Conservative management of degenerative rotator cuff tears: A systematic review of long-term clinical outcomes and cost effectiveness.

Background: A corticosteroid injection is commonly used to treat tendinopathy, but it has been associated with negative effects on tendon homeostasis. Platelet-rich plasma (PRP) is known to have proliferative and anabolic effects as well as cytoprotective effects against corticosteroids on tenocytes. However, the combined effects of a corticosteroid and PRP on the anti-inflammatory, matrix synthesis, and cytoprotective potential of tenocytes in conditions simulating tendinopathy have not been investigated. Purpose: To assess the effects of PRP on tenocytes from degenerative rotator cuff tears with the concomitant use of a corticosteroid in interleukin 1β (IL-1β)–induced tendinopathic conditions. Study Design: Controlled laboratory study. Methods: Tenocytes were enzymatically isolated and cultured from patients with degenerative rotator cuff tears. PRP was prepared using a plateletpheresis system, and growth factor concentrations were measured. To evaluate the gene expression of proinflammatory and anti-inflammatory cytokines, enzymes and their inhibitors, and matrix molecules, cells were cultured with 1 ng/mL IL-1β, 1 μM dexamethasone, and 10% (vol/vol) platelet-poor plasma (PPP) and PRP of 200, 1000, and 4000 × 103/μL; quantitative real-time reverse transcriptase polymerase chain reaction was also performed. Western blotting was performed to investigate the protein synthesis of degradative enzymes and their inhibitors. Cell viability, apoptosis, and senescence assays were also conducted. Results: PRP did not interfere with the anti-inflammatory effects of dexamethasone on tenocytes pretreated with IL-1β, but it increased the synthesis of tissue inhibitor of metalloproteinase (TIMP)–1 and -3. Meanwhile, PRP did not induce anti-inflammatory cytokines that had been suppressed with a corticosteroid. It did increase the type I/III collagen ratio mainly through the suppression of type III collagen expression. PRP reversed the decreased viability, increased apoptosis, and induced senescence with IL-1β and a corticosteroid. Conclusion: This study shows that the addition of PRP does not interfere with the anti-inflammatory effects of a corticosteroid on IL-1β–treated tenocytes from degenerative rotator cuff tears but that it does avoid the deleterious side effects of a corticosteroid. Clinical Relevance: PRP can be clinically useful with a corticosteroid as a treatment for tendinopathy.

Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial

To analyze the effect of stump-preserving repair on rotator cuff healing and shoulder function for degenerative total rotator cuff tears. A clinical data of 152 patients with degenerative total rotator cuff tears, who underwent arthroscopic repair between April 2019 and May 2022, was retrospectively analyzed. There were 76 males and 76 females with an average age of 55.4 years (range, 24-78 years). MRI was performed at 6 months postoperatively to evaluate the rotator cuff healing according to the Sugaya classification. Pre- and intra-operative related factors were included for univariate analysis, including age (≥60 years/<60 years), gender (male/female), passive activity disorder (yes/no), disease duration (≤3 months/>3 months), stump-preserving repair (yes/no), use of suture bridge technique (yes/no), shoulder joint abduction angle at knotting (<45°/≥45°), acromioplasty (yes/no), glucocorticoid injection (yes/no), time for patients to start postoperative passive exercise (≤2 weeks/>2 weeks), and time for patients to start postoperative active exercise (≤3 months/>3 months). The influencing factors of tendon healing were screened; further logistic regression was used to conduct multivariate analysis to screen for risk factors. Two sets of data were balanced by propensity score matching. The American Shoulder and Elbow Surgeons (ASES) score and Constant-Murley score of shoulder joint function at 6 and 12 months postoperatively, as well as rotator cuff healing rate at 6 months postoperatively, were compared between groups based on whether or not stump-preserving repair was used. All patients were followed up 12-33 months (mean, 23.8 months). MRI at 25-31 weeks postoperatively showed the 121 cases of rotator cuff healing and 31 cases of non healing. Univariate analysis showed that the disease duration, stump-preserving repair, shoulder joint abduction angle at knotting, and the time for patients to start postoperative active exercise were the influencing factors of rotator cuff healing ( P<0.05). Multivariate analysis showed that non-stump-preserving repair, shoulder abduction angle more than 45° at knotting, and the time to start active exercise within 3 months postoperatively were risk factors affecting rotator cuff healing ( P<0.05). A total of 51 pairs of cases were matched based on the grouping criteria of whether the disease duration exceeded 3 months, whether the shoulder abduction angle at knotting exceeded 45°, and whether the time to start postoperative active exercise exceeded 3 months. The rotator cuff healing rate, ASES score, and Constant-Murley score of the preserving repair group at 6 months postoperatively were superior to those of the non-preserving repair group, and the differences were significant ( P<0.05). There was no significant difference in ASES score and Constant-Murley score between the two groups at 12 months postoperatively ( P>0.05). For degenerative total rotator cuff tears, the stump-preserving repair can shorten the healing time and promote the shoulder function recovery, but has no significant effect on shoulder function at 1 year postoperatively.

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CORR Synthesis: What Is the Role of Platelet-rich Plasma Injection in the Treatment of Tendon Disorders?

Isolated bioinductive repair of partial-thickness rotator cuff tears using a resorbable bovine collagen implant: two-year radiologic and clinical outcomes from a prospective multicenter study.

BackgroundDiscriminating traumatic rotator cuff tears (RCTs) from degenerative RCTs is sometimes difficult in elderly patients because the prevalence of asymptomatic RCTs increases with age. Little intraoperative information is available on the characteristics of traumatic and degenerative RCTs in elderly patients. The purpose of this study was to compare the arthroscopic findings and histological changes of the coracoacromial ligament (CAL) between traumatic and degenerative RCTs in elderly patients.MethodsForty-two shoulders of 42 patients aged ≥ 65 years underwent arthroscopic rotator cuff repair. Nineteen patients had traumatic full-thickness RCTs (Group T), and 23 had degenerative full-thickness RCTs (Group D). The quality of the rotator cuff tissue and the condition of the long head of the biceps were examined. The grade of CAL was evaluated both arthroscopically and histologically. The stiffness of the musculotendinous unit was calculated by measuring the force and displacement using a tensiometer. The arthroscopic and histological findings of the two groups were compared.ResultsAlthough the mean tendon displacement was comparable, the stiffness was different between Group T and Group D (0.56 ± 0.31 and 1.09 ± 0.67 N/mm, respectively; p < 0.001). Both arthroscopic and histological analysis of the CAL showed that the degenerative changes in the CAL were milder in Group T than in Group D (p < 0.001 and p < 0.001, respectively). There was a moderate positive correlation between the arthroscopic findings of CAL degeneration and the histopathological changes in this ligament (r = 0.47, p = 0.002).ConclusionsTraumatic RCTs were characterized by preserved elasticity of the musculotendinous unit and milder CAL degeneration compared with degenerative RCTs even in elderly patients.

Radiographic progression of arthritic changes in shoulders with degenerative rotator cuff tears

To analyze the available evidence comparing the clinical and functional outcomes of physiotherapy vs. surgical repair in the management of degenerative rotator cuff tears (RCTs), and to perform a meta-analysis to clarify the possible superiority of one approach vs. the other. A literature search was carried out on the PubMed, Scopus and Web of Science databases on May 30th, 2020, to identify all the randomized trials comparing surgery to conservative management of degenerative rotator cuff tears. The following data were extracted from each included study: patients' demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, overall clinical findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment. A total of 7 studies, including 326 patients and dealing with conservative treatment vs. surgical repair for rotator cuff tears, were included in this study. Although surgery provided superior results both in terms of VAS (p=0.017) and Constant score (p<0.0001) compared to conservative management at 1 year follow-up, this superiority did not reach the "minimal clinical important difference". Otherwise, a few data are available about long-term outcomes, thus there is insufficient evidence about the role of surgery to prevent the progression of tendon wear. A proper rehabilitation program is able to provide similar results compared to surgery at a short term follow-up in degenerative RCTs. Further long term data are necessary to understand if tendon repair might have a protective role towards worsening of degeneration thus providing better clinical outcome than conservative management.

Lambers Heerspink FO, van Raay JJ, Koorevaar RC, van Eerden PJ, Westerbeek RE, van’t Riet E, van den Akker-Scheek I, Diercks RL. Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. J Shoulder Elbow Surg. 2015 Aug;24(8):1274-81. ### Question: In patients with degenerative rotator cuff tears, how does surgical repair compare with conservative treatment with respect to functional outcomes? ### Design: Randomized (unclear allocation concealment), unblinded, controlled trial with 12 months of follow-up. ### Setting: A university hospital and 2 regional hospitals in the Netherlands. ### Patients: 56 patients (mean age, 61 years; 63% men) with degenerative, nontraumatic full-thickness rotator cuff tears were enrolled. Exclusion criteria included trauma associated with the onset of complaints, previous shoulder surgery, frozen shoulder, osteoarthritis of the glenohumeral or acromioclavicular joint, diabetes, cognitive disorders, and neurologic diseases affecting the upper extremities. 45 patients (80%) were included in the analysis. ### Intervention: Patients were allocated to surgery (n = 25) or conservative treatment (n = …

Objective To investigate the effect of autologous platelet rich plasma (PRP) gel in arthroscopic rotator cuff repair. Methods All of 44 patients with rotator cuff tear undergent arthroscopic rotator cuff repair were randomly divided into two groups: PRP group (22 patients were received autologous PRP and hemocoagulase) and normal saline (NS) group (22 patients were received NS and hemocoagulase). All patients had the same accelerated rehabilitation protocol and were followed up in 1, 3, 12 months. Evaluation consisted of inflammatory reaction, wound healed, visual analogue scores (VAS), University of California at Angeles (UCLA) Shoulder Scores and American Shoulder and Elbow Surgeons (ASES) Scores. Results After operation, no inflammatory reaction was in 20 cases of PRP group and 19 cases of NS group, mid inflammatory reaction 1 case in PRP group and 2 cases in NS group, moderate inflammatory reaction 1 case in PRP group and 1 case in NS group. Wound healed by first intention in all of PRP group and 21 patients of NS group. In PRP group, the preoperative, 3 months and 12 months postoperative VAS were 6.6±2.0, 3.4±1.8, 1.8±1.3, UCLA were 15.2±2.9, 24.3±2.7, 32.4±2.1, ASES were 35.6±12.4, 63.4±10.4, 92.3±7.5. In NS group, the preoperative, 3 months and 12 months postoperative VAS were 6.7±1.9, 4.6±1.9, 2.0±1.2, UCLA were 14.8±3.0, 21.2±2.5, 31.7±2.3, ASES were 32.7±13.8, 55.8±11.8, 90.7±8.1. Three months postoperative VAS, UCLA, ASES were statistically significant differenece in PRP group and NS group. Twelve months postoperative VAS, UCLA, ASES were not statistically significant differenece in the two groups. Conclusion Using autologous PRP gel in arthroscopic rotator cuff repair can speed up the healing of operation incision with no adverse effect, reduce pain in the postoperation three months, accelerate the rotator cuff repair and recovery of the function of shoulder joint. It has good short-term clinical effect. Key words: Platelet rich plasma; Shoulder; Lacerations; Reconstructive surgical procedures

Background/Objectives: The optimal surgical timing for rotator cuff tears (RCTs) remains controversial, particularly regarding how tear etiology influences the final functional recovery. This study aimed to compare the clinical outcomes of early versus delayed arthroscopic repair stratified by etiology, providing evidence for etiology-specific surgical timing. Methods: A retrospective cohort study was conducted on 183 patients who underwent arthroscopic rotator cuff repair for isolated full-thickness supraspinatus tears. Patients were stratified into traumatic (n = 74) and degenerative (n = 109) groups based on etiology. They were further divided into early-repair and delayed-repair subgroups based on symptom duration (traumatic cut-off: 3 months; degenerative cut-off: 6 months). Clinical outcomes were assessed preoperatively and at the final follow-up using the Visual Analog Scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) score, and range of motion. Complications, including retear rates and stiffness, were recorded. Results: In the traumatic group, early repair yielded significantly better postoperative pain relief (VAS) and higher functional scores (ASES and UCLA) compared to delayed repair. Notably, the delayed traumatic group exhibited a significantly higher retear rate compared to the early group (16.7% vs. 2.6%; p = 0.039). Conversely, in the degenerative group, comparisons between early and delayed repair revealed no significant differences in the final functional scores, pain levels, or complication rates (p > 0.05). Conclusions: Surgical timing significantly impacts outcomes in traumatic RCTs, where early repair is critical to optimize functional recovery and minimize retear risks. In contrast, delayed arthroscopic repair for degenerative tears yielded comparable outcomes to early repair, suggesting that an initial trial of conservative management is safe and does not compromise final surgical outcomes.

Degenerative rotator cuff tears are associated with a low Omega-3 Index

BackgroundLong head biceps (LHB) degeneration, in combination with rotator cuff tears, can be a source of chronic shoulder pain. LHB tenotomy reduces pain and improves joint function although the pathophysiological context is not well understood. Tendon integrity depends on the extracellular matrix (ECM), which is regulated by matrix metalloproteinases (MMP). It is unclear which of these enzymes contribute to LHB but we chose to study MMP 1, 3, and 9 and hypothesized that one or more of them may be altered in LHB, whether diagnosed preoperatively or intraoperatively. We compared expression of these MMPs in both LHB and healthy tendon samples.MethodsLHB samples of 116 patients with degenerative rotator cuff tears were harvested during arthroscopic tenotomy. Patients were assigned to 4 groups (partial thickness tear, full thickness tear, cuff arthropathy, or control) based upon intraoperative findings. Partial and full thickness tears were graded according to Ellman and Bateman's classifications, respectively. MMP expression was determined by immunohistochemistry.ResultsMMP 1 and 9 expression was significantly higher in the presence of rotator cuff tears than in controls whereas MMP 3 expression was significantly decreased. MMP 1 and 9 expression was significantly higher in articular-sided than bursal-sided partial thickness tears. No significant association was found between MMP 1 and 9 expression and full thickness tears, and the extent of the cuff tear by Bateman's classification.ConclusionIncreased MMP 1 and 9 expression, and decreased MMP 3 expression are found in LHB degeneration. There is a significant association between the size and location of a rotator cuff tear and MMP expression.

Massive degenerative rotator cuff tears (MRCTs) represent a persistent challenge in shoulder surgery. While arthroscopic rotator cuff repair (ARCR) remains a widely accepted treatment with good functional outcomes, it is associated with a risk of retear and progression to cuff tear arthropathy. Reverse shoulder arthroplasty (RSA) has emerged as a viable alternative, particularly in cases where the reparability of the cuff is uncertain, offering pain relief and functional improvement. However, the optimal treatment approach for repairable MRCT in patients aged 60 to 80years remains debated. This trial aims to assess whether RSA provides non-inferior outcomes to ARCR in patients with degenerative MRCTs, with a particular focus on function, pain, and quality of life. This is a prospective, randomized, controlled, non-inferiority trial. A total of 145 patients with symptomatic, repairable MRCT will be enrolled and randomized in a 1:1 ratio to undergo either ARCR or RSA. The primary outcome is the American Shoulder and Elbow Surgeons (ASES) score at 24months postoperatively. Secondary outcomes include ASES at 6weeks and 6months; Visual Analog Scale (VAS) for pain; Single Assessment Numeric Evaluation (SANE); Constant score; range of motion (ROM) in flexion, extension, and internal/external rotation; repair integrity (ultrasound for ARCR, radiographs for RSA); and complication rates. PROMs will be assessed at baseline, 1.5, 6, and 24months. All adverse events and complications will be systematically recorded. This trial will provide robust comparative data to assess whether RSA is non-inferior to ARCR at two years postoperatively in terms of shoulder function and patient-reported outcomes in patients with repairable MRCT. The results aim to support evidence-based decision-making in clinical practice. The protocol was approved by the Ethics Committee Board (CCER 2023-00111) in March 2023 and by ClinicalTrial.gov (NCT05807854).