Simple Combination Therapy May Heal Rotator Cuff Tears
Edward G. Loniewski, DO, FACOS, FAOAO
Rotator cuff tears affect over 22% of the normal population and this percentage climbs to over 36% in patients in their 80’s according to one study published in the Journal of Orthopedics. The scary fact found in this study that up to 2/3rds of the patients above the age of 60 had no symptoms of the tear! Thus, we can see that rotator cuff problems are very common as we age and most of us will never know if we ever have this problem until our shoulders become painful and dysfunctional at a later date.
The rotator cuff is a group of four major muscles coming together to help “rotate” the shoulder joint. The true cause of rotator cuff tears can be multifactorial meaning that there are many reasons we cannot account for the disease. However, some researchers have found a common thread in biopsies performed at the area of the tear. There seems to be a link between a decrease in stem cells around where the tear happens. Repairing the tear and supplementing the repair with stem cells helps the repair process and prevent retearing according to another study. Although, there are only a few studies on this subject, there appears to be a link between the lack of cells and disease and the replacement of these cells and success.
A new technique combining hyaluronic acid and platelet rich plasma named enhanced PRP may provide this same type of results without a major surgery or the extended cost of stem cell therapy. Hyaluronic acid has been used for numerous medical conditions such as cataracts, skin wrinkles and arthritis for over 20 years. In orthopedics we have used this under the trade names Orthovisc, Monovisc or Supartz with about 50-60% of patients responding positively with knee arthritis. Although the mechanisms of action are many, a simplified explanation is that this cushions and lubricates the joint. However, not only does it cushion and lubricate, it is a natural carrier or substrate for growth factors. Hyaluronic acid provides an optimal environment for cells to live and thrive. However, it lacks the essential growth factors found in our body for the repair of damaged tissue. Luckily, platelet rich plasma contains numerous growth factors including Platelet Derived Growth Factor (PDGH) and Vascular Endothelial Growth Factor (VEGF). These are released fairly quickly when injected into an area of damage and they are lost within the bloodstream. However, when they are injected with a hydrogel such as hyaluronic acid, they can be slowly released in the area of damage over a longer period of time. This slow release, coupled by the fact that hyaluronic acid acts as a scaffold for tissue healing provides an optimal environment for the treatment of small to midsize rotator cuff tears. Not only is this a theoretical treatment, but one which was tested in a double blinded, placebo controlled study.
Patients were split into 4 groups of about 50 patients into each group. All the patients had a partial tear of the rotator cuff. One group received normal saline as a placebo, Group 2 received Hyaluronic Acid ( HA), Group 3 received PRP and Group 4 received the combination of PRP + HA. Patients were followed closely with follow up visits at 1,3,6 and 12 months and a repeat MRI. Patients were asked to complete two surveys ( the Constant Score and the American Shoulder and Elbow Surgeon). The PRP and the PRP+HA groups improved. The PRP + HA group improved the pain and function ASES score by 40.82 points and the PRP group improved by 27.02 while the HA group only improved 11.34 points and the Saline group worsened by 1.21 points. The Constant score confirmed these findings with an improvement of the PRP+HA group by 33.19 pts. The PRP group improved by 23.73 pts and the HA group by 12.93 pts. However, surprisingly the MRI scoring of the size and retraction of the rotator cuff also improved. In the combination therapy group, the score improved 5.85 pts; the PRP group also had an improvement of 2.89 pts and the HA group only improved 0.41 pt. However, the saline group worsened by 2 pts. What this data shows is that not only does the combination of HA and PRP provide far superior clinical results with reduction of pain and increased function of the shoulder, but it also demonstrates healing of the partial rotator cuff tears.
The best part of this treatment is the value for patients. The cost of this combination therapy for shoulders is about $1050 which is much lower than the cost of many PRP injections and certainly lower than stem cell therapies and surgical repair. In addition, the complication rates of these injections is very low. At Cellular Healing, we provide nearly painless injections with the additional use of nitrous oxide (laughing gas) anesthetic. There are no major restrictions after these injections and you can return to work or play the next day. The only drawback is the fact that you may need to have this repeated every 1-2 years. Thus, you could argue that the combination treatment of HA and PRP is one of the best values in orthopedic medicine.
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 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
 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. PubMed [citation] PMID: 25757411
 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. Epub 2014 Jun 7. PubMed [citation] PMID: 24913770
 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