Rotator Cuff Tendinopathies: A case for regenerative injection therapies?
A painful shoulder is one of the most common complaints seen by orthopaedists. Athletes who participate in repetitive overhand throwing sports such as baseball, basketball, and volleyball are at increased risk for shoulder injuries. The same holds true for those who work in an occupation requiring overhead activity. Pain and dysfunction to the shoulder(s) can also arise from normal aging. The term rotator cuff syndrome is often used when referring to tearing within the rotator cuff tendons.
Anatomically, the rotator cuff is made up of four tendons: supraspinatus, infraspinatus, subscapularis and the teres minor. These tendons originate along the scapula and attach at various points along the head of the humerus. Within the shoulder there are several bursa which normally facilitate smooth gliding of the tendons and muscles.
Many painful conditions related to overuse that encompass the rotator cuff tendons and surrounding soft tissues, are commonly referred to as rotator cuff tendinopathy. Rotator cuff tendinopathy is a very complex, multifactorial process involving both intrinsic (within a tendon) and extrinsic (outside of a tendon) factors. Clinically, patients often complain of pain with specific motions such as reaching overhead, with lifting, and often at night when sleeping on the affected shoulder. Loss of normal range of motion may also be present with forward elevation of the shoulder and with abduction (moving arm away from the body). Weakness and further loss of motion often result from disease progression. These symptomatic complaints may be caused by underlying degenerative changes within the tendons resulting in mechanical overload. Additionally, compression on the tendon(s) caused by bony structures may also accompany the forementioned intrinsic factors.
The combination of a good detailed patient history of complaints, a sound physical examination, and an MRI of shoulder can help the physician provide the proper clinical diagnosis and direct treatment. Traditionally, treatment for tendinopathies has included NSAIDs, physical therapy, and corticosteroid injections. Many can be successfully managed utilizing these non-surgical treatments. As previously mentioned, rotator cuff tendinopathy is a complex condition and in some cases traditional treatments fail to help improve symptoms. While there are varying surgical options depending on the specific underlying issue(s), the risks of the procedure and outcomes must be weighed.
In the last decade, the use of regenerative injection therapies for rotator cuff tendinopathies, has been developed and continues to evolve. Prolotherapy, Platelet-Rich Plasma (PRP), and even stem cell therapies have been applied. Presently there is limited data to support regenerative injection therapies as a part of a standard medical treatment plan for rotator cuff tendinopathies. However, its use has been reported with increasing frequency by the media among professional athletes.
A few randomized controlled trials and prospective studies utilizing Prolotherapy and/or PRP have been published in the last few years. Outcome measures have focused on pain scales, patient satisfaction, and disability indexes (Western Ontario Rotator Cuff Index, Shoulder Pain and Disability Index). The results for the most part have been positive. Further studies to show efficacy are needed.
Bertran H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose Prolotherapy versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil. 2015 Aug 21.
Scarpone M, Rabago D, Snell E, Demeo P, Ruppert K, Pritchard P, Arbogast G, Wilson JJ, Balzano JF. Effectiveness of Platelet-rich Plasma Injection for Rotator Cuff Tendinopathy: A Prospective Open-label Study. Glob Adv Health. Med. 2013 Mar;2(2):26-31.