What is the rotator cuff? How do stem cells help repair rotator cuff tears? What evidence is there that stem cells help with rotator cuff injuries? Get the answers to these questions and more in this informative article.

What Is the Rotator Cuff?

The Rotator Cuff is a group of 4 principal muscles that stabilize and support the shoulder joint. The four muscles, and their attached tendons that comprise the Rotator Cuff are the supraspinatus, infraspinatus, subscapularis, and teres minor, and any of these could be where we could find Rotator Cuff tears. The Rotator Cuff is also important in shoulder functions such as reaching overhead, rotation, and putting your hand into your back pocket. The tendons are the parts that attach the muscles to the bone.

Rotator Cuff Injuries

The Rotator Cuff tendons can be torn with a traumatic injury, or with wear and repetitive use over time. Tears in the Rotator Cuff can be within the muscle itself or at the site where the tendon attaches to the bone. There are different types of Rotator Cuff tears: partial tears where only a portion of the muscle or tendon is torn, or full-thickness tears where the tear extends throughout the entire muscle or tendon. If the injury involves a complete tear through the muscle to the tendon, then it is called a rupture. Rotator Cuff tears have been found to have fewer stem cells than normal tendons.

Treatments for Rotator Cuff Tears

Small tears in the Rotator Cuff usually do not heal on their own but the pain associated with them can sometimes be helped with physical therapy alone. Larger tears traditionally would be treated with shoulder surgery. However, surgery can have a long downtime and often fail, or re-tear. Now stem cells can be used to treat many of these tears. Tendon ruptures cannot be helped with stem cells and still require surgery to fix.

How Do Stem Cells Help Repair Rotator Cuff Tears?

Stem cells are the body’s repair cells and can be found in higher concentrations in bone marrow. Via a simple bone marrow harvest procedure, we can isolate bone marrow cells and stem cells which are a part of that mixture. Then that concentrated bone marrow containing stem cells is precisely injected into the damaged tendons. This requires a highly skilled musculoskeletal specialist using ultrasound guidance. After this injection procedure, the cells stimulate repair of the tendon and reduce inflammation that causes pain.

What Evidence is There that Stem Cells Help?

We have been performed these types of Rotator Cuff stem cell procedures for more than a decade. We have many examples of Rotator Cuff tendons recovering and patients reporting significantly improved pain and function. We track our patients in a registry and have outcomes for shoulder procedures. We have published those results for all shoulder problems (1). Additionally, we have been enrolling patients in a randomized controlled clinic trial. We published the results for part of that study and it showed very good results. Patients treated with their own stem cells showed significantly improved pain and function verses just exercise therapy, and showed improvement on post procedural MRI’ s. The average reported improvement was 89%! See the above before and after images as an example of how a partially torn Rotator Cuff showed healing on MRI after stem cell therapy. Other groups have also published on stem cells helping Rotator Cuff tears and to help healing rates after surgery (2-6).

What Does a Rotator Cuff Tear Look Like on an MRI?

The normal MRI on the left demonstrates the supraspinatus muscle as it attaches on the humerus. On the right, the same muscle is torn (dark signal). The MRI below also shows a tear in the Rotator Cuff as noted in the dark signal in the muscle (white arrow).

Bottom Line

Newer treatment options for Rotator Cuff tears include using your body’s own repair cells to treat the damaged muscle or tendon using stem cell therapy. Regenexx enables patients the ability to use the healing power of their own stem cells to treat tears in the Rotator Cuff. Regenexx is a simple needle-in, needle-out procedure that enables the patient to avoid surgery, anesthesia, and the long down time commonly associated with surgical repair. Please review the MRI below in which a patient had a tear in their rotator cuff. They underwent stem cell therapy for shoulder pain at Regenexx with healing of the tear, 100% resolution of pain and return to normal function.

References

1. Centeno CJ, Al-Sayegh H, Bashir J, Goodyear S, Freeman MD. A prospective multi-site registry study of a specific protocol of autologous bone marrow concentrate for the treatment of shoulder rotator cuff tears and osteoarthritis. J Pain Res. 2015;8:269–276. Published 2015 Jun 5. doi:10.2147/JPR.S80872
2. Kim SJ, Kim EK, Kim SJ, Song DH. Effects of bone marrow aspirate concentrate and platelet-rich plasma on patients with partial tear of the rotator cuff tendon. J Orthop Surg Res. 2018;13(1):1. Published 2018 Jan 3.

What Is The Rotator Cuff?

By
John Pitts, MD
|
May 7, 2020
|
Rotator Cuff, Shoulders

What Is the Rotator Cuff?

The Rotator Cuff is a group of 4 principal muscles that stabilize and support the shoulder joint. The four muscles, and their attached tendons that comprise the Rotator Cuff are the supraspinatus, infraspinatus, subscapularis, and teres minor, and any of these could be where we could find Rotator Cuff tears. The Rotator Cuff is also important in shoulder functions such as reaching overhead, rotation, and putting your hand into your back pocket. The tendons are the parts that attach the muscles to the bone.

Rotator Cuff Injuries

The Rotator Cuff tendons can be torn with a traumatic injury, or with wear and repetitive use over time.

Tears in the Rotator Cuff can be within the muscle itself or at the site where the tendon attaches to the bone. There are different types of Rotator Cuff tears: partial tears where only a portion of the muscle or tendon is torn, or full-thickness tears where the tear extends throughout the entire muscle or tendon. If the injury involves a complete tear through the muscle to the tendon, then it is called a rupture. Rotator Cuff tears have been found to have fewer stem cells than normal tendons.

Treatments for Rotator Cuff tears

Small tears in the Rotator Cuff usually do not heal on their own but the pain associated with them can sometimes be helped with physical therapy alone. Larger tears traditionally would be treated with shoulder surgery. However, surgery can have a long downtime and often fail, or re-tear. Now stem cells can be used to treat many of these tears. Tendon ruptures cannot be helped with stem cells and still require surgery to fix.

How Do Stem Cells Help Repair Rotator Cuff Tears?

Stem cells are the body’s repair cells and can be found in higher concentrations in bone marrow. Via a simple bone marrow harvest procedure, we can isolate bone marrow cells and stem cells which are a part of that mixture. Then that concentrated bone marrow containing stem cells is precisely injected into the damaged tendons. This requires a highly skilled musculoskeletal specialist using ultrasound guidance. After this injection procedure, the cells stimulate repair of the tendon and reduce inflammation that causes pain.

What evidence is there that stem cells help?

We have been performed these types of Rotator Cuff stem cell procedures for more than a decade. We have many examples of Rotator Cuff tendons recovering and patients reporting significantly improved pain and function. We track our patients in a registry and have outcomes for shoulder procedures. We have published those results for all shoulder problems (1). Additionally, we have been enrolling patients in a randomized controlled clinic trial. We published the results for part of that study and it showed very good results. Patients treated with their own stem cells showed significantly improved pain and function verses just exercise therapy, and showed improvement on post procedural MRI’ s. The average reported improvement was 89%! See the above before and after images as an example of how a partially torn Rotator Cuff showed healing on MRI after stem cell therapy. Other groups have also published on stem cells helping Rotator Cuff tears and to help healing rates after surgery (2-6).

The normal MRI on the left demonstrates the supraspinatus muscle as it attaches on the humerus. On the right, the same muscle is torn (dark signal). The MRI below also shows a tear in the Rotator Cuff as noted in the dark signal in the muscle( white arrow).

Bottom Line

Newer treatment options for Rotator Cuff tears include using your body’s own repair cells to treat the damaged muscle or tendon using stem cell therapy. Regenexx enables patients the ability to use the healing power of their own stem cells to treat tears in the Rotator Cuff. Regenexx is a simple needle-in, needle-out procedure that enables the patient to avoid surgery, anesthesia, and the long down time commonly associated with surgical repair.

Please review the MRI below in which a patient had a tear in their rotator cuff.  They underwent stem cell therapy for shoulder pain at Regenexx with healing of the tear, 100% resolution of pain and return to normal function.

References
(1) Centeno CJ, Al-Sayegh H, Bashir J, Goodyear S, Freeman MD. A prospective multi-site registry study of a specific protocol of autologous bone marrow concentrate for the treatment of shoulder rotator cuff tears and osteoarthritis. J Pain Res. 2015;8:269–276. Published 2015 Jun 5. doi:10.2147/JPR.S80872
(2) Kim SJ, Kim EK, Kim SJ, Song DH. Effects of bone marrow aspirate concentrate and platelet-rich plasma on patients with partial tear of the rotator cuff tendon. J Orthop Surg Res. 2018;13(1):1. Published 2018 Jan 3. doi:10.1186/s13018-017-0693-x
(3) Kim SJ, Song DH, Park JW, Park S, Kim SJ. Effect of Bone Marrow Aspirate Concentrate-Platelet-Rich Plasma on Tendon-Derived Stem Cells and Rotator Cuff Tendon Tear. Cell Transplant. 2017;26(5):867–878. doi:10.3727/096368917X694705
(4) Hernigou P, Flouzat Lachaniette CH, Delambre J, Zilber S, Duffiet P, Chevallier N, Rouard H. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study. Int Orthop. 2014 Sep;38(9):1811-8. doi: 10.1007/s00264-014-2391-1.
(5) Ajrawat P, Dwyer T, Almasri M, Veillette C, Romeo A, Leroux T, Theodoropoulos J, Nauth A, Henry P, Chahal J. Bone marrow stimulation decreases retear rates after primary arthroscopic rotator cuff repair: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2019 Apr;28(4):782-791. doi:
(6) Cole BJ, Verma NN, Yanke AB, et al. Prospective Randomized Trial Of Biologic Augmentation With Mesenchymal Stem Cells In Patients undergoing Arthroscopic Rotator Cuff Repair. Orthop J Sports Med. 2019;7(7 suppl5):2325967119S00275. Published 2019 Jul 29. doi:10.1177/2325967119S00275

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Treatment Rotator cuff injury

WHAT IS A ROTATORIAL (ROTATOR) CUFF AND WHAT IS IT FOR?

Rotational (rotator) cuff of the shoulder – includes the supraspinatus, infraspinatus, small round and subscapularis muscles. These muscles are necessary to stabilize the head of the humerus and prevent it from moving when moving in the joint. In addition, these muscles allow for rotational movements in the shoulder in all directions.

The subscapularis muscle rotates the arm inward, the supraspinatus muscle raises the shoulder and “anchors” it, i.e. presses the head of the humerus into the articular cavity of the scapula when the shoulder is abducted to the side. In this case, the main abduction force is determined by the deltoid muscle, and the supraspinatus muscle works as a commander, directing the efforts of the deltoid muscle. The infraspinatus muscle rotates the shoulder outward, and the small round muscle rotates outward and brings the arm to the body. Damage to at least one of the four muscles leads to a sharp limitation of movement and loss of function of the shoulder joint.

CAUSES OF DAMAGE OR RUPTURE OF THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Rotator cuff injury can result from acute trauma. In this case, patients often describe a specific injury, after which pain appeared and the function of the shoulder was impaired.

In some cases, rupture of the rotator cuff is the result of chronic microtrauma to the muscles. Most often this occurs in persons whose professional activities are associated with frequent elevated position of the hand or throwing movements. For example, athletes in sports such as baseball, tennis, weightlifting and rowing. Constant microtraumatization of the tendons of the rotator cuff when hitting the ball, serving, throwing can lead to micro-ruptures of muscle fibers, the muscles gradually become thinner and over time, even with a minor injury, they can easily tear.

The rotator cuff tendons are prone to overstressing in teachers who write with chalk on a blackboard with their hand up, painters who paint walls, builders, and the like.

In some patients, rupture of the rotator cuff may be due to the development of degenerative-dystrophic changes in the muscles associated with aging, for example, in the elderly or a genetic predisposition.

TYPES OF DAMAGE OR RUPTURES OF THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Due to the cause of the rupture – traumatic or degenerative ruptures. According to the nature of the damage, partial and complete ruptures are distinguished. Partial ruptures do not pass through the entire thickness of the tendon, full ones extend through the entire thickness of the layers of the cuff. Traumatic injuries are divided into fresh, stale and chronic.

SYMPTOMS OF DAMAGE TO THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Signs of damage to the rotator cuff are pain and weakness in arm abduction or external rotation of the shoulder.

Pain intensifies in certain phases of movement, especially when abducting the arm

at an angle of 70 – 120 °.

DIAGNOSTICS OF DAMAGE TO THE ROTATOR CUFF:

Diagnostic tests:

To diagnose damage to the rotator cuff, special tests are used in which the doctor, bringing the patient’s hands to a certain position, evaluates the motor ability of the injured arm, and observes the patient’s reaction to his actions. The most informative tests are for weakness of abduction and weakness of external rotation of the shoulder. With extensive damage to the rotator cuff, symptoms of a falling arm are also characteristic (the patient cannot hold the passively abducted arm) and raising the shoulder girdle when trying to abduct the arm (Leclerc’s symptom).

Ultrasound – diagnostics

MRI – study

X-ray – research

TREATMENT OF A ROTATOR CUFF INJURY:

Treatment of a rotator cuff injury can be conservative or surgical. Conservative treatment is indicated for partial injuries, when there is hope for restoration of function without surgery. Conservative treatment is carried out along with immobilization of the shoulder joint with a special bandage (orthosis), and includes:

physiotherapy, the use of anti-inflammatory and analgesic drugs, with severe pain – blockade with long-acting glucocorticoids. A very good clinical effect is given by intra-articular injections of platelet-rich plasma into the shoulder joint (“growth factors”, PRP).

If the duration of unsuccessful conservative treatment exceeds 2-3 months, it is necessary to raise the question of surgery.

SURGICAL TREATMENT OF DAMAGES TO THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Repairing a torn rotator cuff tendon is a fairly complex operation. Reconstruction of the rotator cuff can be performed both openly, through an incision on the shoulder, and arthroscopically. The disadvantages of open surgery are the need for large, traumatic incisions on the shoulder to provide access to damaged tendons, which carries a high risk of side effects, and a long recovery after surgery.

In our Medical Center, surgical treatment of rotator cuff injury is performed in a modern way, without incision of the joint – under arthroscopic control. Instead of an incision, local mini-punctures are performed, into one of which an arthroscope with a video camera is inserted, and into the other, instruments for the operation. An enlarged image from the video camera is transmitted to the video monitor, which allows the doctor to examine in detail all the structures of the joint and identify the location of the damage.

The essence of the arthroscopic operation is that the rupture is sutured, and if the tendon is torn off from the place of fixation, then a suture is performed using special “anchor” fixators.

At the first stage of the operation, the joint is cleaned – the removal of all non-viable, degenerative – altered tissues of the rotator cuff. Then the area of ​​the humerus where the rotator cuff was torn or torn off is cleared of soft tissue remnants so that the tendon grows better to it. Usually, 2-3 anchors are required to fix a torn tendon. The latch consists of an anchor and threads. The anchor is attached to the bone, and the tendon is stitched with threads.

The choice of a specific type of anchor is made by the operating surgeon, but in general, the patient should also be informed about which anchor is planned to be used in his case. We recommend using clamps from world-famous companies that have proven themselves for a long time.

REHABILITATION AFTER SHOULDER ARTHROSCOPY:

Properly performed surgery allows you to quickly start active rehabilitation, to prevent the development of complications and optimize the recovery time.

After shoulder arthroscopy, the arm is immobilized in the abduction position for several weeks using a special splint. Such immobilization reduces tendon tension and reduces the risk of re-rupture, creates favorable conditions for better healing of the tendon. The duration of immobilization is determined by the surgeon who performed the operation, since only he can assess the condition of the tendons and the strength of the suture.

Already from the first weeks after shoulder arthroscopy, patients are recommended to perform special exercises aimed at developing movements in the shoulder joint. However, their intensity and sequence should be selected by the operating doctor and an experienced rehabilitation specialist.

In our Medical Center, patients after shoulder arthroscopy are offered a whole range of rehabilitation measures. The rehabilitation program is selected individually and includes:

Special exercises and exercise therapy by rehabilitators of our Medical Center using the kinesiotherapy method. Exercises are aimed at improving the range of motion in the joint, preventing the development of contractures, increasing strength and endurance in the muscles of the shoulder girdle. Exercises are selected on an individual basis and performed on professional equipment in the rehabilitation room, under the supervision of experienced instructors – rehabilitologists. Some of the exercises are signed for the patient to carry out at home.

Physiotherapy on professional equipment from BTL: magnetotherapy, ultrasound therapy with the introduction of drugs, electrotherapy – reduce pain and swelling in the operated shoulder, prevent the formation of adhesions and scars, promote better healing, restore muscle tone.

TRUST THE CARE OF YOUR HEALTH TO REAL PROFESSIONALS!

Injury and rupture of the rotator cuff

Normal mobility of the shoulder joint is the main condition for comfortable performance of the simplest tasks in everyday life: putting on clothes, washing in the shower, raising hands to a certain height to get the necessary thing. The rotator cuff is responsible for these processes, providing rotational movements of the shoulder in different directions.

Structure and functions

The rotator cuff is a complex of four muscles that coordinate the movement of the shoulder joint.

If even one of them, included in the system of its dynamic stabilization, is damaged, the functionality deteriorates sharply. There is not only pain, but also tangible immobilization.

Main causes of the problem

Trauma is a common motive for rotator cuff injury. Most patients easily remember the case, after which the rotational functions of the shoulder were limited, unpleasant pain appeared.

Often, a factor becomes a periodic or rather constant microtraumatization of the tendons of the muscles. It is directly related to the profession, where you have to keep your hands in an elevated state or perform throwing movements. Heavy lifters, tennis players, baseball players, and rowers suffer from the problem. As a result of the efforts applied to hitting, serving and throwing sports equipment, microfractures of muscle fibers can occur, over time they become thinner and rupture in case of minor or serious injury. The tendency to damage the rotator cuff is in teachers, painters, builders.

Another reason for tendon rupture can be degenerative changes in the elderly associated with natural aging.

Sometimes the root cause of pathologies of the rotator cuff of the shoulder is a small distance between the head of the humerus and the acromial process of the scapula. This condition is most often provoked by a fracture and improperly fused large tubercle of the humerus. There is also an abnormal anatomy of the acromion – like a hook, which triggers its constant contact and friction of the tendons of the shoulder joint.

Those who have taken certain medications (for example, some groups of antibiotics) and also locally injected glucocorticosteroids are also capable of facing damage to the rotator cuff of the shoulder.

The last of the most common causes is the occurrence at the lateral end of the scapular bone of the so-called additional – osacromiale, leading to damage to the rotator cuff of the shoulder.

Symptoms

The main sign of a rupture of one or more muscles that make up the rotator cuff is pain and weak shoulder abduction. They are especially intensified when raising the arm at an angle of 70 to 120, and there is also a springy resistance, characteristic of a dislocation of the shoulder joint. It is impossible to press the hand to the body.

On examination, it can be seen that the area of ​​the shoulder joint with a rupture of the rotator cuff is flattened in comparison with the healthy one. Often there is a bulge when moving, the shoulder seems to be shortened or vice versa elongated.

Late stages of damage are characterized by a symptom of a “frozen shoulder”: even passive abduction becomes impossible. This is explained by the overgrowth of Riedel’s pocket.

What are the types of damage

The rupture of the rotator cuff of the shoulder joint occurs in different types, and it is on this factor that the selection of methods and the effectiveness of treatment depend.

According to the reason that caused the damage, the disease is divided into traumatic and degenerative. It happens complete and partial, and also stands out the rupture of one of the tendons of the shoulder joint or several at the same time. It is also important to understand that, according to the time of occurrence, it is diagnosed as acute or chronic. All this determines the nature of the course and the severity of the symptoms.

Diagnostics

Symptoms of damage to the rotator cuff of the shoulder joint have a similar clinical picture with dislocation, so accurate diagnosis is very important. It is not uncommon for patients to apply after undergoing rehabilitation in the trauma department and wearing a plaster cast. The task of the doctor in this case is to correctly diagnose and prescribe an effective treatment.

One of the main diagnostic methods is to examine the patient and use special tests to assess the rotator functions of the shoulder joint. One of the informative ones in this case is to check the rotation and abduction of the hand. If they are weak, we can safely talk about the rupture of the rotator cuff. There is also a symptom of Leclerc, in which the shoulder girdle rises if you try to withdraw the arm, and a symptom of a falling arm: the patient is not able to hold the arm after passively abducting it.

In addition to testing, visual examination and palpation of the joint, instrumental methods are also used for diagnosis:

1. Ultrasound.

2. X-ray.

3. MRI.

Principles of treatment

The choice of treatment regimen for rotator cuff injury depends on many factors: the size of the gap, the degree of joint degeneration, the age and needs of the patient, and his activity.

Today, one of the methods of surgical, conservative, arthroscopic treatment or a whole complex of them is successfully used.

If degenerative or inflammatory changes have occurred in the rotator cuff of the shoulder, and the damage has occurred relatively recently, non-surgical treatment is used. It consists in the complete immobilization of the shoulder with an orthosis and the appointment of painkillers with anti-inflammatory effects of drugs. After a complete reduction in joint pain, special-purpose exercise therapy is recommended. The exercises included in the complex are aimed at regenerating the normal rotator mobility of the shoulder in full, removing stiffness and discomfort.

Good results as a conservative therapy for damage to the rotator cuff are given by physiotherapy, as well as blockade with glucocorticosteroids with prolonged action. Often, with ruptures of the tendons of the shoulder, injections of plasma, with an increased number of platelets, are used directly into the joint itself.

This technique does not work for all patients, and it is not suitable for all. If the effect does not appear within two to three months of conservative therapy, it is worth using other methods.

Rotator cuff injuries in young active people, especially athletes, require faster resolution. The same result with a complete rupture of the tendons of the shoulder can be achieved by surgical treatment.

Modern surgery makes it possible to perform a closed surgical intervention, receiving only a few punctures near the joint. This technique is called arthroscopy. The operation is performed using special high-tech equipment and anchor clamps with a diameter of 2.5-6mm. Using them during the intervention makes it possible to completely restore the anatomy, and most importantly, the normal rotator functionality of the shoulder joint.

In case of damage to the rotator cuff of the shoulder, the surgeon makes five mini-incisions around the joint capsule. Arthroscopy is performed in an aquatic environment, which ensures a thorough cleansing of tissues from blood and damaged elements. Only after the complete removal of bone hyperplasia, microprostheses (fixators) are introduced, which are necessary to restore the rotator cuff after a shoulder injury.

The main advantage of arthroscopic shoulder surgery is that the patient can return home within a few hours. And to fully restore damage to the rotator cuff, simple rehabilitation measures will be needed.

The arthroscope, which is used to repair ruptures of the rotator cuff of the shoulder, is an endoscopic equipment with a small diameter. It allows you to assess the condition of the joint, because during arthroscopy, the image is transmitted to the monitor. During the operation, minimal incisions are made, which makes it less traumatic.

For older people, a surgical treatment option may be arthroplasty, that is, joint replacement. The cost of such a solution to the problem of damage to the rotator cuff is quite high. Younger patients may benefit from tendon grafting from other muscle types. The only thing is that such an intervention does not restore the functions of the rotator cuff of the shoulder by 100 percent. Among the advantages: a more affordable price and physiology.

Rehabilitation

Recovery after a rotator cuff injury is an important part of treatment. It consists in performing special exercises that can restore the functionality of the joint, relieve the feeling of stiffness. They are used both after arthroscopy and conservative treatment. But it is very important that the doctor monitors the intensity and correctness of the execution.

Physiotherapeutic methods are also used as rehabilitation measures. All this allows you to return to normal life as quickly and competently as possible and forget what a rotator cuff injury in the shoulder is.

If you are experiencing shoulder pain, stiffness and other symptoms of damage, do not self-medicate and hesitate! Make an appointment with Taras Rokita and get high-quality diagnostics and treatment!

Typical Example of Incomplete Rotator Cuff Injury #1