Shoulder and Rotator Cuff Pain

Shoulder pain traces back to a short list of causes: rotator cuff tears and tendinopathy, subacromial bursitis and impingement, a frozen shoulder, a SLAP or labral tear, instability after dislocations, and arthritis. This page collects what Don Buford, MD has written about each of them: office based orthobiologic injections, the research this practice has run and presented, and arthroscopic surgery when surgery is the right answer. It is written for patients deciding what to do next and for physicians deciding what to refer.

Most shoulder pain starts in the rotator cuff

Rotator cuff pain is why people cannot sleep on one side, cannot reach a shelf, and cannot get through a workday. For many the disability is significant enough that they are unable to sleep or work for any length of time.

The first question is not which treatment you want. It is what is actually torn or irritated, and how much of it. A tendinopathy with no tear, a small partial thickness tear, a bursitis, and a large full thickness tear behave differently and respond to different things. Examination and imaging separate most of them, and when the picture is still unclear a needle scope under local anesthesia can settle it in the office.

What PRP and bone marrow concentrate can do for a cuff tear, and what they cannot

For partial tears and cuff tendon pain the injection evidence is real. A level 1 study in the journal Arthroscopy compared platelet rich plasma with a steroid injection for partial thickness rotator cuff tears. At 3 months the PRP patients had significantly better function and pain relief than the steroid patients, and that held even at the lower of the PRP doses tested. In this office a single injection is enough about 95 percent of the time, placed under ultrasound guidance.

Bone marrow concentrate has been studied here directly. In a practice study presented at the 2021 ARMI Spring Conference, patients with shoulder pain from rotator cuff tears received a single in office bone marrow concentrate injection. Two years later they reported 80 percent less pain and rated themselves 84 percent better by SANE score. A separate 25 patient office study followed partial thickness tears for a full year after a single bone marrow derived injection.

The limits matter as much as the results. PRP does not replace surgery for a type 2 SLAP lesion, a tear and detachment inside the joint. There the honest goal of an injection is a period of pain relief, and registry data sets expectations for how long that tends to last. Regenerative medicine keeps growing inside orthopedics and still cannot replace surgery for many conditions.

Dose is why studies on PRP disagree

Published trials of PRP in the rotator cuff reach opposite conclusions, largely because many of them never define the treatment they gave. A rotator cuff meta analysis in Arthroscopy defined PRP dose by volume alone. Dose is volume multiplied by platelet concentration, so two studies injecting the same number of milliliters can be giving very different treatments, and pooling them produces a conclusion that means little. When you read that PRP did or did not work for cuff tears, check first whether anyone reported the platelet count.

When repair surgery is the right answer

Since 2009 arthroscopic rotator cuff repair has healed about 90 percent of the tears it is used for, and recent studies report a 91 percent success rate when the repair is augmented biologically. Healing is something you can see: an arthroscopic video taken 2 years after repair of a 2 cm complete tear shows the tendon healed, with the sutures covered over by tendon and bursal tissue.

Biologic augmentation is now part of the operation. Adding PRP to a rotator cuff repair has been reported to lower retear rates. A scaffold patch used for cuff augmentation was tested straight out of the operating room and held 89 percent of its weight in PRP before being sutured into place. An intra-osseous injection into the greater tuberosity immediately after a repair takes under 3 seconds through an ordinary 18 gauge needle.

Age by itself is not a reason to rule out an operation. A published review compared rotator cuff repair in 54 patients over age 75 with 54 patients under 75 at 2 years, and age alone was not a barrier.

Frozen shoulder runs on a different clock

A frozen shoulder is a shoulder that has lost normal motion, and it is usually painful, especially at the end of whatever motion remains. It most often follows minor shoulder trauma. Patients are commonly told to wait it out and that it will settle in 1 to 2 years. The goal in this practice is closer to three months from the first evaluation.

Treatment depends on how much motion is gone and how much pain there is. For a patient who has already lost 50 percent or more of motion in any plane, an early manipulation under anesthesia, a procedure of about 10 to 15 minutes, has in Dr. Buford's experience restored motion the fastest and saved months of recovery.