After just posting nice registry results for rotator cuff tears treated with the patient’s own stem cells instead of surgery, I thought a paper published this week would be a great segue. The rotator cuff is a series of deep shoulder muscles that help to stabilize the shoulder and move the arm. When there’s a tear in the muscle, the surgical approach is to sew the rotator cuff tear together and hope it heals. However, too often it doesn’t heal-with rates of surgical failure as high as 6 in 10. In addition, big tears fare even more poorly. Why? It’s been thought that many rotator cuff muscles and tendons tear because they have poor blood supply, leading to weak tissue. In addition, all too often, the extensive bracing required causes the rotator cuff muscle to atrophy, making it weaker still. Could there be another reason these tears don’t heal that involves the local repair cells?
In a study published this week, physicians in Norway took muscle biopsies from patients with rotator cuff tears. They then stained the tissue using tags that would identify cells that were actively trying to grow and repair, muscle stem cells, and the byproducts of muscle repair. The result? Patients with full thickness rotator cuff tears had less cellular repair potential than those with partial tears. We’ve theorized this for a while, as many full thickness rotator cuff tears just happen with some unusual activity (not severe trauma). The implication is that the tissue is bad as it failed under slightly higher load than usual. Hence trying to sew together bad tissue isn’t going to be that successful. The tissue first needs to have its regenerative potential restored. This is what we believe stem cell injections accomplish. In fact, based on our clinical experience, many of these tears will heal themselves without the need for surgery once the local repair response is augmented with more stem cells. This fits with the high rates of success seen in our recently published treatment registry data on rotator cuff tears treated with only stem cell injections and without surgery.
The upshot? Your torn rotator cuff may have bigger problems than the tear, it may lack in rotator cuff stem cells and may be incapable of healing and maintaining itself, leaving any attempt at suturing the tear more likely to fail. IMHO, restoring that repair potential is the key to healing many tears.
We are excited to announce three new Regenexx Clinical trials…. Do you have a disc bulge pressing on a nerve? Or a partially torn rotator cuff? Perhaps a torn knee ACL ligament? If you do, you may be a candidate for a trio of studies we’re funding. To find out more, see below:
Regenexx PL-Disc for Low Back Disc Bulges: This study is a randomized controlled trial (RCT) which compares traditional steroid epidurals to Regenexx-PL-Disc (an epidural with the growth factors isolated from your blood platelets) for a low back disc bulge or herniation pressing on or irritating a spinal nerve. You will be randomized to one or the other treatment and then at 3 months, if you have no response, switch to the other group. See http://clinicaltrials.gov/ct2/show/NCT01850771?term=NCT01850771&rank=1
Regenexx-SD for Rotator Cuff Tears: This study is also a randomized controlled trial comparing Regenexx-SD versus exercise therapy for partial and complete non-retracted rotator cuff tears. You will be randomized to one or the other treatment and then at 3 months, if you have no response, switch to the other group. http://clinicaltrials.gov/ct2/show/NCT01788683?term=NCT01788683&rank=1
Regenexx-SD for Knee ACL Tears: This study is also a randomized controlled trial comparing Regenexx-SD versus exercise therapy for partial and complete non-retracted knee ACL ligament tears. You will be randomized to one or the other treatment and then at 3 months, if you have no response, switch to the other group. See http://clinicaltrials.gov/ct2/show/NCT01850758?term=NCT01850758&rank=1
All procedure related care for this trio of RCTs is free, other indirect care (i.e. that which would be required to accurately diagnose your condition) will be billed to your insurance carrier. If you have an interest, contact StudyCandidate@regenexx.com or call 1-888-525-3005.
Will a rotator cuff tear heal on it’s own? Will a rotator cuff tear get bigger without surgical repair? These are the questions asked by many of the 40,000 patients each year that opt for surgery to repair their torn rotator cuff. Obviously, the answers to these queries factor into whether a patient decides to have surgery or wait. First, as I’ve blogged before, there isn’t much good research that supports that surgery is very effective for rotator cuff tears. In addition, in larger tears of the rotator cuff, approximately 6 in 10 don’t heal with surgery. Finally, shoulder surgery recovery is difficult in patients over 60, with 1 in 3 rotator cuff tears not healing in that age group. Second, what if the research showed that even a complete tear isn’t very likely to get bigger? Well a new study out this week just looked at that issue. In this case, 24 patients who had full thickness supraspinatus tears and who opted to forego surgery were tracked over time. In 2 of the 24 patients, the rotator cuff tear completely healed on it’s own and in 9/24 the tear was smaller. In 9/24 patients the rotator cuff tear size didn’t change and in 6/24 patients the tear was bigger. So in 75% of the patients, the tear was either healed, smaller, or didn’t change. How about muscle atrophy? This phenomenon can occur and involves the rotator cuff muscles shrinking and being replaced by fat. While there was a slight trend in that direction, no patient had serious fatty atrophy at follow-up. In addition, this study is consistent with another study that shows that the size of a rotator cuff tear is more likely than not to stay stable. The upshot? Surgeons frequently tell patients that their rotator cuff tears will get bigger over time, hence the reason for operating right now. In fact, according to this study (and others), waiting to see if the tear heals or gets smaller might make allot of sense. In addition, this window of opportunity would allow many patients to avail themselves of newer biologic injection therapies under ultrasound guidance using PRP or stem cells. You may want to see if these non-surgical approaches work before trying more invasive surgery that may provide little benefit.
Is rotator cuff surgery recovery time impacted by the specific type of shoulder surgery? One of the big issues with rotator cuff surgery is the long recovery time spent in an immobilizer brace. The more procedures the surgeon performs in the surgery, the longer the recovery time. Shoulder acromioplasty is a shoulder surgery that to me has always seemed well intentioned, but like alot of things has unintended consequences. The surgery is performed on the concept that the shoulder rotator cuff is being pressed upon (impinged) by the bones and ligaments above the rotator cuff. The surgeon will cut these ligaments and shave down a piece of the acromion, a bone that’s sticks out out of the front part of the shoulder blade. My concern is that these ligaments are some of the major stabilizers of the shoulder, so when you cut them you end up with an unstable and sloppy shoulder. For more on the long-term implications of instability, see our practice’s e-book, Orthopedics 2.0. So is it really necessary to cut these ligaments especially considering that this additional procedure may add to rotator cuff surgery recovery time? A recent high level study set out to answer that questionby randomizing patients into one group where a rotator cuff tear was repaired and another where the surgeon added an acromioplasty. The result? There was no outcome advantage to shaving down the bone and cutting these important ligaments. The upshot? If you’re planning on getting your rotator cuff tear repaired through surgery (we’d recommend stem cell injections for many patients rather than shoulder surgery as this dramatically reduces recovery time), then ask your surgeon not to cut out these important structures. The only caveat may be in the less common circumstance where there is severe impingement by an extra large acromion bone or really big bone spurs.
Interesting study out this week on women and rotator cuff shoulder surgery. In this study, women were found to have more pain and disability after rotator cuff surgery than men. The question is, why? Rotator cuff healing ability or time would depend on a few different things. First, size of the rotator cuff tear and other factors such as prior surgery. In this study, these things weren’t significantly different between women and men. There are another set of factors that are very important for proper rotator cuff healing-the local healing environment. One of the big players in this healing of rotator cuff tears is of course what effects all healing in the body-adult stem cells (see our medical practice’s book, Orthopedics 2.0 for more discussion on stem cells and healing). With our culture experience from the Regenexx-C stem cell procedure, when we analyzed our data, we did see differences in the stem cells of women and men (see graph above-the higher the bar the better the stem cells grew). While these differences weren’t significantly different for normal weight men and women (blue and red bars above-there is a difference, but this is not statistically significant), they became much more pronounced with heavier women (green bar above). What’s interesting is that normal weight men and heavier men didn’t have this same type of steep drop off in stem cell activity (blue vs. yellow bars above). The good news for heavier women is that in our procedure, this less robust stem cell growth didn’t seem to translate into a poorer treatment outcome. This may be because the Regenexx-C procedure can get so many more stem cells to the area when compared to the numbers involved in normal healing-essentially overwhelming the area. Why would heavy women in particular have adult stem cells that don’t grow as well? One significant reason may be hyper-insulinism and metabolic syndrome, which clearly has negative impacts at a cellular level. For example, we know that in rotator cuff repair surgery, bone and tendon healing is impaired if the patient is diabetic. We also know that patients with metabolic syndrome are “diabetics in training”, meaning that even though their blood work doesn’t yet define them yet as a diabetic, they’re in the early stages of the disease progression. If you have plans for rotator cuff surgery and are female, what can you do to increase your chances of healing? First, if you’re overweight, definitely consider going on a strict low glycemic diet before surgery (see #2-diet recommendations in the top 10 causes of cartilage loss list). A good way to follow your progress here would be to have your doctor measure and monitor your HBA1c, a measure of long-term blood sugar control. Second, in our opinion, many rotator cuff tears can be treated through a stem cell rotator cuff surgery alternative without the need for surgery. Using this method, we see less significant differences in outcome between men and women through injection, even though there does seem to be a difference in stem cell activity.