We will see many patients after a shoulder surgery with less than hoped for results. One reason the surgery was not thought to be a success was the patient’s over-expectation of what the surgery could do and how fast they could return-to-play their favorite activity.
Researchers at the Department of Orthopaedic Surgery, Stanford University, North Shore Hospital, University of Auckland, Auckland, New Zealand; Sports Science and Medicine, Women’s Tennis Association Tour, St. Petersburg, Florida working in conjunction of a new study say:
“In professional female tennis players, a high return to play rate after arthroscopic shoulder surgery is associated with a prolonged and often incomplete return to previous level of performance. Thus, counseling the patient to this fact is important to manage expectations.”
In this study, there was an over-expectation of what the surgery could do.
The arthroscopic shoulder surgery could get the player back to the game in most cases, but could not get the player back to “their” game as quickly as hoped for. In fact it took years if at all. Here are more details from this study:
During the study period, 8 professional women tennis players from the WTA tour underwent shoulder surgery on their dominant arm. Indications included rotator cuff debridement or repair, labral reconstruction for instability or superior labral anterior posterior lesion, and neurolysis of the suprascapular nerve.
- Seven players (88%) returned to professional play.
- The mean time to return to play was 7 months after surgery.
- However, only 25% (2 of 8) players achieved their preinjury singles rank or better by 18 months postoperatively.
- In total, 4 players returned to their preinjury singles ranking, with their peak singles ranking being attained at a mean of 2.4 years postoperatively.(1)
Surgery was so unappealing that doctors from the New York Football Giants and the Hospital for Special Surgery in New York highlighted these observations in their paper published in Current reviews in musculoskeletal medicine.(2)
“Conservative management of rotator cuff injuries continues to be the “gold standard” in the elite athlete. This includes a comprehensive rehabilitation program, anti-inflammatories, and corticosteroid injections. Newer treatment techniques such as intramuscular dry needling and the use of biologics such as platelet-rich plasma and stem cells demonstrate early promising results; however, these modalities require further investigation to determine their effectiveness. Rotator cuff injuries can range from contusions and tendinopathy to full-thickness tears. A comprehensive evaluation is needed to determine the extent of injury and appropriate plan of care. Management strategies can range from rehabilitation to operative intervention and are guided by the size of the tear, time of season, sport, performance limitations, and presence of concomitant pathology.”
These professional players showed these results while receiving the best in rehab, training opportunities, training equipment, personal trainers, etc. What about the average patient? Is there an over expectation of what shoulder surgery can do for them?
Researchers have documented that surgical interventions for subacromial impingement syndrome (also called Swimmer’s Shoulder, inflammation and degenerative shoulder disease from repetitive motions as in swimming), show that no technique is convincingly better than another surgical technique or that surgery is superior is any way to conservative interventions.(3)
Further, when having arthroscopic stabilization, even in youth athletes, it must be emphasized to the patients and their relatives that the recurrence rate of surgery damage and need for more surgery could be expected. Younger athletes being more vulnerable than in the adult athletes.(4) That was suggested in a well cited 2012 study published in the journal Arthroscopy.
Here again is a discussion of expectations in the athlete. While studying surgical options, no procedure showed itself better than non-surgical procedures and there is a good chance for the need of a revision surgery to repair the previous surgery.
A patient with problems of the rotator cuff or shoulder impingement may think so, however surgery is a still an invasive procedure that requires lengthy recovery and physical therapy even if successful. Further, even successful surgery has been shown to not always relieve all the pain and that shoulder weakness can remain. Complications may also include nerve damage.
A more optimistic study in 2019 in the Journal of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (5) said this:
“Adolescent athletes who undergo Bankart repair for traumatic anterior shoulder instability have an 81.5% rate of return to sports to preinjury levels of play at an average of 5 months following surgery. The overall total mean incidence of recurrent instability in the adolescent population is 18.5%, while the mean incidence of revision surgery is 12.1%. The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery.”
Again these are optimistic results:
- 4 out of 5 will have successful surgery
- 1 out of 5 will not
- 1 out of 8 will have to have another surgery.
Throw these numbers out when you consider athletes who participate in contact sports. “The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery.”
In the Journal of the American Academy of Orthopaedic, surgeons offered a realistic level of expectation of surgical complication. “Most patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms post-operatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge.” Your treatment options include another surgery to repair the first one. Surgery to transfer a tendon into the area, and arthroplasty.(6)
Shoulder tendon repair without surgery
The shoulder tendons are main players in rotator cuff problems, shoulder impingement, shoulder osteoarthritis and disorders of pain and weakness that get worse over time.
The symptoms of tendon weakness and injury are many and include inflammation of the tendons ( tendonitis), and/or bursitis, inflammation of the bursa (the protective sac that sits between the bones of the shoulders and allows the tendons the space they need to move.)
All would agree treating the tendons and allowing the tendons to function normally would be the optimal treatment in shoulder pain, but that is where the agreement ends. Surgeons will insist that surgery after failed conservative treatments is the way to go, other doctors are trying something else for faster results.
Stem cells and Platelet Rich Plasma Therapy are injection techniques that can accelerate the body’s own inflammatory response to repair the tendons.
In many articles on this site I discuss the growing interest medical researchers have in cellular communication. This interest is based on observations that stem cells, when introduced into a damaged joint, spontaneously change the joint environment from diseased to healing by signaling the native healing cells to get ready to rebuild.
A recent paper from a research team in Australia confirms how this change of joint environment works.
- When introduced into a diseased joint, bone marrow stem cells display plasticity and multipotency (the ability to change/morph into other cell types and multiply). They also signal the native stem cells to join them.
- They also send signals to suppress inflammatory T–cell proliferation (inflammation) and provide an anti-inflammatory effect.
- Stem cells express various growth factors – an array of bioactive molecules that stimulate local tissue repair – These growth factors, and the direct cell to cell contact between MSCs and chondrocytes (the present remaining cartilage cells in the joint), have been observed to influence chondrogenic differentiation and cartilage matrix formation – in simple terms – stem cells regenerated cartilage.(7)
PRP for the shoulder research
- Injections of PRP have led to reduced pain and improved recovery for the treatment of rotator cuff tears.(8,9)
- PRP also enhances rotator cuff repair following arthroscopic shoulder surgery.(10)
- At a meeting of the American Academy of Orthopaedic Surgeons, researchers suggested that PRP injections may be a safe and cost-effective treatment alternative for rotator cuff tendinopathy (RCT) (11) My My experience is that it also works on full-thickness tears. I inject shoulders every day, and have seen patients who can’t lift their arm because of a tear, get pain free, complete range of motion.
Ask Dr. Darrow about your shoulder pain
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1 Young SW, Dakic J, Stroia K, Nguyen ML, Safran MR. Arthroscopic Shoulder Surgery in Female Professional Tennis Players: Ability and Timing to Return to Play. Clin J Sport Med. 2016 Jun 22.
2 Weiss LJ, Wang D, Hendel M, Buzzerio P, Rodeo SA. Management of Rotator Cuff Injuries in the Elite Athlete. Curr Rev Musculoskelet Med. 11(1):102-112. doi: 10.1007/s12178-018-9464-5. Epub 2018 Jan 13. PubMed PMID: 29332181; PubMed Central PMCID: PMC5825345.
3 Tashjian RZ. Is there evidence in favor of surgical interventions for the subacromial impingement syndrome? Clin J Sport Med. 2013 Sep;23(5):406-7. doi: 10.1097/01.jsm.0000433152.74183.53.
4.Castagna A, Delle Rose G, Borroni M, Cillis BD, Conti M, Garofalo R, Ferguson D, Portinaro N. Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports.Arthroscopy. 2012 Mar;28(3):309-15. doi: 10.1016/j.arthro.2011.08.302. Epub 2011 Nov 30.
5 Kasik CS, Rosen MR, Saper MG, Zondervan RL. High rate of return to sport in adolescent athletes following anterior shoulder stabilisation: a systematic review. J ISAKOS. 2019 Jan;4(1):33-40. doi: 10.1136/jisakos-2018-000224. Epub 2018 Nov 10. PubMed PMID: 31044093; PubMed Central PMCID: PMC6487304.
6. Strauss EJ, McCormack RA, Onyekwelu I, Rokito AS. Management of failed arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2012 May;20(5):301-9.
7. Seol D, Zhou C, et al. Characteristics of meniscus progenitor cells migrated from injured meniscus. J Orthop Res. 2016 Nov 3. doi: 10.1002/jor.23472.
8. Mei-Dan O, Carmont MR. The role of platelet-rich plasma in rotator cuff repair. Sports Med Arthrosc. 2011 Sep;19(3):244-50. doi: 10.1097/JSA.0b013e318227b2dc.
9. von Wehren L, Blanke F, Todorov A, Heisterbach P, Sailer J, Majewski M. The effect of subacromial injections of autologous conditioned plasma versus cortisone for the treatment of symptomatic partial rotator cuff tears. Knee Surg Sports Traumatol.Arthrosc. 2015 May 28. [Epub ahead of print]
10. Yang J, Sun Y, Xu P, Cheng B. Can patients get better clinical outcomes by using PRP in rotator cuff repair: a meta-analysis of randomized controlled trials. J Sports Med Phys Fitness. 2015 Oct 16.