Shoulder issues include sprains, strains, dislocations, and rotator cuff injuries. According to the American Academy of Orthopedic Surgeons, 4,000,000 US citizens suffer shoulder problems yearly.
Rotator cuff injuries and tears are common, affecting more than 3 million people in the US yearly. Most of the rotator cuff injuries respond to conservative therapy such as physical therapy, activity modification and potentially injections. However, those who do not respond because of a significant tear, surgery is often performed.
There are between 400,000 to 500,000 rotator cuff repairs performed each year in the US. As the population ages, this number is expected to increase in the coming years.
Rotator cuff injuries are seen in both the young and old population.
They are much more common in the older population as people age the muscle and tendon tissue of the rotator cuff loses elasticity and becomes more susceptible to injuries. In this population, injuries often occur with normal daily activities. Repetitive stress causes a wearing down of the tendon. This degeneration occurs over time and is compounded by the lack of blood supply to this area as we age. The body’s natural ability to repair these tissues is impaired by the decrease in the vascularity.
In the younger population, traumatic injuries are the common etiology. Abnormal stress in placed on the rotator cuff and the injury occurs such as baseball pitchers.
Shoulder injuries are frequently caused by athletic activities that involve excessive repetitive overhead motion. These are frequently seen in swimming, tennis, pitching and weightlifting. However, they can also be seen in normal activities such as washing walls, painting or any work that involves overhead motion.
The shoulder complex is composed of three bones,
The shoulder is a ball and socket joint. The head of the humerus fits into a shallow socket in the scapula. The humerus is kept in the socket by the rotator cuff.
- Teres Minor
The rotator cuff is a group of four muscles and the tendons form a covering about the head of the humerus. When activated, these tendons lift and rotate the humerus.
The most commonly injured rotator cuff muscle is the supraspinatus. The reason it is commonly injured is the muscles tendon passes through a narrow space between the head of the humerus and the underside of the acromion of the scapula. The action of this muscle is to lift the arm to the side and up called abduction.
Symptoms of Rotator Cuff Injury
Signs of a rotator cuff injury include difficulty and pain when raising the arm. Popping or clicking sounds when moving your arm. Shoulder pain that worsens at night or with repeated use. Inability to lift above shoulder height and inability to hold arm out or to the side when stress is placed on the arm. Weakness when lifting or rotating the arm is common. Since tears usully occur in the dominant arm, the weakness and pain are progressive and more noticeable over time.
Tears occurring suddenly from a fall or other traumatic incident usually cause intense pain. There may be a snapping sensation and immediate pain and weakness.
Physical exam is the primary way to diagnose rotator cuff injuries.
Confirmatory x-rays, ultrasound, CT or MRI to evaluate a tear and the size of the tear
Stages of Rotator Cuff Tears
Partial Tear- this type does not completely detach the tendon from the bony attachment. The tear only involves a partial tear through the tendon.
Full Thickness Incomplete Tear- This tear does involve a detachment of part of the tendon from the bony attachment.
Full Thickness Complete Tear- The tendon is completely detached from the bone.
- Grade 0 represents a normal rotator cuff
- Grade 1 – superficial fraying less than 1 cm in size
- Grade 2- fraying 1 to 2 cm
- Grade 3- tissue disruption in 2 to 3 cm of the tendon
- Grade 4 – substantial cuff tear with more than one tendon usually involved
- Rest, Ice, Heat
- Physical Therapy
- Medicines such as NSAIDS
- Cortisone shots for pain and inflammation
- Platelet Rich Plasma
- Surgery- arthroscopic or open
- Do nothing- One of the most painful conditions that may develop is called a frozen shoulder. Medically called adhesive capsulitis the range of motion of the shoulder is severely restricted and usually this condition will continue to develop from moderate to severe restriction. Manipulation under general anesthesia is usually attempted and if this fails, total shoulder replacement.
Complications from shoulder surgery are common. The most common is stiffness with studies showing about 20% of patients exhibiting stiffness six to twelve months post operation. If arthroscopic repair, the usual rehabilitation period is 6 months.
Healing failure after arthroscopic rotator cuff repair remains an unsolved problem. Despite the development of operative techniques and newer surgical devices, healing failure rates between 20% and 94% have been reported. Furthermore, the rate of healing failure tends to be higher as the tear size increases, and the postoperative functional outcome is generally worse in patients with healing failure. Achieving anatomic healing of a torn rotator cuff is crucial to enhance the long-term outcomes in these patients. Healing failures are usually attributed to abnormal fibrous regeneration of the tissue at the tendon bony attachment.
For a complete tear and reattachment, the arm may not be used above shoulder height for months after surgery.
In one study, rotator cuff surgery for complete full thickness tears resulted in improvement that was not significantly better than conventional non-surgical therapy such as extended physical therapy. Rotator cuff surgery does not seem to result in less pain regardless of the severity of the tear.
Platelet Rich Plasma
Platelet Rich Plasma is an autologous blood concentrate that has increased growth factors, cytokines and bio-active proteins. This concentrate has the ability to restore damaged tissue and has been proven, with thousands of studies in the literature, to revive and regenerate areas of injury.
PRP has been shown to be superior to other modalities such as cortisone for treatment of partial thickness tears of the rotator cuff.
Studies for Partial Thickness Tears and Tendinopathy
Med Sci Sports Exerc 2019 Feb;51(2): 227-233 PMID 30199423
Purpose: The treatment of partial thickness rotator cuff tears remains controversial. Few studies have focused on the conservative and new measurements of small to medium PTRCT. The use of sodium hyaluronate or platelet rich plasma as a method for rotator cuff repair requires further investigation. The aim of this study was to evaluate the combined use of HA and PRP in the treatment of small to medium rotator cuff tears.
Conclusion: Our study provided evidence of the efficacy of PRP injection in the healing of small to medium rotator cuff tears. Moreover, the combined injection of HA and PRP yielded a better outcome than HA or PRP alone.
- Editorial Commentary: Platelet Rich Plasma has Advantages over Corticosteroid for Nonoperative Treatment of Rotator Cuff Pathology: Another Step in the Right Direction
Arthroscopy 2021 Feb;37(2): 518-520 PMID 33546790
Abstract- The existing literature is limited, among other things, by underpowered studies and imprecise descriptions of the administration and/or formulation of the platelet rich plasma over corticosteroid injections in the nonoperative treatment of rotator cuff pathology. In light of evidence showing a deleterious effect of corticosteroids on subsequent surgical interventions, surgeons should continue to be wary of subacromial corticosteroid injections if alternatives such as platelet rich plasma exist. A corticosteroid injection may have been the “go to” nonoperative intervention in the past, but platelet rich plasma may be a more effective arrow in our quiver.
- Corticosteroids or Platelet Rich Plasma Injections for Rotator Cuff Tendinopathy: A Randomized Clinical Trial Study
J Orthop Surg Res 2021 May 21;16(1):333 PMID 34020672
Background: Studies evaluating the role of both corticosteroids and platelet rich plasma in the treatment of rotator cuff tendinopathies have been contradicting. We compared structural and clinical changes in rotator cuff muscles after corticosteroids and platelet rich plasma.
Conclusion: We found that PRP render similar results to that of corticosteroids in most clinical aspects among patients with rotator cuff tendinopathies; however, pain and ROM may show significant improvement with the use of PRP. Considering that the use of corticosteroids may be contraindicated in some patients and may be associated with the risk of tendon rupture, we suggest the use of PRP in place of corticosteroid-based injections among patients with rotator cuff tendinopathy.
Studies for Full Thickness Tears Post Surgery
- Application of Platelet Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systemic Review and Meta-analysis
Ortho J Sports Med 2021 Jul:9(7): 23259671211016847 PMID 34345632
Background: It is unclear how and which factors affect the clinical efficacy of platelet rich plasma applied during arthroscopic rotator cuff repair.
Purpose: To evaluate the clinical efficacy of PRP for arthroscopic repair of full thickness rotator cuff tear and investigate the factors that affect its clinical efficacy.
Conclusion: The results of this review indicated that arthroscopic rotator cuff repair with PRP significantly reduced the long retear rate and shoulder pain and provided improved long term shoulder function in patients. Intraoperative application of PRP, use of leukocyte poor plasma and large to massive tear size contributed to a significantly decreased retear rate for rotator cuff repair combined with PRP.
(Retear rate varies between 5 to 51% with a higher rate in older adults)
- Efficacy of Intraoperative Platelet Rich Plasma Augmentation and Postoperative Platelet Rich Plasma Booster Injection for Rotator Cuff Healing: A Randomized Controlled Clinical Trial
Ortho J Sports Med 2021 Jun;9(6): 23259671211006100 PMID 34159208
Background: Platelet Rich Plasma has been applied as an adjuvant treatment for arthroscopic rotator cuff repair to enhance rotator cuff healing. However, it remains debatable whether PRP enhances tendon to bone healing.
Conclusion: Intraoperative PRP augmentation during arthroscopic rotator cuff repair demonstrated superior anatomic healing results in patients with rotator cuff tears >2 cm as well as reduced pain and increased subjective satisfaction.
Am J Sports Med 2020 Jul;48(8): 2028-2041 PMID 31743037
Background: Many clinical trials have investigated the use of platelet rich plasma to treat rotator cuff related abnormalities. Several meta-analyses have been published, but none have focused exclusively on level 1 randomized controlled trials.
Purpose: To assess the efficacy of PRP for rotator cuff related abnormalities and evaluate how specific tendon involvement, the inclusion of leukocytes, and the use of gel/nongel formulations affect pain and functional outcomes.
Conclusion: Long term retear rates were significantly decreased in patients with rotator cuff related abnormalities who received PRP. Significant improvements in PRP treated patients were noted for multiple functional outcomes. Overall, our results suggest that PRP may positively affect clinical outcomes but limited data, study heterogeneity and poor methodological quality hinder firm conclusions.
Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our platelet rich plasma kits are FDA approved and designed for safety, sterility and effectiveness. They are both cost effective and easy to use. Our kits have been scientifically manufactured to provide a consistent platelet concentrate, devoid of RBCs with a minimal number of leukocytes, critical to the regenerative cascade.
Juventix Regenerative Medical offers a patent pending LED Activator to activate the platelets and begin the regenerative process. This activation is a critical step in the release of cytokines, growth factors and bio-active proteins and is accomplished with LED light. This negates the use of chemical additives such as Calcium Chloride, Thrombin or Collagen.
Juventix Regenerative Medical supplies a Bio-Incubator that transforms the Platelet Rich Plasma into an Injectable Platelet Rich Fibrin. The Platelet Rich Fibrin, commonly called the “second generation of platelet products” has growth factors and cytokines. These factors exhibit anti-inflammatory properties to continue the regenerative process into the final stages of the healing and remodeling of damaged tissues.
RESTORE, REVIVE, REGENERATE- JUVENTIX REGENERATIVE MEDICAL
Dr. Robert McGrath