**10. Discussion**

RCTs in general are prevalent within the population of all age groups. FTTs can present acutely following trauma or as a degenerative process. We have examined the associations with genetic influences, comorbidities, and the complex relationship between tear size, symptoms, and pain. Although there is conflicting literature, there appears to be some consensus on the best indicators for choosing to treat a FTT non-operatively. The established physiotherapy techniques include anterior deltoid training to allow adequate shoulder elevation without upward migration of the humeral head, as well as teres minor training to allow the greater tuberosity of the humerus to clear the acromion during shoulder elevation. Patients who will benefit the most from conservative treatment include those over the age of 60 years with a chronic degenerative tear that is unlikely to heal and with low functional demand. In this scenario, the goal is to improve the function and ROM. The risks associated with these tears include the potential of the progression of the tear, a diminished healing potential due to age or longer symptom duration, muscle atrophy, and fatty infiltration. In addition, poor outcomes have been noted in this group with surgical treatment. Moreover, the indications for surgery following conservative treatment are becoming more defined, and an outline regarding what scenarios warrant a transition from an initial conservative treatment plan has been developed. If the patient does not respond well within the first 6–12 weeks of the conservative treatment and is younger than 60 years, has a higher activity level, and has a healthy tendon and muscle environment, then early operative treatment is likely. Overall, the patient satisfaction indices, and in particular functional scores such as the RC-QOL score, have shown a consistent level of satisfaction regarding conservative management in patients followed from 2 years.

treatment was ineffective, then operative treatment would be recommended. The indications for surgery were 'may be appropriate' in the instances in which the patient responded positively to the conservative management, were healthy before the injury, were experiencing moderate-to-severe pain, as well as in those who were not responsive to non-operative care methods. The duration of time given to determine whether a conservative treatment option is successful is typically 12 weeks. Beyond this time, there was a concern regarding the risk of tear progression. In addition, the authors showed that in patients with a higher level of pain,

If surgery is needed in case of failed conservative treatment, chances for tendon healing are much lower after the age of 60 years [92]. In selected cases, surgery may be limited to a simple arthroscopic biceps tenotomy while leaving the cuff unrepaired with good pain relief and shoulder function in the elderly [93]. In other cases, despite older age, repairing the cuff may

In a study of 20 patients conducted by Baydar et al. [86], 6 months following conservative treatment 55% of the patients reported that they were 'much better' and 45% said they were 'better'. At their 1-year follow-up, 50% rated themselves as 'much better' and 40% rated them-

Kuhn et al. [55] conducted a study over a 3-month period and found that physiotherapy significantly improved pain, function and ROM. Wirth et al. [95] conducted a similar study of 60 patients, with a 2-year follow-up. On the basis of the American Shoulder and Elbow Surgeons evaluation (ASES) and the UCLA score, they found that the patients showed signifi-

Boorman et al. [96] found 75% of the patients were successfully treated conservatively. They noted that the baseline rotator cuff quality-of-life index (RC-QOL) score was a significant predictor of the outcome. Eighty-nine percent of the patients maintained their 3-month outcome at the 2-year follow-up. Even subjects with increased pain and tear progression were shown

RCTs in general are prevalent within the population of all age groups. FTTs can present acutely following trauma or as a degenerative process. We have examined the associations with genetic influences, comorbidities, and the complex relationship between tear size, symptoms, and pain. Although there is conflicting literature, there appears to be some consensus on the best indicators for choosing to treat a FTT non-operatively. The established

they were more likely to recommend surgery.

30 Advances in Shoulder Surgery

**9. Patient satisfaction indices**

still be an option with high subjective patient satisfaction rates [94].

selves as 'better'. This trend was also observed at the 3-year follow-up.

cant improvements. They noted improved pain ratings, strength, and ROM.

to have a significant increase in their functional scores.

**10. Discussion**

Although experiments using injections and biologics to specifically treat RCTs are limited, the literature available is promising in primary treatment, adjunctive care, and to augment surgical procedures. Both CS and HA injections offer modest benefits to the patient in terms of reduced pain and improved function. From an administrative perspective, the injections are practical as they are easily available pharmaceuticals, and are relatively low in prices compared to surgical intervention. These injections have demonstrated effectiveness in ameliorating symptoms following RCT.

The developing benefits of using MSCs, PRP, and other biologics have the potential to be disruptive to current treatment protocols, both conservative as well as surgical, in the approaches to healing RCTs. With improved imaging modalities, diagnostic accuracy, and sensitivity, practitioners of the future will hopefully be able to intervene earlier in the disease pathogenesis cycle. PRP can possibly be an effective method and strategy in the healing process of tendinopathy or PTTs. With standardised preparations and treatment protocols, only a short window of time is required to assess, prepare, and treat patients with this method (less than 30 minutes). The real benefit, although not fully realised at this time, is that PRP follows fundamental biological principles as it releases several growth hormones to stimulate the healing process. PRP also prompts MSC activation, creating a unique regenerative environment that modulates the immune system response and promotes trophic, anti-scarring, and cellular proliferation that in theory further aid the healing process. Regenerative injection therapy provides patients with specific cells and proteins that their body has produced, thus creating a healing environment at the site of injury and/or degeneration. Further studies in the basic science, translation, as well as with high-quality clinical trials are needed to shed further light on this very exciting and potentially game-changing technology.
