;17(9):e23732. Published 2015 Sep 28. doi:
10.5812/ircmj.23732.

8. Cai YU, Sun Z, Liao B, Song Z, Xiao T, Zhu P. Sodium
Hyaluronate and Platelet-Rich Plasma for Partial-Thickness Rotator
Cuff Tears. Med Sci Sports Exerc. 2019;51(2):227–233. doi:
10.1249/MSS.0000000000001781.

9. Rha DW, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the
therapeutic effects of ultrasound-guided platelet-rich plasma
injection and dry needling in rotator cuff disease: a randomized
controlled trial. Clin Rehabil. 2013 Feb;27(2):113-22. doi:
10.1177/0269215512448388.

10. Centeno C, Fausel Z, Stemper I, Azuike U, Dodson E. A
Randomized Controlled Trial of the Treatment of Rotator Cuff Tears
with Bone Marrow Concentrate and Platelet Products Compared to
Exercise Therapy: A Midterm Analysis. Stem Cells Int. 2020 Jan
30;2020:5962354. doi: 10.1155/2020/5962354. PMID: 32399045; PMCID:
PMC7204132.

 

 

 

The post
When Not to have Rotator Cuff Surgery? Know Your Options

appeared first on Centeno-Schultz Clinic.

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